One of the most common sports injuries: The Ankle Sprain

In today’s blog I’d like to discuss one of the most prevalent injuries in sports, especially those activities that are performed on your feet and in multi planar directions, the Ankle Sprain. I will get into possible causes, the nature of the injury, the rehab process and how to best prevent this injury or it’s recurrence.

 

Causes

Ankle sprains occur when the ankle is forced out of its regular position causing the ligaments on the inside, outside or above the ankle (high ankle sprain) that support the joint structure to overstretch, or partially- or fully tear. Often other supporting structures such as tendons and cartilage are also injured in the process. This occurs most commonly when the athlete takes a fall and twists the ankle in the process, or an athlete jumps or pivots and rolls the foot awkwardly over the outside or inside edge of the foot, or during play on an uneven surface.

Symptoms

The most common symptom of any ankle sprain is pain, especially when loading the joint. There can be swelling and bruising as well, depending on the severity of the injury. Due to the occurrence of swelling the ankle mobility is typically limited.

First Aid

The approach to first aid of a sprain injury depends on the severity of the injury, the amount of pain and swelling you experience. The old school approach would lead you to initially follow the PRICE (Protection, Rest, Ice, Compression, Elevation) protocol for 24 to 72 hours and then move on to the MICE (Motion, Ice, Compression, Elevation) protocol. There are however some studies that indicate that early mobilization of the injured ankle might result in a more rapid recovery and return to work or play. In any case whether, you follow the old school approach and start mobilization 24 hours or more post injury, or the new school approach and start mobilizing immediately, your attempts to mobilize the ankle should stay below the sharp pain threshold. Uncomfortable is ok, but sharp pain likely leads to further injury.

To begin remove all ankle bracelets and toe rings from the injured foot.

Ice is being applied for its vaso-constricting and analgesic qualities, helping prevent intensive bruising, swelling, and reduce pain. It can be applied in form of ice cubes in Ziploc bags, frozen peas from your freezer or the commercially sold blue cold packs. I recommend to place a moist thin towel between ice pack and skin for better conduction. Ice for 20 minutes and reapply throughout the next 24 to 72 hours. Make sure to take at least 90 minute breaks between applications to prevent frost-bite.

Compression and Elevation (preferably above heart level) are reducing blood flow into the injured area and reduce the risk of tissue swelling, which prolongs the healing process. You can use an ACE bandage or similar product to wrap the injured ankle.

Rehabilitation

There are light, moderate and severe ankle sprains (Level 1-3). An ankle sprain increases your risk of re-injury by about 40-70%, proper management of the injury and the rehabilitation are crucial to reduce that risk.

Utilizing the PRICE protocol the rehab for all three levels is similar in treatment, but the rehab process increases in length of time with the severity of the injury.

Level 1 – Phase 1: 0-72 hours after injury

Level 2 – Phase 1: 0-7 days after injury

• Continued ice and rest. Apply ankle brace or tape for stability. Full weight bearing as early as pain-free possible. Avoid lateral ankle movement or any high risk activities

Level 1 – Phase 2: Days 3-7

Level 2 – Phase 2: Days 8-21

• Start ankle mobility and strengthening exercises as pain permits. Active dorsi- and plantar flexion (pulling foot up – pointing foot) for mobility. Resisted dorsi- and plantar flexion as well as isometric ankle eversion and inversion (pushing ankle outward/inward against resistance without actually moving the ankle) to start strengthen the joint structure. Possibly introduce alternate hot/cold therapy to increase circulation and speed up healing.

Level 1 – Phase 3: Day 8 plus

Level 2 – Phase 3: Day 22 plus

• Progressively increasing stress on ligaments to promote healing. Careful at this time to avoid re-injury. Move to active eversion and inversion exercises, start single leg stance and unstable surface balance exercises to increase proprioceptive stimulation, move from walking to jogging to sprinting in straight lines and finally start hopping, jumping and cutting and other sports specific training drills.

Level 3 injuries should not be self-treated due to possible other injuries to the joint structure and complications. Crutches might initially be advised when moving. Please seek professional help with your rehabilitation. Prolong initial rehab (Phase 1: mobility exercises only) for first two weeks. The full rehab process for Level 3 injuries is typically 8-12 weeks.

Prevention and Secondary Prevention

To prevent ankle sprains it is important that your training routine includes ankle stability training, and balance exercises to stimulate the different players of your proprioceptive system. Such exercises include single leg stance, exercises performed on instable surfaces such as “Airex” pads, wobble boards etc. There is a bit of controversy in the literature about how much peroneal latency affects ankle stability and especially the risk of recurring sprains. I think it can’t hurt though to integrate some exercises into your routine that improve peroneal latency. Peroneal latency refers to the electromechanical delay and reaction speed of motor response of the peroneus longus (evertor muscle), which according to some helps prevent ankle rolling. Multi directional lunges into single leg stance performed barefoot on a firm surface while activating Janda Short Foot have shown some success in reducing latency. In addition, sports specific drills that offer controlled simulation of the stress placed on the ankle during sports activities should be part of a training program focused to prevent ankle sprains.

Other studies performed with individuals with recurring ankle sprains didn’t show any significant differences in peroneal latency, but showed reduced ankle proprioception and weakness in evertor muscles, which quite possibly are responsible for chronic ankle sprains.

Secondary prevention therefore starts with a refined rehab protocol after the initial sprain. The better and more successful the initial rehab, the smaller the chances of recurring sprains.

We will show some of the exercises mentioned in our next Video Exercise Work-Shop, so please come back and visit us for that!

I hope this short blog helped to better understand ankle sprains and what can be done to prevent those from occurring and recurring.

In good health,

Hartmut

Sources:

https://www.aofas.org/footcaremd/how-to/foot-injury/Pages/How-to-Ankle-Sprain-Strengthening-Exercises.aspx

http://www.webmd.com/first-aid/ankle-sprain-treatment

http://www.mayoclinic.org/first-aid/first-aid-sprain/basics/art-20056622

http://www.podiatrytoday.com/mastering-treatment-high-ankle-sprains

https://www.marshfieldclinic.org/sports-wrap/treating-ankle-sprains

http://www.emedicinehealth.com/ankle_sprain/page6_em.htm

https://www.verywell.com/ankle-sprain-rehab-exercises-3120749

http://www.mayoclinic.org/diseases-conditions/sprained-ankle/basics/definition/con-20032428

http://www.webmd.com/men/features/seven-most-common-sports-injuries

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164380/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164382/

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/

http://lermagazine.com/article/peroneal-latencys-role-in-inversion-ankle-sprain

Your Glutes: Movers and Stabilizers for optmal performance

Dear Friend,

Today's blog is about the importance of strong buttocks for human performance, whether for athletic performance, physical labor or simply Activities of Daily Living (ADL) and the  negative effects of gluteal weakness.
 
Anatomy:
Your buttocks are made up of three gluteal muscles, The Gluteus Maximus, the Gluteus Medius and the Gluteus Minimus.

The Gluteus Maximus is your strongest hip extensor, helping you get off the chair or toilet seat, lift up your grand child, safely climb stairs and manage curbs, and simply stand upright. Gluteus Medius and Minimus counter gravity's adductive forces at the hip through hip abduction and external thigh rotation and stabilize the hip during the swing phase of walking gait. Understanding the job discription of these muscles gives you already an idea of the negative effects that weaknesses in one or more of these muscles can mean to physical performance.

Causes of Gluteal Weakness:
In today's modern world an ever growing number of our population is spending their eight hour work day sitting on chairs in front of computers, returning home to a dinner table and later on to the TV couch and finishing the day off lying in bed. In other words twenty-two hours of most days they spend keeping their gluteals inactive (unloaded/inhibited), leading to atrophy of the gluteals and tightening of hip flexors. Other causes of gluteal weakness include:

• overuse of quadricep dominated exercises
• Muscular imbalances especially abdominals and back extensors
• Knee-, Hip- and/or Back Pain (secondary)
• Postural Deviations i.e. sway back or flat back

Effects of Gluteal Weakness on human performance:
Gluteal inhibition negatively effects performance, lumbar-pelvic-hip stability, postural alignment, and lower body strength causing often chronic pain and injuries whether it's on the athletic playing field or at home performing ADL. In athletics optimal postural alignment means more efficient movement, less muscular fatigue, less stress on joints and ligaments, and a more optimal transfer of energy while moving (more power). In older adults optimal posture reduces the chance of cumulative injuries due to static positions. Gluteal weakness is often the reason for a transfer from independent to assisted living. Conditions caused by weak gluteals:

• Hamstring Strains
• Low back pain
• Anterior knee and hip pain
• ACL (Anterior Crucial Ligament) sprains
• Ilio-Tibial Band Syndrome
• chronic ankle instability etc.

What came first, the egg or the chicken?
In many cases it's not clear whether gluteal weakness causes the condition or the condition causes the weakness. Example: An older adult suffering from osteo-arthritis in the knee might adopt pain related gait changes leading to gluteal inhibition. On the other hand, weak gluteals lead to hip and knee instability and an increase in wear and tear and therefore result in osteo-arthritis.

Treatment:
Studies show that gluteal inhibition/weakness can be successfully addressed and almost fully reversed within a few weeks through appropriate exercises, introducing regularly loaded activities. In order to re-activate the gluteals often functional hip mobility has to be restored first. Sit to Stand Stretch, Active Hamstring Stretches and isolated gluteal stretches i.e. Piriformis Stretch can help with mobility. The second phase should include simple gluteal activation exercises such as Bridging (2 to 1 leg), Clam Shell Exercises, Quadruped Hip Extensions, Fire Hydrant Exercise etc. This phase is followed by loaded exercises to increase/restore gluteal strength. Exercises such as Squats, Dead Lifts (progressing from bilateral to single leg and single plane to multi planar), Farmers Walks, Resisted Walking (sagital as well as frontal plane), and resisted Reverse Lunges promote great gluteal activation and contraction forces.

For detailed exercise descriptions please watch ViEW (Video Exercise Workshops) on "Gluteal Activation and Strength" by visiting our website: www.backinform.com

In summation: Weak Buttocks are a common occurrence in adults of all ages. Untreated, those weak buttocks can cause severe problems and injuries associated with lumbar-pelvic-hip instability and significantly reduce performance on the every day- and athletic playing fields. The good news is, that gluteal inhibition and weakness can be reversed through an appropriate exercise program.

If you need help recreating your buns of steel please give me a call!

A Sante,

Hartmut


Sources:
http://functionalresistancetraining.com/articles/re-activating-and-strengthening-the-gluteal-muscles
http://wannabebig.com/injury-rehab-and-stretching/how-gluteal-atrophy-effects-posture-performance/
http://www.shapefit.com/exercise/gluteal-amnesia.html
http://redefiningstrength.com/glute-activation-10-exercises/
http://www.higher-faster-sports.com/noglutes.html
http://drjohnrusin.com/top-5-glute-activation-techniques/
https://experiencelife.com/article/go-to-glutes/
http://www.brianmac.co.uk/glutes.htm
http://well.blogs.nytimes.com/2010/12/21/when-the-diagnosis-is-dead-butt-syndrome/?_r=1
http://www.healthline.com/human-body-maps/gluteus-maximus-muscle
http://physicaltherapy.about.com/od/humananatomy/a/Gluteus-Medius-Muscle.htm

Exercise and Fitness Training for the child and teenager on the Autism Spectrum

Dear Friend,

in today's blog I am going to discuss the benefits of exercise and fitness training for children and teenagers that are living with Autism Spectrum Disorder. The number of children that already have been- and are being diagnosed as part of the spectrum is growing every year. The Center of Disease Control reports that 1.5% of children born in the USA today are likely to develop an ASD. Most of us have friends, colleagues, neighbors or know of someone who is affected by Autism or has a child that was diagnosed with ASD. If you read this and are not personally affected kindly look around and share this blog with someone who is. Thank you!

What is Autism Spectrum Disorder (ASD)?
ASD is considered a developmental disability caused by neurobiological differences in the brain of mostly unknown cause. The disorder begins before the child turns 3 and last throughout the person's life. A diagnosis of ASD includes a group of conditions that used to be diagnosed separately, including:

• Asperger Syndrome (AS)
• pervasive developmental disorder not otherwise specified (PDD-NOS)
• Autism Disorder (AD)
• Rett Syndrome (very rare)
• Childhood Disintegrative Disorder (CDD) (very rare)

ASD effects a child's life in three different areas:

1. social interaction
2. verbal and non verbal communication
3. behaviors and interests.

A person living on the spectrum does typically not present physical features setting him/her apart from anyone else, but is likely to exhibit differences in the way he/she behaves, communicates, interacts and learns. Some are extremely gifted while others are extremely challenged. Some need very little help in their day to day life while others need a lot of attention and assistance. While ASD is a life long problem, early and continuous intervention strategies are helpful in managing symptoms and increase skills and abilities.

Asperger Syndrome (AS)
Asperger Syndrome is often referred to as "high functioning Autism" and represents the mildest form of ASD. This condition is three times more common amongst boys than girls. The child with Asperger often becomes interested in a single topic or object which he/she will learn about and obsessively discuss. Although the AS child typically has normal to above average intelligence, his/her social skills are distinctly impaired and movement is often clumsy and uncoordinated, leading to a strained relationship with sports and exercise. As AS children grow up to be adults they are faced with an increased risk for anxiety and depression.

Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS)
This diagnosis includes the majority of children living on the spectrum. It refers to the broad middle between the high functioning child with Asperger and the severely disabled child with Autism Disorder (AD). They compare to their peers with AS and AD by typically showing less language skills than the children with AS, but far better skills than the child with AD and fewer repetitive behaviors than either of the two other groups. Common for all three groups is a significant social interaction impairment.

Autism Disorder (AD)
This group is described as being more severely impaired in social and language skills and presents with increased repetitive and stereo typical behaviors. In addition children with AD commonly suffer from intellectual disability and seizures.

Two additional very severe, but thankfully rare forms of Autism include Rett Syndrome and  Childhood Disintegrative Disorder (CDD).

Rett Syndrome
This syndrome is caused by a random gene mutation (not inherited), occurring mostly in girls.

Childhood Disintegrative Disorder (CDD)
The child with CDD loses all of his/her social, language and intellectual abilities over a short period of time. Seizures often develop parallel to the non recoverable losses mentioned before.

Symptoms of ASD:
As previously mentioned the three cardinal areas effected by ASD are social interaction, language skills and repetitive/stereo typical behaviors. Other symptoms commonly associated with ASD are:

• Gastrointestinal Disorders
  GI disorders in the child with ASD can reach from constant constipation or diarrhea to inflammatory bowel disease. In many children these GI problems lead to secondary behavioral changes such as self comforting (rocking) to aggression and even self-injury (head banging)
• Seizures
  The child on the spectrum suffers in nearly 40% of all cases from seizures. Often different types are present in the same child. The easiest to recognize are the Grand mal seizure while other seizures like a Petit mal seizure are harder to detect.
• Sensory Processing Difficulties
  This problem refers to an altered and unusual response to a variety of sensory input (smell, taste, sound, light, touch etc.). Many children with ASD exhibit a hightened sensitivity (hypersensitivity) to sound and touch leading to sensory defensiveness. Other children have a reduced responsiveness (hyposensitivity) i.e. don't respond when called by their names.
• Sleeping Difficulties
  Falling and staying asleep are a common problem amongst children and adults with Autism. The Autism Treatment Network offers a Sleep Strategy Tool Kit that might be able to manage sleep better.
• Pica
  Persons with Pica are eating non-eatable items such as chalk, dirt or erasers etc. Though this symptom is a common part of normal development in children ages 18-24 months, it becomes symptomatic in children and adults with developmental disabilities including ASD beyond those ages. Those living on the spectrum that show signs of Pica should be blood tested for enviromental toxins from time to time.
  

The Autism Treatment Network offers a great variety of tool kits that address the many issues and symptoms that arise when dealing with a diagnosis of ASD. Please check out this link for these helpful kits: http://www.autismspeaks.org/family-services/tool-kits

Treatment
Even though Autism remains incurable, early childhood intervention and a sensible use of medications can improve a child's abilities and skills, and make symptoms more manageable, leading to an overall improved quality of life. Even if a child has not been diagnosed with ASD, the Individuals with Disabilities Education Act (IDEA), makes early childhood intervention treatment services accessible to all children under the age of three that are considered at risk of developmental delays. These services, offered by the state, can evaluate and start treatment before a diagnosis is established.

Treatment Options:
Behavior and Communication Strategies
are trying to provide the child on the spectrum with structure, organization and direction while utilizing family participation.

• Applied Behavioral Analysis (ABA)
  ABA is a widely recognized and utilized tool in the treatment of those diagnosed with ASD. It encourages positive behavior and discourages negative behavior in order to improve and teach skills.
  "There are different types of ABA. Following are some examples:
  
  • Discrete Trial Training (DTT)
    DTT is a style of teaching that uses a series of trials to teach each step of a desired behavior or response. Lessons are broken down into their simplest parts and positive reinforcement is used to reward correct answers and behaviors. Incorrect answers are ignored.
  • Early Intensive Behavioral Intervention (EIBI)
    This is a type of ABA for very young children with an ASD, usually younger than five, and often younger than three.
  • Pivotal Response Training (PRT)
    PRT aims to increase a child’s motivation to learn, monitor his own behavior, and initiate communication with others. Positive changes in these behaviors should have widespread effects on other behaviors.
  • Verbal Behavior Intervention (VBI)
    VBI is a type of ABA that focuses on teaching verbal skills."
    (http://www.cdc.gov/ncbddd/autism/treatment.html)
    
   Additional therapies that complete the behavioral and communication strategies include:
  
  • Occupational Therapy
  • Sensory Integration Therapy
  • Speech Therapy
  • The Picture Exchange Communication System (PECS)
  For more information on these therapies, visit the websites of the Center of Disease Control, the National Institute of Mental Health and AUTISM SPEAKS.

Dietary Strategies
At this time no general dietary recommendations can be made, as some dietary changes might help one child, but fail to help another. Many parents feel that removing certain types of food, especially Gluten and Casein, influences the way their child feels and acts in a positive way. The idea behind this dietary intervention is, that their children digest proteins differently. Instead of the more common allergic reactions to Gluten and Casein children on the spectrum react with behavioral and physical symptoms. Before changing your child's diet please consult your child's physician and possibly a nutritionist familiar with ASD to avoid nutritional deficits

Medication
Today there are no medications that can cure or even help treat the cardinal symptoms of ASD. There are however a variety of medications available that help manage many of the other symptoms such as, attention deficit, hyper activity, depression, seizures, aggression and GI problems etc.

Alternative Treatment Strategies
Alternative types of treatments are controversial as in most cases health benefit claims are supported by little or no scientific research. That said, some of these alternative treatments have shown success in individual case . About 30% of parents, desperate to help their child with ASD, are willing to give these treatments a try. To avoid endangering the child I strongly urge you to carefully research and discuss any alternative treatments with the child's doctor.

Exercise and Fitness Training
Over the past couple of decades Exercise and Fitness Training have proven to be a positive addition to the traditional behavioral modification interventions leading to improvement of symptoms, behaviors and overall quality of life

Regular exercising promotes- and should be part of a healthy life style whether you live with a disability or not. Children on the spectrum are more likely to become overweight than their non disabled peers. About 50% of children on the spectrum are considered either at risk or already overweight. Obesity can cause secondary health problems such as increased wear and tear on muscles, tendons and joints, diabetes, cardio-vascular disease and depression. Some of these secondary health problems are compounded by conditions already existing in many children with ASD such as gastro-intestinal problems, anxiety and depression. The lack of physical activity in this group of children is considered the number one reason for obesity. Other contributing factors are poor dietary patterns and medications such as anti-psychotic drugs that lead to weight gains.

Participation in Physical Education and especially team sports is challenging due to a variety of physical and social issues associated with ASD such as:

• limited motor function
• limited spatial planning
• difficulty in self monitoring
• low motivation
• social interaction difficulties
• increased sensory stimulation might cause overload

According to recent studies children and teenagers living on the spectrum, and despite their challenges, do respond in nearly the same way to physical activity and fitness training like you would expect a non autistic child/teenager to adapt. Over time stamina, balance, coordination, strength and flexibility show significant rates of improvement. Regular aerobic activities have shown to decrease negative self-stimulating behaviors such as body rocking, spinning, head-nodding etc. without effecting other trained positive behaviors, leading to improved learning and social behavior. Physical activity can furthermore promote self-esteem and increase a general feeling of happiness, counter balancing depression and/or anxiety. Those who are able to participate in team sports have the opportunity to develop social relationships with team mates and transfer social cues needed to succeed on the field of play into their day to day lives.

An exercise and fitness program geared towards children and teenager living on the spectrum should first of all be fun (intrinsic motivation) and secondly address areas that are often negatively effected by Autism such as:

• Body Awareness
• Motor Coordination
• Health and Wellness
• Socialization
• Positive Self-esteem
  (My Autism Consultant LLC)

Eric Chessen, M.S. the founder of Autism Fitness basis all of his fitness programming on the "PAC Profile" which he developed over the years working with children and teenagers with ASD. PAC is an acronym for Physical, Adaptive and Cognitive. These are three areas of functioning that Chessen feels need to be addressed and repeatedly screened for.

• Physical refers to the physical abilities of the athlete;
• Adaptive refers to the level of motivation the athlete brings into training;
• Cognitive refers to the athletes ability to learn in a physical activity situation.

According to Chessen designing a program based on these three principles is necessary to eliminate frustration and ensure successful training. The program should include basic activities of general fitness training, including, squatting, pushing, pulling, rotation and locomotion. Sports movements are to specific and complex and might present the athlete with challenges to difficult to manage, resulting in frustration and rejection. In order to adjust to the individual athlete the exercises should be easily progress-able or regress-able.

In summation: Fitness training for the child and teenager living with ASD is greatly beneficial in many ways addressing primary issues as well as secondary health problems associated with the disorder. Besides individual approaches and success stories there are unfortunately not enough scientific studies available detailing fitness program design for this particular group of athletes. Much research and work remains to be done!

I hope this blog does provide you with insights into the importance as well as the challenges of training the child living with ASD.

As always, your questions and comments are greatly appreciated.

A Sante,
Hartmut


Sources:

http://www.autismspeaks.org/family-services/health-and-wellness/fitnesshttp://autismfitness.com/meet-eric-chessen/
http://breakingmuscle.com/coaching/3-tools-for-training-the-autistic-client-that-can-be-used-with-any-client
http://exerciseconnection.com/
http://www.ncbi.nlm.nih.gov/pubmed/24525861
http://asdfitnesscenter.com/
http://myautismconsultant.net/autism-fitness-program/
http://www.autismspeaks.org/science/science-news/sports-exercise-and-benefits-physical-activity-individuals-autism
http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=8766
http://www.nchpad.org/315/1452/Autism~and~Considerations~in~Recreation~and~Physical~Activity~Settings
http://www.ncbi.nlm.nih.gov/pubmed/22207460
http://www.webmd.com/brain/autism/understanding-autism-symptoms
http://www.autismspeaks.org/what-autism/symptoms
http://www.cdc.gov/ncbddd/autism/signs.html
http://www.kevinmd.com/blog/2010/07/physical-features-autism-spectrum-disorder-asd.html
http://autism.lovetoknow.com/Physical_Characteristics_of_Autism
http://www.nimh.nih.gov/health/topics/autism-spectrum-disorders-asd/index.shtml
http://www.webmd.com/brain/autism/autism-spectrum-disorders
http://www.autismspeaks.org/family-services/tool-kits/100-day-kit/treatments-therapies

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