Update on ITBS

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Thanks to whoever the Anonymous poster on the ITBS post was saying you should NEVER foam roller your ITB... an interesting point which I shall get to in a bit. I'm glad that they commented, because the post does need a little bit of updating.
I somewhat arrogantly stated that THE reason for ITBS is lack of musculature/ strength in the deep 6 rotators. Now this is indeed true, but it is not the ONLY reason for friction to occur down on the knee.

First of all, lets clear something up.
Illiotibial Band (Friction) Syndrome is actually caused by the LENGTHENING of the ITB. Yes, I wrote that correctly. Generally, the Tensor Fascia Latae- as mentioned in the previous post- the muscle that attaches to the ITB- and tensions it, becomes shortened- and as that becomes shortened, it pulls on the ITB - making it LONGER and causing it to become tighter along its whole length - but the key is that it is long and tight.

This is where the anonymous post comes in - if your ITB is already Long and Tight, why would you even consider lengthening it by rolling on it? Exactly. You wouldn't want to lengthen it any more. Its plainly not a good idea.
As for NEVER foam rollering it - I'm not so sure - if you are rollering your Vastus Lateralis - the quad on the far outside of the leg - which I often have cause to do - where exactly does the Vastus Lat stop and the ITB start? You can't really say - simply because the structures exist in 3 dimensions and in order to get to the whole of the tissue I am trying to roll out, I have to roll on the ITB.

So. There is a reason for not rollering your ITB if you have friction syndrome, but its pretty naive to say you should NEVER roll on the ITB.

I say, if it gives you a little relief, by all means go for it, but you should really be focusing on strengthening other structures around the hip which will stop you getting pain from the dreaded ITBS.

As already mentioned, it could be weak lateral rotators.
It could be (and is more likely to be) weakness in the Glutes (glute max and med)
It could be that your adductors (muscles on the inside of the leg) are too tight and are INHIBITING your Glutes- causing the tensor fascia latae to shorten.
It could be that the arch of your foot is flattening more than is optimal (some people might call this over-pronating) which is causing the tibia to torsion medially (rotate inward) causing the ITB to lengthen and create friction around the knee.
It could be that a nerve root in your spine is trapped and is inhibiting nervous signals to the glutes, bringing you back to the shortened tensor fascia latae.
It could be that the hips (innominate and sacrum) are slightly out of alignment and this is causing a biomechanical imbalance, the weak point being your knee - and thus causing pain.

It could be any number of things.
The vast majority of people I have seen with ITB friction syndrome have issues with deep rotators and glutes that don't fire properly.
Don't run on only half the muscles in your legs- practice firing those glutes- clench your butt! More to come on that later.

Trigger Point Therapy for Myofascial Pain

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My book of the month was Trigger Point Therapy for Myofascial Pain by Donna Finando and Steven Finando. It is actually more of a manual than a book to read from cover to cover, a guide to common trigger points in the body and their referral patterns.

A quick explanation of trigger points - in case you don't know what they are - is that they are specific points in muscles which are hyperirritable, found in taut bands of muscle fibre and frequently refer pain to a different area of the body. People often refer to them as 'knots' or 'lumps', and indeed they can often be easily felt within muscles.

The book divides the body into regions, further split into separate muscles. For each muscle included there is a standard format including information on how to locate the muscle, pain referral patterns, causative factors, affected organs, stretch and strengthening exercises plus a few other bits. Each muscle is accompanied by a diagram showing where, in the experience of the authors, they've found to be the most likely areas for trigger points to develop, and another showing pain referral areas. This is the useful part because a therapist can easily look at where pain is felt by the client and then go to a specific muscle to potentially find a trigger point. In practice it doesn't work this way - unless a whole treatment is set up purely to look for trigger points it is more usual to locate the trigger point within a dysfunctional muscle when we palpate it during the course of a treatment. By applying compression on the trigger point we can often replicate the pain a client feels, and with treatment erradicate them.

The introductory chapters are very useful for us as therapists to read and refresh our knowledge. Chapter 1, The Nature of Muscles and Trigger Points, has some good information on phasic and postural muscles. It talks a lot about dysfunction and the reasons that may come about due to postural stresses and physical activities which involve repeated movements. This leads on to areas prone to trigger points because of increased mechanical strain and decreased circulation.  "Our ability to operate in a physiologically optimal manner are all affected by holding patterns of muscular constriction.".

Chapter 2, Qi, Movement and Health, explores the Eastern and Western ways of treating trigger points. There are two points that stand out in this chapter. Firstly is that Eastern and Western therapists would both benefit from studying the others way of viewing the body. However each treats, we do so by seeking to remove constrictions that cause pain and trigger points. Importantly, we both do so by affecting the body on a physical level through movement and the release of contrictions. So, Finando & Finando suggest that Eastern practitioners would benefit from studying myofascial and muscular structures, and Western therapists by studying meridians.

The second point I take away from reading this chapter is related to movement. "Health requires movement, when movement ceases, life ceases." That may seem like a dramatic sentence to highlight, but it has stuck in my mind. Ultimately, without movement comes death. On a less dramatic, but very significant level, without movement your muscles become dysfunctional, pain affects your body and constrictions occur (and thus trigger points).  When the constrictions are released by a therapist the muscle can return to function and this will lead (directly and indirectly) to freedom thoughout the body, at both superficial and deeper levels. The chapter also talks about fascial lines, quoting Dr Paula Scariati on trauma or fascial changes:

Moving on, Chapter 3, Informed Touch, was a good reminder to me as a therapist about the process and thought that goes behind palpation. It's not just about hands on the client, there is so much more thought that goes into the process - from both a physical and emotional point of view. Key point from this chapter is to have a mental image of what your are palpating; know what to expect, then you can see whether there is dysfunction present. Good knowledge of anatomy is vital.

The final chapter, Diagnosis and Treatment gives an overview of what a therapist should be doing - observing the client, evolving palpation skills, listening closely, treating with precision and attention, extending treatment beyond the clinic (i.e. homecare), and allowing feedback from palpation to guide the treatment.

Although a short read, this book (or should I say manual) was good to review. I'll certainly be showing the diagrams to clients more often so they can visualise pain referral patterns, and why when they say the pain is felt in one area I might look to treat elsewhere.

F.I.T.T. Principle

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Ever heard of the F.I.T.T. Principle?
If not, read on - it's important to anyone wanting to progress in their chosen sport.

So you have a training programme but are you following the F.I.T.T. Principle? Well you should be. It's a guideline that will help you get the best out of your training and it stands for

Frequency: how often you train

Intensity: the level of effort you put into each session

Type: the activity you are doing

Time: the duration of a session

Lets expand on those a bit, so you know what you're doing and why this principle is something everyone should adopt. With a word of caution, these are general principles - there's always going to be some people who do things differently, overloading or just beasting themselves!

Frequency:
How often you train for a particular activity is important. There are different frequencies for different things, think about weight training and aerobic training. With weights you really shouldn't train the same muscle groups every day. Neither would you want to do a hard hill session daily. It's all about balance and making sure you give yourself and the muscles worked time to recover adequately between sessions. Muscles get damaged when we use them, even without injuring them so you'd notice, and it's this microtrauma you need to give time to repair sufficiently so that your muscles stay strong and can perform optimally.

Intensity:
How hard you train in a session and how much energy is expended. I'm not going to go into max heart rates, zones and percentages of max - but it's all this stuff you need to factor into your training to get the most out of a session. Work out what you're trying to achieve - is it the 100m sprint record or an ultra-marathon? Training intensity needs to reflect your goals. You need balance here - sufficient intensity to tax your body but not too much so you end up injured or you're overtraining.

Type:
Cardio, weights, mixed sessions (circuits). Are you running, swimming, lifting weights, walking, doing strength and conditioning, circuits, yoga, boxercise classes? Regardless of your overall aim, be it a top 10 finish in a fell race or to beat your PB, you need to mix up your training.  This ensures all muscle groups are being worked, you won't get bored of simply counting down the mileage, and your body becomes stronger by being constantly challenged.

Time:
The duration of your training session will vary, depending on the activity and your goals. If you're working on improving fitness by walking you wouldn't get very far if you did 2 minutes walk, 1 minute rest and repeating 5 times. But for a hill session running these times up a 20% incline would be appropriate. In general, the higher the intensity, the less time you spend training.

Essentially what all this boils down to is that you have to be sensible about your training. No sudden increases in what you're doing. If you're a new runner, don't expect to be able to run 5 miles at marathon pace after only a few training sessions. Build up slowly - use the 10% rule - keep all increases to no more than 10%.  This might seem overly cautious, but it ensures your body adapts to changes and helps to prevent injury.

Guest blog at Combat Sports Clinic

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In October we were asked by Rosi Sexton if we wanted to contribute an article for the Combat Sports Clinic blog. Of course we jumped at the chance - Rosi, in her own words... "...is the founder of Combat Sports Clinic and is a registered osteopath and sports massage therapist. She is also a professional MMA fighter, and is currently ranked amongst the top 10 female fighters in the world."

The topic for our article is the Physiological Benefits of Sports Massage for Athletes it was published in two parts. Enjoy the read of both Part 1 and Part 2 - and as always, let us know if you have any comments.

Advanced Therapy Course

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I was down in Oxford this weekend just gone doing an Advanced Therapy Course with John Gibbons, who has more letters after his name than in it, and is involved in more world class sports teams than I could actually name. (I know he has a new website being made, so when I know where it is I'll link to it).

The idea of doing this course was to get some new ideas, new techniques and get some insights into the structural world of the body. I am mostly concerned with muscles and soft tissue, John comes from an osteopathic background, so to see his take on things was very useful.

Some of the things that stick in my mind - especially now I have had the time to look at and write up my notes are the differences in Spinal mechanics, both in neutral and non-neutral positions, and, perhaps more importantly, how to identify and recognise them. We went through the mechanics and motion of the innominate and sacrum (pelvis) and how to identify and fix dysfunction through various methods.

There was an excellent re-cap on muscle firing patterns, which, although I know, and have been taught, was a welcome reminder, and gave me a few more ideas as to WHY firing dysfunctions may happen, and also more ideas on how to re-fire, and re-educate muscles into correct patterns.

There was more, much more, but I don't have time or space to go into it all now.
I can't wait to put the things I've learned into practice, rest assured they will be tested out and refined on Lynne first before being unleashed on other people!

If there are other therapists who have heard about the Advanced Therapy Course, or even if you haven't, I'd suggest going on it. It was very educational, thoroughly worth the money, and I will be constantly learning from my notes for the foreseeable future. It'll be great when it has all been assimilated into my head, and even better when it is in my style.

November Book of the Month

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In our continual search to improve our skills and knowledge we are reading a new book each. In November our books are:

Tim's choice is Spinal Manipulation Made Simple, A Manual of Soft Tissue Techniques by Jeffrey Maitland

Lynne's choice is Trigger Point Therapy for Myofascial Pain, The Practice of Informed Touch by Donna & Steven Finando

Just because you have books on your shelf doesn't mean you are learning: you need to read them!!

Rehab exercises for ankle sprains

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We've already written about ankle sprains and how to possibly prevent them through strengthening and proprioceptive training. I recently came across some rehabilitation exercises which can also help.


Make sure you are past the acute stage of injury and can fully weight the injured ankle before undertaking these exercises. Do the exercises in bare feet to start with, and on flat, even, ground. Start with stepping in the configurations shown and build up to hopping.

Continue with the direction and step configuration for 1-2 minutes on each leg

Using the different change of directions places multiple stresses on various structures of the ankle, thereby providing all round strengthening. Ensure you do each configuration starting on each foot.

It's hard to say do these for X number of days or X times. Only you know when your ankle feels stronger, and in addition people heal at different rates. Don't rush your rehabilitation - it's better to be conservative, reducing the risk of re-injury. Saying that, you have to put in some hard work and integrate rehab exercises into your daily training (and rest) programme.

Once you are ready to move on you can start to introduce changes in terrain (e.g. grass, sand) and then do drills with running in a circle, figure of eights, plus hill work and different cambers. Finally, remember the hedgehog for proprioceptive training - see the other blog linked at the top if you need a reminder!

Lower back and hip pain - Professor Shirley Sahrmann

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I was privileged to be able to hear Professor Shirley Sahrmann speak in Manchester on Sunday 6^th November 2011. For those who don't know her, she is a highly regarded expert on muscle and movement imbalances. Her book, Diagnosis and Treatment of Movement Impairment Syndromes, is an absolute must read for any therapist working with the body, regardless of modality.

Prof. Sahrmann is based at Washington University, USA, so to catch her on a flying visit to the UK was an opportunity not to be missed.

So what was I there to learn? The official title of the course was Differentiation and Effective Management of Lumbar Spine and Hip Pain using the Movement System Syndromes Approach. A bit of a mouthful I think you'll agree.

Issues covered:

• Kinesiology of the lumbar spine, pelvis and hip.
• The concept of relative flexibility and it's presentation in the lumbar spine and hip
• Current knowledge of the structural variations in the hip including cam and pincer.
• Movement systems syndromes of the lumbar spine and hip joint, and contributing factors.
• Clinical and research evidence of the interactions between the lumbar spine and hip.
• Practical application of the movement system syndromes including screening and clinical reasoning.
• Rehab exercises to correct movement faults.

The objectives of the day were to enhance our treatment strategy when a client presents with back and hip pain, learn how to effectively manage those conditions and have a more systematical way to examine those clients.

What have I learnt?
There were some big issues that have resounded with me since the course last weekend.

• All Systems in the body involve Movement, be it muscle fibres contracting to produce movement via the joints and bones, gases being exchanged in the respiratory system and the circulatory system transporting those gases and nutrients to where they are needed. Any abnormality in any one of the systems affects the others, and all structures in the body. Something works less efficiently, becomes dysfunctional and pain is felt. 

• Repeated Movements and Prolonged Postures cause deviations at joints, making them less efficient, dysfunctional and in some cases painful. The tissue changes that occur with Repeated Movements and Prolonged Postures includes neuromuscular changes. The progression of dysfunction and its associated degenerative changes is not only affected by physiological factors, but also biomechanical interactions and through an individuals lifestyle and personal movement patterns - the way that everyday activities are performed is the critical issue.

• The body will always chose to move along the path of least resistance. With the resulting tissue changes from Repeated Movements and Prolonged Postures, relative flexibility or weakness can develop. For example, long distance runners typically have strong and dominant hamstrings, rectus femoris (one of your quadriceps) and tensor fascia lata (involved in hip flexion, medial rotation and abduction) - bending the hip, turning it in, and pushing it out whereas weakness tends to develop in the iliopsoas (hip flexors) and gluteus maximus (external hip rotation and hip extension). The joint movements can then become disrupted from the optimal, and in this case, where the hamstrings are dominant and gluteus maximus weak, the end result can be a hamstring strain. Sahrmann attributes this to the joint movement being altered because the muscles which should be working to control the precise, pain free movement of hip extension, are not doing so. I'll write more about this soon because it really is fascinating, and definitely a topic for all runners to know more about.

• You get what you train. Quite simply, if you train a muscle to be strong, it will hypertrophy and develop more fibres, and hence be stronger. But, and this is the important point, following on from the previous point about the path of least resistance, those muscles not trained (or not as much) will be comparatively weaker.  Why is this important? Well, if you have strong quadriceps (thigh muscles) but weaker abdominals (stomach muscles) your pelvis will be pulled down at the front and this can lead to lower back pain because of an increased lumbar curve.

• The presence of a muscle doesn't not mean it is being used appropriately. Sahrmann calls this "missing in action"- meaning that although there is physically a muscle being "worn" does not automatically mean it's working the way is should. This also contributes to the path of least resistance in movement.

• The final message which is still ringing in my ears is this, You will continue to do what is familiar, not necessarily what is right.  It's worth reading that again to really get it in your head.

Having a good therapist (and Sahrmann is a very, very good one) test muscles for movement impairments and weaknesses is essential. It is the first step to correcting any imbalances you may have. You have, of course, got to want to make the change, as different ways of moving will need to become habit. They have to become part of your daily activities. Comfortingly, this is one message which we at Global Therapies already advise our clients. We show clients where they have movement patterns or imbalances which are sub-optimal, and then educate them on how to modify movements and strengthen specific areas to improve symptoms.

I have to say that I'm quite overwhelmed by the amount of knowledge passed on by Prof. Sahrmann. She is quite incredible, and to see her working with a client, demonstrating the tests she carries out was truly humbling. I'll be ordering her second book, there's a whole lot more for us to learn yet.

Pain on the heel. Plantar Fasciitis or Achilles tendonitis?

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As you may or may not know, I was in London for a week or so in the past month. Doing a slightly different job to that of my daily work, standing up on concrete all day every day, and cycling 10 miles to and 10 miles from my work everyday. Definitely not in my daily routine as a Soft Tissue Therapist, and a massive change in terms of the FITT principle.

It hardly comes as a surprise when I change the type of shoe I walk around in every day, the type of exercise I do every day and reduce the amount of rest - that something in my body decides that its not happy and goes into a bit of pain.

For clarity, I should say that I was going back to help out in Ski Show, I figured that standing around Earls Court for the best part of a week and a bit in minimalist trainers might hurt my feet quite a lot - so I should go back to a pair of trainers with some "squishiness" to help me out. That, added with cycling everyday for 2 weeks when I haven't been on a bike for a good few months, in biking shoes I haven't really got on with...

After a week of this, I began to feel a little bit of a twinge in the right heel - just on the lateral (out) side of the foot. Funnily enough, I only felt the pain (like a tearing sensation) when my leg was straight and the foot was dorsiflexed (toe pointing upward). When the leg was not straight and the foot was in the same position, the sensation wasn't there.

From that I can work out that its probably an issue with the gastrocnemius rather than the soleus - that's the muscle which goes from the achilles tendon to above the knee joint - as opposed to the one which originates below the knee.

I can happily say that its not plantar fasciitis simply because its not on the plantar (bottom) surface of my foot. Boom. It's not plantar fasciitis.

So, what can be done? Well, from the looks of things, its the gastroc which is causing the issues, so in terms of exercises, I'm not doing anything. Well, maybe a little bit of walking, but certainly not running, I might get on the Turbo at some point this week to see if there is an issue with being on the bike, but I am keeping well away from running - mainly because it involves an awful lot of dorsiflexion with a straight leg. I'd rather just stay off the hills for a few weeks and have it heal faster, rather than push it and then be out for months and months.

I'm also icing it on a regular basis - 84p peas from Tesco - (Tip - if you ever come to my house, don't eat the peas) and having massage and trigger point release on the gastroc on a relatively regular basis - just for 20 mins a day every 2-3 days. Although it doesn't hurt on a general basis, there are a ridiculous amount of trigger points and tender points all down the medial side of the muscle, and it certainly does it good to have them released, so as to relieve pressure on the achilles tendon and the bursae underneath. One other possibility is that its not tendonitis, but might be bursitis, in which case the treatment that I'm getting for it and the things I'm doing and not doing are helping the healing process, no matter.

However, as I have mentioned in other places, being injured is pretty boring. I don't think I'll do it again.

Hydration

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We are bombarded by the media with messages to drink water. The volume quoted by many is 2 litres per day, but that's irrelevant here. What we're interested in is why. Why do we need to ensure our intake of water is sufficient?

To explain that, a little physiology is called for.
And a word of caution - figures quoted in different sources vary, what we have included here are estimates and averages, approximations if you like. But it is a good illustration of what the percentages are like.

Human bodies are approximately 70% water.
Just think about that for a moment.
Actually stop and look at yourself in a mirror.
Nearly three quarters of you is made up of water. How amazing is that.

Two thirds of that water in our body is intracellular - meaning it is inside a cell; the remaining third is extracellular (this includes blood plasma).

Blood is around 85-90% water.
The brain is around 80% water.
Muscles are about 75% water.
Cells are around 90% water.
Bones are about 25% water.

It's claimed that a human can survive about a month without food, but only a few days, a week at best, without water.

Best way to check you are hydrated?
If you're drinking a fair amount and going to the toilet regularly, chances are you are pretty hydrated. When you do go, take a note of the colour - the darker the colour the more dehydrated you are. The most obvious way to tell if you are more seriously dehydrated by how thirsty you feel, but on an intracellular level your body will be suffering before this symptom if felt.

Effects of dehydration

• Chemical reactions in the body need water to function effectively. These processes will be compromised.
• Hormones and nutrients need water to be transported around the body. These, and other substances will not reach their target areas without water.
• Water is used in the lubrication and cushioning of joints - reduced water can lead to joint dysfunction,  restricted movement and pain.
• Oxygen is transported around the body with the help of water. Without oxygen we simply cannot survive. Without oxygen muscles will not function.
• Carbon dioxide is removed from body cells to lungs with the help of water.
• Water helps to dilute toxic and waste substances and transport them to the kidneys and liver for cleaning or removal from the body.
• Water helps to distribute heat around the body - without this help overheating will occur.
• Balancing electrolytes is essential for athletic performance. With good hydration levels sodium, potassium and calcium can be moved from blood plasma and interstitial fluid freely. If these elements are unbalanced performance suffers and cramp is a real threat.

It is common for athletes to sweat when performing. Dehydrating only 2% of body weight can impair your physical performance:

• increased heart rate
• decreased cardiac output
• drained mental sharpness
• reduction in muscle power and endurance
• risk of heat stroke
• mental confusion
• loss of coordination
• fatigue
• muscle weakness
• muscle cramps

At only 10% dehydration muscle spasms, confusion, difficulty breathing and even unconsciousness can occur. Even with a modest level of dehydration the adverse effects on the body are noticeable and performance levels will be reduced.

Staying hydrated is really not very difficult. To be quite frank, we don't see why so many people seem to resist drinking water so strongly. It keeps us alive, keeps our bodies working efficiently and keeps us clean on the inside. Make sure you are hydrated, before exercise have some extra water to prevent fluid levels dropping significantly through sweat loss.

Finally, don't wait until you are thirsty before drinking some water. That goes for cold weather days too.

ART and STR - the differences?

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I've had a few clients come for a first treatment, and they have mentioned that during trips to the USA they received a marvellous and almost magical treatment called ART. They explained it as a stretching kind of motion which caused an almost "Chinese burn" like sensation.

Now to me as a Sports Massage Therapist, this sounded remarkably like STR (Soft Tissue Release), very much one of the standard techniques that we are taught and use on a day to day basis. When I proceeded to do STR on them, they were astounded and the remarks were generally along the lines of

"Yup- that's it, that's ART- wow, it feels MUCH better now."

Interesting.

So what is the difference between ART and STR? Are there any? I decided to do a little bit of delving and see what I could find. Obviously from a position where I use STR on a daily basis, most of my research was based around looking at what ART is and how (if it does at all) it differs.

My first port of call was, as ever, the internet, ART- Active Release Technique "the gold standard in soft tissue therapy" Brilliant, so I get to find out what it is. But not quite.
ART, it seems is a patented version of Soft Tissue Release. You pay your money, and go on a seminar, and learn to do ART. Which is pretty cool... but is there actually a difference between the two techniques - especially as STR certainly isn't patented. As Mel Cash says - you can patent a way to teach something, but you can't actually patent a technique.

I asked around a few therapists, and a few authors of Soft Tissue Release books, and received the somewhat underwhelming response that they thought the techniques were very similar, but weren't really sure.

Thankfully I found a colleague who has been trained in both STR and ART - and is someone I look up to as a tutor and a therapist, he was able to give a little more insight into the similarities and, more importantly, the differences between the two techniques.

It would appear that the main difference between the two techniques in terms of "hands on" palpation is that in STR we apply a lock into the tissue, creating a false insertion to the muscle - creating a restricted range of motion. The muscle is then moved through this restricted range. I suppose you could ultimately call this a "pin and stretch" technique.

ART uses more of a slide and move between components. There is no specific "lock", but more of a non-specific parallel tension - and the limb/muscle is pretty much always moved through the full range of movement. There is no movement of the contact hand- certainly no slide, but perhaps a slight proximal or distal grip.

It would appear that the technique is quite subtle and there are various releases that don't seem to be covered by STR as a rule - things like nerve entrapment releases - which sound really quite intriguing. It has been explained that the tension is used in a way to try to separate myofascia - and seems to be more precise in terms of depth, area and location.

The main massive difference is the way in which it is taught - and this is where ART and STR differ and where the patent comes in. STR is widely publicised and is very much a part of the Soft Tissue Therapists daily tool box. It requires a knowledge of how muscles and fascia work and in which direction they work in, and the subtlety comes from the practitioner. Precise techniques are developed over time and mastery is very much something that you get to from your own exploration of the technique.

From what I've been told, ART is taught in a very regimented and exacting way. Each myofascial structure, each muscle, each nerve and joint capsule has a working protocol and it is all standardised. When you learn, you learn exactly as demonstrated and you do not deviate from the way it is done by the tutor - which is the way it has been handed down from the guy who patented it.

Both versions of this myofascial release and the way in which they are taught have their benefits and their downfalls, but they both get the job done in remarkably similar ways.

As such, I will continue treating with STR, but now, when people ask about ART and the treatment they may have had elsewhere, I know where they are coming from and what they are expecting in terms of treatment. Interestingly, I often feel that STR might be a little too aggressive and choose to let the lock slide, so perhaps I'm already using some form of ART to obtain more subtle tissue changes.  I would like to actually go on an ART course in order to have hands on experience of the differences between them, but unfortunately as far as continual professional development, my time and resources have been allocated already for the moment. Hopefully next year I will get a chance to see and feel the difference. When I do, I would hope to be able to give more of an insight as to the differences, instead of just writing down what I have gleaned from other people.