Archive for April, 2014

When Should I Stretch?


Should I Stretch At All?

In the scientific world we rarely jump on new research findings.  Research is done in so many different ways, and there are as many opinions of the veracity of particular research styles and techniques.  A hard look at any one research paper by anyone familiar with these styles of research will elicit at least one criticism of that paper.  So as a general rule, particularly in the exercise science field, we wait for several research projects to arrive at similar findings before we accept them as a newly accepted confirmed concepts.  In the stretching world we are nearing one of those changes, and that change is to do with the value of stretching.  The newest research in the area is heading towards discounting the value of stretching for healthy muscles.  But there’s a history to ‘stretching’ heading back many years.

The Changing Face of Stretching

The possibility of injury in the first phases of exercise prior to good blood flow to the working muscles, particularly as we get older, has over the years, generated a number of methods for ‘warming up’ the working muscles prior to starting exercise.  If we were to define stretching, we would say it is the action of lengthening the muscle towards it’s full range of extension.  This has been a common theme during warm up activities for as long as anyone has exercised past the age of about 15 years old.  Up to that point we can get away with not warming up as far as causing serious injury is concerned, but because the point at which a warm up is required varies from person to person and day to day, and because we want people to develop good habits,  exercise professionals will always include a warm up prior to activity.

If you look at the old school activities that have stayed fairly rigid in their warm up processes, such as marital arts, dancing, weightlifing (not weight training), and weekend sports where the coach has no training apart from what he did when he was a kid, you’ll see the remnants of what we used to do to warm up.  The 50s, 60s and 70s were times where ‘ballistic’ stretching was the warm up.  Muscles and joints were flung around at all angles with high leg kicks, bouncing duck walks, fast twisting windmills and tuck jumps the go.  You either warmed up or tore your hamstring.   It was always thought that the delayed onset muscle soreness (DOMS) felt for the next few days was due to the activity we did, but it was strange that the guys who skipped the warm up were never as sore!  Of course we now know that flexing a muscle forcefully stretches the opposite muscle and will, if there is not yet sufficient blood flow, initiate the ‘stretch reflex’ in that opposite muscle.  The stretch reflex is a safety mechanism designed to minimize damage to an over stretched muscle by causing a flexion in that muscle against the stretch.  The sudden flexion in the muscle causes microscopic tearing which leads to the pain in the following days.  So the warm up caused more injury and soreness than the activity in many cases.

When sports science caught up and recognised that the stretching needed to be less ballistic, we probably went too much the other way.  During the 80s and 90s we went to static stretching – that is long slow stretching for between 10 and 30 seconds per stretch – as part of the warm up.  Unfortunately we’ve discovered what a waste of 30 minutes this actually is.  There was a landmark study done in Australia by the army which identified no reduced injury incidence between those who stretched prior to activity and those who did nothing.  It turns out that static stretching separates the fibres in a muscle.  Instead of the muscle working as a full unit, it works as several separate bands making each ‘band’ more susceptible to injury because of the reduced cross sectional area over which the force is applied.  This makes the muscle actually more likely to tear in the initial phase of activity until sufficient blood flow from movement enables the muscle to work as a unit again.

Of course, most athletes included movement as part of their warm up anyway, so mostly no harm was done by stretching unless it was the only source of warm up.

So in the early to mid 90s we went back to movement as our warm up tool, but we have since called it ‘dynamic stretching’.  Really all that means is that we move the joints and muscles we plan to move during the activity in a controlled way, avoiding the end of the range of movement until there has been sufficient blood flow to the muscle.  The warm up ‘stretching’ normally starts as a general whole body set of movements and then becomes sports specific, especially if dynamic and ballistic activities are part of the training or event.  If you’re looking for a general dynamic stretching warm up you can find one here.


What About Afterwards… Doesn’t It Help With Soreness?

Well that’s what we’ve always preached.  Static stretching after activity separates the muscle fibres, allows blood flow between them and assists in flushing out waste products thus at least reducing DOMS.  But like I said, the research is not heading that way.  A couple of recent studies have shown no difference in the level of DOMS between those who stretch afterwards, and those who don’t.  However, a couple of studies does not make it a fact at this stage.  I will say, from personal experience, I have always found stretching a waste of time and have avoided it as a rule.  Given my age (52) and my physical condition (pretty good really) I’d have to agree with the recent research, but of course it’s only my opinion (and that’s not research!).  So we’ll wait for some more work to be done in the area before we completely ditch it.

I use stretching after workouts for my clients for another reason though… if you’ve worked hard (and if you read my blog article on how hard you should work you’ll see that intensity is the key) then you probably won’t feel right straight after you stop.  I get my clients to do the standard ‘cool down’ by working at a reduced intensity for a period after their last interval training rep, but when they come to a complete stop they (and me too) can still be a little light headed.  The last thing they should do is jump straight in the car and drive off.  So we spend some time stretching to allow a slowing down of the metabolism and a period of time where your blood flow can catch up with your reduced requirement and you can be more at an equilibrium before heading off.  If you’re at the gym, you should do stretching for the same reason at least.

So Is There Any Value At All In Stretching?

The short answer is yes.  If the muscle is shorter than it’s normal working length then you need to work on it make it the length it should be.  So stretching is useful as a therapeutic tool where there is injury or there is what we call hypertonicity in a muscle that has cause it to shorten.  So when you tear muscle fibres, the surrounding fibres tend to tighten around the damage in an attempt to protect the injured area.  This is clearly desirable in the initial stages of an injury, but can cause the muscle repair tissue (the scar tissue) and more particularly the surrounding muscle tissue to be thick and inflexible if not stretched out as it repairs.  In order for the muscle to repair with a minimum of scar tissue restriction we encourage stretching throughout the repair.  But of course, stretching at the appropriate intensity – mild at first with only a small amount of stretch felt, then more as the muscle starts to lengthen and the chance of re-injuring the muscle by stretching too far has reduced.  Eventually we want symmetry.  We want the damaged muscle to have the same length as the same muscle on the other side.  In this case the stretching is definitely of value and an important part of rehabilitation.

The other time stretching is useful is when hypertonicity is present.  Hypertonicity occurs where a muscle gradually shortens through a couple of different processes, and will result in pain in a particular region due to the pull of the muscle on its attachments, and/or associated nerve involvement when the muscle tightens around or in the vicinity of a nerve supporting that or an adjacent muscle.  The two most common examples of this involve the head and neck, and the lower back.

Head and Neck Stretching

Many of my massage clients come to me with neck and shoulder pain due to hypertonicity in the neck and shoulder muscles.  They often complain of headaches related to muscle tension in their neck and attachment at the back of the head.  Usually this is sleep position related exacerbated by their job role where they may be at a computer all day, or driving a car or similar things where their head and neck are in static positions.  Rather than go off at a tangent here, I’ll do a later blog on how to prevent and treat this yourself, but for the moment I’ll go through the stretching routine I suggest for them.

These stretches are best done before you go to bed.  Prior to doing them, though, do some rotations of your head and neck so there is some blood flow before you stretch.

The stretching technique I suggest for maximum benefit is neural stretching.  In massage they call it muscle energy technique, and in exercise physiology it’s a reduced form of PNF (proprioceptive neuromuscular facilitation) where classical PNF is done at full effort.  Its works like this… if you apply a contraction to a muscle the stretch reflex of that muscle turns off – that is – the brain sees no need to prepare for a stretch if you are contracting the muscle.  Once you stop contracting, there is a period of time – about 2 or 3 seconds – when the stretch reflex will not initiate even if you stretch the muscle.  The stretch reflex is very conservative in that the amount of stretch it allows at a static stretch is well below that which will damage the muscle.  So we use the above technique to ensure we get a maximum stretch during stretching.

For the head and neck there are two easy stretches I suggest.  The first one is a sidebend stretch like this:

Side Bend Stretch

With this stretch, rather than pull on your head with the other arm, use the weight of that arm to do the stretching.  So you have to ensure that the crook of your elbow is past the top of your head.  Once you’re in position, very gently apply resistance against the arm for the count of three, then relax the resistance completely.  You’ll find that the head can stretch further than before.  Do that two more times as per the video.

The other stretch is a 45 degree stretch along the same lines:

45 Degree Neck Stretch

Put your bicep on your nose with the crook of your elbow above your forehead to start, and the rest is as before.

Lower Back Stretching

Generally, if you just try to stretch your back, you’ll stretch other muscles attached to the same places – hamstrings, gluteals, piriformis etc.  So when trying to stretch your back, stretch these other muscles first to that they don’t interfere with your back stretch.  Again, we use the neural stretching protocol in the same way.  First a single leg hamstring stretch like this:

Single Leg Hamstring Stretch

Then a piriformis stretch.  Note that the hands holding the stretch are under the knee joint not on top of it:

Piriformis Stretch

Finally a lower back stretch that will stretch mostly your lower back, but also thoracic it it’s tight.  Note that you should try to keep your opposite shoulder on the ground and rotate your leg over the top:

Lower Back Stretch

You must do all of the stretches on one side first, then do the other side.


So it seems that stretching for stretching’s sake is on the way out.  The research has indicated for quite a while now that stretching does nothing to help you warm up.  In fact a static stretching warm up is more likely to cause an injury than prepare you for exercise.  The latest research is heading in the same direction in terms of the value of stretching afterwards.  It’s no longer thought to reduce DOMS, and in fact, over flexibility has been shown to reduce the force applied by a muscle and reduce its effectiveness in dynamic situations.

Stretching is seen now to be only useful where the length of a muscle has been reduced through injury or hypertonicity.  It’s still useful however, after a workout, as an activity to assist in settling the body into normal blood flow patterns by allowing a time for gentle body movement prior to driving off in your car immediately afterwards with your head still in your workout.



A Bodyweight Resistance Training Session

Here we start our series on training you can do at home.  

I’ll show you a program you can do yourself with minimal equipment in a short period of time a few times a week to help you increase your fitness and improve your body weight.

As with all new exercise programs, if you haven’t done much recently, speak with your GP or health professional before you start to make sure the session is suitable for you.  

Before you start, of course, you must warm up.  Here’s a suitable five minute warm up similar to what you would do during one of my one- on-one sessions.

This program consists of four supersets.

A superset is a pair of exercises done one immediately after the other with no rest.  Usually each exercise has a different or opposite prime mover from the other, although sometimes we can blitz a particular muscle group.

The program works on intensity.  The more intensely you can do the session within the limitations of your fitness and injury issues, the more benefit you’ll get from it.  You should record the number of reps you do of each exercise and aim to improve this every time you do the circuit.  The increase in improvement is essential to apply the overload principle and ensure that your body makes changes to adapt to the new activity.  This adaptation is what causes fitness improvement and body weight losses.

I use a fitness app on my iPhone to do this, and there are plenty to choose from.  I use Full Fitness but you can choose one that works for you or even just write down your progress.

We start the circuit by doing the first exercise of the first superset for 30 seconds, immediately followed by the next exercise for 30 seconds and then a 30 second rest.  Each superset is done three times like this in total before you move to the next superset.  So you’ll spend four and a half minutes on each superset.

Superset One,

1. Push up 

2. Resistance band pull.

Your push up can start like this.  A beginners’ push up on your knees.  Your weight should be on your arms, and you should bend your elbow until your chest touches the ground and then return to the start position.  Do the down phase slowly, and the up phase as quickly as you can.  

Modified Push Up   (click on the link and wait… it will come up in another window)

Once the beginner push up gets to easy, you can do a cheat’s push up like this.  The down phase is done with a straight body, and the up phase with knees on the ground.  Again, the down phase should take twice as long as the up phase.

Cheat Push Up  (click to view)

When the cheat push up is too easy, do full push ups like this.  Try to put your chest on the ground.  Down slowly, up twice as fast.

Standard Push Up (click to view)

As you improve you can progress to a close grip push up with your elbows in at your side.

Close Grip Push Up (click to view)

After 30 seconds stop your push ups and pick up your resistance band.  You can pick one of these up at kmart fairly cheaply, or send me a text and I’ll give you one for free.  Stand tall, fully extend your arms, and return.  Pull out quickly and return at half that speed.

Band Pull (click to view)

Do 30 seconds of push ups, 30 seconds of band pulls then rest for 30 seconds.  You’ll do this another two times for a total of three before you move onto the next superset.

Superset Two

1. Prisoner Squat

2. Stability Ball Roll-Out

These are done the same way.  30 seconds of Prisoner Squats like this remembering to go down as low as you can with your weight on your heels.  Down slow, up fast.

Prisoner Squat

Then immediately onto 30 seconds of Stability Ball Roll Outs.  Tense your abdominals as if someone is about to punch you in the stomach as you roll the ball out to full extension

Stability Ball Rollout

Have 30 seconds rest, then repeat again to a total of three times.

Superset Three

1. Stability Ball Leg Curl

2. Stability Ball Plank

Again, 30 seconds of each exercise followed by 30 secs recovery and repeat for a total of three times.  With the leg curl it’s important to start with your backside off the ground and keep it off for the whole set.  Notice that the bend is mostly at the knee and not at the hips.  The hip angle should remain mostly straight throughout the exercise.

Stability Ball Leg Curl

Then just turn over for the plank.  Again, tense your abs as if someone is about to punch them and maintain a full extension without sagging in the middle.  This shouldn’t happen if you’re tensing them anyway.

Stability Ball Plank

Then onto the last superset.

Superset Four

1. T- Push Ups

2. Stability Ball Gluteal/Hamstring Extension

The T-Push ups can be done either modified like this

T-Push Up Modified

or with full push ups like this

T-Push Up Standard

and as usual count your reps for 30 seconds then go immediately onto the extension

Stability Ball Gluteal Hamstring Raise

Taking care not to hyperextend to any great degree.  A little bit past straight extension is ok but there should be no pain other than fatigue in the working muscles.

30 seconds of these followed by 30 seconds recovery and then back to the T-Push ups to repeat the superset to a total of three times.

Making It Harder

As you get better at the exercises and can do all of the advanced techniques outlined, you will need to make the session harder to maintain an overload as mentioned above.  There are three ways you can do this.  Firstly, go harder in the 30 seconds of each activity, ensuring you are increasing the number of reps whilst maintaining your correct technique.  There will come a time when the technique doesn’t allow you to do more in the time allocated.  Increase the time for each activity to 40 secs, then 50 secs, then one minute if you can.  Alternatively add a set to each superset so that you are doing four sets instead of three.

After six weeks though, it will be time to change your program.  It’s very tempting to get in a groove and keep doing the same thing for ever, but if you want results you have to change things around regularly.  You could take up some of my other sessions… The next one focuses on doing a whole session with one set of dumbbells of the same weight.

Stay tuned…

You can, of course, short cut the whole thing by booking in for a session with me.  We’ll do a short physical assessment, I’ll show you all the session and check your form, and we’ll run through it in real
time.  You can book by sending me a text or book on clickbook, accessible from the Fix Your Body FaceBook page.  First book a free assessment then we can book a discounted personal training session for a time that suits you.


How Often Should I Have A Massage?

Do I need a Massage Yet?

The short answer is probably yes.  You will benefit from a weekly massage no matter who you are.  But it’s not really that simple is it?  Finding an hour a week at a regular time is not always practical, and a weekly fee is, for most people, not possible.  So how should I decide when to book in?  Well, it depends on a few things, and the reason why you want a massage.

I Have An Injury

Most people show up the first time because they have an injury of some sort and somebody has recommended me.  For injury repair, frequency and regular sessions are important.  For muscle tightness (hypertonicity) – usually neck and shoulder, lower back or leg tightness I recommend once a week for three weeks initially, and then on the third session we reassess where you are.  Extreme tightness gathered over a number of months or years may take longer than this.  Massage treatments like this take a few days for their full effect to occur, and generally the tightness will return.  I will eventually be able to have you come for just a regular treatment for a period of time I’ll talk about below, but usually if you have no soreness after a week we extend the break to two weeks, then three and then four if that is what works for you.

If you have a muscle tear then I need to see you more frequently – usually twice a week for two or three weeks, then we start to spread the treatments out.  For soft tissue injuries I can be as effective as a more expensive practitioner.  See the blog entry of why you should choose me.

The aim is always to get you to a steady state situation where you attend for regular massage treatments not related directly to the injury.  This allows monitoring of your physical ailments, and a preventative program if it is such that you are likely to suffer from similar injuries in the future.  This can actually save you money down the track.

I Just Need A Regular Massage

This is actually true for everyone.  Even me.  Especially me!  The question is how regular.  Massage is shown to assist in many areas. Reducing pain from previous or chronic injuries, enabling proper sleep patterns, assisting immune function, sharpening brain function, alleviating depression symptoms, and reducing cortisol (the stress hormone).  Firm massage also produces pain endorphins and the hormone oxytocin, both of which reduce stress levels.  A massage takes time to work as it relies on the blood flow generated by pushing to do the magic.  The magic can begin immediately, but it’s not until a few days later that the maximum benefit is achieved.  It’s for this reason there needs to be a few days at least between treatments.  Ideally, if money is not a barrier, a weekly massage will manage the above things optimally.  But of course, money is always an issue when you have to spend it.  Many of my clients see the value of a massage above many other things and budget for a fortnightly massage.  I guess this is the best compromise, but for some it’s still a bit steep financially.  Alternatively, a once a month massage will set you back less than a latte a day in your local coffee shop and is a sound investment in your health.  Outside of a monthly treatment, the benefits of massage are certainly there, but the proactive element goes by the wayside and you’re really just treating your ongoing issues in a spasmodic fashion.

I Just Need Some Instant Stress Reduction

This is not very proactive if it’s a one-off massage, but it works.  You won’t get the ongoing pain relief, immune and brain function or depression reduction in one session, but you will sleep well and feel relaxed.  If it’s all you can do then it’s still worthwhile.  Every now and then, an occasional massage, just for a treat, can be done whenever you want.

So What’s Best?

Maintaining good health has many components.  Diet is extremely important.  An exercise program will assist you in maintaining optimal health, and a regular remedial massage will promote blood flow to assist with ensuring the good things you do with diet and exercise are realised with a stress free body.  Massage should be a part of your routine and you should develop a relationship with your therapist such that he or she knows your physical condition and can treat it in the best way.  The clients that get the best treatment in this respect come once a week or once a fortnight.  My monthly clients also get a good balance of treatment and prevention.  So what’s best is what you can prioritise in terms of money spent.  It’s up to you.  But don’t leave it too long or the benefits are reduced.


Why Choose a Remedial Massage Therapist for Injury Repair?

Ouch… That Hurts!

So you have an injury that needs treating… where do you go?  Most people think of the physiotherapist first – after all that is specifically what they train to do – fix injuries, and mostly they do that.  Or you could go to a myotherapist or osteopath who also do the same thing.

But what about a remedial massage therapist?  Have you asked yourself what the difference is, and if a remedial massage therapist can help you in your particular case?

A remedial massage therapist (RMT) is trained to treat soft tissue, and we do it a number of ways.  All of these practitioners generally follow the same process.  They first ask questions, touch and move you and do an assessment of some kind.  The questions they ask relate to the injury you have and how it was acquired.  They should also ask you about what movements cause pain, what sort of pain it is, if the pain has an identifiable location and if it moves or radiates from the location.  A myotherapist, osteopath or physiotherapist will then make a diagnosis based on this information, and treat you according to the standard treatment for that diagnosis.  In terms of scope of practice, a RMT will only make a ‘working diagnosis’ – a full and concise one requires more understanding of muscular movement and function.

Most people will recognise the difference in training and prefer the physio… but in actual fact a working diagnosis is all you need to treat soft tissue injury at or below a grade 2 muscle tear. The purpose of all of these practitioners is to use techniques that speed up the natural repair process of the body.  They use manual or technological techniques to increase blood flow to the affected area which assists in the repair of the injury and the separation of muscle fibres that have become stuck together to protect the injured area.

The Mechanics of an Injury

So what happens during a soft tissue injury?  Well it depends on how it is caused, but most muscle strains / tears occur when the muscle is extended beyond it’s working range of movement.  This causes muscle fibres at the area of most strain to tear, and initiates the stretch reflex which pulls the rest of the muscle into a slight flexion.  The surrounding muscle fibres contract around the damaged area to provide protection and prevent further tearing.  Blood flows to the area, as does lymph fluid.  Lymph fluid generally works to assist the immune system and like blood, rushes to an area of pain to assist the body to protect itself.  In the case of soft muscle injury, its value is limited.  More often than not its presence swells the area and restricts blood flow lengthening the time taken to repair the muscle.  So when you tear a muscle you apply ice to reduce the pain which causes lymph fluid to move away from the area.  This is good for freeing up the local area, but unfortunately it also reduces blood flow for the same reason.

However research indicates that keeping the lymph fluid away for a couple of days decreases repair time.  Which is why you apply ice immediately after injuring a muscle.  So why bother going to anybody?  Well… the role of the therapist is to increase blood flow (as explained above) using specific processes that improve the injury without increasing lymph flow to any great extent.  The research around RMT indicates a 50% quicker repair of the injury.

So who can do that?  Well anyone who understands that process and is trained to respond with a therapeutic system.  Normally it involves manual pushing and prodding or using a device that causes increased blood flow for a period of time that will assist repair, and then cooling down that area afterwards before lymph flow starts.  In the case of a RMT it involves prodding and poking, or movement to initiate blood flow, some neural stretching or similar to get the muscle to a working length for access to all of the fibres, then some deep tissue massage to both increase blood flow and separate the fibres described above.  Only a RMT does all of that unless your physio uses only manual techniques during your session.

So… What’s the Difference?

When you compare a physio and a RMT you can see the difference.  A physio will typically treat you for 20 -30 minutes, and RMT 45-60min.  Physio’s prefer to use machines such as ultrasound devices, infrared heat devices, TENs like machines and the like to increase blood flow.  They treat more people each day so they use their manual skills sparingly and for the least amount of time.  Of course these devices work to this end, but typically that is all the physio does for you.  My memory of going to the physio is a brief assessment followed by the physio asking me ‘where does it hurt most?’ and getting me to treat the area myself for 15 minutes whilst he treated the person in the next cubicle.  My understanding is that things are mostly better than this these days if you get a good physio, but it is still all about treating the most people possible in the time available using a narrow location focused repair strategy.

A RMT will use a more holistic approach to the injury.  If it’s a shoulder injury you’ll probably also have your back and neck treated.  If it’s a hamstring or quad injury you’ll get a back treatment as well as the opposite part of the leg, and neck and shoulder pain also gets a back treatment.  This is based on the fact that with the exclusion of impact injuries, they rarely occur in isolation – that is – there is an underlying cause as to why that muscle gave way and it’s generally tight muscles in the opposite or attached muscle groups.  And you’ll have the RMTs undivided attention for the whole time.

Ouch… That Hurts My Wallet!

And then there’s the cost.  For a muscle strain, a RMT will treat you once a week for three or four weeks.  Deep tissue massage to increase blood flow and separate the adhered muscle fibres using holistic methods that fix more than just the exact location of the injury.  Three or four sessions will normally provide a result for my clients, after which they can revert to ‘maintenance’ mode where I can monitor their condition and any other things that arise during their regular session (Read the blog on how often you should have a massage for more info). A total cost of $240 for a grade 3 (mild) hamstring strain.

A physio will treat you two to three times a week using some physical therapy and some mechanical devices for at most 30 minutes at a time with no follow up or monitoring once you’re ‘fixed’  for $65-$80 a session for four to six weeks.  That’s a minimum of over $1000 for a grade 3 hamstring strain.  If the problem is related to a muscular imbalance and you do it again, then back you go for the same treatment.  Again.

So for a soft tissue strain a RMT will be cheaper, treat more of you for a longer time and because remedial massage is an ongoing relationship, your injury and condition will be monitored from that point on.  My clients become more than just clients because I see them regularly, so I take an interest in their physical condition.

But there’s more…

If you come to me there’s another advantage.  I’m not just a RMT,  the larger string to my bow is that I’m an exercise physiologist.  An exercise physiologist is often employed in hospitals to assist the physio with problematic patients.  We do the exercise/lifestyle part of a patient’s treatment.  Typically we provide advice on a person’s physical condition in relation to diet and nutrition, exercise and lifestyle issues.  A sort of personal trainer incorporating lifestyle issues and chronic illness limitations to provide solutions for improving health.  Specifically in relation to being a RMT, I have the same anatomical and biological study background as a physio, with a better understanding specifically about muscle function and movement.  So I can provide the same standard of injury assessment and set exercises for recovery using movement principles to identify muscular imbalances that lead to your injury and will work towards it not occurring again.  That’s better than your local physio.

The Absolute Truth…

If you have a serious injury involving ligaments, bone, your spine or a specific joint damage type injury caused by impact or sudden movement then you should go to a physio in the first instance.  It may be that after some initial treatment it will be cheaper and more effective to come to me for ongoing treatment and monitoring, and an exercise program for repair and to address muscle  imbalance.

But if you have a soft tissue injury – muscle strain or tear (grade 2 or 3), tendonitis, fascia soreness caused by exercise or overuse then come to me.  I’m cheaper, can offer you a more comprehensive service and ongoing monitoring and rehab exercises.