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What those links show is that you do not understand the difference between what physios do and what osteopaths do
I'm not even sure what definition of "spinal manipulation" you're working with. Have got your own one which you're not sharing?
You seem to have a very specific bee in your bonnet about osteopaths and spinal manipulation, but in two pages of ranting you've not been able to describe what it is.
You've not been able to show me or tell me what the difference is between the spinal manipulation you think is good and the spinal manipulation you think is bad, other than the spelling of the person that's doing it. I show you a picture of a physio doing spinal manipulation on a website which says physios treat back pain with spinal manipulation and you tell me that it's not spinal manipulation.
You keep talking about the evidence and how well you understand it, but doesn't appear you've even read what you posted. You linked to a metastudy which reviewed studies on the effectiveness of spinal manipulation, which included more studies of physios than osteos but did not choose to distingiush between them. Why not, if the treatments are so very different?
You linked to a study about the adverse effects of spinal manipulation, which describes spinal manipulation generally, irrespective of who's doing it.
Spinal manipulation or adjustment is a manual treatment where a vertebral joint is passively moved between the normal range of motion and the limits of its normal integrity, though a universally accepted definition does not seem to exist. It is occasionally used by osteopaths, physiotherapists and physicians, and it is the hallmark treatment of chiropractors
The case studies are broken down into only 2 groups: adverse events after spinal manipulation performed by 1) chiropractors, 2) non-chiropractors.
which bits of these studies did you read?
Just repeating "evidence based practice" in capitals and with exclamation marks doesn't help to explain your reasoning. If anything, it suggests that maybe there isn't any.
Its very simple.
Evidence based practice is doing what the evidence states works. As there is no evidence for any form of spinal manipulation doing anything significant in the way of good and plenty of evidence of it doing harm, evidence based practise means you do not do spinal manipulation!
I am using spinal manipulation to mean the type of manipulation that osteopaths adn chiropractors use - where they take the sp[-inal joints beyond the normal range of movements. What some physions will do is move the joints to the normal range of movements in order to stretch tight muscles and or ligaments. A very diffeernt thing
Why am I so adamant about this - its because osteopathy does no good, cost a lot of money and often does harm. I am hoping to prevent people being injured by it and wasting their money on claptrap.
So go on. Find a reputable study that shows osteopathic spinal manipulation does any good. a proper peer reviewed study like the ones I linked to that show no significant evidence of good adn a lot of ecvidence of harm.
A while ago I had back pain for around 3 years on and off,it wasn't too bad just a really dull ache.Anyway I met a newly qualified osteopath in the pub through a mate who had just set up his own practice.I had one session with him which he asked loads of questions then massage then at the end manipulation(cracking my back)technique,two days later I had severe sciatica which lasted 3 months due to slipped disc.And four years on my back still flares up in pain more than it did before that appointment.I may be wrong and I did feel bad about it but I blamed him for causing my slipped disc so I wouldn't see a chiropractor or osteopath again.
Yup - you are one of the many people injured by an osteopath.
Thanks Twodogs, good read.
As always we have to ask ourselves if "alternative medicine" is effective and safe, why on earth is it an "alternative medicine". Why isn't it just "medicine"?
I love this part.
perhaps most damning – and surprising for anybody who has paid for the treatment – is that nobody can explain how manipulation would theoretically work, even the practitioners. Matthew Bennett, the president of the British Chiropractic Association (BCA), says that one explanation they’re working on is that a physical force through the spine removes stiffness, though it is unclear what causes this “stiffness” or, therefore, how a physical force might remove it. Another is that it changes the body’s perception of pain. “We’ve spent 100 years or more going through various other hypotheses,” he says, “but those seem to be the ones where most of the encouraging work is going on.”
Over 100 years of cracking bones and all the President of the BCA can do is shrug, when pushed on how it's supposed to work.
Quackery dressed up in quasi-scientific clothing. Anyone who admits to being one of these charlatans should be ashamed.
OK, I'll try but I don't think it's going to do any good. You've not shown any inclination to get to grips with what I've written before.
You might recognise these.
Here's a study that looks in depth into the adverse effects of spinal manipulation but does not seek to make any distinction between the type of spinal manipulation done by osteopaths and the type of of spinal manipulation done by physiotherapists. You would think if there was a distinction, especially one as directly correlated to harm as you believe there is, one would be made. But no.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1905885/
And here's a metastudy, combining and summarising the results of 74 individual studies looking into the benefits of spinal manipulation (or SMT - Spinal Manipulative therapy). This metastudy does refer to different practitioners and different types of SMT.
16 of the 74 studies involved chiros
14 involved physios
5 involved osteos
The types of SMT it identified are:
high velocity, low amplitude (HVLA) thrust SMT,
low velocity, low amplitude (LVLA) passive movement techniques
and a mixture of both (HVLA manipulation and LVLA mobilisation)
I'm going to take a liberty and assume in TJ World HVLA is Bad, and LVLA is Good. And because the bad kind is so very very bad, good in combination with bad can only be bad.
So, which types of practitioner used what kind?
Chiros: 7% Good, 93% Bad
Physios: 43% Good, 57% Bad
Osteos: 60% Good, 40% Bad
The results make no distinction between the benefits or harms of HV versus LV therapies, which is odd if one was so obviously fine and one was so harmful.
Taken as a whole, it concluded that "SMT [in general - no distinction for type or practitioner] results in a modest, average clinical effect at best"
and in summing up the harm: "The body of evidence, which includes data from large, prospective observational studies of SMT[again - no distinction for type or practitioner] , suggests that benign adverse events are common and serious adverse events are rare. The incidence and causal relations with serious adverse events are difficult to establish, in part due to inherent methodological limitations of the included studies. Importantly, predictors of these events are unclear. Given this, clinicians should ensure that patients are fully informed of potential risks before treatment." Which is fair enough and no-one's suggested otherwise.
How, given the above, do you arrive at such a strongly held opinion that a) there is a special type of Osteo SMT, b) that this type is universally bad, and c) the type of SMT that Physios do can be recommended without hesitation?
I suspect the answer is because you're tj, and that I won't have much motivation to reply again.
sorry to read about your injury, dannymite. Must have been especially annoying to be injured by someone who was supposed to be sorting you out.
@Ned
from article I linked:
"Philip Sell, an NHS spinal surgeon, says that “manipulation is not appropriate in the neck at all – it can occasionally cause stroke. There’s a definite risk of harm and it is not recommended.” As Singh concluded in his article that led to the lawsuit with the BCA, “if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market”.
Surprisingly, Sell isn’t completely dismissive of chiropractic or osteopathy for people with low-back pain, for which he says there is probably no harm. He concedes that there’s little evidence that spinal manipulation works, and that there’s little reason to think that it would, but adds: “What they do with their hands isn’t particularly important, it’s what they end up saying to the person that might help them manage pain better and keep active.”
you seem to be lumping all spinal manipulation together - for lower back pain, probably no harm, but little evidence for any benefit.
anyway, I'm out, arguing on the internet never changed anyone's mind
What you have missed ned is that ALL spinal manipulation as practised by osteopaths and chiropractors is bad. the data is quite clear. No evidence of good, plenty evidence of harm
a physio who is doing spinal manipulation that exceeds normal movement is putting their registration at risk by using a known harmful technique. I guess the confusion is that physios will use spinal manipulation withing the normal limits of movement to stretch ligaments and muscles. An osteopath will exceed the normal limits of movements to "correct dislocations / subluxations" which apart from being baloney is harmful
So the difference between what an osteopath and a physio will do is about the normal limits of movement. An osteopath will exceed this and that is where the danger lies, a physio will not exceed the normal limits of movement thus causes no harm
Evidence based practice!
The reason I have such strong views on this is I understand the basics of medicine and I hate charlatans who prey on the credulous. Its not so bad when its crystals or homeopathy but osteopathy with is potential for serious harm needs to be countered.
How, given the above, do you arrive at such a strongly held opinion that a) there is a special type of Osteo SMT, b) that this type is universally bad, and c) the type of SMT that Physios do can be recommended without hesitation?
I expect the difference is that physios do spinal treatments for spinal issues rather than because you've got a cold.
In any case, there's increasing pressure* within the profession for them to stop doing it, because of the risks and because it encourages and validates things like chiropractic.
(* - sorry)
you seem to be lumping all spinal manipulation together
Not me. TJ's trying to make a distinction based on "the evidence", and "the evidence" he links to makes no such distinction. There's no basis for his position in there. The studies lump them all together. Where distinctions are made, there are certainly no osteo bad/ physio/good.
I've just been responding to TJ being a dick about the side he's picked, trying and failing to back it up with selective reading, sloppy thinking and sloppy arguments. And whatt some guy said 130 years ago.
Anyhoo, til the next time!
As someone who cracks his neck a lot (it feels a relief when I do it plus I think it may be a ‘stim’ for me) this thread has made me realise the stroke risk. It’s going to be a hard habit to break 😣
Where distinctions are made, there are certainly no osteo bad/ physio/good.
SMT bad, whether it's done by an osteopath, a chiropractor, a physiotherapist or a used car salesman. It's efficacy is at best debatable, certainly when compared to other treatments, and the risk vs potential reward is too high.
I found this, from March:
https://www.bmj.com/content/364/bmj.l689
which concludes (emphasis mine), "SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT."
... and a 'rapid response' to this study here:
"In conclusion, these results demonstrate no convincing evidence for the superiority of SMT over sham SMT, and a lack of clinically important benefit of SMT when compared with any other treatment. The lack of a benefit of SMT over sham therapy indicates that SMT is unlikely to have any direct benefits and observed improvements are the result of contextual and other effects. It is likely that the apparent equivalence with both ‘recommended’ and ‘non-recommended’ therapies tells us more about the disappointing effectiveness of those approaches than it does about the benefit of SMT."
TL;DR - spines are delicate things, leave them alone.
Flippin' heck. Go on then.
What you have missed ned is that ALL spinal manipulation as practised by osteopaths and chiropractors is bad
Can you please show me the parts I've missed that show this?
I've taken great pains to read and analyse what you've linked to, I've quoted, summarised what I've felt are the salient points (all of which you seem to ignored). And believe me, I've looked hard for evidence of the conclusion you've reached above, because I'd have been quite happy to hold my hands up and accept that evidence if it was there.
But I've not found it.
Have you?
Where is it?
The reason I have such strong views on this is I understand the basics of medicine and I hate charlatans who prey on the credulous.
Not because you love a good argument then! 😀
Ned - I gave the explanation. the differnce is physio techniques do not eceed the normal limits of movement, osteopathic does. One is safe, one is not.
A physio using osteopathic treatments is not practicing physiotherapy and is putting their registration as a physio in danger by doing so. They would have no defense in a professional misconduct hearing as they are acting outside of their training
I linked to that piece to show the evidence of harm and the lack of evidence of benefit of this technique
Evidence based practice. the evidence is clear. Osteopathic spinal manipulation techniques do no good and do harm.
Now go on seeing as you believe that osteopaths can do good - find some evidence to back you up
I found this, from March:
keep up, we've been arguing about that one since tj linked to it on page 1!
Ned - its states it clearly You even quoted it
“The body of evidence, which includes data from large, prospective observational studies of SMT[again – no distinction for type or practitioner] , suggests that benign adverse events are common and serious adverse events are rare.
What you fail to understand is the difference - physio treatments do not exceed the normal limits of movement, osteopathic does.
A "physio" who uses osteopathic techniques by going beyond the normal limits of movement is not practicing physiotherapy as they are trained to do
I saw a shamster at a show the other day offering this:
www.eurotherapy.org.uk/
He even looked like the spiv out of Dad's army which ought to be a clue. Old ladies loved it though, they were queuing up to hand their cash over.
Ned – I gave the explanation. the difference is physio techniques do not exceed the normal limits of movement, osteopathic does.
Can you show me the evidence for this difference existing in any of the studies you linked to?
The different types of SMT referred to are HVLA and LVLA. All "Low amplitude". If there was a difference in how far the movements were pushed, there would be High Amplitude, surely? But no. No mention of any difference worth categorising in the amplitude of movements in different types of SMT used by differrent practitioners.
I'm quite happy to hold my hands up and admit if I've missed something, but you've got to help me find it!
its not in those studies. Its just basic stuff. What that study includes is people who are physiotherapists who are using techniques that are not physiotherapy. Neither HVLA and LVLA.are physiotherapy! NO spinal manipulation of that type is physiotherapy. Anything that takes it outside of normal movement is not physiotherapy.
its not in those studies. Its just basic stuff.
Righto. If that's all you've got, then I'm definitely out.
There's a good reply on that Guardian link, above:
"This piece does not, perhaps, convey adequately the fact that there is a wide range of beliefs among osteopaths. The best of them are indistinguishable form physiotherapists (indeed they may be better than that subgroup of physiotherapists who think that sticking pins into patients is a good idea). At the other extreme, there is utterly barmy "cranial ostepathy", an entirely bogus form of treatment for which there is not a jot of evidence."
... neatly dispelling all the anecdotal "evidence" in favour of one over another.
Ned - its in some of the stuff linked to. Thats the difference. Osteopaths can use physio techniques and some physios may use osteopathic techniques. Its the technique that matters not the label of the practitioner. Spinal manipulation that goes outside of normal range of movements is not physio.
So the study you were looking at which includes physios is physios using techniques that actually are osteopathic hence no difference found in outcomes
Osteopaths are gentler than Chiropractors
Thanks Cougar, that's pretty much exactly what I said on page 1. And what our contributing osteopath said too.
What yo have missed again is that anecdote is not evidence! hence cougars inverted commas.
Now - the evidence of osteopathy doing good? found any yet?
It doesn't matter who is doing the spinal manipulation - its wrong, has no evidence base and can be harmful.
Spinal manipulation as described and as the term is used in these studies is not a physiotherapy technique even tho some "physiotherapists" may use spinal manipulation.
I am a nurse. I could do a one year course in spinal manipulation and perform it on the public. However I would not be acting as a nurse if I did so!
and I suppose it is so easy to run a trial with actual spinal manipulation versus placebo spinal manipulation - how would you do the latter ?
they did sham spinal manipulation but of course you cannot do a double blind study - using a sham technique would only be single blind
so how do you obtain meaningful trial data ?
TJ where is the evidence that your evidence based information is in fact based on evidence that is evident and fulfills the evidential requirements of evidence based practice that eventually evidences to this evidence dependent forum that the specific submitted evidence fulfills the requirements of such evidence upon which we will peer review your expected evidence in the context of your non verified evidence based information around evidence based practice.
With great difficulty Turnerguy. all yo can do is look at the data you obtain, use single blind or cohort studies / longitudinal and accept the limitations of the data - like the metastudy I linked to. However whenj yo have enough data points adn the data is heavily weighted in one direct what the evidence indicates is obvious. As it is.
D Faff - my head just exploded!
Tell us all about the time you got the arm issue sorted Tj
Which evidence based practitioner did that for you again ?
The osteo I use was, up until not that long ago, employed as an osteo by the NHS at a London hospital. Confusing isn't it!
TJ the evidence did suggest that such an outcome was likely 😉
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using a sham technique would only be single blind
And one would assume, inherently risky?
Osteopaths can use physio techniques and some physios may use osteopathic techniques. Its the technique that matters not the label of the practitioner. Spinal manipulation that goes outside of normal range of movements is not physio.
And this possibly explains some of the (mis)interpretation on the thread. Saying "Osteopaths are charlatans" (label of the practitioner) instead of "certain osteopathic techniques have no evidence base and can cause harm" (it's the technique that matters).
I've seen a osteopath a few times, and they've helped greatly. They didn't do anything a physio wouldn't have done - all just massage and gentle movements, combined with some good questioning and advice that help identify the causes of the issues and ways of fixing them.
I also doubt whether the clicking and thrusting and cranial has any measurable benefit, and I've always thought it potentially dangerous.
And this possibly explains some of the (mis)interpretation on the thread. Saying “Osteopaths are charlatans” (label of the practitioner) instead of “certain osteopathic techniques have no evidence base and can cause harm” (it’s the technique that matters).
Thats probably air enough. they are not really practicing as osteopaths then are they? Can't claim to be a physio without the training and registration.
But yes - its the technique not the label that counts
but physiotherapists do spinal manipulation, and 'cracking' too...
https://www.physio-pedia.com/Spinal_Manipulation
...I’ve seen a osteopath a few times, and they’ve helped greatly. They didn’t do anything a physio wouldn’t have done – ...
Osteopathy as a field that tries to associate itself with healthcare is a sham, and thus those who choose to practice under its banner are open to scorn.
If they want to practise 'physio techniques' then they should become physios.
I’ve had loads of problems over the years. I’ve regularly seen two physios, an Osteo and currently a sports masseuse. They all have used very similar techniques. Only people to have tried manipulation have been the physios.
Turnerguy - if they do they are not practicing physiotherapy and could lose their registration for doing so given the proof it does not work and that its dangerous.
However see Beejs comments above - it doesn't matter what they call themselves its the techniques that count. spinal manipulation and cracking are inneffective and dangerous - this is a fact well proven.
From the body that maintains the registration of physiotherapists
Registrant physiotherapists must:
1. be able to practise safely and effectively within their scope of practice
So if they are doing spinal manipulation and bone cracking osteopathic type they have breached this
http://www.hcpc-uk.co.uk/standards/standards-of-proficiency/physiotherapists/
The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK's 58,000 chartered physiotherapists, physiotherapy students and support workers.
Here's a course they offer in Spinal Manipulation.
https://www.csp.org.uk/event/complete-manipulation-course-2-days
tj, you've put things in very firm boxes which don't reflect reality: that if an osteopath isn't doing SMT, they're not being an osteopath, and that if a physiotherapist is using SMT, they're either using the good type which isn't SMT, or they're not being a physiotherapist and risk being struck off.
You've made up a distinction between what a physio calls Spinal Manipulation and "osteo" SM which doesn't exist in reality. There's a broad range of SMT techniques and none of the descriptions in the literature talk about this "normal range of movement" you've decided upon. What would normal mean anyway? It's passive or physiological.
The evidence suggests that SMT is of marginal benefit, but then so are the alternatives (drugs, exercise...). So it remains in the toolbox for many professionals, including physios, with caveats about when and when not to use it, given the possiblity of harm and probability of success.
If you go and see a physio or an osteopath with a spinal problem, there's a good chance they'll use some SMT techniques in their treatment, depending on their personal preference and feelings based on their background, personality and professional development.
Whoever you're seeing, ask them about their personal approach to SMT, and if you're not 100% sure, decide between you what's "out of bounds" for treatment, or find someone else.
And it's a good idea to go on recommendation, even though all recommendations are worthless because they're just anecdotes.
Generally, if you adopt a binary, black and white position with no room for grey, you're going to be wrong.
Dr Andrew Leaver, Senior Lecturer in Physiotherapy at the University of Sydney, points out, evidence-based practice is "not a black and white proposition".
"True evidence-based practice is using the best available evidence that you have, and the best available evidence for any intervention is sometimes not that good," Dr Leaver said.
"We don't have robust clinical trials that prove the efficacy of every single thing that we do, but neither does any profession — a lot of medicine is not backed up by robust randomised controlled trials."
I had osteo - maybe the final one - yesterday and here’s what he did for a knotted trap/neck situation
a) cracked my neck vertically, and spine between my shoulder blades
b) manipulated and massaged the knots around my trapezius
c) cracked my neck whilst lying, in a R/H direction (my issue is on the left side)
d) more massage.
I was a year at the physio prior with sports massage and dry needling and I’ve been 8 months with the osteo Both have said it’s a chronic issue and I need to stop cycling for 6months to a year to resolve it, or face continual remedial efforts at undoing the damage from riding and races
The both seem “right”, the results are slightly not as good with the Osteo in terms of short term pain relief. Who to stick with - no idea...
People are getting aerated about this aren’t they!
A few points:
Risk - my annual professional indemnity insurance is circa £270, this means that the chance of me needing it is low. There are risks associated with all interventions, ask a surgeon or anaesthetist what there premiums are.
Treatment - when I trained the definition of osteopathic treatment was ‘treatment provided by an osteopath’. You need to be competent in using your chosen technique, but it is not limited to HVLA manipulation. I use various techniques, including (occasionally) HVLA thrusts, probably the most useful element of what I do in the longer term is offer advice about how to help recovery and reduce the chance of recurrence in the future. Different patients get different treatment, dependent on the nature of their problem and what is appropriate and safe for that individual.
Manipulation - there were pictures in the library where I trained of a chap called Cyriax (a physio IIRC) doing the kind of manipulation described by tj, it was universally felt to be unacceptable then. We were taught that the correct way to manipulate was to create tension using a variety of levers and apply pressure within the physiological range of the joint. Not just ‘take it as far as it can go & then force it further’.
@Kryton53 you are asking the symptomatic area to do more than it can manage, you need to alter what you are asking it to do &/or make it more able to cope with the demands placed on it. Looking at a combination of your strength, flexibility and movement patterns should help.
Guys - there is NO evidence base for spinal manipulation - none at all.
Go on - two osteos have poked their heads above the parapet. I thank you for that.
Your quote about evidence practice is irrelevant - the evidence for spinal manipulation is very clear.
So let me see the evidence for it working because all the evidence I have seen works one way only - its does no good and its dangerous. and given conditions of registration for spinal manipulation then any registerd physiotherapist using it does indeed risk being struck off - as I would if I used nursing treatments from 100 years ago which are proven to have no use and to be harmful
I linked to a major meta study earlier that shows spinal manipulation does no significant good and can do significant harm. given that is the best evidence we have then how can anyone no matter their label perform this?
OK - hint taken!
Nope! This is bigger than SMT!
Seriously, honestly, you are too binary, TJ. There is something in your personality which leads you into black and white answers and doesn't let you out again.
You seem to feel so comfortable about having made a decision, and so uncomfortable about the possibility of reconsidering that decision that you're not able to take on new information. You're literally blind to it.
The studies you linked to do not conclude what you think they do. Physiotherapists use SMT in much the same way as osteos. It's not universally condemned.
The news that the official body for education and registration for physiotherapists offers courses in SMT seems to have made no impact whatsoever to your belief that it's counter to the central tenets of physiotherapy, and that practitioners can be thrown off for using it. How can that be?
Allow yourself the faintest glimmer that you might be wrong and try and read through the thread again and the links again with an open mind. Seek out passages and indicators which show you might be wrong, rather than skimming for the odd sentence which says what you want it to say.
And in life generally, allow yourself the space to believe that there might be truth in a different perspective. You'll learn more. You might find it liberating. You'll certainly have fewer multipage tj-dominated arguments on here.
NOpe Ned( sorry Drac - direct question to me)
The point is no matter who does it spinal manipulation ( even the osto above agrees) has no significant benefits and causes minor harm frequently and major harm occasionally
The studies I linked to show this conclusively.
Therefore this is not a treatment anyone should be using.
BTW - the body the osteo above linked to is NOT the registration body
It really is that simple and that black and white. The fact that some physios may use it does not validate it, it invalidates those physios. It is counter to the central tenets of scientific medicine.
The facts are simple and black and white. spinal manipulation is proven to do no significant good and often causes harm. thats the science
If I or a doctor was using some treatment with no scientific basis, proven to do no good, proven to do harm then rightly we would be stuck off.
You're right TJ, physios register with the HCPC, the CSP is the professional, educational and trade union body for the UK’s 58,000 chartered physiotherapists, physiotherapy students and support workers. Sloppy typing on my part.
As such, they've got plenty of advice on registration with the HCPC, and yet they're still advertising courses by physios, for physios on SMT.
All these evidence based practitioners, the ones you like, all reading the same evidence and coming to a different conclusion to you? That's odd, isn't it? But no glimmer of doubt in your mind?
You're right that there's evidence of only marginal benefit from SMT, and you're right that there's evidence of some harm. What you're missing is the context that no other recommended treatments are much better, while carrying their own risk of harm, and that the risk from SMT is acceptable if care is taken and caution used about when and when not to use it and how and how not to use it based on the patient and the symptomatic areas.
That's why evidence based practitioners use it where appropriate, promote its use, teach it and learn it. Because they understand the evidence.
@nick1c thanks for your last few sentences of advice. With similar results for both I’ve decided to return to the physio after my Hols, and prior to winter training. The basis of this is that when I’ve asked my Osteo for exercises he’s provided a few stretches but seems reluctant to give advice. During physio we tried quite a few things which aggregated the issue so we stopped
I don’t have a great core, and have a bad posture so my intention is to walk into the physio with a dictat of treating the problem but providing me with some relevant winter exercises in association with my Coach to do as you say.