When Injuries Strike

AO2020 - Behind the Scenes Blog Series

By Will Maher

The final part of my Australian Open blog series focuses on the most common tennis injuries I have seen over the past six years both on tour and in our clinic.

Common Tennis Injuries

1.      Lumbar spine

The most common injury presentation for tennis players is the lower back or lumbar spine. This is because of the large and repetitious rotational forces required of the spine in all tennis strokes. More specifically the lumbar spine is not designed for rotation movements, the hips and thoracic spine more readily facilitate rotation.  If for any reason these joints become stiff then the rotational forces can be absorbed by the lumbar spine, with pain dysfunction soon to follow. One of my roles is to ensure that the thoracic spine and hips are not limited on a daily basis.

2.      Shoulder Injuries

There are a lot of acceleration and deceleration movements for the shoulder most notably during the service motion which can place increase load on the labrum (cartilage), rotator cuff tendons and the bursa (pads) in the shoulder.

The cocking stage (see picture) requires the shoulder to be abducted, externally rotated and can lead to injury. Muscle activity (percentage maximum voluntary contraction) during the cocking stage is moderately high in the supraspinatus (53%), infraspinatus (41%), subscapularis (25%), biceps brachii (39%), and serratus anterior (70%) to provide stabilisation. The moderately high activity during this stage demonstrates the importance of anterior and posterior rotator cuff and scapular stabilisation for proper execution of the cocking stage.

If the shoulder becomes stiff and/or muscles are fatigued, the player may not only injure their shoulder.  Compensations along the kinetic chain can injure their abdominal muscles, elbow,  wrist and hip joints. Just to complicate things the opposite is also common with the shoulder being overloaded due to impairments in any of the above mentioned kinetic chain structures. For example a lack of movement in the opposite hip (service landing hip) needs to be accommodated by the trunk and shoulder potentially causing them to break down.

Kovacs, M., & Ellenbecker, T. (2011). An 8-stage model for evaluating the tennis serve: implications for performance enhancement and injury prevention. Sports health, 3(6), 504–513. doi:10.1177/1941738111414175

3.      Abdominal Strain

In tennis players, the abdominal muscles play a significant role in trunk and core stability providing a mechanical link between the lower and upper limbs, and the service motion is undoubtedly involved in the injury mechanism of a rectus abdominus strain. There is large stretching (eccentric load) forces placed on the rectus abdominus during the cocking phase of serving, specifically on the opposite to the hand the players serves with.

Below is an MRI images of 18 year-old male tennis player suffering acute Rectus Abdominus strain lesion. Extended area of haemorrhage and fibril disruption corresponds to a severe injury.

Br J Sports Med 2007;41:842–848. doi: 10.1136/bjsm.2007.036129

4.      Change of Surface

One of the unique challenges tennis athletes confront when considering scheduling and injury management is the change of surface during the year. Imagine a basketball player being asked to play on a normal hardwood floor, change to a clay surface then to a grass surface and back to a hardwood surface to finish the year.  That is what tennis athletes must deal with every year.  Each surface has certain characteristics that require different joint and muscle demands.

Hardcourt: A fast and unforgiving surface combined with modern athletic development of players requiring them to be able to slide on this surface results in large friction and axial loading forces.

Clay Court: A soft surface that can be made up of crushed stone, brick, shale, or other unbound mineral aggregate.  As a result the ball is slowed up considerably when it bounces allowing points to last longer, requiring potentially more shots to win points and games.

Grass Court: Is a slippery surface that causes the ball to skid on quickly, usually not much higher than knee height.  It is particularly stark in contrast to the clay court that it directly follows.  This transition from the French Open season played on Clay to the English Grass Court season requires substantially different neuromuscular demands of athletes.  Assessment and treatment during this part of the year is extremely important.

AO2020 - Behind the Scenes - Part Two

THE AUSSIE GRAND SLAM

By Will Maher

The Australian Open is one of the major events on the Australian sporting calendar. International tennis players love playing in Melbourne and some of the best players have voted the Australian Open as their favourite Grand Slam.

I first attended the Australian Open in 2015 and over the years, I have watched it morph into more than just a tennis tournament. The Australian Open offers a full family experience with several attractions for the kids, amazing food and drink options, shopping and of course plenty of tennis.

The Australian Open is the only major tournament which allows fans to stand within metres of their favourite players while they practice on the practice courts.

Melbourne Park has recently undergone significant refurbishments and now boasts facilities that are the equal of anything in the world, such as:

• State of the art player warm areas

• two fully equipped gymnasium

• two separate recovery centres with ice baths, plunge pools and compression therapy

• private treatment rooms

• indoor and outdoor practice facilities

• Fully catered player restaurant.

The player restaurant offers a Melbourne Café experience, including

• Specialised coffees  

• Italian zone, with all-important pasta stations and a built in pizza oven

• Japanese-style restaurant and made-to-order sushi

• Ice-cream bar

• Outdoor terrace overlooking Grand Slam Oval and Melbourne Arena

The Australian Open has always led the way in the beauty and grooming stakes and the Player Beauty Bar has set the benchmark in Grand Slam pampering. In 2019 services expanded even further to include:

• Nail Bar

• Brow Bar

• Hairdressing – cut, colour and styling

• Full beautician service – waxing, facials, makeup and more

• Men’s barber and shaving.

The majority of these facilities are located directly underneath Rod Laver Arena. There are also a series of tunnels underneath Melbourne Park which allows players to move around the park without having to go into the public areas.

There is something special about a home Grand Slam and I am very lucky to experience it year after year.

Below are some photos of the facilities at Melbourne Park.

AO2020 - Behind the Scenes - Part One

A Day in the Life

By Will Maher

Melbourne has the privilege of hosting one of the four biggest tennis tournaments in the world every year during January and I am excited to be heading to my 6th Australian Open to work as a physiotherapist.  It is a great opportunity to meet Doctors, trainers and other physios from all over the world and exchange treatment ideas and information about how best to help our patients with injuries.  It also comes with built-in pressure to ensure you make good decisions for athletes when managing and preventing injuries, with potentially serious implications for their career.

I became involved with professional tennis in 2014 through word of mouth and have since travelled to New York, Paris, London, Miami, Indian Wells, Lyon, Nice and have been away from home anywhere between 6-18 weeks of the year. I am fortunate to have a wonderfully supportive family and workplaces that have allowed me to do this.

When on tour a day may start around 10am and can finish as late as 1am depending on scheduling.

A typical day involves: Morning assessment and treatment and Practice or a warmup hit. Practice is followed by recovery varying from compression therapy, stretching or gym-based work and more treatment. It is not uncommon to then have a period of down time as the players wait for a match to finish before theirs can commence. 

Every player has different habits and tendencies but minimising mental and emotional energy drain during this time is critical and typically may result in more treatment.

Following the match there is more recovery and treatment again varying from ice baths to massage. 

It takes seven grueling best of 5 set matches to win a Grand Slam. My job is to ensure that the player is in the best physical shape possible. I work closely with a player’s trainer around nutrition, hydration, sleep and training scheduling is critical for getting the best results over what can be two weeks of competition. This process is like a race car being serviced by a pit crew regularly to ensure it doesn’t break down.

Complete Concussion Management - What's in a name?

At Accelerate we just completed our Complete Concussion Management certification as a clinic. This is an important step for us to be able to assess and treat concussions. As clinic with an interest in sports, this is a very important skill to possess and one that we don’t take lightly. According to the latest research, it’s estimated that 10% of athletes playing contact sports suffer a concussion with a full 50% of them going unreported. Those are headache inducingly high numbers. 

I took a lot away from the course, but I think what stuck with me most is the introduction of the term mild traumatic brain injury (mTBI) to define concussion. I believe calling them concussions takes away from the nature of what’s occurred. I think we hear concussion and, unfortunately, the social context takes over. Whether that’s the old, “she’ll be right with a schooner after the match” or the newly minted fear of crippling disability post concussion, we’ve been told conflicting ideas of what a concussion entails. Neither of these narratives are correct and both can be devastatingly harmful.  

I like mTBI. I think it encapsulates nicely what’s occurred and offers a better insight into the prognosis post injury. Let’s break it down: 

Mild- Well that’s a relief 

Traumatic- Yeah, well that makes sense too 

Brain- This seems pretty self-explanatory 

Injury- Now we get to the crux of the issue. This is just an injury and injuries happen. Sure, it’s happening to the most important structure in the body, but injuries heal. You don’t roll your ankle and immediately pack it in and give up on whatever you were doing. With appropriate management, your brain will heal, much like a sprained ankle. The more diligent you are with rehab and following the protocol, the better your chances at making a full recovery. 

So, let’s call these injuries what they are, mTBI’s, and approach them the same way we do other parts of the body. If you suspect you’ve had an mTBI please see a qualified health professional for your rehab, sooner rather than later. At Accelerate we pride ourselves on approaching every injury with an evidence-based focus and giving you the most up to date information regarding your situation, the brain not excluded. 

-Elliot Rechtin 

MPhysio 

Accelerate Physiotherapy 

Brace Yourself

Two things I need you to understand before we begin.  Your spine is a strong resilient structure and moving it in all directions is key to keeping it healthy. Also, your spine is living tissue and should be adequately protected. The dual nature of the spine is no different from any of the other tissues in the body. However, we treat it differently. Far too often we get this idea from ill informed sources that your spine is under constant threat. Bend too far and you’ll “do your disc” or twist to quickly and, boom, you’re laid up in bend hoping to ever walk again. This is simply not the case. In general, your spine IS strong but even the strongest structures can do with a bit of support.  

Brace yourself. 

No, seriously, brace yourself. Whenever you plan to lift or shift something heavier than you’re used to, you should at the very least be aware of your core. You should be able to switch it on and off and use it to control the forces you’re putting through your spine. Great, now you’re walking like a robot. Don’t do that. Always on, is in many ways just as bad as never on. Control is the name of the game. Use it when you need it. Move forces towards the big muscle of the hip when lifting that bag of mulch or slowly and accurately turn the corner in the shopping centre with a full trolley. I’d also like you to be able to touch your toes.  

Can’t do all that? Maybe it’s time you had someone assess your spine and core strength. We also offer Core Connections classes led by our physio Kylie. It’s a solid hour of teaching you how to move.

 Elliot Rechtin, MPhysio, Accelerate Physiotherapy

Running takes Practice

Running should be easy. It may not always be fun or even enjoyable, but it really shouldn’t take too much conscious thought. You’ve probably been running for years, maybe not as regularly as you’d like, but I imagine a short period of time after you started walking, you started running. You may be thinking, “this guy’s crazy, I’m a terrible runner” or “running is hard”. I’m here to tell you you’re wrong. You’re not a terrible runner. You’re just a runner.

 Everyone runs differently. Your stride and form are uniquely yours. Your belief about being a terrible runner is more likely stemmed from a lack of fitness or practice. So, practice but practice smart. Build slowly and progressively and the fitness will come, along with a significantly reduced risk of injury. 

 The caveat to the above is pain. Running, bar marathons and the like, shouldn’t be painful. You should be able to make a very real distinction between being uncomfortable and being in pain. Pain could be from a variety of reasons but if it’s painful only when you’re running its time to have a think about your technique.

 The quickest and easiest way to get an idea as to the issues with your running form is to have a running assessment by a trained professional. They can do an assessment and will video your gait in order to highlight things that need adjustment. A worthwhile endeavour if you want running to be fun or enjoyable or, more important, pain free. 

Book in a running assessment with Adam at Accelerate and he’ll get you running pain free in no time.

Physiotherapy: A Lifetime of Learning

I really enjoy this profession and here’s why: no matter what stage of their career, there are physios who have committed themselves to being the best for their patients by expanding their knowledge and being evidence based.

A few months ago I went to an event hosted by the APA that really highlighted how impressive this profession is. The APA or Australian Physiotherapy Association is a national organization that represents the interests of physiotherapists and their patients. Their main focuses are continuing education, advanced training, and collegial support. None of this was more evident than at the research symposium I attended. The symposium was organized, in part, by Adnan who is the ACT APA musculoskeletal committee chair and a branch councillor. It was an opportunity for local physiotherapists and researchers to present their work to colleagues who can begin to incorporate their findings into practice.

My admiration stems from my company at the event. I sat between two physios with a combined 40 years of experience and across from students who were yet to graduate. There was a broad spectrum in terms of clinical experience but everyone was there to learn. Everyone was there to find out what the research said. This wasn’t shot in the dark type stuff. This is what science tells us is the best way to make people better. I imagine other professions do this but sitting in a room full of my peers being presented with the best available evidence to guide the things I do made me proud of my decision to become a physiotherapist.

 Elliot Rechtin

MPhysio

Accelerate Physiotherapy

Do you have a Happy Heart?

Your heart is a muscle, and a super important one.

That may seem like an incredibly obvious statement, but I think it’s an important point to remember. I feel we often treat the heart as this separate entity that just does its thing and should be left alone. It’s there beating away and if we mess with it, we could cause it to fail and that isn’t ideal.

However, the heart is just a muscle. Yes, it’s a complicated one with its own blood supply and electrical system but a muscle all the same. So, like any muscle, we need to strengthen it. We need to make it more resilient, increase its capacity to do work, stress it and all the while monitor its response.

The best way to challenge the heart is through interval training.

Interval training is essentially increasing the demands on the heart for a set period, then, allow it to recover. Doing this repeatedly increases the hearts ability to cope with a stressful stimulus and then return to a baseline or slightly elevated resting heart rate. If you can do this regularly and with a progressive increase in the challenging nature of the interval or activity, you can make a real, measurable change in the heart’s ability to deal with the burdens of everyday life.

At Accelerate Physiotherapy, do the above and we do it with consideration given to any other injuries or issues you may have. We choose exercises that are designed to ensure the heart is the primary focus and we monitor your heart rate throughout. Our goal to provide a safe and effective stimulus to make your heart stronger. Come join one of our Happy Hearts classes at 9:30 on Wednesday mornings in our clinic.

By Elliot Rechtin

M.Physiotherapy

A glimpse into why we were named a Telstra Business Award Finalist

By Jennifer Maher

This year, we were nominated, shortlisted, then named a finalist for the 2019 Telstra Business Awards. There were over 2100 applications across the ACT and we made it to the top five in our category.

While we didn’t win the title, we came close and here is why:

Back in April 2017, Ads approached Will to discuss whether he wanted to start a physiotherapy clinic with him. Will’s immediate thought was no, it was going to be too much extra work, running the business and providing the best care to his patients. 

Then I entered the conversation.

I am Will’s wife of almost 10 years. Before I had my kids, I lived and breathed all things administration and office management. When I told Will I would manage the clinic so he could focus on physiotherapy - Accelerate Physiotherapy was born.

For those of you who have been with us from the very beginning, you would remember we opened in July 2017 with 2 physiotherapists, a part time receptionist and me. Fast-forward 2 years and 2 months, and we have 5 full time physios, 1 part time physio, 1 massage therapist, 4 reception staff and me. Crazy hey!

From the outset, we wanted to make Accelerate the best workplace we could for our staff.  You may not know this but every day our staff have lunch together in our lunchroom.

Our lunchroom is a place of banter, coffee, delicious treats and way too much ESPN and Fox Sports. This is the heart of our physiotherapy practice. This hour together each day has been instrumental in building our rock-solid team culture.

Physiotherapy can be a challenging profession, both mentally and physically. We offer our staff, including administration staff, a 4-day week, which allows us to work hours that are convenient to our patients but also offers a balance with everyday life.

We also offer our staff various allowances such as professional development to ensure that our physios are up to date with the latest research. A mental health allowance is also available to our physios to put towards a range of services to help to relieve the everyday stress of life as a physiotherapist.

Little details in the clinic have been carefully considered, all staff are trained on reception and answer the phone if the admin team are busy and every person wears the same uniform. This creates a cohesive culture as we are all equal, no matter your role.

It’s all these little things behind the scenes that build our strong team which in turn benefits you as a patient. A Happy worker makes an exceptional physiotherapist.

When we met with the judges, they were thrilled with our proactive approach to redefine the practice of physiotherapy and our commitment to customer satisfaction. While we have fallen short on Thursday night, the process which we went through allowed us to reflect on what we have achieved over the past two years and also make some grand plans for the future…

Watch this space.

Squat to it!

I’d like to paint you two pictures. In the first, you are a novice gym goer who is looking to get fit and healthy this winter but really struggles with planning your gym routine or deciding which machine to use. The second scenario sees you as an avid gym attendee who has developed an occasional knee ache over the course of a few months and is now concerned about which exercises to do and which to avoid for fear of “setting it off”. In either scenario you’re now headed to the gym, what exercise is at the top of your list for tonight?

The answer should be squats. It should always be squats. Even if you did them yesterday. Even if you plan on doing then tomorrow. Do more squats.

Why should I be squatting you ask? For a beginner this may seem like a bridge too far. A compound lift that requires too much technical skill, the squat, you’ve heard, can be dangerous. As for the gym regular, who may have the form down pat, the squat is a knee intensive exercise. Surely a movement like that will only aggravate their knee. While these are valid concerns in the minds of either of our avatars, they are wholly unfounded. Let me explain why.

First let’s discuss the technical/dangerous aspect of a squat. Can you stand up from a chair? Yep, you’ve mastered the squat. That’s all squatting is and if that’s challenging enough for you then do that. A bunch. At some point this might become easy for you in which case it’s time to start adding weight or variations but by then you’ve got the basics down.

If knee pain stops you from squatting, you may be missing out on one of the best exercises to help clear that up. A new study shows therapeutic exercises do not exacerbate knee pain or cause inflammation1. The squat is most definitely a therapeutic exercise. With most joint injuries the goal is to increase the resiliency of that joint and its ability to cope with the rigours of everyday life. Squatting will do that. Building muscle mass in the quads, glutes and hamstrings offloads the knee joint and makes you more able to get up from a chair, get up a flight of stairs or just get up to face the day.

As an aside, high weight/low rep or, conversely, low weight/high rep multi-joint exercises increase testosterone production in the body. Testosterone builds muscle, which burns fat, which makes you a better you.

Go do some squats.

If you’ve got knee pain and need a program tailored for you or you want to start squatting but are unsure of the finer points, come in and we’ll get you started on the right path.

Elliot Rechtin

MPhysio

Accelerate Physiotherapy

 1.       Bricca, A., Roos, E.M., Juhl, C.B., Skou, S.T., Silva, D.O. and Barton, C.J., 2019. Infographic. Therapeutic exercise relieves pain and does not harm knee cartilage nor trigger inflammation. British journal of sports medicine, pp.bjsports-2019.

OWN IT!

One of my favourite things when seeing a patient is when it becomes increasingly obvious that they’ve done a bit of research into their condition. I enjoy when a patient asks if trans ab or multifidis exercises would be beneficial for treating their lower back pain or whether I think their pec length and poor posture are contributing to their shoulder discomfort. It tells me a lot about the person sitting in front of me. It says that they want to understand their condition and get better while acknowledging that this isn’t their area of expertise and need guidance when it comes to rehabilitation. It also means that, in general, this individual is going to adhere to the advice that I give and ultimately get better, faster.

Research has shown that active participation in rehabilitation leads to better outcomes.(1-3) Normally this applies to adherence, which will be discussed later, but I have found that people who do their research and increase their understanding of what’s going on with their body fare better on the path to rehabilitation. This, of course, comes with a bit of a disclaimer: Take Google search results for what they are, an algorithm-based response to key words. They cannot replace the tests we perform and the bigger picture information we process on our way to your diagnosis.

Adherence is key. We don’t ask you to do exercises for our own amusement or stop you doing what you love as a form of punishment. We want to see you get better. We want to get you back to what you love. The advice we give out is based on evidence and experience and when followed it should go a long way towards addressing your pain. Try to stick to what we advise. The feedback we get for your body’s response is invaluable for planning the rest of your rehab journey.

That’s not to say your input isn’t important. As discussed earlier, if in the course of your research there are things that you’d like to try, let us know. It may not be appropriate but it also may be a perfectly acceptable course of treatment and the feeling of being involved in that process has been shown to improve outcomes.(4)

The moral of the story is ownership. Own your injury, own the rehabilitation process, and own the feeling of achievement of being able to do what you love pain free.

Elliot Rechtin

MPhysio

Accelerate Physiotherapy

1. Bassett, S.F., 2003. The assessment of patient adherence to physiotherapy rehabilitation. New Zealand journal of physiotherapy, 31(2), pp.60-66.

2. Marshall, A., Donovan-Hall, M. and Ryall, S., 2012. An exploration of athletes’ views on their adherence to physiotherapy rehabilitation after sport injury. Journal of sport rehabilitation, 21(1), pp.18-25.

3. Kolt, G.S. and McEvoy, J.F., 2003. Adherence to rehabilitation in patients with low back pain. Manual therapy, 8(2), pp.110-116.

4. Jordan JL, Holden MA, Mason EEJ, Foster NE. Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD005956. DOI: 10.1002/14651858.CD005956.pub2.

Pain: A Primer

As physiotherapists we encounter all sorts of pain and the people affected by it. Pain is a very complex thing and would require thousands of pages to properly explore, so instead I’d like to focus a bit more on how we as physios interpret your pain and the information it provides us. The hope is that after reading this article you have a better understanding of why we ask the questions we do and what that tells us about the pain you feel.

Describe your pain.

What we’re looking for here is to be as descriptive as possible. We want to know if your pain is dull, sharp, tingly, burning, and/or all of the above. These adjectives give us clues as to what might be causing your pain. We also want to know the intensity of your pain. This is usually described on a scale from 0-10. 0 being no pain at all to 10 being the most excruciating pain you could possibly imagine. Although this is varies from person to person, it gives us a good idea as to what treatments are appropriate for you.

When does your pain occur?

I don’t mean at 9:45 on Tuesdays, I mean is your pain associated with a period of the day or activity. Is it worse in the mornings? Does it come on 2km into a jog? Is it the first few steps after getting up from your desk? Again, your pain pattern tells us a lot about the structures involved. Part of this line of questions involves giving us an idea as to how long you’ve been in pain and if it’s getting better, worse or staying the same. While the exact amount of time may not be important, a close approximation is. A 3-day old knee injury is very different from a 3 month or 3 year old one.

Where is your pain and is this your pain?

This tends to be a notoriously tricky question to answer and knowing that, as physios, we’ll try to help you answer with some tests. These tests may be uncomfortable but are very important in nailing down the specific structure involved in producing your pain. If a test elicits pain we need to know about it and we need to know if that’s the pain that’s brought you in to see us.

How does your pain change?

What we’re looking for here is how specific movements and positions change how your pain feels. When I press here does your pain get better or worse? If you’ve been popping an ice pack on your shoulder, does it help? If you bend forward, does your pain go away? While this can reaffirm the structure involved, it also gives us ideas as to how to help you feel better.

Basically, we’ve covered the how, what, when, where and it’s our job to tell you why. When we arrive at the why we can come up with a plan to sort out the pain you’re feeling. The take-away here is to be mindful of your pain and pass on as much information as possible to your physio. It might just save you some unnecessary pain.

Elliot Rechtin, MPhysio

Accelerate Physiotherapy

Not just tennis elbow

Ah, finally, spring is in the air. While the warmth and beauty of spring brings about good feelings for most, there may be a small sense of dread for others. The weeds need to be picked, the roses pruned, and the backhand needs a bit of work if you’re ever going to beat the neighbour in the weekly tennis match.

So, what do you do? You get motivated and set aside a weekend to kick goals. While this may seem like a good idea, you may be setting yourself up for injury…Cue the dreaded Tennis Elbow (AKA Lateral Epicondylalgia)

Tennis Elbow is a painful condition and, as anyone who has been afflicted with it will tell you, is fairly debilitating. It affects the outer part of the forearm just below the elbow and can be characterized by a sharp pinch with certain movements and a dull ache when aggravated. Usually brought on by either a long history of intensive upper body workload or, as above, a sharp increase strenuous elbow usage, Tennis Elbow affects 40% of people at some point in their life. A full 50% of tennis players encounter this pathology at some point in their career and as many as 17% of upper body intensive manual labourers are affected with Tennis Elbow.  The scary thing about this condition is the disability and longevity of symptoms.

Diagnosis is straight forward. A physiotherapist taking a good patient history with a good knowledge of human anatomy can narrow down the diagnosis quickly. The trick is knowing what to do about it.

The best available evidence we have points to exercise and load management as the best treatment. Isolated, focused exercise can go a long way towards fixing the problem while investigation and treatment of the neck and back will help keep the issue from coming back.

Prevention, however, remains the best treatment. Enjoy the spring but increase activity gradually and incorporate lots of rest to smell the roses and banter with the neighbour about how good your backhand has gotten.

 What can we do for you:

-      Diagnosis

-      Education on pain management

-      Tailored exercise prescription

-      Global biomechanical investigation

-      Advice regarding injury prevention

 Author: Elliot Rechtin, MPhysio - Accelerate Physiotherapy