Hamstring function – This is not just a knee flexor!

Hamstring function – How it assists in knee extension

While on the subject of knee extension….

The hamstring can flex the knee against gravity when prone or standing with the foot in non-weightbearing….but during most function, the action of the HAMSTRING is so much more complex.

During swing phase, the hip is flexing and the knee is extending. Both of these motions lengthen the hamstrings so that it is switched on before heel strike. At heel strike, the forward motion of the trunk tries to flex the hip. This is decelerated by the hamstring. At the same time, the tibia is moving forward with knee flexion, which the hamstrings can slow down when the foot is on the ground.

As the heel bone everts, the lower leg internally rotates and because of its greats attachment onto the lower leg and the pelvis, the hamstrings can decelerate both internal rotation of the tibia and the hip. In the frontal plane, the hamstrings also decelerate abduction of the knee after the heel has everted.

The lengthening and eccentric loading of the hamstring at multiple joints in many planes make it very eccentric with the front leg in gait. But once the ‘unload’ has started, the hamstrings become very concentric in all planes.

All of this eccentric control (loading) allows it then to do the opposite (explode) once it has been stretched and proprioceptively ‘turned on’.

So in function and gait…. the HAMSTRING is used so much more than to flex your knee as the books suggest.

Hypermobility part 2 (March 2012)

Hypermobility Syndrome – part 2

James Dodd

Part 1 of this article looked at giving readers a better understanding of Hypermobility Syndrome (HMS) and the implications it may have on the musculoskeletal system. Having a greater understanding of the common problems associated with hypermobility syndrome, how it is diagnosed and its relationship to other connective tissues disorders provides us with a solid base by which we can then go about developing a corrective exercise program. Part 2 aims to provide a more extensive look at assessing the hypermobile patient and taking a region specific approach to training. A detailed case history and screening process should alert you to any problematic areas or regions which may be predisposing, maintaining or aggravating your patient’s musculoskeletal problems. Static observation will help you to define any asymmetries in posture. Observation from all three views (frontal, lateral and posterior) will help you focus on areas of possible dysfunction. Functional testing in sagittal, frontal and transverse planes may highlight other areas of dysfunction

Muscle and Movement Testing

Carry out stretches and tests to identify weak, tight and shortened muscles. Take particular care in the hypermobile patient as range of movement may be much greater than expected. They are also good at ‘cheating’ to hide a dysfunctional area.

Assess functional activities such as gait, step up/down, lunge, squat, one leg stand and reach, anterior reach, posterior reach and push up for functional capability. Look for asymmetries, imbalances and glitches within the movement patterns to alert you to potential areas of dysfunction. Common causes of dysfunctional movements could be inhibited/over facilitated muscle activity in agonist/antagonist or synergistic muscles, tight and short or weak and lengthened muscles, hypo/hypermobile joints or body regions and balance, proprioception and coordination problems.

Always remember to seek advice from your patient’s general practitioner, osteopath or physiotherapist if you suspect any serious possible musculoskeletal problems or red flags.

A Regional Approach to Training the Hypermobile Patient

Common presenting features in the hypermobile patient include the following:

Shoulder, hip, neck, lower back, knee and foot pain

Poor body awareness, balance and proprioception

Flat, pronated feet

Hyperextended knees

Anterior pelvis

Clicking/popping joints

Hyperkyphotic or reduced movement in the thoracic spine. This could also be chronic muscle spasm

Tight and shortened hamstrings, gastrocnemius, iliotibial band, tensor fascia lata, pectoralis major/minor muscles

Weak anterior deep neck muscles, iliopsoas, core stabilizers and gluteals

Poor core stability

Upper rib breathing and poor diaphragmatic breathing

A good case history, observation and assessment should highlight any areas of dysfunction and will help you to focus on devising a program that will help restore optimal health and posture. Foam rollers, static stretching, active stretching and Muscle Energy Techniques (MET) are treatment strategies that can help stretch, activate and restore muscle balance. Remember to train the patient as a whole. The body works as one, and all systems are connected. Therefore, any one problem or area can predispose to a dysfunction elsewhere. The tissues are generally weaker and more vulnerable to injury than the non-hypermobile patient.

Hypermobility and the Lower Back

Poor overall functional stability is common among those individuals with lower back pain. In conjunction with poor stability, the hypermobile patient may also have poor kinesthesia and proprioception.

Focus training on:

Improving body awareness (anterior and posterior tilting of the pelvis)

Finding neutral spine

Teaching diaphragmatic breathing

Activating core muscles

Incorporating core muscle activation into functional activities

Balance, proprioception and coordination

Look for an ability to activate the core muscles:

Without co-contraction of more global muscles such as the rectus abdominis and external oblique muscles

Independently breathing

Diaphragmatic breathing? (often you will observe upper chest breathing)

Exercises that will be useful for the patient with core stability issues include:

Anterior and posterior tilting of the pelvis (standing, supine).

Core muscle activation (supine, prone, side-lying and four-point kneel).

Core muscle activation standing, seated.

Remember to isolate muscle activation and then integrate into functional activities.

Hypermobility and the Neck

Hypermobile patients may present with a history of neck complaints, ranging from the acute ‘wry’ neck to chronic neck pain. Individuals may present with an upper crossed syndrome pattern, which could be predisposed, maintained and aggravated by hypermobility, work and lifestyle postures such as sitting and slouching.

Look for:

Forward head posture (chin poking forwards)

Increased kyphosis (rounding) through the thoracic spine and Cervico-Thoracic C7/T1 region (base of the neck)

Reduced mobility through the thoracic and cervical spine

Tight upper trapezius, levator scapular, pectoral minor, sternocleidomastoid and scalene muscles

Weak rhomboids, lower trapezius and deep anterior neck flexors

Winging, elevated or protracted scapulars. Look for asymmetries in static

observation, movement and muscle weakness in shoulder stabilizers

Focus training on:

Lengthening short and tightened muscles

Strengthening weak muscles

Activating inhibited and de-facilitating over active muscles

Balance, proprioception and coordination

Exercises that will be useful for the patient with upper crossed syndrome and neck pain include:

Scapular retraction and setting

Ys and Ts exercise

Other useful exercises that aim to improve mobility of the neck, strengthen deep anterior neck flexors and increase body awareness include:

Chin tucks (similar to an emu neck movement)

Isometric neck flexion (using soft ball to push head against)

Isometric lateral neck flexion (using soft ball to push head against)

Pulling shoulder blades backwards and down, whilst lifting sternum to the roof

For more information on isometric neck exercises, see Paul Chek’s “How to Eat, Move and Be Healthy!”

Hypermobility and the Shoulder

The shoulder is the most unstable joint in the body, and often the hypermobile person will have a glenohumeral joint and/or scapulothoracic joint dysfunction. Problems may develop due to poor neuromuscular control, increased laxity of the capsule and rotator cuff weakness. Individuals may also present with subacromial impingement signs and symptoms. In some circumstances, your patient may require referral to an osteopath or physiotherapist to rehabilitate and teach correct scapulothoracic setting and glenohumeral positioning before commencing an exercise program. Focus training on:

Scapulothoracic setting

Rotator cuff strengthening

Stretching tight and shortened muscles i.e. pectoralis major and minor

Strengthening weak muscles i.e. serratus anterior, rhomboids, lower trapezius

Training functional exercises which address adjacent areas (cervical, thoracics, lumbars and hip/pelvis), muscular slings, synergistic and agonist/antagonist muscles

Hypermobility and the Hip

Like the shoulder, the hip is a ball and socket joint that has a large range of movement. It is essential that the neuromuscular, active and passive systems are working effectively to allow adequate movement and yet stabilize the region sufficiently. The hypermobile person is more likely to suffer from clicking/popping hip. The exact cause of this could vary from an intra to extra articular causes such as a tight iliopsoas to a labral tear or loose body. It may or may not be associated with pain. In those individuals presenting with extreme or constant pain, refer them off to the GP, sports medical doctor, osteopath or physiotherapist for further assessment. Typically, hypermobile patients will have poor control of their hip, pelvic and lumbar regions, and these often need to be addressed to correct any imbalances and prevent further problems developing.

Focus training on:

Lumbar (lower back) stability

Hip stability

Weak iliopsoas

Weak gluteus medius and maximus

Tight hamstrings, iliotibial band, tensor fascia lata

Balance, proprioception and coordination

Hypermobility and the Knee

Patellofemoral problems are common in hypermobile individuals. The cause of patellofemoral problems can be both structural and non-structural related. Common causes include a variable Q angle, genu varum, increased foot pronation and biomechanical and muscle imbalances.

Focus training on:

Tight iliotibial band, tensor fascia lata, hamstrings, gastrocnemius

Weak vastus medialis, gluteal muscles

Pronation and supination foot

Balance, coordination and proprioception

Exercises that will be useful for the client include:

Seated heel presses (helps to activate vastus medialis)

Foam rolling ITB and quadriceps muscles

Exercises that will be useful for the patient include:

Seated heel press (helps to activate vastus medialis)

Lunge – Forward

Lunge – Multiplanar

Squat – Against Wall with SB

Squat Touchdown – 1 Leg

Step Up to Balance – Frontal Plane

Hypermobility and the Foot

Pronated (flat) feet is common in the hypermobile patient. Over pronating can lead to problems with the subtalar joint, mid and forefoot, possibly causing plantar fasciitis and other problems up the biomechanical chain. Over pronation will cause internal rotation of the tibia and fibula, therefore potentially creating dysfunctions further up the chain at the knee, hip/pelvis and lower back. Individuals with flat feet may benefit from an exercise program or orthotics prescription.

Focus training on:

Tight plantar fascia, gastrocnemius and soleus muscles

Activation and control of tibialis anterior, peroneal muscles

Tight iliotibial band and weak gluteal muscles

Balance, coordination and proprioception

Exercises that will be useful for the patient include:

Active plantarflexion and dorsiflexion of the foot

Rolling feet inwards (pronation) and outwards (supination)

Single leg balance (stable to labile surface i.e. wobble board, bosu ball)

Swiss ball squat with ball between the knees finishing with standing on toes

Exercises that will be useful for the patient include:

Side to Side Hip Swing (Hip)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Posterior Reach

Hypermobility and Balance and Proprioception

Hypermobile individuals are likely to have poor balance, proprioception and kinesthesia. Exercises that challenge these components will translate over to improvement of general daily activities and reduce the likelihood of injury.

Exercises that will be useful for the patient include:

1 Leg Balance

1 Leg Balance Reach (anterior, posterior, lateral)

Balance Hold 1 Leg – Overhead Anterior Reach

Balance Hold 1 Leg – Overhead Lateral Reach

Step Up to Balance – Frontal Plane

Equipment such as wobble boards, Bosu Balls, cones, Airex Balance Pad, Swiss ball, Theraband, etc. can be added to further challenge balance and proprioception.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http://www.ehlers-danlos.org>

www.hypermobility.org <http://www.hypermobility.org>

www.marfan.org <http://www.marfan.org>

www.marfanssyndrome.net <http://www.marfanssyndrome.net>

www.medicinenet.com/hypermobility_syndrome <http://www.medicinenet.com/hypermobility_syndrome>

http://medlineplus.gov/

www.oif.org <http://www.oif.org> (Osteogenesis Imperfecta)

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http://www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html>

Important Disclaimer:

No express or implied warranty (whether of merchantability, fitness for a particular purpose, or otherwise) or other guaranty is made as to the accuracy or completeness of any of the information or content contained in any of the pages in this web site or otherwise provided by personal training on the net. No responsibility is accepted and all responsibility is hereby disclaimed for any loss or damage suffered as a result of the use or misuse of any information or content or any reliance thereon. It is the responsibility of all users of this website to satisfy themselves as to the medical and physical condition of themselves and their clients in determining whether or not to use or adapt the information or content provided in each circumstance. Notwithstanding the medical or physical condition of each user, no responsibility or liability is accepted and all responsibility and liability is hereby disclaimed for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content in this website, and any and all liability for incidental and consequential damages is hereby expressly excluded.

Hypermobility pt 1 (January 2012)

Hypermobility Syndrome – part 1

James Dodd

There is Hypermobility and Hypermobility Syndrome (HMS). Hypermobility syndrome is the hypermobile patient with symptoms. Not all hypermobile patients are, or ever become symptomatic. HMS is a condition many individuals often experience their entire lives without ever having it diagnosed and managed correctly. Hypermobility has certain implications for the joint itself, as well as the surrounding ligaments, bones, joint capsules, muscles and tendons. It is important for a hypermobile patient’s well-being that they have effective neuromuscular control and active and passive systems that can support the joints in the body. Hypermobile joints by definition are those “displaying a range of movement that is considered excessive, taking into consideration the age, gender and ethnic background of the individual.” Hypermobility Syndrome, also known as Joint Hypermobility Syndrome or Benign Hypermobility Syndrome, is defined as ‘generalized joint laxity with associated musculoskeletal complaints in the absence of any systemic disease’. HMS is an inherited form of a connective tissue disorder. Those with Hypermobility Syndrome are believed to experience pain as a result of joint microtrauma, which has been caused by overuse and/or misuse of the tissues in which there is an inherent weakness in the collagen.

It’s signs and symptoms are so often missed and so it goes undiagnosed and so is mismanaged. This means the suffering patient can go on suffering unnecessarily.

Common Features of Hypermobility

•Females are often more mobile than males.

•Mobility varies amongst ethnicity (Asian populations seem to be more affected than European populations).

•Mobility decreases with age.

•Hypermobility can be inherited or acquired i.e. repeated subluxation of the shoulder joint.

•Hypermobility Syndrome is typically determined by the genetic make up of the individual, in particular the genes causing hypermobility are those that are responsible for the production of collagen, elastin, fibrillin and tenascin.

•Certain sports and activities (i.e., gymnastics, ballet dancing, swimming) have shown to have a greater number of individuals with hypermobility.

•Musculoskeletal regions commonly affected include the achilles tendon, patellofemoral joint, rotator cuff, carpal tunnel, cervical and lumbar spine (non specific lower back pain and medial and lateral epicondyles.

•Hypermobile individuals may suffer from clicking, spondylolithesis and pars fractures.

•Hypermobility is a risk factor for the development of early Osteoarthritis.

•Fibromyalgia is commonly diagnosed in individuals with Hypermobility Syndrome

Diagnosis

The Beigton Score System (below) is a 9-point scale originally introduced to recognize hypermobile patients within the population. Primary health care practitioners now use it as a common screening process to help determine whether an individual has hypermobility.

•Passively dorsiflex 5th metacarpophalangeal joint to > 90 degrees (2 points)

•Passively take thumb to forearm (2 points)

•Passive hyperextend the elbow to > 10 degrees (2 points)

•Passively hyperextend the knee to > 10 degrees (2 points)

•Actively place hands flat on floor without bending the knees (1 point)

There can be a total score of 9. The revised diagnostic criteria for hypermobility requires you to get a Beigton score of 4/9 and have arthralgia (joint pain) for longer than three months in more than four or more joints.

There is also the Brighton Criteria that aids in the diagnosis of Hypermobility Syndrome. These include:

Dislocation and/or subluxation in more than one joint and on one or more occasions.

Abnormal skin: striae, thin skin, increased stretch of skin.

Eye signs: drooping eyelid or myopia

Varicose veins, hernia, or uterine/rectal problems

Soft tissue rheumatism (i.e., epicondylitis, tenosynovitis, synovitis)

Hypermobility and Connective Tissue Disorders

Marfan’s Syndrome, Ehlers-Danlos Syndrome and Osteogenesis Imperfecta are each genetic disorders in which the connective tissue of the individual is affected. Each disorder is different in its epidemiology, incidence and clinical presentation. While it is beyond the realm of this article to discuss each of these conditions in detail, if you have a patient with one of these disorders, you should conduct further reading in order to gain a better understanding of the disorder, its implications and how you can alter your training program to better suit your patient.

Rehabilitation and Exercise Prescription

Management of the patient will largely depend upon his/her age, current physical condition, hypermobility state and personal goals. The primary aim of dealing with any hypermobile patient should be to reduce disability and increase function. This should incorporate a holistic approach which addresses not only the fitness components but also addresses dietary, work and other lifestyle components.

Hypermobility and Acute or Chronic Injury

The acute hypermobile client should be managed like any other acute musculoskeletal injury. During the acute stages, you should be aiming to reduce swelling, inflammation, pain and restrict any aggravating or maintaining factors. Always refer your patient to a medical practitioner or hospital if you suspect anything serious. In the sub-acute or chronic hypermobile patient, the aim should be to restore normal function and reduce pain to a comfortable level. This could range from prescribing an exercise program to referring your patient for specific treatment from a GP, Physiotherapist, Osteopath or Podiatrist. It is always best to seek treatment from a practitioner that that works with and understands the implications of HMS. Failing to correctly manage with your client’s sub-acute/chronic injury could result in the development of compensatory patterns, which in turn could lead to problems developing elsewhere.

Program Design

Training the hypermobile patient requires special attention to certain training principles. You need to consider all joint, muscle and ligament actions when training, making sure that you train throughout the entire range of movement and training the muscles for isometric, isotonic, concentric and eccentric actions.

Stability of a joint is determined by the integrity of the musculoskeletal system (muscle, tendon, capsule, ligament and articular surfaces) and the neural control system (motor and sensory). It is important to address these aspects when devising a program in order to develop optimum function.

The key fitness components that need addressing in the hypermobile client include:

Proprioception

Balance

Coordination

Kinesthesia

Core stability

Endurance

Strength

Controlled flexibility

Cardiovascular fitness

Each of these fitness components requires extra attention in clients with Hypermobility Syndrome. However, each program will differ considerably depending upon each patient (i.e., client age, current physical state, hypermobility and goals). Programs could range from being as simple as improving one’s functional state (i.e., daily living activities such as walking, squatting, sitting up and down) to training elite athletes. Essentially, you will need to assess each case individually and design a program specific to the client’s needs.

Your program should try to:

Train function. Include functional activities such as push/pull, step up/down, squat, lunge and rotation exercises in your program.

Strengthen muscles equally and ensure there is a balance among agonist, antagonist and synergistic muscles.

Train movements rather than muscles, when possible.

Progress from slow to fast, stable to unstable, simple to complex, non weight bearing to weight bearing, closed chain to open chain, one plane to multi plane.

In Part 2 of this article, I will be taking a more in depth look at the individual assessment of the hypermobile patient and how we can deal with the common musculoskeletal issues one may have. The article has been divided into bodily regions, outlining what we should be looking for in the assessment, how this interacts with other regions of the body and how we can go about correcting these problems.

References:

Cook, G. Athletic Body in Balance, Human Kinetics, USA, 2003.

Gray, G. Functional Video Digest Series <http:> </http:>

Gray, G. Total Body Functional Profile, Wynn Marketing, 2001.

Janda, V. Muscle Function Testing, Butterworths, London, 1983.

Keer, R. & Grahame, R. Hypermobility Syndrome, Recognition and Management for Physiotherapists, Butterworth/Heinemann, 2003.

Kendall, F et al. Muscle Testing and Function with Posture and Pain, Lippincott Williams & Wilkins, 5th Edition, USA, 2005.

Murtagh, J. General Practice, McGraw Hill, 3rd Edition, Sydney, 2003.

Osar, E. Complete Hip & Lower Extremity Conditioning.

Osar, E. Complete Shoulder & Upper Extremity Conditioning.

Petty, N.J & Moore, A.P. Principles of Neuromusculoskeletal Treatment and Management, Churchill Livingstone, London, 2004.

Santana, J.C. Functional Training: Breaking the Bonds of Traditionalism <http:> .</http:>

Wolf, C. Human Motion: A Pictorial Guide to Functional Integrated Movement Patterns. Human Motion Associates.

Resources:

www.ehlers-danlos.org <http:> </http:>

www.hypermobility.org <http:> </http:>

www.marfan.org <http:> </http:>

www.marfanssyndrome.net <http:> </http:>

www.medicinenet.com/hypermobility_syndrome <http:> </http:>

http://medlineplus.gov/

www.oif.org <http:> (Osteogenesis Imperfecta)</http:>

www.nlm.nih.gov/medlineplus/osteogenesisimperfecta.html <http:></http:>

Important Disclaimer:

No express or implied warranty (whether of merchantability, fitness for a particular purpose, or otherwise) or other guaranty is made as to the accuracy or completeness of any of the information or content contained in any of the pages in this web site or otherwise provided by personal training on the net. No responsibility is accepted and all responsibility is hereby disclaimed for any loss or damage suffered as a result of the use or misuse of any information or content or any reliance thereon. It is the responsibility of all users of this website to satisfy themselves as to the medical and physical condition of themselves and their clients in determining whether or not to use or adapt the information or content provided in each circumstance. Notwithstanding the medical or physical condition of each user, no responsibility or liability is accepted and all responsibility and liability is hereby disclaimed for any loss or damage suffered by any person as a result of the use or misuse of any of the information or content in this website, and any and all liability for incidental and consequential damages is hereby expressly excluded.

Could your groin injury be coming from your hip?

Groin pain can be a difficult problem for patients as well as their clinicians. Part of the problem is that the location of the pain is often a poor indicator of the where the pathology actually lies. Additionally, when the pain becomes chronic, multiple pathologies can be generated, adding a further layer of complexity.

It is very important to make a clear diagnosis, and we should seek to look beyond merely labelling the problem as a ‘groin sprain’. There many causes of pain in the groin, but approximately 50% of groin pain can be attributed to pain generated by the hip joint; a surprise, perhaps, for younger patients. As in any medical condition, the patient’s history will give us many clues. It is extremely important to rule out sinister ‘red flags’, such as night pain, severe pain on loading the leg, weight loss or systemic symptoms, and we need to be mindful of conditions which may occur in certain age groups, such as slipped epiphysis in teenagers.

Common causes of groin pain besides the hip, include those generated by the lumbar spine, pubic overload (osteitis pubis), iliopsoas and adductor tendon pathologies and stress responses in the femoral neck in runners. Abdominal wall hernias may cause pain which is a little higher in the groin, and less commonly, younger patients can experience the rectus femoris pulling away from its attachment at the anterior inferior iliac spine. Testicular tumours and avascular necrosis can present insidiously and we need to be on the lookout for them.

A big proportion of patients who present with groin pain as a result of hip pathology, have an underling condition known as ‘femoral acetabular impingement syndrome’, or FAI. This is essentially a problem resulting from a tear in the acetabular labrum, usually caused by repetitive trauma due to a ‘bump’ or ‘CAM’ on the head neck junction of the femur, which may be genetic.

This can cause groin pain which is worse with exercise, sitting or standing, and the pain can be brought on by putting the patient in the ‘impingement position’ of hip flexion + internal rotation + adduction. In the long term, we believe that the tear in labrum causes changes in the acetabular articular cartilage next to it, and over many years, this may lead to osteoarthritis in the hip.

FAI can affect people of all ages, and is often missed in 30-40 year olds. Taking a careful history, and carrying out a thorough examination can help identify the likely cause. Imaging, such as MRI arthrogram of the hip, can help confirm the underlying diagnosis (as X-Ray cannot rule out FAI), but it should be remembered that imaging needs to be interpreted in light of the history and examination findings. FAI may require treatment with hip arthroscopy surgery, but in some cases injection therapy and robust physiotherapy or osteopathy may be enough to get a person back to full activity.

Sports Physicians and Osteopaths are ideally placed to identify the underlying cause of unexplained groin pain, and are skilled in directing the rehabilitation necessary to resolve the problems.

If you have any problems at all and would like in to see James Dodd or one of the team at Back to Back, please call 020 8605 2323.