Tools From My Past, Reflecting On Change

Recognize those objects in the photo? They are pelvic wedges, used by some health professionals for a variety of reasons. Most rationales center around their use to balance the asymmetrical pelvis.

I learned why and how to use them in a myofascial release (MFR) course on the pelvis, somewhere around 1994. The theory was that pelvic asymmetry, or torsions, was due to injury, birth trauma, and other nefarious insults and needed to be corrected for the pain to lessen, gait, and posture to improve, and many more reasons.

I learned a lot in that class, much of it I used for many years. Those pelvic wedges are well-worn, as I balanced the hell out of many pelvises over a long time. And you want to know something? I helped a lot of patients with their back and related pain through the use of those wedges.

Then around 7-8 years ago I noticed that I was using them less often. In the present, they tend to stay unused. Why is that? Don’t I want to help people as I did in the past?

7-8 years ago is when I seriously began questioning all things therapy-related, both from a manual therapy perspective, but also from an exercise/strengthening perspective. I had departed my MFR world in 2006 after being told to conform or leave. (I chose to leave.)

But I stuck with those MFR principles and philosophies for a number of years and applied them in my work, including what I thought was balancing the pelvis. After a few years I began drifting into other worlds; into other ways to describe and define the effects of manual therapy in general, and MFR in specific. At first, I didn’t like what I read and learned, as there was a lot of confusion and uncertainty over just how manual therapy impacts the human being.

As I learned more, I saw the flaws in many of the simplistic explanations therapists use, as well as how the public views and repeats those simple concepts. Exercise, for instance, is often quite helpful, though I now know that those effects had little (if anything) to do with being weak. The common simplistic statement physical therapists tell their patients that being stronger will help you support yourself better, which leads to less pain was simply false. Or, the statement was so weakly true that it made little sense even to say it.

However, patients say things like that all of the time. It was much of what the core stability craze grew from. “Getting strong” is helpful, but the strength itself is not what diminishes pain. It is a complex combination of factors that vary from person to person. Movement is helpful. Motion is lotion.

MFR, and manual therapy in general, suffer from similar simplistic errors. When one reads through some of the latest evidence (Bialosky, 2009, 2010, 2018; Geri, 2019; Kolb, 2020), these papers read very differently from the way I learned MFR. But I can wager that if you underwent advanced training in any of the popular branded modalities in manual therapy, the science that you learned may not align completely with what others see as truth. How do you put all of that together?

Let’s go back to my wedges. As an MFR-based PT, I saw people coming to me for issues of pain in the low back, peels, hip, sacroiliac joint (SIJ), and more. Often, one of the first places I began my evaluation was at their pelvis. “If you don’t balance the pelvis, nothing will stick” was a familiar phrase I was taught in my MFR of training. Along with postural assessment, a pelvic assessment was key to knowing what was at fault and what needed doing (on my part). Pelvis assessment was done by palpating both the ASISs and PSISs (front and back landmarks on either side of the pelvis), as well as looking at possible upslip/downslip of the pelvis, etc. There were some SIJ assessments, to see if one side was stuck, as well as other assessment procedures, mainly postural. After all of this, I would put it all together and tell my patient why they were having pain (what I thought to be the cause) and what needed to be done to correct things. Many times patients simply agreed to what I said was wrong and trusted me to fix them.

That’s when the wedges came in.

I’d place the wedges in precise locations so that when my patient rested on them, with the assistance from my MFR intervention, their pelvis was released back into a better alignment. We might repeat this over the course of a few sessions and I would reach them homework to reinforce the pelvis corrections. And most got better.

Wedges are used by other professions and by other modalities, so we MFR therapists didn’t own the patent. But the way we used them was said to be unique. Other clinicians wasted their time with ineffectual chiropractic adjustments, etc., but none of them had the long-lasting effects as we did. (I spoke like that a lot back then.

So why did I stop using them? Why would I stop using them?

In today’s culture on social media, evidence and research seem to have taken a turn for the dark places.

Many mistrust research, feeling like scientists are always changing their minds and claiming all research is bought and paid for by big industries, etc. Science does self-correct continually, but that is the nature of the scientific method.

During the period when I left my MFR tribe, I began reading studies, many of which seem to refute what I had been taught and what I had witnessed as a clinician. For instance, in 1999 Levangie looked at the relationship between pelvis asymmetry and low back pain. While they found a weak association between the asymmetry of the PSISs and lower back pain, overall, “Pelvic asymmetry was not positively associated with low back pain in any way that seemed clinically meaningful.” One study does not make a believer out of many, and rightly so.

But the more I dove down this and related research rabbit holes, the greater dissonance I found with what I learned and practiced. While I could go on for quite a while on the weakness of the link, suffice to say there is sufficient evidence that made me question just what it was that I WAS doing.

The use of the wedges seemed to correlate in some way to my patient’s lower back pain resolution, but apparently, if I was to believe that dastardly evidence, it wasn’t because I reduced the asymmetry. (And for those of you who fancy yourself as a skilled assessor of pelvic levels, check out this systematic review of the reliability of palpating the PSISs. “Current methods of palpating for PSIS asymmetry do not result in levels of interexaminer reliability supporting clinical utility” (Cooperstein, 2019). Fake news, you say??? Try again. Another study points to the difficulty in accurately assessing pelvic tilts and ASIS/PSIS level due to inherent pelvic variations in pelvic morphology that render each side of the pelvis different from the other side. WE cannot measure what we think we are measuring when the underlying structure is not arranged as we think it is! Link

So what could it have been?

First off, I am not in any way calling anyone who used wedges ineffectual. Not in the least.

But what I am suggesting is that the process of using of wedges with a patient, from introducing the concept that pelvic misalignment may have a good deal to do with pain, to the rituals involved with the measurement of their posture and pelvis symmetry, to the rituals involved both with the precision of wedge placement as well as the exactness in which I proceeded with treatment, is a part of contextual factors that often go underappreciated. Add in neurological input through the patient’s skin/soft tissue which can signal to higher centers that things are happening, leaving the patient able to participate in the process of change (read those initial references I gave you for more on these concepts), as well as potential local reactions from the body, and often the pain is lessened. Does the pelvis change in a meaningful and lasting way? Many insist that it does and they claim to have proof. Maybe they do, but even if the pelvic alignment changes, how can we be certain of the cause? Meaning, was it the wedges? Our input over their skin/tissues, while on the wedges? The nervous system adapting over time to a novel stimulus? Or a wide range of other variables?

Those of you who use and swear by wedge usage, postural deviations as the cause of pain, and other similar narratives, there is a very strong chance you’ve already given up on this story, as there is too much cognitive dissonance occurring for you to remain.

However, as I learned more about how neurological and behavioral influences impact pain and movement quality, I saw that the wedges were simply a tool to access that entire human in front of me. I learned that I could use simpler tools to accomplish the same end, namely conversation and assuring a richly contextual therapeutic relationship, one that my patient played a larger role in creating.

I continue to use manual therapy (I dropped the MFR brand), though coupled with strong suggestions for movement (exercise, strengthening, walking, dancing, etc.) as a means to get them moving. Do I get better results than I did back in my MFR wedging days? That is difficult to accurately and objectively say, as such data is difficult to analyze. My patients seem satisfied, as are the insurance companies that often pay the bill.

Why don’t I use them anymore?

That I cannot completely answer, as I still see them as potentially useful. If other means did not seem to spark the attention of a patient then I may drag them out and put them into action. Should you stop using your wedges? Nope. Just realize, the wedges may have less important that you and I were led to believe. I can tell you in full honesty that it has been many years since I performed a standing postural assessment, pelvic measuring included. It has been that long since I pinned my patient’s pain on their pelvis being out of alignment.

Much of our training is about learning recipes and rituals. We take more training as we believe it will give us more skills, which it might. But additional training allows the educator additional access to your brain, filling it with the jargon and recipes of your modality. By using those recipes you set up a context that seems precise, but in the end, maybe no more helpful than that provided by the next person. I do find irony in the position put out by some modalities, educators, and clinicians who feel that they use no protocols or recipes; every patient is a unique experience. While that should be true, such clinical models often rely on recipes and rituals, such as “find the pain, look elsewhere for the cause (recipe), if you don’t balance the pelvis, nothing will hold (ritual), and many others.

Many argue against what I’ve said thus far by pointing to their experience and successes. Who can argue with all of those satisfied customers? No one, but what I will take issue with what you feel the reason you were able to help. Many modality educators make money off of the uniqueness of their product and love to inflate their outcomes and sense of importance. Surprised? Probably not, after all, one needs a good sales pitch in this world. But why is it that most of use take multiple lines of training and come up with our own unique hybrid approach? We are not following the rules and recipes of each of our mentors, rather, we are making that information our own. That’s life. Wedges are not magic. They are a part of a recipe, one I let go of and still manage to find ways to help my patients, probably just as much as any of you.

Another problem with rituals that involve my so-called skills is the dependency that this can create. If I pin my patient’s pain on their out-of-balance pelvis, restricted fascia, stuck SIJ, or any other tissue or structural-based problem, dependency may be fostered. It is very easy for a patient to sell themselves on needing us, now and if the pain returns, instead of educating them on strategies for them to take ownership. Many manual therapists do foster such independence through self-treatment education, which is better in keeping with what should be ethical standards of care. But how do you come across? Are you selling secret causation to patients? One that no one else knows the truth?

The moral of this story? Use wedges. Or don’t use wedges. Just understand that the experience of treatment is nuanced and multifactorial. Many factors go into why our patient improves, many more than I am listing here, that to reduce it as being caused by the use of wedges, or the use of MFR, or anything else you can think of. Including the things I think are important.

If you enjoyed some of the concepts presented here, or if they left you angry and frustrated, have a listen to a great podcast (not mine!). Dr. Oliver Thomson’s Words Matter podcast is a dive into evidence and approaches to manual therapy, exercise, and a better understanding of the words we use.

Happy wedging. Or not.

Articles Of The Week November 29, 2020

One of the most valuable things that we can give to pain clients is validation. Yet, this is something that patients will often spend years trying to attain from a practitioner.

I believe you! – Adam Meakins

COVID-19 has been hitting us all through 2020, but the opioid crisis that was here before that never went away. This analysis of addictions treatment highlights the tragic lack of pain-management during substance recovery, even though pain accounted for nearly half of the respondents’ relapses.

Assessment of Chronic Pain Management in the Treatment of Opioid Use Disorder: Gaps in Care and Implications for Treatment Outcomes – Ellis et al.

By now, we are aware that recommending rest and removal from activity is not a sound step towards overall recovery. The Barbell Physio talks about some strategies to help individuals, especially active ones, continue to move and train around their injuries.

How To Continue Training When Injured – The Barbell Physio

In a pandemic, it’s often taboo to even consider physical contact with others. It’s important to remember, however, the mental AND physical health benefits of physical touch between individuals. As manual therapists, this may also help make a case of traditional manual techniques over electrical modalities and soft-tissue release instruments.

Touch forms bonds and boosts immune systems – Richard Lebert

Whether it’s a massage or a foam roller, our understanding of pressure as a therapy tool has evolved. While we’re getting better at redefining and explaining our techniques, now is also the opportunity to restrategize how we use them in the first place.

The 4 Ds of Pressure Therapy – Dr. Chris Leib

3 Exercises To Help Patients With Back Pain

As you know, we’re big advocates for therapeutic exercise around here.

This is one of those occasions where I’ve had to do some self care to help a little pain spot I deal with. On the left side of my mid to lower back I get this one little spot that flares up once in a while. so I went to a friend of mine to get a little work done in the area.

They recommended doing some back extensions on a machine at the gym, however, most of us don’t have access to a gym in our clincs.

So, I figured out a way that any of us could do some effective therapeutic exercise right in our treatment rooms just using a theraband, and here’s what I came up with.

Here’s how to do an Isometric, Concentric, and Eccentric load for extension.

 

Here’s some ideas for rotation.

Another great exercise for rotation is the Palloff Press (also one of the exercises my friend recommended for me). This is usually done with a cable machine at the gym but can easily be done with a theraband as well.

Takeaways

  • Communication with your patient regarding comfort level for length of time and repetitions are key.
  • Start with isometrics, then move on to concentric, then eccentric.
  • Remember, a bit of discomfort is okay, just don’t cause pain with the exercise.
  • Make sure your patient is comfortable doing the eccentric portion as it may cause more muscle soreness.

Articles Of The Week November 22, 2020

As we continually push for evidence-based practice in our profession there is often discussion around the techniques we use when treating people and whether they are evidence-based techniques.  However, it’s important to remember that what we do, is important and we have value.

“Your Work, Your Massage Therapy Techniques, YOU Still Matter” – Chrystal Ladoucer

While this article is directed towards the chiropractic profession, it could be applied to any one of the manual therapy professions.  Should we do away with all our different titles and become one big group of manual therapists?

“What’s The Problem Within The Chiropractic Profession?” – Richard McIlmoyle

When I started as a therapist, all I wanted to do was work with athletes and team sports. I’ve been pretty fortunate along the way but when I took “sport massage” classes in school, it didn’t really seem all that different from any other technique. So what is the difference?

“Sports Massage. It’s Not Hot Sauce” – Taylor Laviolette

Richard does a great job of putting together educational lists we can refer to. Here are some great instagram accounts you can follow to help educate yourself a little.

“Educational Instagram Accounts For Massage Therapists” – Richard Lebert

Over the years I’ve treated a few people who have scoliosis,  some were athletes, some were office workers. This is a great review of not only what scoliosis is but also what kind of treatment helps.

“What Is Scoliosis? Review Of Evidence And Treatments” – Frances Tregurtha

What Kind of Exercise is Healthiest?

Physical activity is now considered one of the “big four” lifestyle factors (along with smoking, nutrition, and drug abuse) that have major effects on health. In 2015, the Academy of Medical Royal Colleges put out a report summarizing the benefits of exercise, calling it both a “miracle cure” and a “wonder drug.” [1] The report observes that regular exercise can prevent dementia, type 2 diabetes, some cancers, depression, heart disease, and other common serious conditions — reducing the risk of each by at least 30%. This is better than many drugs.

A recent analysis of data from more than 60,000 respondents found that people exercising 1-2 times per week had a 30% reduction in all-cause mortality compared to those who got no exercise. There was a 35% reduction for people who exercised 3-5 times. [2] Similar studies have concluded that a sedentary lifestyle is a primary cause of 36 diseases, and that exercise is an effective treatment to prevent them. [3, 4] Numerous experts have observed that if exercise came in a pill, it would be the most effective and widely prescribed medicine ever developed.

While the evidence supporting the health benefits of exercise is undeniable, I don’t find the metaphor of it being “medicine” totally appealing. First, medicine is something most people would rather not take, so the marketing is not very good. Second, the term medicine suggests cure of a particular disease, which is misleading.

Physical activity can improve your health in many different ways, just as light, water and soil will nurture a plant. But it’s not a targeted intervention that “fixes” a specific problem.

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I think a better metaphor for the benefits of physical activity is one recommended by Katy Bowman and Nick Tuminello: movement is like food. This analogy works on many different levels. First, nutrients in food are beneficial when consumed in some goldilocks amount — not too much and not too little. For example, you need a minimum dose of iron to avoid anemia, but too much is toxic. Many kinds of inputs to the body follow this pattern, even water. With physical activity, some minimum amount is essential, too much is toxic, and there is a broad range of happy mediums.

Another analogy between food and movement is that you need a well-balanced diet of many different nutrients, all of which have a different optimum dose. If you have a deficiency in Vitamin A, it won’t help to double up on Vitamin B. The same is true of physical activity. The bench press is a fine exercise, but if that’s all you ever did, you would become deficient in other areas of physical function.

If movement is like food, how do you eat a balanced diet? Part of the answer is that … it depends. A twenty-year-old athlete will need a different diet of movement than a 65-year-old with knee pain. In fact, two 65-year-olds with knee pain might benefit from completely different programs. To find what works best for an individual, you will need to explore a wide landscape of different options. The good news is that some parts of the landscape are more worth exploring than others. To get a rough idea where they are, we can look to two sources of data: (1) formal recommendations from government health groups; and (2) research analyzing the physical activity of hunter-gatherers living in natural environments. I think of these guidelines as major landmarks for orientation on the movement landscape. Fortunately, they both point in the same basic direction.

Recommendations From Health Groups

Numerous governmental agencies, including the World Health Organization, the U.S. Department of Health Services, and the National Health Service in the U.K., have published physical activity guidelines. [5, 6] They are based on expert analysis of the voluminous research looking at physical activity, fitness, and health. Here is a brief summary of their advice, which is almost the same for each source.

The Amount

The guidelines suggest at least 150 minutes per week of “moderate” physical activity or half as much “vigorous” activity. (See below for definitions.) But this is just the minimum, and a better goal would be 300 minutes of moderate activity per week. Adding more exercise may continue to reduce mortality until as much as 750 minutes per week, after which point the health benefits of physical activity seem to flatline. [7]

“Moderate” Activity Defined

Moderate activities are usually light aerobic exercise — continuous cyclic movements done at an easy pace. Examples include:

  • brisk walking

  • hiking

  • gardening or yard work

  • jogging, cycling, or swimming at an easy pace

Moderate exertion feels like you are working, but not in a way that is unpleasant or difficult to continue. Heart rate is about 60-80% of maximum, and breathing rate is elevated to a point where it would be difficult to sing, but easy to talk. You may break a light sweat but will not become significantly overheated. After finishing a session of moderate physical activity, you could probably complete another one if necessary.

“Vigorous” Activity Defined

Vigorous activity is higher intensity work that can be either continuous or intermittent. Examples include:

  • resistance training with weights, machines, bands, or bodyweight

  • sprinting or high-intensity interval training on a cycle or rowing machine

  • continuous running, cycling, swimming, or rowing at a challenging pace

  • heavy manual labor

During continuous vigorous activity such as running or cycling, you are approaching the fastest pace you can sustain for twenty or more minutes. Your breathing rate is high enough that you cannot have a conversation. Intermittent activities like weight lifting, sports or sprinting cannot be performed continuously, but only in intervals. Vigorous physical activity feels hard and requires willpower to continue. When you are finished, you will probably want to rest at least a day before completing a similarly tough workout.

Movements That Challenge Strength

Most guidelines recommend that the above weekly totals should include at least two sessions that maintain or build strength in all major muscle groups. Although the majority of research on physical activity relates to aerobic exercise, there is a large and growing number of studies showing equally impressive health gains from strength training. Some of these benefits are not available with aerobic exercise, especially preservation of muscle mass, which declines with age, often to a point where function is significantly compromised. [8]

Movements That Challenge Mobility And Basic Coordination

Some popular guidelines, but not all, recommend inclusion of movements that maintain functional ranges of motion, and basic movement skills like squatting or single-leg balance. This doesn’t mean you need exercises specifically devoted to this purpose, such as stretching or corrective exercise. Many common activities challenge mobility and functional movement skills, including dancing, swimming, martial arts, gymnastics, climbing, calisthenics, or classic compound strength exercises like pushups, pull-ups, rows, presses, squats and lunges. On the other hand, if all you do is bike or run, you will not be challenging your mobility or coordination very much.

Physical Activity Levels Of Hunter-Gatherers

Another way to approach the question of how to move is to consider the physical activity levels of humans living in more natural environments. This is the same logic you would apply to analyzing the health needs of any other animal. If you had a pet cheetah and wanted to know how much running she should do to maintain good health, you would try to learn something about how much cheetahs run in the wild. If you had a pet chimp, you would take him to the climbing gym, not the swimming pool.

Anthropologists who study hunter-gatherer cultures observe that they generally enjoy excellent health and fitness, and have low to non-existent rates of chronic diseases associated with a sedentary lifestyle. [9] They engage in high levels of physical activity, but certainly do not consider it to be exercise or medicine. [10] Movement is simply inseparable from almost every meaningful event in their lives. Although each hunter-gatherer culture has a different lifestyle, there are some general patterns and averages that are informative.

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Men usually spend the day hunting, which requires lots of walking, occasional jogging, and the odd sprint. They sometimes climb trees, dig to find tubers, and carry food back to camp, which must be butchered. Women generally spend their days gathering plants and also caring for young children, who often must be carried. Back at camp, men and women engage in toolmaking, and food preparation. Downtime is spent sitting on the ground in positions like squats that challenge lower body mobility. [9]

Although they are moving all day, the pace is not grueling. Recent studies on the Hadza tribe in Tanzania show that they do about 135 minutes per day of moderate to vigorous physical activity. [11] That’s about 900 minutes of activity a week, just a bit past the point at which recent studies have found that adding more exercise stops providing any significant additional health benefits in terms of reduced mortality.

Some days involve hard work, but they are usually followed by easy days. Presumably, some days will involve maximum intensity effort, such as sprinting or carrying a heavy load. Interestingly, activity levels do not decline much with age. The 65-year-old elders keep up just fine with the young adults. A good percentage of the total workload is walking 5-10 miles per day. If you think in terms of steps, this is about 10 to 20,000.

How does this organic, all-natural program for fitness compare to the standard-issue government cheese? There are some obvious similarities. The majority of the work is moderate continuous movement like brisk walking. Vigorous activity is a smaller percentage of the whole and includes work that challenges strength (climbing, digging, carrying, butchering) or power (sprinting).

Many of the activities require mobility, coordination, and balance, such as walking over uneven terrain, climbing, and scrambling, digging, lifting and carrying odd-shaped items, throwing, and sitting on the ground. One major difference is that hunter-gatherers do a higher volume of low-intensity work, even compared to highly active modern humans. They are not doing more bench presses, but they are getting in more steps.

Interestingly, walking is exactly the type of physical activity that modern humans would probably like to do quite a bit more, if only they had the time. Paddy Ekkekakis studies motivation to exercise and observes that although high-intensity exercise is quite effective at delivering health benefits quickly, most people don’t do it because … (prepare to be shocked) … they don’t like it. But people tend to enjoy walking. Under the right circumstances, say being with a friend in a nice environment, they do not consider it to be exercise at all, but an enjoyable and invigorating experience that delivers immediate rewards.

Another notable feature of walking is that it provides health benefits with only a minimal risk of injury. More intense exercise (e.g., a set of barbell squats) offers a relatively narrow window between too much and not enough. The difference between a good workout and an injury might be just a few extra reps or plates on the bar. But the margin of error with walking is huge. After a healthy dose of walking, most people could double it and recover easily.

It makes sense that walking delivers the highest bang for your buck because this is the movement we are best adapted to perform. Like any other animal, our primary physical function is locomotion, and walking is the most energetically efficient way to get the job done. If you did nothing else but walk a lot, you’d be in better shape than most Americans.

A Quick Summary

If you want to “play” with fitness as a way to improve general health, here are some “rules of the game” to keep in mind. Have as much fun as possible within these basic constraints:

  • Aim for at least half an hour and up to two hours of physical activity almost every day.

  • Movement should be varied in terms of volume, intensity, and type. Most activity can be fairly light. Walking is the most natural and beneficial movement for human beings.

  • Every few days, include some high-intensity work that significantly challenges your strength, power, and/or capacity to sustain high energy output for a short period of time. Climbing, running and resistance training are logical choices.

  • Include movements that challenge coordination, balance, and range of motion.

Or to put this in even simpler terms:

  • Move around a lot at a slow easy pace.

  • Frequently move with some urgency or pick up something heavy.

  • Every once in a while, move like your life depends on it.

And have fun!

Physical activity isn’t like taking medicine, you know.


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The preceding was an adapted excerpt from my new book called Playing With Movement: How to Explore the Many Dimensions of Physical Health and Performance.

Articles of the Week November 15, 2020

Here we have an article using one of our favourite terms, “resilience”. This study looks at the implications of coaches pressuring athletes to be “perfect”, which we may be able to translate right over to the effect that clinicians have on clients when doing the same.

On Perfect Technique – Derek Miles

 

We hear this one a lot in the exercise rehab world: “Don’t use the knee extension machine!” Like many old beliefs, however, it may be time to crunch the facts on this one.

Is the Knee Extension Machine Safe to Use? – Tommy Mandala

 

If you’re newly certified and fresh in the field of your practice, you may have experienced imposter syndrome at one time or another. This is a fantastic article to help you get past your barriers and be the best practitioner that you can be!

5 ways to beat imposter syndrome:  These health and fitness pros tell you how they did it. – Camille DePutter

 

It’s never okay to fat-shame a client. But, as the holiday season approaches us, many of our clients may have concerns about their weight – especially if it may exacerbate some of their pain – and look to you for advice on how to keep it under control.

Top 3 Tips for Weight Loss During Physical Therapy – Dr. Sean M. Wells

 

Hamstring strains are one of the most common sports injuries that we see, especially in active populations. It’s also common for these injuries to become a recurring problem. Mike Reinold talks on his podcast about the importance of treating these chronic strains individually to best help our clients.

Chronic Versus Acute Hamstring Strains – Mike Reinold