http://www.greglehman.ca Tue, 31 Mar 2015 18:15:17 +0000 en-US hourly 1 Treatment Fundamentals: a simple framework to reconceptualize pain and injury treatment http://www.greglehman.ca/2015/02/19/treatment-fundamentals-a-simple-framework-to-reconceptualize-pain-and-injury-treatment/ http://www.greglehman.ca/2015/02/19/treatment-fundamentals-a-simple-framework-to-reconceptualize-pain-and-injury-treatment/#comments Thu, 19 Feb 2015 23:31:31 +0000 http://www.greglehman.ca/?p=63 The following article was also published at Medbridge Education.
During our roundtable discussion on Pain: Where Does Biomechanics Fit on MedBridge, a good question came up: “How do you keep up with the literature to guide your practice?” The daily volume of publications can make it difficult. My solution is to regularly refer to my fundamentals of treatment, which stay the same, and occasionally “redecorate” them with new ideas. This way, new research complements my fundamentals and rarely throws me for a loop. For your own practice, I’d recommend writing down what you consider to be your fundamentals of treatment. What do you hope to accomplish within your treatment session? What are your views of the body? What can you do to affect your patient?

My Fundamentals of Treatment (aka Axioms of Function)

1. Rule out red flags
When dealing with pain, I want to be sure that pain is the primary problem. Pain – secondary to cancer, autoimmune disorders, infections or anything sinister – must be dealt with appropriately.
2. Rule out serious tissue pathology
Although hurt doesn’t equal harm, sometimes harm equals hurt. I like the biopsychosocial approach to treating pain and injury, as it recognizes the importance of bio. Dealing with a runner who has experienced months of anterior hip and groin pain, I can’t automatically assume that they have chronic pain and a sensitized nervous system. They could have a stress fracture of the femoral neck, a tissue pathology to be addressed. Yet, recognizing the bio doesn’t mean freaking out about rotator cuffs tears, hip labral tears, degeneration, etc. – we know they can co-exist in healthy, pain-free individuals.
3. The body is strong and adaptable
After ruling out the pathologies, I can view the body positively. Regardless of pain levels, I can tell the patient that their tissue is strong and start treating the whole person. I want to change their beliefs about their body and convince them in the above axiom. The human body isn’t a stack of blocks that will fall apart if there’s something slightly off.
4. Pain is more about sensitivity than about injury
In my treatment, I use every opportunity to show that pain is modifiable, to prove that it’s more about sensitivity than damage. The patient learns that their connective tissue is robust and their pain is due to a sensitive ecosystem meant to protect them. The pain often has little to do with their structure or strength; it’s more of an allergic response by the body. People don’t die because of a bee sting, but because of their allergic reaction to it. Pain is the same way. You can remove the stinger (i.e. heal the tissue) but still be left with the protective responses driving the dysfunction. When you modulate a patient’s pain in 5 minutes and contrast it with the obvious fact that they didn’t heal in 5 minutes, these ideas start to click.
5. Treatment is about finding the appropriate stressor/load
I put stress on tissues because I know those tissues will adapt. But the body is an ecosystem, and there will be responses to that stress elsewhere. I have no idea which components of the biopsychosocial model I’m influencing with an exercise program, but I assume all might be involved and try to maximize it. Therapeutic neuroscience education is a stressor (see Adriaan Louw’s great course). We’re not teaching patients to pass a test, but to actually change their opinion of their body and ecosystem. Do you think a spine stability program really needs to change spine stability to influence pain? Of course not. If proposed in the right manner, it can change a patient’s views on their strength, adaptability of their body, and malleability of their pain. I think exercise is a BPS intervention. I think the tissue is important, but I don’t fully know how it influences pain. Exercise is a great psychosocial intervention if we frame it so. We’re challenging (a form of stress) the patient’s view of their body. If patients view themselves as weak, the pain-free exercises help them to change opinions about their body. As patients progress, I might even have them poke the bear – confront the pain. They learn that it can hurt – and they modify the movement to change the sensitivity – but then they persist with the activity with no flare up and no harm.
We find the right stress at the right time. This can work the other way, too. We challenge the patient’s beliefs about pain and injury, influencing how they experience pain and how they choose to move. Suddenly, you’ve changed their beliefs and they pass a spine stability test.
6. The patient is an active participant in their own care
My job is to do nothing that makes the patient rely on me. I don’t tell patients that they have scar tissue, adhesions that need breaking up, shifted ribs that need correcting, or anything that requires outside help – it would contradict the axiom that the body is strong, robust and adaptable. I can’t have patients thinking they’re an inherently unstable stack of blocks. So those are my fundamentals. Then, I add decorations.

Decorations: Useful Though Not Fundamental Axioms

1. Gauge your treatments by assessing sensitivity
Treatment at its core is about desensitizing and then building back up. We find aggravating variables and modify them (e.g. a squat hurts the knees so we change the biomechanics to unload the knees temporarily) but at the same time, we also build the tolerance to the offending activity. Some patients are so sensitive that we need to resort to imagined movements (Graded Motor Imagery), but then we still increase the load incrementally (Graded Exposure – for a great review see bettermovement.org).
2. Manual therapy is an adjunct to fundamentals
I use manual therapy to prove to patients that their pain is about sensitivity. Manual therapy isn’t about correcting anything, although it may help in the short run. It’s about changing what they feel and helping to believe in their adaptive potential. I often fake manual therapy. For example, I might “correct” the scapula with a scapular assistance test and then have the patient lift their arm – and it hurts less. After 1-2 repetitions, instead of pushing the scapula, I just twist the skin – still less pain. Then, I twist the skin in another direction – still less pain. Then, as they keep lifting, I stop “correcting” completely – still less pain! I explain that there is no way I’ve corrected their scapular motion. Rather, I’ve changed how they feel – their sensitivity. Perhaps they became more confident, less fearful. Perhaps something happened in the brain (likely, but I don’t always get into it). I use that change as a learning tool and then use exercises to reinforce the new perception (a nice discussion can be found here).
3. Your assessment reinforces their belief in strength
Patients think they are falling apart. They think they are tight and in need of correcting. I confront those beliefs in my assessment. Patients often believe they have tight hip flexors and weak glutes. I wonder where they got that pernicious and pervasive idea? Often, their hips extend equally on both sides, yet they only have pain on one side. I ask how can this be if their tight hips are the problem. I point out they don’t fall over when they walk or run, so how can their glutes be so weak as to cause problems? If they feel that they have pain because their core is weak, I ask, “How can that be?” A stable core takes less than 10% of maximum contraction of the anterior abs, even during a loaded barbells squat, and most of their pain is in sitting. These confrontations help change how patients view their body.
4. Comprehensive capacity trumps assessment-driven correctives
I wrestle with the relevance of regional interdependence. It seems logical and right, but only if I view the body as a machine or a structure, and not as this complicated ecosystem. I agree that hip movement will change knee movement. I agree that a thoracic kyphosis will change scapular movement and thus affect shoulder flexion. I question its relevance to pain. Hip strengthening exercises can be great to treat knee pain (review here), but so can the old boring knee extension or knee strengthening exercises (a cherry-picked paper here, but you can follow the related articles to get the point) and hip strength may not precede knee pain (review here). And guess what! The hip strengthening exercises don’t even have to change hip kinematics to improve pain (paper here, but ignore the title – there were no changes in kinematics that most people think are important for knee pain e.g. knee valgus). So, the hip can influence the knee, but it doesn’t have to influence it mechanically to alter pain and function.  That regional interdependent idea can certainly be questioned when it comes to biomechanical changes that are “driven up the chain” from the foot – this is especially evident in the transverse plane (see here).
My solution/alternative is comprehensive capacity, my term for a shotgun approach: I’m no sniper, I am a bumbling hunter.  This approach addresses the uncertainty we should all recognize.   We don’t have to just find “flaws” in how someone moves. We can look at the painful joint, at the joints above and below, and say, “I want you to be able to do everything!” I want strength, control in all ranges of motion, a variety of movement options, speed, agility, the ability to bounce and “pop” – all done fearlessly and confidently. After all, if I’m really honest, none of us knows how these mechanical and psychosocial variables interact. If you have an injured athlete, make them the best athlete and healthiest person they can be. That’s good rehab.
5. Postural and movement assessments reveal habits but not flaws
The dominant view is that when joints deviate from a neutral position during rest or physical activity, there’s a risk for pain. If a person has an anterior tilted pelvis, hip adduction and weak glutes, the default is to blame this abnormality for their back, knee, foot or shoulder pain. Those movement patterns can be relevant, but I question why they should be the default. If no previous research or ideas existed, would we still hold this view? Consider how common and varied these movements are in the pain-free population, how incredibly robust and adaptable the body is, how pain can contribute to these movements. Should we still default to these patterns as the cause for the pain? Will they become the new structural “damage/degeneration” bogeymen we dismiss on radiographs?
I might change the habits of movement, but only to give patients variety and uncouple those movements from pain. It’s a temporary fix, akin to a bandage for a cut or a 6-week heel lift for plantar fasciopathy. But I don’t want any patient to fear any movement. BUT, I recognize the possibility for exceptions…If the research makes a strong case that certain movement patterns in certain populations under certain conditions are related to injury (e.g. increased knee abduction moment during landing in females in sports with high ACL prevalence), then I take that research and redecorate my structure. But do I freak out when every girl who runs 2 km twice a week shows up on my treadmill with some knee valgus? No. (More on this here)
So those are my fundamentals. What are yours? Should I be redecorating?
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Treatment manual workbook http://www.greglehman.ca/2015/02/17/treatment-manual-workbook/ http://www.greglehman.ca/2015/02/17/treatment-manual-workbook/#comments Tue, 17 Feb 2015 14:48:51 +0000 http://www.greglehman.ca/?p=54 The following document is a 26 page treatment manual and workbook for therapists and patients.  It has a number of different features for treating pain and injuries and lays out the start of a simple but comprehensive approach to rehabilitation.

treatment manual and therapy map greg lehman feb 2015

3d Guy: Attempting to Lift BarbellThe treatment manual helps address:

1. Assessment Suggestions for evaluating the entire person and determining which factors are contributing to the pain.

2. A novel exercise prescription map: this section helps therapists choose exercises based on the specific patients needs, goals and their presenting complaints. It is different to how much exercise is prescribed is introduces the therapist to comprehensive capacity training, when its OK to push into pain, symptom modulatory exercises and why keeping things simple is always appropriate.

3. Report of Findings page and Exercise Prescription page.

4. Patient handouts for deconstructing many myths about injury

5. Introduction to Graded Motor Imagery and Graded Motor Exposure

6. Patient goal setting sheets to explore meaningful task exercise (sports, hobbies, work) and graded motor exposure

 

**Please note, while I hope the manual can be used as a standalone workbook for many therapists it is part of a course that I teach that explores the areas in more detail with more practical applications.  Regardless, I hope it is helpful for all.

You haven’t seen the Pain Science Workbook consider reading that first.

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Courses Available http://www.greglehman.ca/2015/02/02/courses/ http://www.greglehman.ca/2015/02/02/courses/#comments Mon, 02 Feb 2015 21:04:16 +0000 http://www.greglehman.ca/?p=24 PhysioFundamentals: Reconciling Biomechanics with Pain Science (2 day) 

This course is geared toward the health care provider dealing with patients in pain.  It provides practical methods of integrating the therapeutic neuroscience and biopsychosocial model of pain with traditional biomechanical techniques.  The course simplifies many of those techniques and distills the most relevant and important aspects of those techniques for pain resolution and injury management

 Physiofundamentals: Reconciling Biomechanics with Pain Science (1 day)

This course is based on two therapist and patient workbooks.  The first book is a therapeutic neuroscience education workbook that helps the therapist begin to teach patients about pain and start reconceptualizing how they view their injury and pain.  The second workbook is a therapy map book that helps the therapist determine the drivers of pain and then engineer an exercise, resumption of life roles and graded motor exposure – activity goal setting plan of management.

Pain Science, Exercise Prescription and Neurodynamic Assessment and Treatment for clients in pain

This course is geared toward the kinesiologist, strength coach, personal trainer, athletic therapist or anyone health and fitness professional working with clients in pain.  The aim of the course is to help these professionals simplify their approach to working with clients and provide science based explanations to clients about the pain they experience.

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Course Schedule http://www.greglehman.ca/2015/02/02/course-schedule/ http://www.greglehman.ca/2015/02/02/course-schedule/#comments Mon, 02 Feb 2015 21:00:41 +0000 http://www.greglehman.ca/?p=21 Interested in hosting a course? Please send me an email and we can talk  greglehmanphysio@gmail.com

The following course schedule details the two courses I am currently teaching.  One is the Physiofundamentals: Reconciling Biomechanics with Pain Science and the other is The New Trends in Running Injury Prevention from therunningclinic.ca.  Please note, I can not schedule talks for the running course.  This is best done through their website.

Schedule 2015

TORONTO, ON. January 16 and 17, 2015: New Trends in the Prevention of Running Injuries.

TORONTO, ON. March 7 and 8, 2015: Reconciling Biomechanics with Pain Science with MSK-Plus: Register Here

Brighton, England. March 18, 2015: One day Reconciling Biomechanics with Pain Science course.  Register here at Eventbrite

SEATTLE, Washington: April 11/12, 2015: Reconciling Biomechanics with Pain Science. Hosted by Dr. Michael Li. You can REGISTER for the course at Dr Li’s website here.

BUENOS AIRES, ARGENTINA: April 24, 25, 26 2015: Reconciling Biomechanics with Pain Science.

REGINA, SK, Canada: May 9/10 2015: New Trends in the Prevention of Running Injuries

TORONTO, ON: May 22/23 2015: New Trends in the Prevention of Running Injuries

BOLOGNA, ITALY May 30/31 2015: Reconciling Biomechanics with Pain Science Register HERE

EDINBURGH, Scotland, June 3/4: Reconciling Biomechanics with Pain Science. Register HERE

London, England June 6 and 7, 2015 hosted by Adam Meakins at Spire Bushey Hospital. Reconciling Biomechanics with Pain Science: Register here.

CLIFTON, NEW JERSEY: September 12/13: Register at Eventbrite by clicking here.

HAMILTON, ON: October 3/4 2015: Reconciling Biomechanics with Pain Science

WINNIPEG, ON: November 7/8 2015: Reconciling Biomechanics with Pain Science

MILAN, ITALY November 14/15: Reconciling Biomechanics with Pain Science

TORONTO, ON: November 21/22 2015: Sports Chiropractic Train Smarter Conference

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Physiofundamentals: Reconciling Biomechanics with Pain Science http://www.greglehman.ca/2015/02/02/physiofundamentals-reconciling-biomechanics-with-pain-science/ http://www.greglehman.ca/2015/02/02/physiofundamentals-reconciling-biomechanics-with-pain-science/#comments Mon, 02 Feb 2015 20:59:06 +0000 http://www.greglehman.ca/?p=16 A comprehensive approach to using a traditional biomechanically based practice within a biopsychosocial approach.

 

Brief Overview

A percentage of this course is based on the Pain Science Workbook and The Treatment Manual Workbook.  Please download if you are interested.

The biopsychosocial model of pain and injury has been argued as superior to the traditional biomedical approach for more than two decades. However, traditional therapy typically relies on explanations and a clinical reasoning model that is predominantly biomechanics based.  Significant research in the pain neurosciences and biomechanics field often appears to undermine the reasoning and justifications for many of the therapeutic approaches and techniques of the physical therapy profession.  By addressing the both the weaknesses and strengths of the biomechanical approach we can see that treatment can be much simpler, congruent with the cognitive, neuroscience approach and best evidenced based practice.

This course teaches the therapist how to teach patients about pain science in a treatment framework that still utilizes specific/corrective exercise and manual therapy. Therapists are taught a model of treatment that simplifies the assessment process and the treatment.

Special topics include therapeutic neuroscience education, cognition targeted interviewing, assessment and exercise prescription, introductory neurodynamic techniques, an introduction to graded motor imagery and a reconceptualization of manual and exercise therapy that is symptom modification based rather than biomechanically driven.

What can the student expect to come away with from this course?

  • up to date assessment techniques for partitioning the role of biomechanics and therapeutic neuroscience in the treatment of pain and injury
  • interviewing techniques to address the multifactorial nature of pain
  • exercise prescription informed by biomechanics and therapeutic neuroscience
  • simplified manual therapy techniques that are consistent with therapeutic neuroscience and the biomechanics of manual therapy
  • immediate means of applying therapeutic neuroscience to a traditional biomedically based practice
  • confidence in the leaving behind the traditional and outdated biomechanical model of care while learning how to integrate previously learned skills
  • access to patient centred handouts/workbooks (electronic) that reinforce the teachings and approach of the therapist to their patient

Course Content

The course attempts to address a series of a clinical questions that both patients and practitioners pose. By addressing clinical questions in an interactive lecture format the student will learn practical means of addressing these questions with their patients as well as the thought process and literature used to arrive at a defensible answer. This is primarily done through rapid case scenarios and examples. Hands on and practical components are mixed with interactive discussion based lectures.

All students are provided with courses notes. Note taking is not required

Clinical Questions and Topics

Clearing the Way for a different approach

  • a detailed critique outlining the limitations of the traditional biomechanical model of therapy. Topics included:
    • the lack of scientifically plausible manual therapy mechanisms and assessment techniques an alternative view will be provided
    • discussions on ideal posture and form. Reconciling current beliefs with the evidence
  • The importance of clinical explanations in pain resolution: how the traditional biomechanical model can be adapted to help our patients

PhysioFundamentals: Salvaging best practice

  • The antidote is the anecdote: how to teach pain neuroscience to patients
  • How to explain common clinical diagnoses and aches and pains to your patients consistent with best practice and therapeutic neuroscience. Explain the mechanisms of pain helps support and rationalize that therapeutic solution that we offer.
  • Comprehensive Capacity: why traditional “corrective exercise” and kinematic ideals fall short in pain resolution and injury management. An simpler alternative is supplied
  • The Tendon Loading Model of Rehabilitation and its application to common clinical disorders an evidence based approach to understanding pain and rehabilitating common conditions
  • From Graded Motor Imagery to Graded Motor Exposure how exercise dosage is the key to building robust, confident patients
  • Reconceptualizing Manual Therapy: Using imagery, touch, guided movements, novelty and 3D movement exploration to fine tune existing manual therapy techniques. This section will also simplify manual therapy based on the current research.
  • Resolution through confrontation: how simple exercise and manual therapy techniques help resolve pain and reap the benefits of mechanotransduction

Case Study Applications

A series of case studies will be used throughout the course to illustrate all concepts

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Bio http://www.greglehman.ca/2015/02/02/bio/ http://www.greglehman.ca/2015/02/02/bio/#comments Mon, 02 Feb 2015 20:56:48 +0000 http://www.greglehman.ca/?p=18 Dr Greg Lehman BKin, MSc, DC, MScPT

I am a both a physiotherapist and chiropractor treating musculoskeletal disorders within a biopsychosocial model.

Prior to my clinical career I was fortunate enough to receive a Natural Sciences and Engineering Research Council MSc graduate scholarship that permitted me to be one of only two yearly students to train with Professor Stuart McGill in his Occupational Biomechanics Laboratory subsequently publishing more than 20 peer reviewed papers in the manual therapy and exercise biomechanics field. I was an assistant professor at the Canadian Memorial Chiropractic College teaching a graduate level course in Spine Biomechanics and Instrumentation as well conducting more than 20 research experiments while supervising more than 50 students. I have lectured on a number of topics on reconciling treatment biomechanics with pain science, running injuries, golf biomechanics, occupational low back injuries and therapeutic neuroscience. My clinical musings can be seen on Medbridge Health CE and various web based podcasts. I am currently an instructor with therunningclinic.ca and with physiofundamentals.com. Both are continuing education platforms that provide clinically relevant research that helps shape and refine clinical practice.

While I have a strong biomechanics background I was introduced to the field of neuroscience and the importance of psychosocial risk factors in pain and injury management almost two decades ago. I believe successful injury management and prevention can use simple techniques that still address the multifactorial and complex nature of musculoskeletal disorders. I currently maintain three websites geared to health professionals (physiofundamentals.com and thebodymechanic.ca) and patients (painphysiotherapy.ca). I am active on social media and consider the discussion and  dissemination of knowledge an important component of responsible practice.

If you are interested in hosting a course please contact me at greglehmanphysio@gmail.com.

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Pain Science Workbook http://www.greglehman.ca/2015/02/02/pain-science-workbook/ http://www.greglehman.ca/2015/02/02/pain-science-workbook/#comments Mon, 02 Feb 2015 20:54:19 +0000 http://www.greglehman.ca/?p=12 January 19, 2015 Updated: Click here: pain science patient and therapist workbook january 2015

The workbook is an introduction to pain science and is composed of one page infographics that are followed by questions to be worked through.  The workbook can be used in its entirety or single pages can be selected.

You may distribute this work as you see fit.  I only ask that attribution be made to this website or myself.

This workbook is the foundation for the course Physiofundamentals: Reconciling biomechanics with pain science.

This workbook along with the Part Two of the workbook (an interactive treatment manual and pathway for therapists and patients) helps therapists reconceptualize a biomechanics approach to treating injuries and pain within a Biopsychosocial framework.  Hint, you’ll never have to diagnosis a pelvic upslip or SI joint movement asymmetry again.

Naturally, this is a work in progress.  Please submit any suggestions for future infographics or sections and you might see them incorporated into future additions.

pain science patient and therapist workbook january 2015

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Physiofundamentals Course Series http://www.greglehman.ca/2015/02/02/physiofundamentals-course-series/ http://www.greglehman.ca/2015/02/02/physiofundamentals-course-series/#comments Mon, 02 Feb 2015 20:48:56 +0000 http://www.greglehman.ca/?p=10  

With a better understanding of both Biomechanics and Pain Science the treatment of pain and injury can become infinitely more simple

 

A clinical practice rooted in the biomechanical model will have difficulty adapting to many common research conclusions that we have seen through the years.  Such as:

 

“motion palpation is not valid”

“aberrant movement patterns fail to predict injury”

“core stability has very little to do with pain”

“posture and form is poorly related to future pain or injury”

“treatments can be helpful but for reasons other than what is typically supposed”

Unfortunately, the answer to the normal clinical doubt that this research can engender has been to modify our clinical approach to make it increasingly complicated.

Explaining pain and injury with increasingly complex and convoluted biomechanical reasoning is not necessary to help patients in pain.  This type of approach is not new and ignores much of biomechanical research that contradicts it as well as research in other fields that is more appropriately applied to out patients in pain.

Therapeutic neuroscience and treatment approaches which attempt to address function and patient cognitions within a BioPsychoSocial framework are touted as being THE way forward in treating patients.  But the HOW of doing this is often difficult when the approach and explanations a therapist  uses continues to rely on less than established biomechanical reasoning.

The aim of this website and the associated Courses is to reconcile these view points.  Therapists don’t need to abandon much of what they have learned.  Rather, a different perspective on how a therapist conceptualizes and uses their training is offered.  Best of all, things can be much simpler.  Doubts will remain but a framework can be established to manage those doubts and keep helping patients.

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Big Changes and a New Website http://www.greglehman.ca/2015/01/09/big-changes-and-a-new-website/ http://www.greglehman.ca/2015/01/09/big-changes-and-a-new-website/#comments Fri, 09 Jan 2015 23:05:13 +0000 http://www.thebodymechanic.ca/?p=1589 I am finally teaching again.  I have developed a new course that aims to help therapists, strength coaches, personal trainers and kinesiologists integrate pain science with biomechanics.  Its very easy to critique the typical biomechanical approach to treating and preventing injuries and I think it often leaves people feeling frustrated and confused.  Along with other great courses out there I am hoping to help people reconceptualize biomechanics (i.e. salvage the good) and show how it can fit into a framework that uses pain science in a true BioPsychoSocial approach.

You can see more at greglehman.ca

Within the next few days that webpage will be sharing my new Pain Science Workbook for Patients.  I think its a great introduction to pain science and its meant to be used by the patient with the therapist.

 

I have upcoming Physiofundamental courses in Toronto, Argentina, Italy, Winnipeg, Hamilton, Israel and the UK.

I am also hopefully partnering up with a great mystery practitioner in US.  Stay tuned for details.

1 long web logo 848 x 120

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Todd Hargrove’s Book: A guide to better movement http://www.greglehman.ca/2014/06/16/todd-hargroves-book-a-guide-to-better-movement/ http://www.greglehman.ca/2014/06/16/todd-hargroves-book-a-guide-to-better-movement/#comments Mon, 16 Jun 2014 12:12:02 +0000 http://www.thebodymechanic.ca/?p=1582 Guide-to-Better-Movement-3D-Transparent-BG-e1400717590270-212x300Todd Hargrove is a great fitness and health writer at bettermovement.org.  I’ve been talking with Todd for years and find his information and thought process excellent.

He has a new book out which I recommend to everyone.  I agree with much of it and the great thing with Todd is that we disagree on a lot too.  However, Todd is open to your disagreements and discussions about contentious issue.

You can Todd’s book at Amazon.

By the way, I get no kickbacks for this.

 

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