0:00 what I want to do today is in this last
0:02 session and now it's after the afternoon
0:04 break and but you can't can all relax a
0:07 little bit I'm not going to be
0:08 controversial or anything like that so
0:10 sorry Twitter oh this is really a
0:13 clinical paper and it's probably a
0:16 marriage of two great interests of mine
0:18 tendinopathy and also that of chronic
0:23 hamstring issues and this is pretty much
0:25 this the group that I'm trying to cover
0:27 here and I guess I'm going to try and
0:29 share with you more from a clinical
0:31 perspective and whatever we do have out
0:33 there in the literature of how we might
0:35 approach these particular patients so
0:37 the way we go I'm just gonna go a little
0:41 bit on Anatomy and Anatomy is boring but
0:43 Anatomy still is the basis of so much
0:46 that we need to consider so again I'm
0:49 not going to read through all this but
0:50 one of the really interesting anatomical
0:52 features in this quite complex origin of
0:55 the hamstring anthesis is we have this a
0:58 protuberance ligament here which is I've
1:01 seen series with the biceps the biceps
1:04 tendon and semi men semitendinosus has a
1:09 variable tendon in fact quite often it's
1:11 actually just muscle tissue that inserts
1:13 into the bone so and it really is very
1:16 variable between people but the the
1:19 interest the one of greatest interest to
1:21 us of course I'm sorry is the
1:23 semimembranosus tendon which is quite
1:26 flat but it arises deeply from up here
1:29 it's deep and lateral and there is
1:32 actually a little speculation at the
1:33 moment that and you consider it's
1:36 probably in flexion and some adduction
1:38 where there can be a sort of twisting
1:40 and compression that area a little bit
1:42 like um jewelers alluding to with the
1:43 plane Taurus but as I say that's just a
1:46 little speculation at the moment but
1:47 there's certainly a lot more to learn
1:49 about so many facets of this area it's
1:51 an area that's been hard done by in the
1:54 literature there aren't a lot of
1:55 articles are there so we're pretty
1:58 limited in what we know in this area
2:01 what we do know and again these are from
2:04 surgical series is that there's some
2:07 variability in what people wear people
2:09 report the pathology to be that limp
2:12 onin
2:13 it's mostly from semimembranosus
2:14 Bernardo thinks there's a distribution
2:17 across both biceps tendon and and the
2:20 others as you see there so and again
2:23 that could be just variations in their
2:25 their client group the article we did
2:28 with Tom Goom
2:30 I think pulls out the fact that we're
2:33 dealing both with compression and we've
2:35 heard a lot about compression today till
2:37 then with others
2:38 shear forces and tensile forces and it
2:41 is this combination of forces as you
2:44 know the hip joints put in all sorts of
2:46 I hope you didn't get that one but in
2:49 all sorts of funny angles within sport
2:51 and of course then this place is quite a
2:54 deal of variable stresses through this
2:57 quite complex and pieces and it is truly
3:01 an enthesopathy if you like it is at the
3:03 tendon bone junction as you see there
3:06 there's decided to be some breakdown of
3:10 of the of the delineation between the
3:14 tendon and the subchondral bone there's
3:17 bone edema and insertional cliffs and
3:19 also in my second last point there it's
3:22 the typical tendinopathy that the Jill
3:24 alluded to in her last presentation you
3:26 know the increased ground substance
3:28 changes in collagen changes in 10mins
3:31 cells so no surprises there now there's
3:35 a startling a mission in this particular
3:37 one which I'll explain in a moment but
3:39 the typical presentations I've seen most
3:41 recently in the desperate and dateless
3:44 group that I have as well Jill they're
3:46 obviously the more Australian
3:49 footballers and and the rugby men so
3:52 both of whom do a lot of work in deep
3:54 flexion or racking over the ball or
3:57 those things but but we see it less in
3:59 our you know in the round ball soccer
4:01 type football I think because they're
4:04 generally more upright but that's in the
4:06 group that we see middle-aged female
4:08 runners are a big client group and I
4:11 think they have some
4:13 a couple of elements in their
4:15 presentations that I'll try and allude
4:16 to during the day
4:17 these non-athletic women and a bit like
4:22 the non-athletic
4:23 Achilles tendinopathy is that they're
4:25 not always helped with the load load
4:27 based approaches but it's certainly
4:29 worthwhile as Rogers last point in his
4:33 presentation that a lot of what we do
4:34 end up seeing are these desperate and
4:36 dateless non-athletic people sometimes
4:39 all they need is a bit more load on
4:41 their tissues and get them back into a
4:43 zone where their tendons might be a
4:45 little more capable I've had a lot to do
4:48 with race Walker's and hamstring
4:51 tendinopathy is endemic within that
4:52 group but my bigger mission talking to
4:55 says in early today of courses the 20
4:57 odd years that spent with our sprint
5:00 hurdles group and so sprinters and
5:01 hurdlers are a very large group of these
5:04 presentations here so apologies for that
5:07 omission a big challenge is that there
5:11 are a number of pain so a pain sensitive
5:14 structures or enum structures that can
5:17 present with pain in the general ischial
5:20 region and so the main thing is for us
5:23 to try and work through in a very
5:25 systematic and very accurate way if you
5:28 like through our normal exam history and
5:32 examination is to which structures might
5:34 be involved and this area more than any
5:38 other tends to have its own individual
5:41 presentations it's certainly not one
5:42 that you can give an exercise sheet to
5:44 and off you go because there's this
5:46 incredible mixture of presentations that
5:49 include or exclude neurological or
5:52 sciatic nerve impingement sore issues
5:56 with the other my tennis areas which
5:58 I'll explain in a little more detail the
6:02 history of onsets generally insidious as
6:04 you know and you know this well but the
6:06 two big groups that you want to try and
6:08 elicit pick out pretty early are those
6:11 that have had an over stretch injury
6:13 this occurs in rugby league football
6:15 rugby union football as well as their
6:18 rocking or the water skiing accident or
6:21 the overstretch in tennis and these are
6:23 the group that Carl asked Ling wants to
6:25 bring forward because of course
6:27 we do need to know whether they have
6:29 either complete or partial tears of the
6:32 semimembranosus and they take a lot
6:34 longer to heal as those of you read
6:36 those articles it is also a common sight
6:40 for the in fact off quite often the
6:43 initial presentation for ankylosing
6:45 spondylitis so that the the young male
6:48 who often has quite stiff hips and or or
6:51 back and has you know pain in in their
6:55 back at night and and other portions of
6:58 their presentation that's certainly
6:59 something that you need to consider too
7:01 so and these all happen you know it's
7:03 not as though their era tees and we need
7:05 to forget about them these present to
7:07 all of us and you're all primary contact
7:09 practitioners as I'm aware how these
7:13 athletes present with their pain
7:15 localization or covering the resultant
7:17 slides will also talk about low response
7:21 tests a little different from what we
7:23 have earlier we're going to examine
7:26 through this area I won't spend time on
7:28 this we really want to hone on the
7:30 hamstring tendon and lastly considering
7:34 imaging and as to Jill's point earlier
7:37 like imaging is not something we do
7:38 first but it is something we might do to
7:41 complement how our our clinical
7:44 examination and and really you know it
7:47 all has to make sense so the imaging
7:49 changes need to marry up with your
7:51 clinical findings not uncommon ly as
7:54 people age that we'll see either
7:55 age-related changes or load related
7:58 changes in or around the anthesis which
8:01 may not necessarily have anything to do
8:03 with the pain they're presented with and
8:06 all in all that comes down to clinical
8:08 reasoning and you're all great
8:09 clinicians that's why you're here that's
8:11 why you're sports physios and this area
8:13 I think as much or more than most other
8:16 areas can really challenge and excite
8:19 and I really enjoy seeing this area as
8:23 you probably guessed so the pain sites
8:28 the typical pain site of course for our
8:32 hamstring enthesopathy is just a little
8:35 lateral and and so they posterior to the
8:39 ischial tuberosity and as of
8:40 consistent sight both to where they will
8:45 direct their their pain until you the
8:47 way their pain is is predominantly but
8:50 there are subtle differences from this
8:52 that often direct us to other structures
8:55 the most common is people who get vague
8:58 aches slightly lateral to that and it
9:01 may travel up and down a bit and be a
9:04 little inconsistent in the way it
9:05 presents not uncommon ly that's more
9:08 these peripheral entrapments of the
9:10 sciatic nerve anywhere between through
9:13 the lists from acidic notch all the way
9:17 down to as it passes under biceps we see
9:20 an adductor Magnus either a trigger
9:26 point type problem or they can get a
9:28 true enthesopathy
9:30 and there is a true little tendon in
9:32 there described by obey which I have on
9:34 a subsequent slide we get a lumbar spine
9:39 referral which is pretty vague and
9:41 whatever we can have a biceps tendon
9:44 disruption out from the common tendon
9:47 here and we also have a little lesion
9:49 that we see in semitendinosus in its
9:52 posterior fascia which can sometimes be
9:55 be of some interest to us because it
9:59 will refer pain here to intents and
10:01 purposes it presents like initial issue
10:04 but you come up with you know negative
10:07 provocation of the site itself and
10:10 generally negative radiological findings
10:13 too so it's a matter of trying to pick
10:15 all these things apart and then put them
10:17 back together now provocative tests were
10:20 described in the article with Tom Goom
10:22 and will generally start with things
10:24 like a hamstring bridge does that
10:26 produce our pain how much pain do we get
10:28 adding new internal rotation and if that
10:32 increases their pain we we're pretty
10:35 suspicious that it is that
10:36 semimembranosus portion of that common
10:39 tendon because of course that's picking
10:41 up the the medial group to get a high
10:46 level provocation of compression
10:49 actually then going to things like
10:51 arabesque another test that I like is
10:53 that of
10:54 catchy O's group who uses three stretch
10:57 tests but I think the third is the most
10:59 provocative when we're looking for
11:01 something to really nail the hamstring
11:04 tendon where he takes people into
11:06 maximum hip flexion and then adds quite
11:09 fast in the extension and whether that
11:12 reproduces the pain in in and around the
11:16 the hamstring emphasis so they're things
11:18 that were able to use they're things
11:20 that of course we can come back and
11:22 utilize his reassessment as well I've
11:26 discussed the the imaging and this is a
11:29 normal hamstring in thesis here and this
11:32 is an abnormal one here so that the one
11:35 of the first signings when sightings one
11:37 sees is this breakdown of the normal
11:39 antha seal plate here so that rather
11:42 being a really sharp margin it is
11:44 actually blurred and lost we've got a
11:47 little bit of intra tenderness edema
11:48 we've got some para tenderness edema as
11:50 well bone edema is not unusual and we
11:55 might imagine a little bit of bone edema
11:57 here but the other reason we can use mr
12:00 and mrs generally the the modality of
12:03 choice is that ultrasound is it's pretty
12:07 difficult to pick up and and really
12:11 delineate between too many of these
12:13 structures so it's more these axial
12:16 Emma's which are probably our favorite
12:19 Hernando in both Luis Perez described
12:23 these fibrous bands that exist on the
12:25 deep surface of gluteus maximus can wrap
12:28 around the psychic nerve and be tethered
12:30 in any way there and and and this is an
12:33 issue they're not always visualized on
12:37 the on the EMR but they are something
12:40 that gives us real problems with these
12:42 Sider contraptions which is a whole
12:44 other syndrome of itself but I'll be
12:48 alluding to it a couple of times in this
12:49 presentation just the last one I didn't
12:52 cover here is a delamination these are
12:55 pretty rare but I'm going to look on the
12:56 normal side so it's the people who
12:58 really tear away the origin of the
13:01 hamstring away from the in thesis so we
13:03 see a pretty clear line of fluid in and
13:06 around this area
13:08 these 10 these are rare but David young
13:11 one of our surgeons suggests that they
13:14 have a very poor conservative response
13:17 and a generally best manage to
13:19 conservatively I'd be interested in
13:21 other people's opinions on them so I've
13:27 alluded to the differential diagnosis we
13:30 need to consider and and the first one
13:32 obviously these side ignore entrapment
13:34 so I've probably covered a fair bit of
13:35 that but I urge you all to read the
13:38 articles on the deep gluteal syndrome by
13:40 hell Mart and he he brings forward a
13:43 suite of tests that are pretty nice for
13:48 only quotes both the sensitivity and
13:50 specificity of those tests to be able to
13:52 determine whether that's more
13:54 provocative than what any of our
13:55 hamstring type tests might be and as you
13:58 can see we can have em treatments
14:00 anywhere along that tunnel my I've also
14:05 discussed this that so the article by
14:07 obey which many of you might be
14:09 interested in that that they certainly
14:12 do occur and are easily picked up and
14:15 it's a person who comes in and and you
14:18 say Oh where's the pain and they're
14:21 going immediately quite medial to the
14:23 hamstring tendon so I think that needs
14:25 to be a first line of suspicions
14:28 there are a number of areas of sort of
14:31 trigger points or you know Maya
14:33 tenderness strains or call it what you
14:34 will that do present through the
14:37 external rotators the the gluteals and
14:39 others and these are all I not a typical
14:44 pain generators whether they're the
14:48 primary issue or not is is always one
14:51 for great debate and but but the big
14:54 issue as we sorry I'll just go back but
14:56 the big issue that we have is that not
14:59 uncommon ly with a more common chronic
15:01 presentations that we're dealing with
15:03 more than one pathology we may well have
15:05 a truly hamstring tendinopathy but
15:09 having to manage areas within you know
15:12 the gluteal muscle group the external
15:14 micro rotator muscle group and all the
15:16 site ignore other structures is is not
15:18 uncommon there's a number of rare
15:20 syndromes that
15:21 that we need to consider at times when
15:24 we're not getting our clinical results
15:26 with others and certainly in our
15:29 desperate and dateless group that we
15:30 might spend quite a bit of time trying
15:32 to tease out these particular things
15:35 which time is going to prevent me
15:36 spending too much time on those today
15:38 but but I urge you to consider these
15:41 when you've exhausted the top three or
15:43 four and you generally start there so
15:46 they're there stretching a Vulcan
15:48 fractures often the avulsions obviously
15:53 occur in youngsters but we see people
15:56 post a Vol'jin in their 20s and 30s
15:59 wanting to sprint or play football and
16:02 get ongoing issues from perhaps they're
16:05 really of options so that's another
16:06 group here as well okay so here's what
16:11 we're here for which is to be able to
16:12 share and it's probably the only tendon
16:14 we're able to share quite the whole
16:18 approach to in terms of the
16:20 rehabilitation so I'll go through the
16:21 four stages you've heard all this before
16:23 so what are we going to do we're going
16:25 to unload the tenant well how do we do
16:27 that well we take out the things that
16:29 provoke it in training well what might
16:31 they be well it might be our hurdling it
16:34 might be our sprinting it might be our
16:36 accelerations it might be our change of
16:38 direction so depending on the sport
16:39 they're the things that you're going to
16:41 be looking at first can you take those
16:43 out the other thing you can do is of
16:45 course is rather than participating in
16:48 whole sessions you can drop them back to
16:49 half a session so these are all means
16:51 pretty simply of unloading the tendon
16:53 but of course just resting or unloading
16:56 is not where we need to get to we
16:59 actually need to get to actually
17:01 reloading the tenon the other thing is
17:04 I've said is unloading compression so
17:06 it's anything of trunk on hip flexion
17:08 and lastly and again we've how many
17:11 times have we said this today team but
17:14 going through the kinetic chain so what
17:16 are the ways of actually sparing the
17:18 load on the hamstring emphasis and of
17:21 course the synergy between the the
17:23 gluteus maximus and the hamstring is is
17:25 probably the primary thing we need to
17:27 consider here we're then going to
17:31 strengthen up our muscles again no big
17:34 going to take out something there but
17:36 don't poke the bear is a term that we
17:39 use and we weren't going to use today
17:41 but because bears are so there's a part
17:44 of Boone on day so so it is taking the
17:47 the tendon to a point where you actually
17:51 are going to poke the bear and actually
17:52 increase its symptoms so that was where
17:55 it came to but of course you're all
17:56 going to understand that answer because
17:57 you probably poke bears more than we do
18:00 and lastly of course the progressive
18:02 loading and that's what I really want to
18:03 share with you today so we've mentioned
18:08 in others the this monitoring the
18:11 progress with the provocative test that
18:13 24 hours after your high load sessions
18:15 it's all the same here so again this
18:18 should be sit back relax enjoy the ride
18:20 and nothing did that you haven't heard
18:24 already today Evan I showed you this
18:27 slide and this is really about finding
18:30 positions that we're going to get our
18:32 early isometrics in so we really don't
18:34 want to be getting pain with the
18:36 isometrics or mate we may get a little
18:38 pain but when we retest with our
18:41 provocative test afterwards which might
18:42 be a hamstring bridge we want to know
18:44 that isometrics have actually reduced
18:47 their pain maybe not to zero in the
18:49 single session but one or two sets of 45
18:52 second holds of one of these has
18:54 actually changed their pain that gives
18:57 you reassurance and also your patients
18:59 reassurance that the hamstring tendon or
19:02 n thesis is a part of this our big
19:05 challenge early was how do we get big
19:06 forces into a hip neutral sort of
19:09 position and so we started with things
19:13 like having a we call this a trunk
19:17 extension machine or some call at a
19:19 Roman chair now we can do double leg
19:21 holds with weight but we really as Jill
19:24 alluded to and ebony that we want to get
19:26 to single leg holds pretty early to get
19:30 friends Bosch eventually gets to people
19:32 in this sort of position plus seventy
19:34 plus body right pretty much but we tend
19:37 not to take people that high but of
19:39 course you'll go as high as you need to
19:41 or isometric holds in a machine their
19:44 issue is that most people don't have
19:46 these machines at home
19:48 and we want to do them four times a day
19:50 so then what do we use we use our long
19:52 legged bridge and you can actually get
19:55 them to just bias it to the affected
19:57 side and that that way you're actually
19:59 able to be reasonably effective and you
20:01 get pretty fair loads early so that's
20:04 some that's what you would be using at
20:05 home and anytime they can't get to the
20:08 other equipment we can use an internal
20:10 rotation bias if you really think that
20:12 it is the semimembranosus portion the
20:17 second stage was about strengthening the
20:20 muscle Jill talked of this earlier today
20:22 I'm not going to tell you how to
20:23 strengthen muscles you do this all day
20:25 every day but you know the principles
20:27 that what we want to do is sets that
20:30 induce lactate so you know three or four
20:33 sets with it up and where it's three or
20:36 four seconds up three or four seconds
20:37 down and you're doing six to eight reps
20:39 so that the overall duration is about 60
20:42 to 70 seconds that's going to induce
20:44 your lactate partial recovery cow again
20:47 we need to do it at least three times
20:49 sessions a week and we need to have a
20:51 know it's not just a single exercise
20:53 it's a suite of exercises that really
20:55 tackle our hamstrings there your options
20:59 we might after listening to every knee
21:02 and other since were a lot so I really
21:04 like using isometric Spree session to
21:07 train our brain to get maximal
21:10 activation of our hamstrings so this is
21:12 a very important part we might also use
21:14 TNT as a means of utilizing that so
21:18 again let's adopt all of these things of
21:21 course if we need to strengthen gluts
21:23 and other things we'd be doing that in
21:24 the same session - Jill had this in in
21:29 section three doesn't matter whether
21:31 it's late stage two or a section three
21:33 it doesn't matter but here we're
21:34 starting to re-introduce compression
21:37 okay so we're getting exercises where
21:40 we're not doing fast movements initially
21:43 we're doing fairly slow movements but
21:44 we're starting to introduce that
21:46 compression of trunk on the trunk on hip
21:51 we were stunned
21:52 what happened there where we're starting
21:56 to get increased flexion and increased
22:00 compression at the
22:01 to join so we can do things like just
22:04 lateral sumo squats and we can gradually
22:06 increase compression and gradually
22:09 increase compression as you do it that
22:10 makes a lot of sense I use the sled drag
22:13 the sled push quite a bit where we can
22:16 do just repeated pushes we can weight
22:20 the sled up and I'll show you what that
22:21 looks like later but of course we can
22:23 then get more and more hip flexion as
22:26 their symptoms are telling you they can
22:29 tolerate so we can really grade our
22:31 compression quite nicely and that's why
22:33 I like these exercise it can be quite
22:34 accurate with the way that you add add
22:37 compression walking lunges are another
22:39 good way so again all these things that
22:41 you know well and it's only very late
22:43 stage that you might look to provoke
22:46 them
22:46 if this sport requires it to have to go
22:49 into full deep hip flexion so they might
22:52 go to a single or double leg leg press
22:55 but if the sport doesn't require don't
22:57 do it because it's just going to add
22:59 pain add length to rehab that you really
23:02 don't need to do stage 3 adding speed
23:05 same principles that we spent all
23:07 morning talking about so controlling
23:11 range early and in fact often you'll
23:12 bring them back out of their range a bit
23:14 as you're starting to add speed so what
23:16 are things that we might do for the
23:19 hamstring tendon things like box jumps
23:22 things like faster sled you know where
23:25 we're starting to really push along and
23:28 I'll show you what this looks like by
23:30 far more athletic people on me
23:32 we did some analysis in that same group
23:34 that we talked about before
23:36 I love scooters I'll have run throughs I
23:38 love accelerations so all of these
23:40 things three-day load cycle again you've
23:43 learned about that before so this was an
23:45 analysis of doing this sled and that
23:48 what's happening at the and again you
23:50 know these these quite well but what's
23:53 happening in the sled at the when we
23:58 sorry when we do a slow sled a fast lead
24:02 and then the third step of an
24:03 acceleration and you can see here not
24:06 much difference in the tensile force but
24:08 the big difference is in the rate of
24:10 loading and the rate of loading with our
24:12 fast lead is pretty much where we get to
24:14 with Maksim
24:15 acceleration in highly trained sprinters
24:18 highly trained runners so that we know
24:20 that what we're doing in the gym we can
24:22 increment between here and here to take
24:25 us all of where we need to get to so I
24:27 think that can be reassuring too so now
24:29 we're getting becoming more informed in
24:32 in this sort of exercise we do one thing
24:34 we did find in this testing though is
24:36 that we need to consider the friction if
24:39 we have less friction here of course we
24:41 get less less peaking force and we can
24:44 gradually add friction as your way of
24:46 loading that tendon Stage four again
24:49 just looking for activities that's going
24:52 to take them all the way back to their
24:54 sport the really important thing is
24:57 don't overload these incremental things
25:00 that we all we need to do as a little
25:01 bit so that can get back to whatever
25:03 sport they need to do the really
25:06 important thing is that once they resume
25:08 sport or resume the training take out
25:10 all these high load activities Duke
25:13 showed you I think a slide where when we
25:14 added high load activities there were
25:17 eccentric exercise in fact to people who
25:19 are already training that of course they
25:22 in fact got worse and the same happens
25:24 here so really important in this
25:26 sequence that we remove some of our
25:29 other loads as we're working back into
25:31 sport kinetic chain we know well and I
25:36 guess I've alluded to before the big
25:38 thing is gluteus maximus is the big
25:41 synergist with hamstrings and in fact I
25:43 discussed our middle-aged running women
25:46 and and so many of them when we see them
25:48 actually are quite strong in their
25:50 hamstrings but their big problem is that
25:52 all they use is their hamstrings and
25:54 they often have their if we ask them to
25:57 do a hip extension they can't fire their
26:00 gluteus maximus at all I'm talking at
26:03 all and so so much of the approach is in
26:06 fact trying to strengthen their glute
26:07 max through thrusters and other things
26:10 rather than spending all their time on
26:13 the hamstrings so I did want to make
26:14 that point we've got a rig now that we
26:17 use is a force transducer down here and
26:20 a strap we were actually able to
26:22 quantify hip extension strength and look
26:25 at the relationship beat them side to
26:27 side and also its relation to
26:29 the flexor strength as well so we're
26:31 starting to get some normative data with
26:33 that which you'll see in their coming is
26:36 same picture so overview it's a
26:40 multi-modal approach to management and
26:42 that sometimes work in concert with our
26:45 doctors we're looking at using
26:46 medications and/or injections to hit
26:48 some of these other pain generators to
26:51 really clarify the picture for us so
26:52 that we can get back to concentrating on
26:55 the hamstring tendon and its
26:57 rehabilitation at a time that really it
27:00 is about effective tissue loading hand
27:03 quite considered loading over time these
27:05 things do take time the hamster this
27:07 hamstring anthesis is generally not slow
27:10 to rehabilitate but none of them are and
27:12 it is really about lots of accumulating
27:15 load over time and I've said that so
27:20 happy endings there's two things that
27:22 really worried us so introducing
27:24 compression too early and sometimes you
27:26 need to back off that keep going through
27:28 other progressions and then reintroduce
27:30 compression later and then this elastic
27:32 function in the late phase it's an area
27:35 that again is can become a bit
27:38 intolerant and this relationship and I
27:41 didn't spend and I can't spend time
27:43 talking about the site ignore but
27:45 there's almost another lecture you could
27:47 give around strategies further SciTech
27:49 nerve and settling that down which is
27:52 not uncommonly needing to do in your
27:54 rehabilitation here so that's it for me
27:57 again thank you very very much for the
28:00 experience and mr. chair back to you
28:04 [Applause]
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