Avin Patel

Referred Pain

Sometimes pain is felt somewhere different to the area that’s caused it. We see this a lot with upper back stiffness causing the lower back to overwork and become painful. But referred pain is different: here the brain misinterprets the pain signal that it receives.

referred pain

Understanding the Pain Signal

The body is full of nerves that can send a pain signal to the brain to alert it to potential danger. Everyone is slightly different, but we all follow a similar pattern of nerves. Each nerve supplies a stripe of the body with sensation.

Pain at any point in the stripe will trigger the nerve to send a signal to the brain. The brain knows which nerve is providing the message, but sometimes it misinterprets the detail. The misinterpretation is just like how some people have a heart attack without chest pain, just jaw or arm pain. If a joint within a stripe is irritated, such as the neck joint labelled above, the brain could assume the pain is anywhere within the stripe. As a result, you may feel no neck pain at all, just pain in the arm. But the arm wouldn’t be tender, and movement might not alter symptoms either.

Another commonly affected area is the pelvic joint: the SIJ. This can cause pain in the back of the thigh that can be easily mistaken for sciatica. But unlike sciatica, the pain is unlikely to be sharp or shooting, and tests that identify sciatica will come up negative.

With the heart attack example in mind, we do need to be aware that sometimes referred pain comes from organs. Again, there are patterns that we expect the body to follow, but there is overlap between referred pain that could be coming from a joint, and the same symptoms coming from an organ. We use our detailed case history to help catch these cases, but we will also monitor your progress and refer you for further investigation if appropriate.

Diagnosing Referred Pain

Although everyone’s stripes vary slightly, they are all pretty similar. Your osteopath will be able to tell which nerve is responsible by the area in which you feel the pain. From here, they can work back to other structures within that nerve’s remit to identify the irritated area. Looking at the way you move, as well as testing the joints and muscles passively, we can work out the joint or other area that’s causing the problem.

Managing Referred Pain

Identifying the cause is the first step towards getting on top of the pain. Often, once the problem area is identified, the referred pain should respond quickly to treatment. Whereas sciatica-type issues can take days or weeks to respond to changes further up the nerve, referred pain is often much more immediate. If the cause of the pain is a simple irritated joint, sometimes a quick click will take the edge off the symptoms. A combination of the usual strategies to relax off tight muscles and improve movement in joints can make a big difference, especially when supported with advice and exercises.

In any case, your osteopath can give you an idea of a prognosis at the end of your first session. Your osteopath will also give you a tailored plan and diagnosis to structure your recovery.

Make an appointment in Rutland or Leicestershire here

The Stomatognathic System

This complicated name simply refers to the mouth (stoma-) and the jaws (-gnath). Osteopaths look at the stomatognathic system with particular interest in its relationship with the rest of the body. It might come as a surprise that the two have much bearing on one another, but it can be a relevant consideration when getting to the bottom of your problem. It can be especially significant with neck and shoulder pain, or some headaches.

The Stomatognathic System

How Posture Affects The Jaw

The image above shows the demands placed on the jaw muscles by slouching.

  1. The front of the neck is stretched to keep the head up
  2. This would pull the mouth open, but…
  3. A reflex tightens the muscles around the jaw to keep the mouth closed

These muscles that tighten up are the same that might be tight if you clench or grind your teeth. While the muscles on the front of the neck are stretched, those on the back are working hard. The muscles right at the top of the neck, at the base of the skull, contract to raise the head. They are only small, so can be overworked quickly. It is often these that are involved with cervicogenic headaches. Treating these muscles might provide symptomatic relief, but will not solve the problem if the slouching remains.

Causes of Slouching

Often, when we examine someone who struggles to sit up straight, we find two things. Firstly, the muscles on the front of the shoulders and chest are tight and shortened. Secondly, the muscles of the upper back that work against those tight ones are weakened. In the simplest terms, the plan here is to relax and stretch the muscles of the front, and then strengthen the upper back muscles. When we look at an individual, we might find that there are additional areas to work on in terms of mobility. If you’ve been stuck in a hunched over position, the base of the neck will have had to overwork to compensate for lost movement. There might also be stiffness in the joints around the shoulder, such as those at either end of the collar bone.

We look at these findings as part of the larger picture, aiming to identify and manage each one to allow the whole body to move more efficiently. In managing these symptoms, you may find that other minor problems resolve themselves too, such as tension that was affecting your breathing.

Osteopathy and the Stomatognathic Complex

Your osteopath will evaluate the problem as a piece of the whole body puzzle. A detailed case history at the start of your first appointment will help us to get a better understanding of the factors at play. Sometimes correcting a slouched posture is as simple as improving the balance of muscles as mentioned above. If the problems originate from the stomatognathic system, and especially the alignment of teeth, we may want to work alongside your dentist to solve the problem in its entirety.

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Delays to Joint Replacements

Waiting lists for joint replacements are at an all time high, and the 18 week target for hip and knee replacements has been scrapped. If you are already waiting for a replacement to an arthritic joint, we may be able to help with function and comfort in the meantime. Osteopaths are qualified to help with arthritis, and the earlier you start treatment, the more we can do.

Joint replacements

Early Stages of Osteoarthritis

Osteoarthritis is a condition of the cartilage within a joint. Cartilage has a poor blood supply, so relies on movement to keep nutrients flowing into the joint where it can absorb them. It exchanges nutrients for waste, and movement again helps to flush this away. If movement is limited, the nutrient input is reduced, and waste products are stuck close to the cartilage for longer than ideal. These changes to the local environment play a role in reducing the health of the cartilage, from which point a vicious cycle can develop.

Even without you consciously realising, if the cartilage in a joint becomes roughened, the body might respond by adapting movement. This can be particularly evident in the hip. As movement is now sub-optimal, the fluids in the joint are not flushed through as much as they should be. There may also be areas of cartilage that are no longer compressed and decompressed, so the tissue relies purely on diffusion to exchange those products.

Avoiding Joint Replacements: Managing Arthritis

If spotted early, your osteopath can start to improve movement again. Muscles will be tight to try and protect the joint, which only reduces movement further. By working on those muscles and encouraging joint movement directly, we aim to restore some lost movement and improve cartilage health. Osteoarthritis responds really well to exercise too, so you can expect to have an exercise plan throughout your time with us.

Relief While Waiting for Joint Replacements

In some cases, a joint replacement is the only real solution. But with long waiting times, it can be difficult to make it to the surgery date. Even when cartilage is significantly reduced within the joint, what is left can still respond to treatment. We can also help to relax muscles that are trying to protect the area and potentially causing more pain than they solve. Finally, if other areas are overworking to compensate for the joint pain, there may be things we can do to reduce the burden on them.

If your joint pain leads you to walking with a stick or a frame, we may be able to offer advice for using them in a more efficient way.

Prehabilitation

Just like you would expect physical therapy after your surgery to improve your joint function, we can help to get your body ready for surgery. If your joint pain affects the way the rest of your body moves, we can work to improve the function of those areas that are adapting. This means that when you do get walking on your new joint, there’s one less thing to iron out.

Make an appointment in Leicestershire or Rutland for your joint pain here.

IBS: Irritable Bowel Syndrome

IBS is a common condition, but it can be hard to pin down as it is considered functional. This is in contrast to structural conditions, in which a sign would be there to find through imaging, biopsies, or other tests. However, this is not to say that IBS is not real.

IBS Basics

The condition is characterised by:

  • Abdominal cramps
  • Bloating
  • Diarrhoea
  • Constipation

Sometimes it can be difficult to spot a pattern, or you may find that stress or certain foods trigger them. It can become a vicious cycle when the stress and anxiety of potential symptoms actually aggravates them further.

Some people find that they develop back pain alongside IBS flare ups, which can be a direct referral from the digestive system rather than a back problem as such. Therefore, osteopaths need to be aware of the symptoms of IBS and how we may be able to help a patient manage them.

Diagnosis

As the condition is functional, any diagnostic tests are performed to rule out other conditions. There are similarities with conditions that require treatment and monitoring such as ulcerative colitis and Crohn’s disease. Not to be confused, they are under the umbrella of IBD. This stands for Inflammatory Bowel Disease, and can be life threatening if not managed properly.

Your GP may also use blood tests to check for deficiencies. These are more likely when the body is not absorbing nutrients properly, such as IBD or IBS where diarrhoea is significant. Be sure to mention if your diet does not contain a specific food group, such as vegetarianism or veganism. B12 deficiency is more common in people who do not consume animal products, so special effort may need to be made to ensure adequate intake of certain nutrients.

Osteopathy and IBS

The ASA recognises that osteopathy can help with some issues of digestion. A research study has also shown that there may be benefit to patients with IBS to have manipulative treatment to the spinal joints (“clicking”). Clicking joints has a local effect on the joint, muscles, and nerves, so a possible explanation for this is that the click calms down the nerves that supply the bowel. This may just provide temporary relief, but sometimes taking the edge off helps to wind down the cycle of anxiety and IBS. Thinking mechanically like this, your osteopath may also want to treat further up the back in case there is a relationship between a lower back that is overworking and the nerves mentioned above.

Stress is often an aggravating factor for IBS. We can help with the effects of tension, which you may find helps to break the stress cycle somewhat. There is also a relationship between the diaphragm, which typically tightens up with chronic stress, and the digestive system. We know that the diaphragm has a direct effect on reflux as its normal function supports the sphincter at the top of the stomach. For people whose IBS symptoms involve stomach symptoms (such as increased burping), this could be a useful avenue to explore in clinic.

Make an appointment in Leicestershire or Rutland here for digestive issues.

Self Management Basics

The points made below are non-prescriptive, and intend to give an idea of the advice your osteopath may give you after fully analysing your case and giving you a diagnosis.

Studies repeatedly show that the best results come from treatment alongside self management. This might include:

  • using a warm or cool compress
  • stretches
  • strengthening exercises
  • general aerobic exercise

Your osteopath will give you advice tailored to your case at the end of your initial appointment. As your symptoms change, your self-management advice will be changed accordingly.

self management: exercises

Heat vs Ice for Self Management

During the case history, we ask patients if they’ve found anything that makes their symptoms better or worse. It’s not uncommon for someone to say that they wanted to try heat or ice, but were unsure which was the right one.

As a general rule, ice is good for reducing inflammation, and heat is good for tight muscles. As heat can aggravate inflammation, and even sore muscles are typically a bit inflamed, ice is generally the safer bet. That said, you don’t want to keep it in place for more than 10 minutes per hour, as the aim is to take the edge off rather than limit the blood supply. There are also times when a bit of inflammation is a good thing. It comes up for a reason, and it brings nutrients to the area that needs it. The problems arise when the inflammation stays stagnant for too long, in which case contrast bathing might be the most appropriate.

Contrast Bathing

The term refers to the use of both a warm and cool compress. Some people prefer to do this in the shower, letting the water run warmer and cooler on the affected area. For others a cool pack and a wheat bag are more suitable. Your osteopath can advice what might be appropriate for you. Heat or ice alone should be used for no more than 10 minutes in an hour. Contrast bathing needs shorter and more frequent usage, as the idea is the heat opens up blood vessels and the cool closes them. This essentially creates a pump in the area, encouraging blood and fluid to come and go- great for moving on old inflammation.

Do not go straight from one extreme of temperature to the other. With contrast bathing, a couple of flannels that have been run under warm or cool water may be extreme enough. Your osteopath can also advise about how long you should let the skin acclimatise before switching to the other temperature.

Exercises for Self Management

The exercise plan your osteopath devises will be completely personalised to you. General exercise is almost always a good thing to promote healing and reduce pain. If you are recovering from an acute injury, this may not be appropriate, as you will be advised.

Stretching can be good to manage a tight muscle. Often we don’t realise that muscles are tight, because they cause a problem elsewhere. Patients often come in and mention their “bad posture” of rounded shoulders, but the shoulders themselves are often relatively comfortable. In this case, tightness comes from the chest muscles, and a combination of stretching the chest and strengthening the upper back can bring the shoulders back to where they should be. If this strain was causing problems elsewhere, such as in the neck or lower back, this might be the first step.

Strengthening is sometimes used in a seemingly counterintuitive way. For example, if a muscle is tight because it is working too hard, what we really need to do is make it work harder still in order to strengthen. If the demands placed on it are then less than it’s capable of, it will function better.

Make an appointment for your aches and pains in Leicestershire or Rutland here.

What is an Osteopath?

An osteopath is a professional whose title is legally protected. This means that anyone who calls themselves an osteopath is a member of the General Osteopathic Council, has completed a recognised qualification, and annually maintains their professional insurance and knowledge.

What do osteopaths do?

A simple explanation of osteopathy is that it’s a therapy focused on the musculoskeletal system, and its diagnosis and treatment without medicines. Osteopaths use your case history and observation of movement to understand the problem and its causes. Treatment itself is usually hands on, using massage techniques and joint movements to improve the body’s function.

What can an Osteopath Treat?

You’re welcome to book in with any aches and pains that you think could be related to muscles, joints, or nerves. We can also help with chronic pain, where the cause can be harder to identify. The ASA allows us to claim to treat the following conditions (click on one to read more):

We may also be able to help with problems that are not listed, you’re welcome to get in contact if you are unsure whether we can help.

Osteo, Physio, and Chiro

We are often asked about the difference between what we do, and what a physiotherapist or chiropractor would do. Our training is all quite similar in terms of knowledge and techniques, although it could be argued that chiropractors have the most emphasis on joint manipulation (clicking). Physiotherapists are typically not taught this at undergraduate level, but may learn it in postgraduate training. Most osteopaths are likely somewhere between the other two professions in terms of treatment style and manipulation- but it is important to understand that we all fall on a spectrum. The question should maybe focus less on which profession you need to see, and rather which individual suits you.

What to Expect at your Appointment

Your osteopath may send you some forms to fill in ahead of time, so check your email after booking. When you arrive, you can expect to be treated sensitively and professionally: your treatment and its contents is confidential. Your osteopath will take an extensive case history to help identify any possible factors in your presenting complaint. After this, they will have a few ideas of what might be going on, and they may ask you to remove some clothing. You might prefer to wear a vest and shorts for comfort, but you will not be required to dress down further than you are happy to. We can work through clothing where necessary.

You will be examined, with the osteopath asking you to perform movements and maybe repeating them for you when you are sitting or laying down. Other tests may be appropriate too to get to the root cause of your symptoms. When they are happy with a diagnosis, they can begin treatment. As mentioned above, this is usually a combination of work to muscles and joints, and your consent will be required throughout.

At the end of your session, you can expect to have a diagnosis and explanation for your symptoms, an idea of how long it will take to manage, and often a few exercises to do at home. Some conditions can be resolved quickly, and others are expected to take longer or to come and go. You don’t need a referral from your GP to see an osteopath, so if you’ve been on the fence about making your appointment, you can click the link below.

Make an osteopathy appointment in Leicestershire or Rutland here

Mythbusting in Osteopathy

We hear a lot of misinformation in clinic, whether our patients pick it up from other medical professionals or less trustworthy sources. It might seem pedantic, but correcting the way we think can hugely improve our pain. If you believe that your back is fragile, you are likely to worry more about it and become over protective. In reality, movement is exactly what most problems need. Here are some of the most common myths we hear from our patients, and the associated truths:

“Arthritis means suffering until a joint replacement”

Osteoarthritis (the “wear and tear” form of arthritis), is a condition affecting cartilage. Sometimes we forget that cartilage (and bone, in fact) are living tissues. If you broke a bone, you would expect it to heal. If your cartilage is damaged, it will take a while, but it does have the capacity to improve. Identifying arthritis in its early stages has a good outlook. The condition produces a vicious cycle, where reduced movement negatively impacts joint health overall, allowing the cartilage to become more damaged. Your osteopath can work with you to improve local movement, which allows nutrients back into the area and gives the cartilage the best chance to heal.

“A slipped disc will cause me sciatica forever”

Firstly, we need to address the “slipped disc” idea. Some people use the term without thinking too much into it, but others report feeling that something popped out, or even feeling the bulge itself. Discs are made of a couple of layers: inside they are soft, whereas the outside is a flexible but strong fibrous layer. They are so firmly stuck to the vertebrae above and below, that in a severe accident, the bone is more likely to break than for the disc to detach. So don’t worry about a disc moving freely away from the spine.

What can happen is that the soft inner layer can push against a weakened spot in the fibrous layer. This can cause a bulge in the disc, or sometimes the soft layer can partially leak out. Sometimes either of these scenarios will cause pain locally in the back, or they might irritate a nerve, causing pain down the leg.

It is important to note that disc bulges often happen without any symptoms. A study showed that after the age of 40, most people had at least one bulging disc. However, less than half the population suffer from lower back pain or sciatica. This is one reason why the NHS does not routinely offer imaging for lower back pain or sciatica. This changes if there are any red flags present.

Sciatica, disc bulges, and spondylolistheses

“My spine needs clicking back into place”

This one is similar to the idea of discs being somewhere they shouldn’t. Clicking a spinal joint is quite a lot like clicking your knuckles. If you’ve done so, you might notice that when you get the click, your finger moves a bit further with the noise. That’s not to say that the joint was out of place, it was just stiff.

When we click a spinal joint, we choose a restricted one. The short but powerful movement demands a little bit extra from that joint, and aims to get the movement back that has been lost. It’s never about repositioning. Rarely, a vertebra is out of place, but clicking would not be a solution. This is called a listhesis (fig. D), and is also known as a spondylolisthesis (spinal listhesis) or retrolisthesis (a backwards slippage instead of forwards). Sometimes this is purely anatomical, causing you no problems and only identified on a scan that’s looking for something else. Alternatively, it can be traumatic, in which a fracture to part of the spinal bone allows a shift in positioning. If the slip is significant enough, your osteopath may be able to feel a “step” in your spine, however this will require referral back to your GP, as we don’t click joints back into place.

Make an appointment here for a full osteopathic assessment and treatment in Leicestershire or Rutland

Perthes’ Disease

Perthes’ Disease is a rare childhood disease affecting the shape of the hip joint. It eventually burns itself out, but can be a cause of arthritis later in life. It also goes by the name “Legg-Calve-Perthes Disease”.

Perthes' Disease

What Is Perthes’ Disease?

This is a condition in which the blood supply to part of the thigh bone is disrupted. Specifically, it is the head of the femur (the ball of the ball and socket) that is affected. Bone is living tissue, and in children affected by Perthes’, it is still growing. Reduction of the blood supply causes part of the bone to die (necrosis), and become misshapen. Long term effects depend on the details of the repair stage described below.

Frustratingly, we don’t know exactly what causes the disease to develop. Some cases are associated with rapid growth spurts that somehow disrupts the blood supply. Other cases are associated with trauma or infection, or even congenital hip dislocation. In about 1/10 cases the other hip develops the same condition after the first.

Symptoms of Perthes’ Disease

Perthes’ begins between the ages of 4 and 10, and many more boys are affected than girls. Early signs often include a limp, which is likely to be worse after exercise. This may be completely painless or persistently painful. Where there is pain, it may spread to the groin or as far as the knee (illustrated above).

The Repair Stage

Once blood flow returns, the body begins to heal the damaged tissue. Some cases heal perfectly, and even an X-ray would not clearly show that there was ever a problem. Other cases can lead to a deformed femoral head, which may have a flat portion or a rough texture compared to a healthy one. This is likely to impact range of movement and may cause a limp. Sometimes a brace will be recommended by the orthopaedics team, in order to hold the femoral head in the roundest part of the socket. This aims to encourage the bone to grow into the correct shape.

Your Osteopath’s Role

We cannot resolve the blood supply, but we may be able to help with the compensatory patterns that develop in response to the pain. A child with suspected Perthes’ Disease requires referral to their GP and on to the orthopaedics team. We can support with symptom management and ensuring the hip maintains as much normal movement as possible.

Longer term complications of the condition can include a limp or early onset arthritis. We may be able to help manage the arthritis, especially if addressed at the earliest symptoms. A limp caused by asymmetry of the thigh bones is not an inherent problem- a well managed limp can be pain free. This depends on the body’s ability to adapt to the demands of the limp. As long as the legs and back can compensate for these changes indefinitely, it should be comfortable. This might require intermittent treatment over years, or it may be perfectly manageable with prescribed exercises.

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Long Covid

Long Covid is a poorly understood condition, and new information is still emerging. This post was last updated in February 2022

Long covid

Early reports (before the vaccine roll-out) suggested that around 4.5% of people who contracted covid would still suffer the effects 8 weeks later. 2.3% still had symptoms 12 weeks after onset. However, we expect to see fewer new cases of long covid now that the majority of the adult population has been vaccinated. ONS reports that people are 13% less likely to report LC symptoms after the first jab, and 9% less likely again after the second.

Symptoms of Long Covid

The most common symptoms, as identified by a survey of over 1500 LC patients, were:

  1. fatigue (affecting the vast majority of those surveyed)
  2. muscle aches
  3. shortness of breath
  4. difficulty concentrating
  5. inability to exercise
  6. headache

There are a number of cross overs in these symptoms with conditions like ME/CFS and fibromyalgia. Osteopaths are qualified to help manage the symptoms of fibromyalgia.

As muscle aches and headaches are symptoms that we often help with, it’s important that we are informed about Long Covid. Patients may come to clinic looking for pain relief without realising that their symptoms are the long term effects of a covid infection.

Management Strategies

As LC is a new condition, management protocols are few and far between. There have been articles published in medical journals suggesting potential strategies, such as one in the BMJ. This post recognises the difficulty in managing LC, but also the importance of a multidisciplinary approach.

Initial assessment should be done by your GP or hospital team. Pre-existing conditions can be affected by LC, for example blood sugar management in diabetes can be more difficult. Your medical team can also watch out for red flags and other complications.

When your team is happy with your progress, you may benefit from a wider multidisciplinary team. The BMJ article mentioned above puts emphasis on mental health support, return to exercise where appropriate, and improving general health. If you do not receive sufficient support to rebuild your capacity for exercise, your osteopath can take on this role. We can prescribe and monitor exercises, while addressing the mechanical changes that may contribute to your reduced ability.

Changes in Breathing and Osteopathy

We have written before about the role of stress on breathing. When the diaphragm is dysfunctional, breathing is less efficient, and smaller muscles are recruited to help around the shoulders. This can be associated with headaches– another feature of long covid. Work to the diaphragm and associated muscles aims to improve breathing efficiency. With this we hope that you will be able to breathe deeper and easier, improving fatigue and exercise capacity. With these muscles under less demand, muscular pains in the shoulders and neck should begin to settle.

Make an appointment in Leicestershire or Rutland here

Reflux

Acid reflux or heartburn can affect all ages. In this post we will cover both adult and infant cases of reflux.

Reflux

Newborn Reflux

Young babies are renowned for “spitting up” after feeds. This is normal, and often the amount they produce looks like a lot more than it is. Spill a teaspoon of milk on a hard surface or muslin and you’ll be better able to estimate how much of their meal they’re really losing.

Reflux is different, and may or may not involve being sick at all. If your baby is routinely being sick and you have concerns about their ability to gain weight, speak to your health visitor or GP in the first instance.

Signs and Symptoms

One important sign for young babies is arching of the back. Other suggestions of discomfort after feeding can be vague, including:

  • persistent crying, even when held
  • resisting being laid down on their front, back, or side

They may also show signs that something is amiss during feeding. Noisy feeding, taking on air, and hiccupping can be associated with infant reflux. They may be signs of something else though, such as tongue tie.

Silent reflux can, unsurprisingly, be a lot harder to diagnose. The arching back might be the only clear sign, as the stomach contents does not make it back up to the mouth. This may be misdiagnosed as colic, which is a symptom rather than a diagnosis in itself.

Adult Reflux

The anatomy is slightly different for adults, so we generally think about different causes for symptoms. Some specific foods and drinks might aggravate your symptoms, or simply consuming too much at once and laying down soon afterwards could do it.

Persistent irritation of the base of the oesophagus can cause more significant damage, so if your symptoms don’t improve as expected, we may want to refer you back to your GP.

The Role of the Diaphragm

At any age, the diaphragm can play a significant part in reflux. The diaphragm is a sheet of muscle that attaches to the lower ribs, like a parachute. As it forms a membrane between the abdomen and thorax, anything that runs between the two areas will have to pass through the diaphragm itself. This actually helps to protect against reflux and is termed “the anti-reflux barrier“. Tension from the diaphragm around the base of the food pipe (oesophagus) helps to keep stomach contents from returning. However, dysfunction of the diaphragm could reduce the efficacy of the barrier.

Stress can often cause diaphragm problems, alongside changes in breathing and gastric function. This is covered in more detail in our blog post here.

Osteopathic Management

Treatment will vary from case to case. Work to release the diaphragm will often feature, which might entail direct massage to the area, or stretches to the ribs to encourage movement. If stress is the root cause here, it may also be beneficial to work on the upper back and shoulders. We may also to offer advice for aggravating factors in diet.

For babies, it may be more helpful to think outside the box, and begin to develop the ability to adopt more upright positions. This will depend on your baby’s age, ability, and other factors in their case.

Make an appointment here to assess your baby’s or your own reflux