Victory for Men's Health
Half a lifetime ago, I fell in love with a young man who used to like telling me about health and fitness. Ever the observant girlfriend, I fairly soon noticed in his bedroom copies of popular magazine Men's Health: my amour's goal, it seemed, was to be a cover model.
A short while into our relationship, however, his words of wisdom dried up. This may have been because I began buying my own copies of Men's Health, reading them faster than he did (I had to sit through physics lessons; he at a couple of years older had an actual job) and then quoting the articles at him. He had nothing more to say. We didn't last long, and he never did become a cover model, which is a shame, as he had lovely abs.
Not being their target audience, I hadn't picked up a copy since then; but if you are a MH aficionado, you'll know that on a semi-regular basis, they set their journalists physical challenges, which they then have to complete and write about for the amusement and edification of their readership. The current such challenge is for two ectomorphic journalists, both coincidentally called Ed, to compete for the most impressive "transformation" with a personal trainer. In effect, the trainers are competing to make the greatest difference to their clients.
And this is how I came to meet Ed Reeves, or "Big Ed" as he is affectionately known to readers of MH. Ed has been working with top Foundry trainer and former Olympian Sarah Lindsay since the start of January, trying to pack on enough muscle in three months to beat "Little Ed" Vanstone, who is himself working with MH cover model and trainer Olly Foster.
Big Ed somehow bypassed our usual pre-training musculoskeletal assessment; but given that he has never trained before, and with a pretty dodgy starting posture and various underlying issues, it wasn't a huge surprise to anyone other than himself when he broke down and found himself being poked and prodded by me and by Victory's osteopath Ray Yong.
I'll not go into details of what we saw and found - medical confidentiality being pretty important to both me and Ray! - but suffice to say that we were both able to offer suggestions of diagnosis and treatment. Ray is a fan of acupuncture, and I'm a fan of the Sarah Key method; I think Ed would have been happy with either (and either would have been effective) but as Ray was heading home, I treated Ed myself. And he seems quite happy with the results!
Having said that, Ed was lucky to recover so quickly. If you are thinking of embarking on a new training regime, it really is sensible to get checked out beforehand. I don't just mean the usual GP checkup for blood pressure, though if you're seriously out of shape, of course that is important. But from an injury perspective, or rather from an injury avoidance perspective, it is worth getting a good pre-training musculoskeletal assessment with a therapist who is familiar with the demands of personal training and who will talk to your trainer. Our assessments help the Foundry's trainers to personalise their clients' programmes, adding in specific corrective exercises and avoiding anything that's likely to be detrimental. Most of our clients have relatively sedentary jobs, or jobs that involve repetitive movements - I've lost count of the clients I've described as "chair-shaped" over the past year - and corrective exercises, particularly using the back block as an "anti-sitting" device, really do make a difference and help them to avoid injury.
If you're thinking of starting a course of personal training, whether at The Foundry or elsewhere, it's worth getting yourself checked out. We're not the only option, but we're pretty experienced and we're happy to talk to your trainer - what have you got to lose? Contact us for your 30-minute MOT!
Teaching - the Sarah Key way
Last year, Sarah Key invited me and nine other physiotherapists (all accredited practitioners of the Sarah Key Method, or APSKM) to a meeting at Highgrove, where she revealed that she was beginning to think about retirement and wanted us to consider taking on the legacy of teaching her courses in the future, and also that she was planning to write a textbook of her method for physiotherapists, to which she wants some of us to contribute. I understand that her popular books are already being studied in some schools of osteopathy, but she’s written nothing specifically for practitioners yet.
As experienced physiotherapists and enthusiastic practitioners of the SKM, we were all pretty flattered to be invited, and keen to get involved; and as Sarah has never let anyone else teach her courses before, we set out to train ourselves up. We’ve had help with this from Sarah herself, who has given us access to the PowerPoint presentations we’d be teaching, and also from her administrative staff Carmel, Ruve and Federica – and most of all from physiotherapist and researcher in spinal biomechanics Manos Stefanakis and his PhD supervisor, Professor Mike Adams who presented a superb lecture at our teacher training meeting at Kensington Palace in June.
We’ve all put in a lot of individual work into reading and absorbing reference papers, learning teaching and presenting skills; and meeting up on a regular basis to practise, update each other on the latest spinal research and discuss logistics, in Tetbury, Bristol, London and Belfast and during Skype-based conference calls.
And this month, we finally had the chance to put it all into practice as five of us took turns to teach the Sarah Key Masterclass 1 course at Highgrove.
With Sarah herself and Manos watching and assessing our teaching, we were all a little nervous; but the fifteen delegates were enthusiastic and the course went really well, with no real glitches. Everyone felt well prepared, and I think the work we’d put into learning and understanding the academic research behind the presentations really paid off. They do say that if you want to improve your knowledge of something, you should teach it; and that definitely rings true for me.
After the course, Manos took each of us aside to feed back on our performance, which was extremely helpful and reassuring as he felt we had all done well; but equally important and gratifying was the response from the delegates, who reported back with comments including:
- “enjoyable and helpful”,
- “I have honestly never been to such a good course before”
- “a fantastic few days”
- “a huge inspiration”
- “a really enjoyable 3 days of amazing learning and discussion”
- “your course has ignited my passion again... I can’t fully express to you my sense of relief and enlightenment”
Pretty awesome, huh? Of course, the real credit goes to Sarah as it's her passion and years of work that underpin the Masterclass; but it's nice to hear that we managed to convey it successfully.
The next Sarah Key Masterclasses will be run in 2012 in Scotland and Northern Ireland, as we’re breaking away from just using Kensington Palace and Highgrove to make the courses more accessible. They’re open to physios and osteopaths. If you’re interested in attending, please contact Federica Bertolini at admin.uk@sarahkey.com.
*Picture taken by Manos Stefanakis of me standing on Sarah Key, at her 2010 Back in a Week course.
Shakespeare? What a pain!
I was lucky enough taken to the Old Vic recently by an old friend, to see Kevin Spacey playing the lead role in Sam Mendes’ production of Richard III. I’m not generally a huge Shakespeare fan (memories of watching Macbeth at the National Theatre when I was studying it at GCSE put me off somewhat; and I found Jacobi’s Lear unconvincing this summer) nor am I a particular Spacey fan; but this show really blew me away. I was enthralled and barely glanced away from the stage for the entire three hours.
But three hours is an awfully long time for a man to play a twisted hunchback; the King is rarely offstage and the physicality of Spacey’s performance was quite extraordinarily compelling and consistent. He played a man in pain extremely convincingly; in fact I’d be amazed if he wasn’t genuinely in quite some significant pain by the end of the production, and I wonder if I was the only audience member relieved to see Richard hoisted aloft by his ankles at the end: at least he finally got some traction to relieve his poor, tortured spine!
After all, Kevin Spacey wouldn’t be the first actor to be left crippled by Shakespeare. I rather assume this story is apocryphal, or at least that the wording has been altered over the years; but according to Antony Sher’s “Year of the King”, at the end of the original production of Richard III, Burbage told Shakespeare “If you ever do that to me again, mate, I’ll kill you.” Somewhat later, in 1972, Robert Hirsch of the Comédie-Française apparently found some sort of solution: his Richard limped on alternate legs from night to night!
Simon Russell Beale managed a five-month run as Richard III in Mendes’ production for the RSC in 1993; but just three days after it transferred to the Donmar Warehouse, he was forced to retire and to have an operation on a prolapsed spinal disc. The same thing happened to David Tennant in 2008 during a run of Hamlet: after a successful summer run in Stratford-upon-Avon, the production moved to the Novello Theatre and Tennant ended up in surgery.
Given how slowly spinal discs go wrong, it seems unlikely that Shakespeare and his directors can be completely blamed for this spate of injuries to leading men. They probably had some degree of back pain before they took up their roles. However, there’s no doubt that the physical demands of playing a role which requires extreme postures to be maintained for prolonged periods, will cause a degree of soft tissue deformation and also of extreme concentrations of compressive stress on the spinal discs. Moving and changing position regularly causes compressive stresses to alter, and it is thought that this assists with disc nutrition (which is why it forms the basis of Sarah Key’s “pressure change therapy” theory); the reverse is also true, with prolonged relatively static postures, particularly extreme postures, effectively reducing the discs’ nutrient supply and causing damage.
So my pleasure in watching this extraordinary production was tempered somewhat by the thought of the damage the leading actor was doing to himself in his effort to provide a superb experience for the viewing audience. Mr Spacey, I do hope you have a good physio!
Why use the back block?
I had an e-mail this week from a blog reader who asked whether the Sarah Key exercises I've blogged so far would be good for spondylolisthesis.
Spondylolisthesis is a condition which affects 3-6% of the population in which one vertebra - most commonly the L4 or L5, at the bottom of the spine - slips forward on the one below it. Left uncontrolled, it produces a more exaggerated curve of the low back, like those you often see in men with really big tummies or pregnant women. The grade of spondylolisthesis is determined by an X-ray to see how far the upper vertebra has slipped - a grade I being a forward slippage of 1/4 of a vertebral body, grade II being half, and so on. Surgeons tend to get involved with grade II+ spondylolistheses as the slippage is more likely to be a danger to the spinal cord.
There is a fair amount of evidence in the literature for strengthening the core muscles of spondylolisthesis patients, particularly the transversus abdominis which acts like an internal corset, and the multifidus which acts like the guy ropes of a tent to shore up and stabilise the slipped vertebra. I'll go through some useful exercises for these in future posts as they are excellent for any form of instability, but incidentally this is one situation where I think exercise methods such as Pilates can be really useful.
As well as core exercises, I really rate the back block for spondylolisthesis patients. Traditional physiotherapy extension exercises are carried out from the prone (face down) position, where the patient pushes up onto elbows or hands to extend the spine. I don't use this for spondylolisthesis patients because gravity, as you can see from the top diagram, acts on the vertebrae to produce an anterior (forward) shear - exactly the same force that causes spondylolisthesis! Lots of physiotherapists have therefore moved away from prescribing extension exercises to spondylolisthesis patients.
By contrast, however, the back block exercises are done in a supine (face up) position. This results in gravity pulling the vertebrae towards a position of backward shear, as you can see in the lower diagram - and thus into a more neutral position away from the spondylolisthesis slip.
The effect of this tends to be (gradual, cumulative) better alignment of the spondylolisthetic segment, and also reduced muscle spasm and reduced pain.
Of course, not every case is that simple: longstanding spondylolisthesis problems often lead to altered muscle control and movement patterns, as you start to compensate for the discomfort of the injury. Using a back block doesn't replace a proper assessment and treatment plan in every case. But if your physio isn't already getting you onto a back block, it might be something to discuss.
Please feel free to ask questions - either here on the blog or by e-mail - or get in touch to arrange an appointment.
Sarah Key Method - Back Block
Time to get back to backs!
This exercise is another of Sarah Key's, and is great for stretching your low back. You'll need what Sarah calls a back block; they're also known as yoga bricks. Roughly the size of a house brick, they come in a variety of materials including wood, bamboo, cork and foam - I usually use one made of solid foam, though in an emergency I have also been known to use a hardback copy of a Harry Potter book!
When we spend all day with our spines in an upright position (sitting, standing, walking, running), gravity combined with our bodyweight squashes our spinal discs, and over the course of the day they flatten out a bit. It's not unusual to be 2cm shorter at the end of the day than you were at the start. Generally, the discs rehydrate and plump up again overnight when you're lying flat, but over time - with age, or particularly with injury - the flattening starts to have a greater effect than the rehydration, and you develop stiff spinal segments.
Sarah's theory is that this process is reversible if you regularly take steps to decompress your spine, and this is where the back block - coupled with the appeasing exercise I described before - comes in.
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Lie on your back on a firm surface such as the floor, knees bent so that your feet are on the floor, and feet and knees together. - Squeeze your knees and buttocks together. Keeping them squeezed, roll up your spine, curling your bottom off the ground first, and - bone by bone - then your low back, mid back and upper back, until your weight is on your feet and shoulders.
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Bone by bone, roll your way back down again, trying to make the space
between each bone as long as possible, and making sure that when you reach your pelvis, the left and right sides hit the ground at the same time. - Make sure your knees and buttocks are squeezed together, and roll all the way up to your shoulders again, bone by bone.
- This time when you are at the top, slide your back block underneath your pelvis (NOT under your low back) and roll your bottom down onto it. The block should be horizontally aligned and on its shallowest side.
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Slide (don't lift) one foot along the ground and away from you, and then the other. Allow your ankles to relax and roll outwards. Relax your calves, then your knees, then your thighs, buttocks, low back... - Let your arms roll outwards so that your palms face the ceiling, and relax completely for a minute.
- Then slide one foot back up towards you, and then the other.
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Squ
eeze your knees and buttocks together, and roll your way up off the block (at first this may be sore; don't worry, this is quite normal and it does get better!) - Slide the block out from underneath your bottom, and roll down just as you did before.
- Now do 30 seconds of the appeasing exercise, and repeat the whole thing three times.
NB - any discomfort you feel on curling up off the block should fade quickly and should improve over the first few days of practising this exercise. If it is too painful, or remains significant for more than a week of doing this, you should discontinue the exercise and get your back assessed. (Of course, I'd recommend that you see a Sarah Key-trained physiotherapist...)
Thanks to the lovely Graeme Marsh for posing for these pictures at The Foundry.
Shoulder pain - an underdiagnosed dysfunction
This post is triggered by Dave Thomas of The Foundry, who commented yesterday on Facebook following a therapy session with me that “if you haven’t had your subscapularis walked on before, it’s a treat!” It seems to be a relatively unusual technique, but one of my favourites, and this is why.
The subscapularis (aka subscap, to rhyme with hubcap) is a triangular muscle which sits between the ribs and the shoulderblade (scapula) – its name meaning literally “below the scapula”. With its base covering the entire of the inside edge of the scapula, it narrows to a tendon which attaches to the inner part of the humerus (upper arm bone) and the shoulder joint capsule. Its role is to twist the arm inwards (place your hand on your stomach and try to push through to your spine: you’re using your subscap) and to pull the humerus forward and down when your arm is raised, thus preventing your shoulder from dislocating.
It’s one of the four muscles that make up the rotator cuff, (the others being supraspinatus, infraspinatus and teres minor, if you’re interested!) but far less frequently torn than the more vulnerable supraspinatus and infraspinatus. Probably because of this, it’s a muscle that’s often ignored by therapists when treating sore necks and shoulders, but in my view that’s a mistake. Good subscap function is essential to good neck and shoulder function, and I have a few theories as to why this is the case.
One theory is the effect that subscap has on the ribs. As I’ve mentioned, subscap sits between the ribs and the scapula. Normal shoulder movement depends on the scapula being able to glide freely over the ribs. When muscles are sore, they tend to tighten up and develop trigger points – isolated areas of muscle spasm; and subscap is no exception. It’s my belief that tightness and/or trigger points in subscap can be partly responsible for dysfunctional movement of the scapula over the ribs. This in turn places excessive strain on the rib and shoulder joints, leading to pain in the upper back, neck and/or shoulder.
I believe that another problem with subscap trigger points is the effect these have on blood flow and nerves. I suspect that when a muscle is tight, its spasmed fibres affect not only each other, but also other local structures such as blood vessels and nerves. In the case of subscap, this could – theoretically - affect the axillary (armpit) artery and the ulnar branch of the brachial plexus – the nerve that goes down to the inside of the elbow and the ring and little fingers. It’s certainly noticeable that patients often comment that they feel odd sensations in these areas, as I release their tight subscaps; or that once I’ve finished, they feel a rush of heat to the area (increased blood flow?)
Releasing the subscap is pretty tricky to do on your own. I often use my heels to release subscap in my patients – most therapists use their fists or fingers, but it’s hard to do that without jabbing your patient and causing more discomfort than necessary. If I have to release your subscap, I’ll ask you to lie on your back with your hand behind your head. This brings the edge of your scapula out to the side of your body, and I can then fit my heel between the edge of your scapula and your ribs, and use my bodyweight to stretch and massage the subscap, gently and rhythmically until the spasm subsides.
Not only does this tend to release the subscap spasm, it also frequently seems to relieve neck pain and increase in rotation at the neck, which is a great side effect. I’m not sure whether this is also due to better rib mobility, or whether there is some sort of chain reaction going on whereby the subscap release causes a release in the levator scapulae – any bright ideas gratefully accepted!
After I’ve released your subscap, I’ll show you how to stretch it yourself, using a chair, Swiss ball or yoga brick, so that you can maintain the improvement at home.
If you're having problems with a shoulder, please e-mail me for advice or for an appointment.
Sarah Key Method - Appeasing exercise
Moving on from last week's diversion - back to the back pain!
This exercise from legendary Australian physiotherapist Sarah Key is suitable for virtually anyone's back, and is the first exercise I teach my patients who have low back problems. The key is to be very subtle with your movements - in this instance, less is definitely more. The idea is to gently appease the low back muscles and coax them out of spasm, muscle spasm being the body's natural - but in this situation unhelpful - response to pain.
If you jerk or move too forcefully while doing this exercise, you are likely to stimulate the stretch receptors in the muscles, which could potentially make the spasm worse. But if you can keep your movements smooth, and "under the radar" of the stretch receptors, then it will really help to soothe your back pain.
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The first step is to lie on your back on a firm surface - a folded blanket on the floor is fine, or in my therapy rooms I use a yoga mat.
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Pull your tummy in gently, as this supports your spine, and bring one knee up to your chest. Hold the knee in the same hand - i.e. if you have lifted your right knee, hold it in your right hand.
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Keeping your tummy pulled in, bring the other knee up to join the first, and hold it in the other hand.
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Cross your ankles, and drop your knees apart, still holding them in your hands. Let your tummy relax.
- Producing the movement with your hands, move your knees gently back and forth, left and right, until you find that your weight is over the sore part of your back. This is where the muscles need to let go. Oscillate your knees gently and repeatedly over this area - I describe this to my patients as "ironing the spine" - for a minute or two until the muscle relaxes and the pain subsides.
- After a minute or two, use your hands to bring your knees back to the middle, pull your tummy in gently, and then lower first one foot to the floor and then the other. Rest for a minute or two and then repeat twice more.
- On the second and third repetition of the exercise, you may find that the sorest spot in your back has moved a bit. Hunt around until you find it; but remember to keep the movements subtle and gentle.
If your back is really sore, you may need to do this exercise very regularly, perhaps as often as every hour at first. Some people also find that heat is helpful, so you may also want to try using a hot water bottle on your back (obviously, all the usual precautions apply here: please don't burn or scald yourself!)
If you can't relieve your pain by yourself, then of course please do e-mail me for an appointment. I am at the Foundry on Mondays and Tuesdays, and at the Back Shop on Wednesdays and Thursdays.
Thanks to my lovely model Graeme at The Foundry - the cheque's in the post!
Sarah Key Method - Stage 1: Stiff Spinal Segment
Back in September, I started a series of blog posts detailing Sarah Key’s theory on back pain. I wrote about spinal anatomy and explained how the spine should work in a “normal” situation.
Now it’s time to start talking about what goes wrong with backs. Sarah’s theory is that back pain occurs in five consecutive stages.
She simply calls the first stage a “Stiff Spinal Segment”. Not a sexy or particularly gripping description, I’m sure you’ll agree; but most people have at least one, and it is a condition which underpins all the later and more devastating types of back pain.
As I mentioned, spinal segments (each segment consisting of a vertebra and the disc that sits on top of it) are barely viable at the best of times, so arduous is the journey from spinal canal or vertebral endplate to nucleus and back again, that fluid and nutrients have to take.
The many potential obstacles to the nutrients reaching the nucleus and waste products then being expelled include:
• Unremitting spinal compression – for example, staying in one position for too long, or carrying a heavy load for a prolonged period.
• Weakness of the tummy muscles, which allows uneven compression of the spinal segments.
• Chronic protective muscle spasm, which happens when you are in pain.
• Injury – a fall, for example, which can cause a traumatic rupture of the vertebral endplate.
The problem in all of these scenarios is that the disc is compressed (thus squeezing out fluid) but not unloaded again. It’s therefore not able to suck in fluid and nutrients to replace the fluid that has been lost. As a result, the all-important proteoglycan synthesis is not stimulated and thus the disc begins to become dehydrated and to flatten. In turn, the spinal joints then become stiff, which is the point at which you are likely to notice it, because stiff joints hurt when you try to make them do perfectly normal everyday activities, such as putting your socks on.
Manual therapists such as physiotherapists can feel these stiff joints when we palpate, or poke, your spine. (That’s the bit where we make noises like a car mechanic finding a dodgy spark plug and you start to worry for the safety of your wallet.)
The good news is that – with a bit of manual therapy and a lot of home exercise - a stiff spinal segment is a reversible condition. That is, it is possible to get the joints moving again, and thus to promote better disc metabolism; it may even be possible for the discs to rehydrate. In my next blog post, I’ll explain the basic exercises that everyone with a stiff back should be doing to help themselves.
In the mean time, I am at the Foundry on Mondays and Tuesdays, and at the Back Shop on Wednesdays and Thursdays. Please e-mail me for an appointment.
Victory at St Mawes
I'd like to start with an apology for not posting last week. I was in deepest Cornwall with Sarah Key, helping to run her Back in a Week course for patients. It was very interesting - a completely different feel and pace, compared to the military rehabilitation courses I used to run - and the setting, St Mawes, was utterly beautiful.
The down side, however, was the lack of phone signal - my mobile was completely dead all week. So if I missed your call or text, then please send it again: I'm not purposely ignoring you, it didn't come through.
During the week I enjoyed a lot of physio geekery - endless discussions of applied anatomy and physiology, with Sarah herself and also with the lovely (but sickeningly intelligent and well-informed) Manos Stefanakis, a Greek physiotherapist who has almost finished his PhD in spinal biomechanics at the University of Bristol. I also had the chance to immerse myself once again in Sarah's method and vivid phraseology, and to treat her a couple of times. It's great to be able to practise on her, because you don't get much clearer feedback on your treatment than when you're treating the inventor of the method! So I was delighted when at one point she commented "it doesn't get much more perfect than that!" Thanks, Sarah!
Despite being generally busy assisting Sarah in her lectures, treatment sessions, classes and note writing, I also managed, one afternoon, to take a trip with Manos to St Mawes Castle (pictured), just five minutes' walk from Hotel Tresanton where the course is held. The Castle was built for Henry VIII but is so well-preserved and in such a strategically-important location for defence from sea-based attack that it was still in use as recently as World War II.
But I'm now back in London, and have returned to some very exciting news. Victory is going to be opening at least one, and hopefully two, small branches in New Cavendish Street near Marylebone in central London. I'll blog more about this once they are confirmed - watch this space!
Back in a Week
No, I'm not off on my holidays - well, not exactly.
This week I am in St Mawes, Cornwall, where I am assisting Sarah Key in running her Back in a Week programme at the amazing and gorgeous Hotel Tresanton.
This is an intensive residential course where Sarah closets herself away with up to 8 patients, teaching them about their backs and how to look after them, and treating their individual problems with a combination of pedal therapy (where Sarah uses her heels to get the individual vertebrae moving) and specific exercises to free up the spine and improve muscle control.
There is also a massage therapist available if needed.
I'm really looking forward to it. I've seen Sarah assess and treat "demonstration" patients during her masterclasses for therapists, but I can't wait to see how she handles patients in a more intensive, sustained setting, and builds her relationships with them. Having attended and run rehabilitation courses myself in the Army, I am intrigued to see what the differences will be between Sarah's courses and the Army's version. I have a feeling the discipline might be a little different, however: somehow I can't imagine Sarah's patients being made to stay behind and clean the gym floor if they're late to class...!
While I'm away, hopefully my own patients will keep doing their exercises - and I'll be back in Marlow offering treatment sessions on Fridays from 5 November. I'm getting quite busy there now but if you'd like an appointment, please don't hesitate to e-mail me.
Blog for Victory
Hi, I'm Nell Mead. I'm a former Army physiotherapist and I specialise in sports medicine and back pain. This is my blog, where I write about issues that are on my mind. Some of these are about issues that are specific to particular injuries or medical conditions but I will also be updating you on events occurring inside Victory and in the wider world of medical rehabilitation. I also publish guest posts by Victory's other therapists whenever I can persuade them to sit still for long enough to write something!
When we're not writing, we're offering appointments at The Foundry in Liverpool Street. We'd love to see your comments on our posts - and we'd love to meet you even more, so do pop by and meet the team.