The Physio Manifesto

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One of the best summaries of the current state of ACL knee injury management.

[physiomanifesto]

The BMJ‘s Amazing Shock and Awe Assault on Sport Drink Science

wow.

Wow, WOw, WOW!

What words would you use to describe a situation where one of the world’s most prominent medical journal publishes, not just one article critical of a specific category of food, but seven such articles, and where those articles come to the conclusion that the food is being marketing on the basis of food industry funded hype and collusion?

I’d use the words, “Thank You”!

You’ll definitely hear about it in the news today as the British Medical Journal has 7 incendiary pieces that are highly critical of sport and energy drinks, their Big Food parents and the researchers that are conflicted by them.

The first piece (Research: The evidence underpinning sports performance products: a systematic assessment) has researchers analyzing sport drink advertising and identifying an astonishing 431 performance enhancing claims for 104 different products. Those claims were “backed up” by references made on the products’ websites to 146 references. Of those 146, the authors could only actually find half of them, and of that half:

“84% were judged to be at high risk of bias“,

Read More here: 

[physiomanifesto]

Identification of Acetabular Labral Pathological Changes in Asymptomatic Volunteers

Source: Identification of Acetabular Labral Pathological Changes in Asymptomatic Volunteers Using Optimized, Noncontrast 1.5-T Magnetic Resonance Imaging.

Schmitz MR, Campbell SE, Fajardo RS, Kadrmas WR.

Am J Sports Med. 2012 Mar 15. [Epub ahead of print]

Background: Acetabular labral tears as a source of potential hip pain have received a great deal of attention in recent literature. The gold standard for identifying acetabular labral tears is hip arthroscopy, but recent advances in optimized, noncontrast magnetic resonance imaging (MRI) have proven effectiveness in identifying intra-articular hip pathological changes without the invasive nature of hip arthroscopy or gadolinium-enhanced arthrography. There are little data in the literature on imaging results in an asymptomatic population.

Purpose: The objective of this study was to use an optimized, noncontrast 1.5-T MRI protocol to identify hip abnormalities, including paralabral cysts, in asymptomatic volunteers.

Study Design: Case series (prevalence); Level of evidence, 4.

Methods: In this study, 42 hips in asymptomatic patients with an average age of 34 years (range, 27-43 years) were prospectively imaged with optimized, noncontrast 1.5-T MRI scans. Two fellowship-trained musculoskeletal radiologists interpreted the scans at 2 different points in time and commented on the presence of labral abnormalities including paralabral cysts. The results were analyzed for both interobserver and intraobserver reliability.

Results: Acetabular paralabral cysts were identified in 11 of 42 (26.2%) and 9 of 42 (21.4%) hips by the 2 respective radiologists, with an interobserver reliability of 90.5% (κ = .74) and intraobserver reliability of 95.2% (κ = .87). In addition, acetabular labral tears were identified in 36 of 42 (85.7%) and 34 of 42 (80.9%) hips, with an interobserver reliability of 90.5% (κ = .70) and intraobserver reliability of 95.2% (κ = .83).

Conclusion: Utilizing an optimized, noncontrast 1.5-T MRI protocol, we report the previously undescribed prevalence of acetabular labral pathological abnormalities and paralabral cysts in a young, asymptomatic population. This emphasizes the importance of correlating patient symptoms with history and physical examination when evaluating patients with hip pain and radiographic abnormalities as defined by MRI criteria. These data demonstrate that labral tears can occur without symptoms.

[physiomanifesto]

Nine questions every athlete should ask before taking a supplement

Elite sport dietitian examines the benefits of nutritional supplements

Champaign, IL—Nutritional supplements claim to improve athletic performance, but not all supplements are created equal. According to Nutrition Australia life member Glenn Cardwell, athletes vary greatly in their response to training, environmental conditions, psychological barriers, and nutritional supplements, which makes it difficult to assess the value of proposed ergogenic aids. "Improvement is not proof that a supplement works. It may be just a convenient coincidence," says Cardwell, author of the forthcoming new edition of Gold Medal Nutrition (Human Kinetics, 2012). "Proof only comes when the same result can be repeated time and time again."

Before taking a nutritional supplement Cardwell advises assessing its potential value by asking nine vital questions.

Has there been any independent research on the supplement? Many supplements have not been researched in healthy athletes, or the research has been done only in-house and not independently assessed.

If research has been conducted, has it been published in an independent, peer-reviewed scientific journal? The marketing of some supplements relies on articles written about the product. “An article is not the same as research,” Cardwell says.  “Before an article is published in scientific journals, experts in the field review it to make sure it is up to a high standard and conclusions are valid.”

Is the research relevant to athletes? Many supplement manufacturers cite research articles that are unrelated to the claims for the product. “One food bar claimed to assist body fat loss, yet none of the references cited to support its claim were about weight loss,” Cardwell explains. “If you can’t assess the research yourself, ask a sports dietitian or go to a reputable website for their opinion on the research.”

Is the supplement patented? If a product has been patented, then the patent holders usually do most of the research because they will directly benefit from future sales. “Truly independent research is rarely published in such circumstances,” Cardwell says.

Is the majority of research from one researcher or laboratory? The value of a supplement can be determined only if many researchers from different laboratories work independently to assess it under varying conditions. “This has been done, for example, in the case of creatine and sports drinks,” Cardwell notes.

Has the research been performed on athletes under normal training or competition condition? Just because a product has benefits for people with certain conditions such as heart disease or nutrition deficiency, it doesn’t follow that the same benefits hold for fit and healthy athletes.

Although there may be research suggesting a benefit of a supplement, is there any research showing ‘no effect’ or possible dangerous side effects of using the supplement? “If one research paper shows a positive effect, but 10 others show no effect, then it is disingenuous to mention the positive result and not to say that the balance of evidence is for no effect,” Cardwell says. 

Is the product suited to your sport and your level of training? “Taking supplemental creatine can benefit sprint and power athletes, but it is unlikely to benefit marathon runners,” Cardwell explains. “If research shows a positive effect for athletes, will you get the same benefit when training purely for health and fitness?”

Have other independent scientists, sports dietitians, sports institutes or sports medicine groups offered supporting comments about the supplement? Examine what organizations such as the International Society of Sports Nutrition, the National Sports Medicine Institute of the UK, the Australian Institute of Sport or Sports Dietitians Australia have to say about a supplement.

“Based on current knowledge, the best regimen for achieving optimal performance is to avoid excess body fat, drink plenty of fluids to avoid dehydration, eat enough carbohydrate to fuel your training program, eat adequate protein for muscle growth and repair, and eat for good health,” Cardwell says. “Most nutritional supplements do not enhance sports performance in well-nourished athletes.”

For more information, see Gold Medal Nutrition, 5th Edition.

Taken from Human Kinetics

[physiomanifesto]

Nine questions every athlete should ask before taking a supplement

Elite sport dietitian examines the benefits of nutritional supplements

Champaign, IL—Nutritional supplements claim to improve athletic performance, but not all supplements are created equal. According to Nutrition Australia life member Glenn Cardwell, athletes vary greatly in their response to training, environmental conditions, psychological barriers, and nutritional supplements, which makes it difficult to assess the value of proposed ergogenic aids. "Improvement is not proof that a supplement works. It may be just a convenient coincidence," says Cardwell, author of the forthcoming new edition of Gold Medal Nutrition (Human Kinetics, 2012). "Proof only comes when the same result can be repeated time and time again."

Before taking a nutritional supplement Cardwell advises assessing its potential value by asking nine vital questions.

Has there been any independent research on the supplement? Many supplements have not been researched in healthy athletes, or the research has been done only in-house and not independently assessed.

If research has been conducted, has it been published in an independent, peer-reviewed scientific journal? The marketing of some supplements relies on articles written about the product. “An article is not the same as research,” Cardwell says.  “Before an article is published in scientific journals, experts in the field review it to make sure it is up to a high standard and conclusions are valid.”

Is the research relevant to athletes? Many supplement manufacturers cite research articles that are unrelated to the claims for the product. “One food bar claimed to assist body fat loss, yet none of the references cited to support its claim were about weight loss,” Cardwell explains. “If you can’t assess the research yourself, ask a sports dietitian or go to a reputable website for their opinion on the research.”

Is the supplement patented? If a product has been patented, then the patent holders usually do most of the research because they will directly benefit from future sales. “Truly independent research is rarely published in such circumstances,” Cardwell says.

Is the majority of research from one researcher or laboratory? The value of a supplement can be determined only if many researchers from different laboratories work independently to assess it under varying conditions. “This has been done, for example, in the case of creatine and sports drinks,” Cardwell notes.

Has the research been performed on athletes under normal training or competition condition? Just because a product has benefits for people with certain conditions such as heart disease or nutrition deficiency, it doesn’t follow that the same benefits hold for fit and healthy athletes.

Although there may be research suggesting a benefit of a supplement, is there any research showing ‘no effect’ or possible dangerous side effects of using the supplement? “If one research paper shows a positive effect, but 10 others show no effect, then it is disingenuous to mention the positive result and not to say that the balance of evidence is for no effect,” Cardwell says. 

Is the product suited to your sport and your level of training? “Taking supplemental creatine can benefit sprint and power athletes, but it is unlikely to benefit marathon runners,” Cardwell explains. “If research shows a positive effect for athletes, will you get the same benefit when training purely for health and fitness?”

Have other independent scientists, sports dietitians, sports institutes or sports medicine groups offered supporting comments about the supplement? Examine what organizations such as the International Society of Sports Nutrition, the National Sports Medicine Institute of the UK, the Australian Institute of Sport or Sports Dietitians Australia have to say about a supplement.

“Based on current knowledge, the best regimen for achieving optimal performance is to avoid excess body fat, drink plenty of fluids to avoid dehydration, eat enough carbohydrate to fuel your training program, eat adequate protein for muscle growth and repair, and eat for good health,” Cardwell says. “Most nutritional supplements do not enhance sports performance in well-nourished athletes.”

For more information, see Gold Medal Nutrition, 5th Edition.

Taken from Human Kinetics

[physiomanifesto]

[kintegrate]

Muscle stiffness (in vivo) is a simple but complex issue. It has 3 major components. 1) Intrinsic properties of the muscle 2) External muscular connective tissue architecture (fascia, skin, tendon etc) 3) Neural drive

Neural drive has two major components 1) descending commands - from a variety of sources....

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More here from the SS forums

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The kinaesthetic sense can be awakened and developed in using any and all kinds of movement, but I believe it becomes conscious only when the inner, that is, the subjective connection is found, the sensation of what it feels like to the individual, whether it is swinging, stretching, bending, turning, twisting, or whatever. People can learn movement in a variety of ways; they are not necessarily enabled to feel it when they do so--it is the concrete, specific awareness of one's own act of moving which is so satisfying. They physical culture courses, of which our friend spoke, work with the body as object, not as subject; and while a general release takes place, there is not corresponding experience of the personal identity, its quality and its movement. This seems to mean that something more is needed than simply body mechanics, that the feelings hidden int the body, the source of all its movement, must be involved.

Mary Whitehouse

[physiomanifesto]

long sitting slump slider.avi (by glehman)

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slump slider movie.avi (by glehman)

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ulnar nerve slider movie.avi (by glehman)

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radial nerve slider movie.avi (by glehman)

[physiomanifesto]

Leslie Kaminoff - Review of "The Science of Yoga: The Risks and the Rewards," by William J. Broad

[physiomanifesto]

Pain, healing, physical therapy and the power of context. How do we tie it all together?

Maybe this is a banal statement, but the pain experience does serve as a very useful perception in our nervous system. Even in occasions where there is damage to tissues or even just the threat of it, it is still very useful information. I think there is a misconception that we should eliminate all pain without insight. At least this is what probably our modern medical establishment strives for--we know how good it is at treating pain.  Pain gives us much insight into our brains and bodies and we must understand it within the context of ourselves and our surroundings. Many people are so disassociated from this sort of understanding of themselves that they need guidance. Thus patients seek out MDs, chiros, and PTs for validation and understanding. Just like when a young child takes a fall, he looks to those around him to make sense of his internal sensations. We are the stewards of information regarding the brain/body just as parents were stewards during our first steps. Unfortunately our medical system is much better at labeling than creating a context for healing to occur. Most patients who enter our health care system are met with gimmicks and insufficient explanatory models--when they work they serve to reinforce the confirmation bias of the advocate--when they don't the medical system has just another difficult patient. Given a proper explanatory model, physical therapy does not actually "fix the injury/dysfunction", it convinces the patient they are in an environment where their own natural mechanisms of restoration of health can occur. Much of this is the nervous system accommodating to the changes that have occurred and to maximize the function it has remaining. Proper PT helps the patient make sense of their internal sensations and facilitates appropriate action. With the proper context the balance of movement and recovery is the key to this re-appropriation of internal sensations. Once the context is created, the therapist is free to use any strategy of sensory inputs to help facilitate this balance (manual, visual, verbal etc.)

Borrowed from my post over at SomaSimple.com

[physiomanifesto]

Reblog: Beginner's Guide to Movement Prep @CorePerformance

Re-blogged from CorePerformance

Overview

Movement prep, as the term suggests, prepares your body for movement. It’s a series of innovative and dynamic movements that increase your core temperature, prepare your nervous system for physical activity and strengthen your body.

Dave Cruz

How Movement Prep Works

As opposed to a traditional warm-up, movement prep actually makes you stronger and helps yield long-term flexibility gains. You’ll actively elongate your muscles in a series of movements, which can improve balance, mobility and stability. Think of it as warming up with a purpose.

You’ll do approximately 5 to 10 repetitions of each exercise in your movement prep routine. Not only will it feel like part of your workout (as opposed to a boring precursor to the real thing), at first it might feel like a workout itself. 

Don’t worry: Your body will quickly condition itself to the exercises, and when you’re done, you’ll feel warmed up, rather than worn down. And you’ll be better prepared for whatever follows, whether it’s a workout, a game or just the normal actions of everyday life.

Benefits of Movement Prep

Movement prep helps you dial in both physically and mentally for your workout. It increases your heart rate, core temperature, and blood flow to working muscles. Another benefit: Nearly everyone, including professional athletes, has at least one muscle group that’s completely shut off. This can cause other areas of the body to compensate, which ultimately leads to injury.

An example of this would be the small muscles of the hips, the gluteus medius, which if not activated will lead to lower-back problems, knee pain, and groin strain. It’s as if someone flipped the circuit breaker, cutting off power to these little muscles. With movement prep, it takes only a day or two to reactivate these inactive areas. These exercises, which require no equipment, enable your body to recall those movements that perhaps haven’t been used since childhood.

By strengthening muscles in this new range of motion, you stabilize all the tiny muscles around your joints that help hold the joints together. That will improve posture and performance and decrease potential for injury.

A Wake-Up Call for Dormant Muscles

We spend most of our time sitting on our butt (glutes), which causes the muscles opposite of them—the hip flexors—to become tight and inactive. The neuromuscular relationship of these opposing muscle groups is known as reciprocal inhibition, which is a fancy way of saying that when one muscle group contracts, the other relaxes. Movement prep is reciprocal inhibition at work. 

Your movement prep routine wakes these muscles up—and not just for your workout. They’ll remain switched on for the rest of the day.

Here’s why that’s important: Let’s say you’re walking on a winter day, and your foot slips on some ice. How well your body reacts to that slip on the ice depends on your proprioception, the system of pressure sensors in the joints, muscles, and tendons that your body uses to maintain balance. Movement prep, in switching on your body’s small muscles, also tunes your sense of proprioception. It prepares your body for random chaotic movement by fine-tuning its nerves and feedback mechanism.

Better Than Old School Stretching

There’s tremendous value in traditional stretch-and-hold, or “static” stretching if executed properly and done after a workout. However, static stretching routines performed before exercise can increaseflexibility only for a short time. There is little scientific evidence that such routines can improve exercise performance, reduce delayed-onset muscular soreness or prevent injuries.

A difference between traditional static stretching and movement prep is that the goal of the former is to relax muscles, to allow you to get into a stretched position and hold it. In movement prep, you’re going to contract your muscles, which is to say you’ll be activating them by squeezing them. This improves the long-term mobility and flexibility of muscles. Rather than have them stretch and go back to where they were—as is the case with traditional stretching—movement prep helps your body remember those ranges of motion.

Just doing movement prep alone can make your body stronger and more stable, and can also help increase speed and power output. Do it before every training session. Use static stretching after your workout.

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Reblog: 4 Things We Are Doing Wrong with Rehab @MikeReinold.com

Reblogged from MikeReinold.com

Today’s guest post comes from Dean Somerset discussing 4 things he thinks we are doing wrong with rehab.  Great job Dean, I always love reading your stuff!  If you want to hear more from Dean (and you definitely should!) I recommend you check out Dean’s new Post-Rehab Essentials program.  It is over 12 hours of great content.  I am still reviewing but have enjoyed it so far, I’ll try to post a full review once I get a chance to finish it all!

4 Things We Are Doing Wrong With Rehab

I’ve built up a profession working the grey zone between where physiotherapists and traditional rehabilitation professionals leave off with their patients and where strength coaches and persona trainers begin. There’s a definite gap between the two, and hopefully more and more trainers and rehab professionals will be able to bridge this gap to effectively help their clients and patients, respectively, through the entire continuum of wellness. Today’s post will hopefully show a few ways to bridge the gap in a more practical sense for some of the common things that aren’t being adequately addressed by either side.

#1. Not looking at foot mechanics – For Everything

A simple test I use with a lot my classes: I get everyone to put their arms overhead as straight and high as possible with a tall and upright posture. Then I have them make their upper back kyphotic, and try to do the same thing, and watch everyone’s expression as they wind up getting half the range of motion necessary. Then I have them do both a posterior and anterior pelvic tilt and see what happens. Yep, you guessed it, less range of motion. As the grande finale, I have them stand tall, and then simply pronate their feet to see what effect it has on their shoulder range of motion. Most if not all involved, will have some reduction in their ability to abduct their arms. Give it a try and see what happens.

Mike made an excellent post a few months back about the kinetic chain ripple effect versus the kinetic chain, and this is an excellent example of that concept. When the spine was kyphotic, it had the most dramatic effect on shoulder mechanics than when the foot was pronated, but the effect was still there, much like ripples in the lake from a stone hitting the surface on the other shore. This shows that even if the foot isn’t directly involved in a lot of issues with the body that it may in fact be indirectly involved with issues of the knee, hip, spine, and even shoulder and neck.

By checking to see if the foot has a fallen, normal or high arch structure to it, as well as if any arch alterations are structural in nature (the bones are formed that way) versus postural in nature (the muscles holding the ankle are weak) can allow a practitioner to get one more piece to the puzzle. If the arch has fallen due to weak muscle support through both the tibialis posterior and the compound effect of a weak greater hallicus longus, you can train the muscles of the foot to stabilize and resist collapsing, which would prevent the internal rotation of the tibia, and everything that would result up the chain.

Altered foot mechanics can affect every movement, from heavy deadlifting (my drug of choice) to how you throw a fast ball, to how at risk you are of low back pain.

#2. Not watching runners’ stride and technique

I’m fortunate enough to have been able to work with a lot of distance runners, even though I consider distance running one of the most pointless activities you could ever do. Seriously, if you have that far to go, drive there. You get a cup holder and air conditioning. Be that as it may, I’ve been able to do hundreds of run stride analyses clients, from beginners looking to complete their first 5km race, to elite marathon and ultra marathon runners looking to shave time, and even those who had repetitive strain issues with their legs and needed to know why. You can see amazing things happen when you use even a basic digital video camera and slow down the replay to watch things like calcaneal eversion, midfoot pronation, valgus collapse, tibial rotation (both internal and external), pelvic stability on impact, foot strike mechanics, knee position and angle on impact, stride length and frequency, and even whether they are in the right shoe for their stride or not. We could debate barefoot versus shod running forever, but I’ll just leave it to say that barefoot isn’t for everyone, and typical running shoes aren’t for everyone either. (An example running gait)

A lot of repetitive strain injuries in runners could be corrected by simply altering their run mechanics, much like a golfer can reduce their incidence of golfers elbow and low back pain by receiving coaching on proper swing mechanics. This could be as simple as using a hand-held video camera to show real-time feedback about performance, or as complex as using a DartFish software package to analyze force vectors and angle and rate of pronation, but in each situation it would result in an improvement in run stride, which would reduce the stress on the involved tissues, and allow runners to keep running with less pain, and probably while going faster.

It’s one thing to watch someone in static posture, and another entirely different beast to watch them move in their desired activity. By simply working on the muscles, joints, and fascia, we’re missing the boat on how their activities are impacting those tissues and what can be done about it. Athletes in most sports that involve running in one way or another (basketball, soccer, field hockey, and to a lesser degree football and baseball) would benefit from having someone analyze their gait and see where there may be some energy leaks and ways to decrease risk of injury.

#3. Not checking breathing mechanics

With the majority of upper body muscles attaching in one way or another to the rib cage, it would be common sense to think that an alteration in breathing mechanics could alter not only core function, but also scapular, glenohumeral, cervical, and potentially even lumbopelvic and lower leg function. If a client isn’t breathing properly through one side of their lungs, they may wind up getting side stitches on the opposite side as it works extra hard to compensate during forced heavy breathing. If they aren’t using their diaphragm properly, they may get neck cramping as their scalene compensate for the short-comings, and so on. On top of that, if the ribs cannot expand and contract properly, it will affect the ability of the thoracic spine to extend and rotate, which will affect the mechanics of the above-mentioned body parts. If they are collapsing into kyphosis, it will alter breathing capacity, which will alter performance and lead to further postural and repetitive strain issues.

Here’s an example of a runner who came in to see me with shoulder pain during her runs. 

Video pre training breathing see here

Notice how the rib cage elevates, but doesn’t actually expand width-wise? Here’s what she looked like after two weeks of doing three breathing exercises each day.She’s still restricted, but using her lower ribs more instead of just relying on scalenes and upper ribs to do her breathing. This is a woman who can run at 10 miles an hour for ever and hold a conversation with you, and has won marathons, Death Races, ultra marathons, and 50-100 mile trail running races galore, all while only using about one third of her lungs. She shaved 6 minutes off her personal best marathon time by only altering her breathing mechanics and stretching her thoracic spine through extension and rotation.

Video Breathing post training

  #4. Not communicating with everyone involved

I’ve been able to work with a lot of good rehab professionals who have been willing to discuss their patients’ status and ways to help them out in our training sessions, and also take my observations and questions in stride. I’ve also worked with a few who weren’t so willing to work with me, and as a result the quality of care wasn’t as good, and the results that the client was able to get were less than optimal.

One of the first questions I ask any rehab professional when it comes to any workouts I’m going to have them do is quite simply “What do you want me to focus on, and what should I avoid?” Essentially, I’m always going to defer to the direction of the doctor or physiotherapist or chiropractors’ directives, and work my program around their guidelines. I may question certain aspects based on the results of my assessments, and occasionally can give them some new information, but most of the time my questioning is to get more information and to learn more from another set of eyes and educational background.

The same could be said in the reverse direction. If your patient is working with a personal trainer or strength coach, reach out to them and ask to discuss their training program. Odds are you can both come to a collaborative conclusion that will only benefit that patient, and result in them getting healthier faster and make you look good to everyone involved. One example stands out in my mind of a client who came in with really severe brachial plexus impingement in both arms, had been to physiotherapists and chiropractors, and seen no relief. I wanted to talk with her neurologist to see if there was anything that I should work on or avoid, and his response was amazing.

“I don’t know, just get her to lose some weight and increase her flexibility. If she says it hurts, move on to something else.”

I then proceeded to refer her on to a really good physiotherapist in my area who checked her out and gave some very good and specific recommendations, and within 6 weeks her pain was nearly half of what it was. The combined approach will always work best.

Strength coaches and personal trainers who don’t have an established network of health care practitioners scare me, and they should scare anyone who is willing to work with a trainer, especially if they already have specific medical or injury concerns. I’ve had countless situations where I needed a second opinion and referred a client out to get an assessment and report back on what they can and can’t do, and as a result we’ve been able to train longer and avoid aggravating issues further. I’m paranoid about making client safety an issue, because if that client isn’t able to train and I can’t find a way to make them better, it affects my bank account at the end of the month, and my reputation as a whole. Having medical referral networks makes trainers money, and increases their respect and reputation. Not having qualified professionals they can ask for help makes them a liability.

For more great information from Dean, be sure to check out his Post Rehab Essentials Program.  It’s a 12-hour program that goes over great topics such as above.  It is a great resource for the personal trainers that deal with people coming off of injuries.

[physiomanifesto]

Another excellent warmup (by CoachKevinCarr)