Low Back Pain: Rest vs. Exercise

Dear friend,

in today's blog I will address a problem that approximately 80% of Americans are faced with at least once during their lifetime and that many live with day in day out: Low Back Pain (LBP) aka lumbago.

This blog will provide some insights into the most common causes and treatment options of LBP and investigate whether rest or activity is more helpful when dealing with acute or chronic back pain.


The most common causes in younger adults:

• Injury or overuse
  A sudden onset of pain and stiffness often after activity, a sudden movement or heavy lifting, is mostly caused by soft tissue injuries to muscles and ligaments in the back and along the spine such as muscle strains or sprains. Other causes that fall into the category of injury or overuse are injuries to the small facet joints of the spine or fractures of the bony processes of the spine (attachment points for muscles and tendons). Both types of injuries commonly heal on their own. A combination of rest, heat/ice applications, anti-inflammatory drugs and low back exercises improving spinal stability can be helpful treatment options.

• Nerve root compression
  An Acute or chronic nerve root compression can be caused by a variety of problems. Some of the more common causes in younger adults are:
• A herniated disc: As discs degenerate and break down, the inner core of the disc starts to leak out through the outer portion applying sudden pressure on nerve endings.
  
• Isthmic Spondylolethesis occurs when a vertebra slips forward causing instability and nerve root compression. The reason for the slippage is often a small fracture in a piece of bone that connects the two joints on the back side of the spinal segment. Th fracture typically happens during childhood, starting to cause trouble in young adulthood.
• Lumbar Degenerative Disc Disease: Even though this is a degenerative disease it often affects young adults in their early 20's. It refers to the breakdown of discs in between vertebrae leading to instability and inflammation.
• Sciatica: All of the previously mentioned causes of nerve root compression if effecting any of the major lumbar nerves can lead to Sciatica . Sciatica refers to radiating pain, weakness and numbness along the pathway of the nerves into the buttocks, legs and even feet. The pain can be worse in the feet and legs than in the back and is certainly more intense than the often dull aching pain resulting from strains or sprains.

The most common causes in older adults:
While older adults can experience the same pain related to the problems that apply to younger adults, they are more likely to experience chronic pain related to degenerative processes of the spine and it's joints.




Degenerative Processes

• Osteoarthritis effects most commonly the small joints of the spine, like the facet joints and the Sacro-Iliac joint between sacrum and ilium at the bottom of the spine. These degenerative joint changes (wear and tear on protective cartilage layers) can lead to inflammation of the joint area itself, causing instability, pain, and stiffness. In addition it can lead to the growth of bone spurs which again can apply pressure to the nerve roots. Osteoarthritis commonly effects other joints in the body as well, such as hips or knees causing gait changes leading to secondary pain in the low back due to compromised body mechanics.

• Spinal Stenosis refers to the degeneration of discs, vertebrae, muscles and tendons that make up the spinal column. This degenerative processes can lead to a choking (greek=stenosis) of the lumbar nerves causing increased leg pain with walking (pseudoclaudication) which improves almost immediately when sitting down.
   
• Osteoporosis is a condition in which the bone density degrades to the point of bone fractures. This condition is most common amongst post menopausal women. One of the most effected areas is the lumbar spine. Osteoporosis in the lumbar spine can result in compression fractures of the vertebra causing significant low back pain.

Less commonly found causes for low back pain worth mentioning are Ankylosing Spondylitis, bacterial infections and tumors of the spine.


Treatment Options:

• Heat and Cold applications are usually the first line of defense patients with low back pain are reaching for. Cold packs and ice have been hailed for many years as anti-inflammatory (antiphlogistic) and pain reducing (analgesic) treatment options. It is recommended to apply cold/ice for 15-20 minutes for the first 48 hours after injury. A newer line of thought questions the value of ice or cold packs as a form of anti-inflammatory treatment, because it leads to reduced blood circulation in the inflamed area, reducing the number of white blood cells (the body's natural defense against inflammation) at the source of inflammation. However the cold will numb nerve endings and reduce impulse transmission speed validating it's analgesic qualities. Try a damp cloth between skin and cold source for better conductivity and better results. If introducing ice as an anti inflammatory treatment I would recommend short ice massages. (Ice massage for LBP relief)  The short introduction of cold triggers greater blood flow to the area and lead to an increase in the number of inflammation fighting white blood cells.
  
  Heat applications are indicated if the source of discomfort stems primarily from muscle spasms. The heat will relax the muscles and promote healing. Don't use heat on injured areas that seem swollen and/or red.
  
  If circulatory issues or nerve damage are present do not use either form of treatment. Even though cold/ice is often recommended for the first 48 hours I suggest you try both, heat and ice and find out which provides greater relief.

• Topical lotions/cremes/rubs are in most cases not much more than a distraction from the pain as they commonly promote surface heat rather than penetrating heat. Those containing Capsaiscin, an extract from red chilli peppers, do effect nerve impulse transmission and can be a helpful addition to analgesic medicine in treating pain. Capsaiscin's effect is cumulative and therefore requires a prolonged period of usage before its full benefit is noticeable.
• Pain medications (Analgesics) reach from over the counter pills like Tylenol to powerful skin patches prescribed one at a time. In severe chronic back pain cases these types of analgesics are often combined with codein causing possibly addiction. Antiphlogistica include non-steroidal anti inflammatory drugs (NSAID) such as Advil, Aleve or Aspirin. NSAID address pain and inflammation. The last group of medications commonly administered for acute and chronic back pain are muscle relaxants. Muscle spasms appear quite often as a result of nerve root compression. Spasms add to pain, reduce circulation and slow the healing process. Muscle relaxants may cause drowsiness and should preferably be taken at bed time.
• Invasive Treatment Methods
  This form of treatment includes most often epidural injections; commonly a powerful mixture of an anti-inflammatory steroid (cortisone) and a local anesthetic used to calm nerve root irritation and reduce swelling.
• Physical Therapy
  In case of an acute injury such as a fracture or a herniated disc the RICE injury protocol as is typically the best choice. Rest, Ice, Compression and Elevation are indicated to prevent further damage/injury and manage irritation and inflammation. This protocol is most effective during the first 48-72 hours and typically followed up with passive Physical Therapy modalities such as cold/heat (see above), Iontophoresis, trans-cutaneous electrical nerve stimulation (TENS), and ultra sound.
  
  Iontophoresis is a modality in which steroids are delivered through the skin using an electrical current. A TENS unit is used to override painful nerve impulses to the brain reducing pain. Ultra sound is a form of deep heating soft tissue often successful in reducing acute pain and enhancing soft tissue healing.
  
  Education and Exercise
  A trained Physical Therapist, Physio-Therapist or Kinesiologist can help identify poor body mechanics or postural deviations, which may be contributing factors to your LBP. Together with the therapist you will develop learn to implement strategies that can help to improve those movement and/or postural issues. Learning about proper lifting techniques, a proper work station set-up, and postural awareness can positively influence the outcome of rehabilitation and secondary prevention.
  
  Postural deviations and poor body mechanics are often caused by a combination of a lack of muscular strength and shortened muscles leading to reduced range of motion in the large joints. Poor range of motion especially in the lumbar-pelvic-hip region of the body places undue stress on the spine, as it often requires the spine to compensate for immobility in hips and the sacroiliac joint. The combination of poor mobility and a significant lack of muscular strength leaves the spine vulnerable to injury and increased wear and tear. Physical Therapy will address these issues by leading you in an exercise program that will improve spinal stability and stretching exercises that will increase functional range of motion.

• Examples:
  Supine Floor Bridge: Lie on your back with your knees bend at a 90 degree angle and soles of feet firmly placed on the floor. Tighten your stomach and buttocks. Slowly raise your pelvis off the floor as far as you can, maintaining neutral spine throughout the movement. Hold at top for specified time and slowly return to floor. Careful if you have neck issues.
  
  
  
  
  Body Plank Prone: Lie down flat on your stomach. Tuck your toes under and place elbows next to your shoulders. Lift body off the floor supporting plank body position on toes and elbows. Keep stomach and buttocks tight to avoid sway back. Hold for specified time and slowly return to floor.
  
  
  
  
  
  
  Clam Shell Exercise: Lie down on your side, placing shoulder over shoulder, hip over hip, knee over knee, and ankle over ankle. Split off top knee keeping feet together and hip over hip (clam shell movement).
  
  
  
  
  
  
  
  
  Dead Bug Exercise: Lie down on your back, secure spine by contracting abdominals and glutes. Bend both hips and knees at 90 degrees and reach arms straight up towards ceiling. Lower right arm and left leg maintaining neutral spine. Return to starting position and use other diagonal.
  
  
  
  
  
  
  Hamstring Stretch: Lie on your back, both knees bent, feet on the floor. Straighten one leg out until you feel stretch on the back side of the thigh. Hold stretch for prescribed time and repeat with other leg.
  
  
  
  
  
  
  
  Kneeling Hip Flexor and Quadricep Stretch: Kneel down on one knee placing other foot in front. Tighten abdominals and glutes and push pelvis straight forward shifting body weight to front foot. You should feel stretch in front of hip and thigh. Hold stretch for prescribed time and repeat with opposite leg.
  
  
  
  Please consult your physician before starting any exercise program. Keep in mind that any exercise program should be designed with individual needs in mind and be instructed and supervised by a trained health professional.
• Rest or Exercise?
  Over the past four decades the rehabilitation protocol for LBP has clearly shifted from rest, sometimes total bed rest, to a more active path to recovery. Despite this change in approach the actual course of action is still determined by the cause of your back pain. Exercises can be beneficial and recommended, or strictly contraindicated if exercising carries a high risk for further damage. Generally the first course of action is to rest and have a physician assess the cause of your back pain and develop a treatment plan. Acute injuries such as compression fractures of the vertebra or spinous processes as well as a herniated disc require immediate rest to avoid further injury and possible nerve damage. Other problems such as strains and sprains of muscles and ligaments in the low back and along the spine often respond positive to gentle forms of stretching and low impact aerobic activities as both can be helpful in reducing muscle spasm. Regular exercises are of great importance in managing chronic back pain often caused by degenerative changes of the spine. Chronic back pain does require an individualized exercise program to stabilize and mobilize the spine as well as the lumbar-pelvic-hip region in order to reduce pain and improve function and movement. Secondary back pain is often the result of postural and gait deviations caused by osteoarthritis to other large joints such as knees and hips. In order to reduce the back pain an exercise program needs to manage the original cause first and later correct gait and posture.

Conclusion:
LBP is responding in most cases positive to exercising and often can be a valid alternative to surgical intervention. The starting point, the intensity, the progression as well as the choice of exercises should be determined by a team of Health Professionals experienced in the rehabilitation and management of LBP.

I hope this article is providing you with some helpful information in dealing with your own low back pain or that of a loved one. As always, your questions and comments are greatly appreciated.

A Sante,

Hartmut 


Sources:
http://www.nytimes.com/health/guides/symptoms/back-pain-low/exercise-and-physical-therapy.html
http://www.injurytreatment.com.au/search-injury-information/back-spine/lumbar-spine
http://www.webmd.com/back-pain/features/relieve-back-pain-with-core-strength-training
http://www.spine-health.com/wellness/exercise/back-strengthening-exercises
http://www.bigbackpain.com/back_pain_treatment.html
http://www.webmd.com/back-pain/tc/low-back-pain-prevention
http://www.webmd.com/back-pain/tc/low-back-pain-cause
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809228/
https://www.inkling.com/read/acsms-guidelines-exercise-testing-prescription-9th/chapter-8/low-back-pain
http://www.spine-health.com/blog/bed-rest-or-staying-active-better-low-back-pain-recovery
http://www.spine-health.com/treatment/physical-therapy/physical-therapy-low-back-pain-relief

The influence of exercising on Andropause, aka Male Menopause

Dear Friend,

after taking a closer look at Menopause last month I decided to investigate the male version in today's blog.

Hormonal changes are a natural part of life and aging and effect both women and men. Today an estimated 10 million U.S. men are significantly effected by hormonal changes as they age. There is growing evidence that some men experience similar effects as women during perimenopause and menopause. This situation is commonly referred to as "male menopause" or "Andropause"  aka androgen decline in the aging male (ADAM), partial androgen deficiency in the aging male (PADAM) or aging-associated androgen deficiency (AAAD. This condition is caused by a gradual, but significant decline in  blood androgen levels, mostly testosterone. Other than in women in which the ovaries completely stop producing estrogen and progesterone, the male testes do never completely stop or pause the production of testosterone, making "Andropause" really a misnomer. The hormonal decline in women happens far more rapidly and absolute than the one in men. Men start a slow gradual decline of about 1% per year as early as age 30. Due to the gradual decline over decades symptoms are often far more subtle and may be overlooked for many years.

Decreases in testosterone levels associated with "Andropause" have been linked to:

• decreases in lean muscle mass and bone density,
• increases in visceral fat
• decreases in muscular strength and power
• erectile dysfunction and decreased libido
• depression and mood changes
• decreased cognitive function
• changes in sleep patterns 

The real good news is that all of the above listed symptoms respond positive to exercise and training. In addition hormone replacement therapy can help ease the severity of most of these symptoms and improve the overall quality of life of those affected. Testosterone replacement therapy might increase the risk of prostate cancer or it's recurrence.

How does exercise effect Andropause or testosterone levels? Recent studies indicate that testosterone and human growth hormone (HGH) levels can be increased through exercises, specifically heavy weight lifting and "High Intensity Interval Training" (HIIT). In other words if you want to maintain or restore favorable levels of testosterone and HGH you might want to engage in these types of work-outs for greater virility. Weight and Resistance Training and HIIT are also great to counterbalance the increases in visceral body fat, the loss of lean muscle mass and bone density. In addition, rest and a healthy diet are equally important when trying to naturally boost your testosterone levels. If you don't get at least 7-8 hours of sleep you cutting your body's time short to produce these hormones. A diet high in protein and moderately low in carbohydrates can increase and maintain serum levels of testosterone. Also avoid "no fat" diets as some dietary fat is needed to produce testosterone. Protein supplements are available, mostly in form of powders. Nuts, beans, low fat yogurt, lean meats and fish are my own preferred source to cover my protein needs. Carbohydrates should be ingested mostly in form of vegetables and fruit which contribute valuable antioxidants.

Summation
Andropause is a natural part of every man's life cycle but does effect some more than others. Due to the slow decline of testosterone levels symptoms are often missed and treatment delayed. Moderate success in treating some of the symptoms has been achieved through hormone replacement therapy. In addition regular exercising, good nutritional choices and plenty of rest and sleep can naturally boost testosterone levels and counter balance many of the negative consequences of Andropause.

I hope as always you enjoyed today's blog, learned a little, and welcome your comments and questions.

In good health,
Hartmut


Sources:
http://www.webmd.com/men/guide/male-menopause
http://www.mayoclinic.org/healthy-living/mens-health/in-depth/male-menopause/art-20048056?pg=2
http://www.medicinenet.com/male_menopause/article.htm
http://www.ideafit.com/fitness-library/andropause
http://www.healthguidance.org/entry/528/1/Andropause-and-Testosterone.html
http://www.muscleandstrength.com/articles/naturally-boost-growth-hormone-testosterone
https://www.youtube.com/watch?v=YzJRipnfitg

Exercising during and post menopause

Today's blog is trying to offer some insights into the challenges women are faced with during perimenopause and post menopause and how exercise can help overcome some of it's challenges.

Menopause is defined as the natural absence of a menstrual period and fertility for at least 12 months. The time from the onset of first symptoms to full menopause is called perimenopause. The time after that last period is called post menopause. Menopause can happen as early as the 30's and as late as the 50's. The median age for U.S. women to reach menopause is 51. Menopause can have a variety of causes. The first and natural cause is the reduced production of the reproduction hormones estrogen and progesterone, which are produced by the ovaries. Once the ovaries shutting down hormone and egg production a woman has reached the state of infertility. Other causes of menopause can be surgical through a full hysterectomy (ovaries and uterus are being removed) or by treatment for certain cancers through radiation and chemo therapy.

The symptoms of Peri-menopause and Menopause can include but are not limited to:

• Irregular periods
• Vaginal dryness
• Hot flashes
• Night sweats
• Sleep problems
• Mood changes
• Weight gain and slowed metabolism
• Thinning hair and dry skin
• Loss of breast fullness

The hormonal changes that occur during the peri-menopausal phase and after menopause can increase the risk for developing other health problems. Research shows that with the drop of estrogen levels women tend to eat more and be less physically active. Lower estrogen levels also lead to a reduction of a woman's metabolic rate. As hormone levels drop the risk for Cardio Vascular Disease, Osteoporosis, urinary incontinence, and weight gain (Hypertension, Diabetes Type2) go up.

Exercising helps to minimize stress and enhance mental outlook, helps to reduce anxiety and depression and increase an overall feeling of well-being. Exercises do help maintain and improve bone and muscle mass and thereby lessening the chances for osteoporosis and weight gains. Keeping the body fat low especially in the midsection during these difficult years shrinks the risk for diabetes type 2, cardio-vascular disease and certain types of cancer. Exercises designed to help strengthen the muscles of the pelvic floor can improve or eliminate urinary incontinence.

Any exercise program should include strength and resistance training, low impact weight-bearing exercises such as walking or jogging, and exercises that address balance to help prevent falls, as well as exercises to increase flexibility and mobility. Thirty minutes of moderate aerobic activities on at least five days per week have proven to have a positive impact on cardio-vascular and respiratory fitness as well as metabolic issues arising from lower estrogen levels. Aerobic exercise increase HDL (good cholesterol) and decrease LDL (bad cholesterol) and Triglycerides. Strength and resistance training helps maintain muscle mass and counter balance the reduction of metabolism after menopause. Weight-bearing exercises help to maintain/improve bone density lessening the risk of fractures at hips, wrists and lower back.

Those of you who are going through this period or are already post menopausal, and have developed osteoporosis, might have to reduce the impact and work load of certain exercises. Shortening levers especially when working around the hip (clam shells instead of long leg hip abduction) can reduce the risk of exercise induced fractures. Those that have already developed cardio-vascular disease and/or hypertension need to monitor blood pressure and heart rate during and after work-outs. If you are diabetic please check blood glucose levels prior to starting your work-out in order to prevent hypoglycemic emergencies.

Conclusion:
Regular exercising is the single most powerful lifestyle choice that not only has a positive effect on the symptoms of peri-menopause/menopause, but can beyond that significantly reduce the occurrence of secondary health problems.

I hope today's write up has given you a better understanding of the importance of exercising during and after menopause. As always, your comments and questions are strongly encouraged.

A sante,

Hartmut

Sources:
http://www.webmd.com/women/guide/women-over-50-fitness-tips
http://www.webmd.com/menopause/guide/menopause-weight-gain-and-exercise-tips
http://www.osteopathic.org/osteopathic-health/about-your-health/health-conditions-library/womens-health/Pages/postmenopausal-exercise.aspx
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3296386/
http://www.mayoclinic.org/healthy-living/womens-health/in-depth/fitness-tips-for-menopause/art-20044602
http://www.mainlinehealth.org/oth/Page.asp?PageID=OTH006116
http://www.acsm.org/access-public-information/articles/2012/01/12/exercise-recommendations-for-menopause-aged-women
https://www.womenshealth.gov/menopause/
http://www.mayoclinic.org/diseases-conditions/menopause/basics/definition/con-20019726
https://www.womenshealth.gov/menopause/menopause-basics/index.html
http://www.mayoclinic.org/diseases-conditions/menopause/basics/symptoms/con-20019726

FITNESS 50-PLUS: Rest and Recovery

Dear Friend,

Unfortunately, identifying the right balance of hard work and recovery is the most difficult part of serious fitness training. So it comes to no surprise that most of my clients are much more focused on the exercises I teach to help them reach their goals of rehabilitation, balance, weight management, health improvement, greater overall fitness etc. Paying attention to proper rest and recovery often is being neglected. I guess if one pays for training rest seems a waste. As a trainer and therapist it is my job to ensure that a client/patient is not sabotaging his/her own efforts of improvement and remind them that adequate rest and recovery are an essential part of any work out program and no less important than the exercise itself. Lack of rest in between exercises within a training session and too little or poor recovery on off days will compromise the success of training whether the goals pertain to rehabilitation, health maintenance, fitness or athletic performance and regardless of age. Rest and recovery will however increasingly gain greater relevance and importance as we age. Some of you might have watched the Winter Olympics in Sochi. Norway's Ole Einar Bjoerndalen (age 40) became the most decorated Winter Olympian of all times. He almost missed the team as he had dropped far down in World rankings in 2012 and only after changing his training and emphasizing rest and recovery did he become successful again. In today’s blog I want to help you better understand the role of rest and recovery and leave you with some tips on how you can maximize your rest and recovery periods to ensure training success.

The role of rest in between sets and different exercises within a training session

Rest in between sets and exercises depend on the intensity of a given exercise (number of reps and work load) the overall demand on the body and the goals of your training . If trying to improve muscular strength endurance/fatigue resistance you trainer will most likely chose light to moderate work loads, high number of repetitions and short (30 seconds or incomplete recovery) rest periods in between sets. If maximum strength is to be improved high to maximum work loads, low number of repetitions, and long rest periods (complete or nearly complete recovery) in between sets are the common choice. Improving aerobic cardio-vascular capacities requires you to train at or near the aerobe-anaerobe threshold for extended periods of time, while improvements of anaerobe capacities require a short high intensity stimulus like a sprint. Rest periods have to be far longer. And yes there are newer methods that have gained great popularity such as High Intensity Training (HIT) or High Intensity Interval Training (HIIT) mostly due to their high caloric expenditure and impact on VO2 that allow for very little or no rest in between exercises. These types of work-outs are typically shorter in total time (15-30 min) and require full recovery on off days to be successful.


Recovery in between training sessions - Super Compensation

Training success relies on the principle of “Super Compensation” which means that training is supposed to stimulate a response that improves the body’s readiness for the next training session and its demands. In order to accomplish “Super Compensation” the work-out has to provide a progressive overload challenging strength, balance, and/or aerobic/anaerobic capabilities etc. In order to ensure optimal results after each session, exercises, work loads, numbers of repetitions and rest in between sets and work outs have to be planned.

Super Compensation requires recovery. In order to improve performance, training has to be timed properly. The best time for the next training session is at the highest level of Super Compensation. Training prior to the climax of Super Compensation limits training results. Training prior to regeneration leads to overtraining and reduced performance. Waiting too long leads to maintenance without improvement. See graphs below for better understanding.

Super Compensation

Perfect timing leads to improvement

Overtraining - negative training


Symptoms of Overtraining may include but are not limited to:

• Persistent muscle soreness
• Persistent fatigue
• Difficulty sleeping
• Elevated resting heart rate
• Reduced heart rate variability
• Increased susceptibility to infections
• Increased incidence of injuries
• Irritability
• Depression
• Mental breakdown

Periodization - variable training intensities and training goals short-, medium- and long term

"Periodization is an organized approach to training that involves progressive cycling of various aspects of a training program during a specific period of time. Periodization is most widely used in resistance program design to avoid over-training and to systematically alternate high loads of training with decreased loading phases to improve components of muscular fitness (e.g. strength, strength-speed, and strength-endurance). This system of training is typically divided up into three types of cycles: microcycle, mesocycle, and macrocycle." (Frankel, C.C., & Kravitz, L. (2000). Periodization. IDEA Personal Trainer, 11 (1), 15-16)

Additional ways to maximize rest and recovery on training days and in between

Whether it is between interval bouts, immediately after an interval session, or the day following strenuous exercise, there is compelling research evidence that active recovery is superior to passive recovery (Del Coso et al., 2010). Here are some ways you can speed up and improve your recovery process.

1. Post Exercise Nutrition Recovery has three goals, refueling glycogen storage by consuming complex carbohydrates (unprocessed, wholesome grains), offering protein for muscle repair and synthesis (first 45 minutes post exercise are key), and restoring fluid and electrolytes lost through sweat while exercising. Nutrition Recovery efforts should start within 45-60 minutes post exercise.
2. Stretch your muscles and/or  perform Self Myofascial Release by using a foam roller.
3. In addition an ice-cold full body plunge, contrast therapy by alternating hot and cold showers, and icing hard trained muscles right after working out can significantly reduce muscle soreness and inflammation and decrease the existing lactic acid build up, speeding up recovery.
4. Ensure a good nights rest with plenty of hours and quality of sleep.
5. Low intensity exercises such as walking or light weight lifting on the day following intensive work-outs will increase circulation and reduce lactic acid build up.
6. A massage to help with myofascial release, circulation and relaxation can further promote recovery in the days following intense work out sessions.

Conclusion

Despite the fact that recovery is an under-researched topic and therefore not as well understood as other areas of training, we do know that it takes a well thought out training plan and active recovery strategies to speed up and maximize the recovery process, and optimize training results and performance in athletic endeavors as well as in activities of daily living.

I sincerely hope I was able to shed some light on rest and recovery and help you improve your current strategies after finishing your work outs. Please feel free to respond with any comments and questions you might have.

In good health,
Hartmut



References:

Del Coso, J. et al. (2010). Restoration of blood pH between repeated bouts of high-intensity exercise: Effects of various active-recovery protocols. European Journal of Applied Physiology, 108, 523–532.

Frankel, C.C., & Kravitz, L. (2000). Periodization. IDEA Personal Trainer, 11 (1), 15-16

http://sportsmedicine.about.com/od/sampleworkouts/a/RestandRecovery.htm

http://www.ffnetwork.co.uk/fitnessfacts/recovery.php

https://www.acefitness.org/certifiednewsarticle/2757/training-recovery-the-most-important-component-of/

http://www.pponline.co.uk/encyc/recovery-training-increasing-your-speed-of-recovery-will-ensure-your-training-is-progressively-expanded-454

http://greatist.com/fitness/18-scientifically-proven-ways-speed-recovery

http://www.sportsdietitians.com.au/resources/upload/120628%20Recovery_SD%20version.pdf

http://sportsmedicine.about.com/od/sampleworkouts/a/After-Exercise.htm

Exercising with advanced chronic kidney disease (CKD)

Dear Friend,

recently one of my long term clients and dear friends started dialysis after years of chronic kidney disease (CKD) as it moved from stage 3 to 4 and finally reached stage 5 which called for aggressive treatment and dialysis.

Today's blog is trying to provide some insights into exercising with advanced chronic kidney disease and dialysis.

Did you know that one in seven adult Americans suffers from chronic kidney disease?

 http://www.physiciansweekly.com/ckd-incidence-prevalence/

The presence of CKD should be established through presence of kidney damage and level of kidney function measured by glomerular filtration rate (GFR). During stages 3 and 4 your kidneys are still able to remove some waste and excess fluids from your blood  and treatment is mostly focused on keeping your body nourished and treating other diseases contributing to the kidney disease. In addition your doctor will closely monitor kidney function to quickly intervene through medication and diet when necessary. Diet recommendations for patients wit CKD change with the amount of kidney function remaining, requiring adjustments in intake of protein, calories and other nutrients.

The most common causes of reaching the end-stage of this disease is diabetes mellitus. If diagnosed with diabetes make sure you watch your blood glucose levels and follow your treatment (insulin and other medications) strictly to prevent renal failure. Another cause for moving on to dialysis is hypertension as it damages the small blood vessels inside the kidneys. Controlling blood pressure by way of medication (often two different types) and reduced sodium intake is essential when trying to reduce the risk of further kidney damage.

Healthy kidneys produce the hormone erythropoietin also known as EPO which stimulates the bone marrow to make red blood cells, responsible for oxygen transport in the blood. Patients with chronic kidney disease do not produce enough EPO and often suffer from Anemia causing fatigue and paleness. Severe Anemia also places undue stress on the heart causing a greater risk for heart failure in patients with chronic kidney disease. Treatment options include EPO injections and iron supplements as EPO treatment is only successful if blood iron levels are sufficient.

Other problems caused by kidney disease effect bone health as phosphorous levels often increase and Calcium and Vitamin D levels decrease. Periodic bone density check ups are therefore warranted.

Knowing about the problems that chronic kidney disease can cause and being aware of possible other contributing diseases is helpful when starting and deciding on an exercise program. Many dialysis patients believe that they can't exercise any longer. The opposite is the truth. A regular exercise program has shown to be very beneficial to both, patients with chronic kidney disease even when undergoing dialysis. A regular exercise program yields the same benefits as it does for healthy individuals including but not limited to:

• increased energy and endurance

• improved physical function and activities of daily living

• greater muscular strength and counterbalance dialysis associated muscular atrophy

• lowering blood lipids

• controlling blood pressure

• improving insulin resistance

• managing body weight

• greater sleep quality

• enhanced mental outlook

Exercising is extremely important for patients with CKD. Studies have shown that physically active individuals predialytic, on hemodialysis and after kidney transplant increase their overall quality of life and improve the outcome of renal disease.
Before starting any exercise program patients with CKD should consult with their physicians and discuss safe forms of exercise and possible risk factors and contra indications. Your nephrologist is aware how much, how often and what types of exercise are beneficial in your particular situation. In case a trainer or Physical Therapist is involved in your effort to exercise I strongly recommend a consult between the fitness expert and your physician ensuring successful and safe work-outs.

When starting an exercise program choose activities that are enjoyable as it increases the chances for better compliance. If you are a novice to exercising start out and progress work-outs slowly. Exercises that have proven to be of great benefit to patients include aerobic activities, such as walking, jogging, cycling, skiing, dancing and swimming. Try to work up slowly to 3-4 weekly sessions of 30 minutes or more. Chose a workout intensity that allows you to keep up a conversation without shortness of breath. Avoid exhaustion.

In addition to aerobic activities CDK patients should get involved in a regular resistance training program that helps increase lean muscle mass and strength. Work out loads should be light to moderate and focus on repetitions rather than load increases. Work-out intensities should be kept moderate to avoid excessive muscle soreness and fatigue. In order to be successful try two or three weekly sessions, strengthening all major muscle groups.

If exercising outdoors avoid the hottest hours of the day; avoid big meals right before exercising, and don't place your work-outs too close to bed time as it might interfere with the ability to go to sleep. Stop the work-out if you experience chest pain, excessive tiredness or shortness of breath. Do not exercise if you have a fever and changed your dialysis or medicine schedule before consulting with your nephrologist.

Conclusion: Not only can CDK patients exercise at any stage of the disease, it is encouraged and vital to the emotional and physical well-being, overall quality of life, and the outcome of the disease. The potential risk of physical activity can be reduced by medical evaluation, risk stratification, careful supervision, and education.

As always, your comments and questions are much appreciated.

In good health,
Hartmut

Sources:
http://www.dciinc.org
http://nwkidney.org
http://www.renalresource.com
http://www.ncbi.nlm.nih.gov/pubmed/15742304
http://www.kidney.org
http://www.davita.com
Physical Exercise in Patients with Severe Kidney Disease
G.C. Kosmadakis, A. Bevington,  A.C. Smith a E.L. Clapp, J.L. Viana, N.C. Bishop, J. Feehall http://www.kidney.org/atoz/pdf/nutri_chronic.pdf
http://www.kidney.org/professionals/kdoqi/guidelines_ckd/p4_class_g1.htm
http://www.kidney.org/kidneydisease/aboutckd.cfm
http://www.physiciansweekly.com/ckd-incidence-prevalence/

Choosing a Personal Fitness Trainer

Dear Friend,

Tis the season after the season. That means gyms are filling up and fitness trainers are getting busy helping all those with New Years Resolutions and Holiday Season Expansion to live healthier and lighter lives. In today's blog I would like to take a closer look at the process of deciding whether or not you should hire a trainer, what benefits to expect from hiring a trainer and how to select the one that fits your needs best.

In a first step let's explore whether you are actually in need of a trainer.

• Are you an experienced fitness enthusiast, a novice or the off and on work out type?
• How fit are you? Out of shape or in top form?
• Are you already following a structured exercise program or are you winging it each time you come to the gym?
• Are you healthy or do you have health conditions that require close monitoring while exercising?
• How comfortable are you using different exercise equipment at the gym?
• Do you educate yourself about trends in sports and exercise science?
• How would you define your own goals for the trainer?
• What is your financial situation like?

Answering the questions above should give you a good idea whether you could benefit from a trainer or whether it would be a wasteful investment. A Personal Fitness Trainer provides the expertise to create customized exercise programs that consider your risk factors and help you accomplish your goals. He/she will asses, motivate, track progress and hold you accountable. A personal trainer can be the difference between an enjoyable and safe work-out or a no hum work out that possibly leads to injury. If you indeed have special health needs  i.e. due to metabolic conditions (i.e. Diabetes) or orthopedic problems (arthritis, joint replacement etc.) or suffer from a neurological disease (i.e. Parkinson's, MS, post stroke etc.) you should very seriously consider hiring a qualified trainer that is experienced in working with these types of limitations. Once you have decided to hire a fitness trainer you need to screen several candidates in order to find the best fit.

Personal Training clients are typically part of either one of two categories. They already have a gym membership or they don't. If you are currently member of a Fitness Club you might want to start your trainer search right at that club. Trainers at clubs are often (not always) a little less expensive, as the employer already makes some income of membership dues. To those of you who aren't members there are two options available, the Traveling Trainer who offers to meet you at your home or work-site or anywhere else convenient to you, and the Fitness Training Studio Trainer who is part of a small Fitness Center that generates income through Personal Fitness Training and/or smaller scaled fitness classes rather than through membership fees.

To find the right trainer you can interview candidates at your club or utilize the internet and find possible candidates on so called referral sites. These sites often are run by Fitness Organizations that certify and/or educate fitness trainers, or are commercial sites that offer trainers an affordable way of self introduction on the internet. Profiles commonly list education, specialties, target groups, insurance status, experience and CPR/AED certification status.

Here is a list of some popular sites:

PATrainer.com
Personal Trainer Listing Service
IDEA Fitness Connect
Fitness Jobs Place
SimpleFit
FindMyFitnessTrainer.com
ACSM Pro Finder
Find an ACE Pro
Find an NSCA Trainer

Personal Trainer Certifications are the industry's self imposed minimum standard. Unfortunately there are today so many certifying bodies that it is very confusing for any prospect client to figure out which certifications are the most reputable. Personally I would welcome a State Board Exam for Personal Fitness Trainers to create a single standard instead of multiple educational standards. For that reason I personally prefer to hire trainers with a four year- or advanced college degree in a Fitness and Exercise Science related field to come to work for Back In Form. Please don't misunderstand, there are many excellent certified trainers out there without college degrees, it's simply up to you to find them.

So how do you screen for the right trainer that meets your needs? A personal interview and asking the right questions can make the decision easier. Here are some of the questions I ask and areas I investigate when looking to hire a trainer.

Philosophy:

• Please describe your philosophy on fitness training.
• What are areas of emphasis? Body Composition, Aesthetics, Health, Weight loss etc.?
• What made you decide to become a fitness trainer?

Education:

• What is your educational back ground?
• What are your degrees and certifications as they pertain to fitness training including CPR/AED?
• Any expertise in working with special health conditions? 
• Any references?
• How do you keep yourself educated on latest trends and science?

Location:

• Are you offering in-home or work-site training?
• Where is your gym located? (Convenience is a big factor. We typically don't stray more than 5 miles away from home or work to train)

Insurance and Policies:

• Are you liability insured?
• What are your business policies? Cancellations, missed sessions, terms of contract etc.

Budget:

• How much do you charge per session?
• How long is each session?
• What are your typical contract terms?
• Are their discounts for long term contracts, partner work-outs etc.?
  
  The trainer needs to fit your budget

And last but not least, as you conclude your interview, decide whether or not you liked the candidate and if you made a true connection. Only if you enjoy the trainer's attitude and demeanor, and respect his/her expertise will you trust and have success.

I hope that 2014 is going to be the year in which you will improve the way you look and feel. Be it with me,  with any of my colleagues, or on your own.

A Sante,

Hartmut


Sources:
http://www.ideafit.com/fitness-library/how-to-choose-a-personal-trainer
http://www.sparkpeople.com/resource/fitness_articles.asp?id=1369
http://www.sparkpeople.com/resource/fitness_articles.asp?id=895
http://www.acefitness.org/acefit/healthy_living_fit_facts_content.aspx?itemid=19