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

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

Osteoarthritis of the shoulder

Dear Reader,

Like my mother many people suffer from chronic severe shoulder pain caused by degenerative joint disease also known as osteoarthritis.

Osteoarthritis occurs when the bone protective- or articular cartilage wears down and causes swelling, inflammation, and pain. In some cases bone spur (osteophytes) growth might occur, as bone rubs against bone. The shoulder is made up of two joints, the acromioclavicular (AC) joint and the glenohumeral joint. The AC joint is located where the clavicle (collarbone) meets the acromion at the tip of the shoulder blade. The glenohumeral joint is the meeting point between the arm bone (humerus) and the scapular (shoulder blade).

In the majority of cases osteoarthritis of the shoulder or any other joint for that matter is found in people age 50 or older. In the earlier years osteoarthritis is typically caused by a traumatic injury to the joint. A very small percentage of young osteoarthritis patients have a genetic predisposition to the joint disease that causes an early onset.

When seeing an orthopedic specialist, he/she will most commonly start the diagnostic process by establishing a medical history and perform a physical exam looking for swelling, pain and tenderness. Often muscular weaknesses surrounding the joint is found due to pain induced inactivity. In addition x-ray and MRI can produce imagery that details the degree of degeneration of the joint more accurately.

Osteoarthritis of the shoulder can be treated conventionally, through medication, and surgically. The first step of treatment is to rest the shoulder and modify activities involving the shoulder. The application of ice or heat packs to reduce swelling, inflammation and pain and improve mobility are typically temporarily and do not eliminate the cause. Your physician might prescribe a physical therapy program focused on  stretching and strengthening muscles to improve joint range of motion.

Should these conventional methods fail to bring relief medications such as Non-Steroidal-Anti Inflammatory-Drugs (NSAID's: Ibuprofen, Naproxen, Aspirin) or Cox2 Inhibitors (Celebrex) can  be used to further reduce inflammation, swelling and pain. Advanced stages and severe shoulder pain is often treated with corticosteroid or hyaluronic acid injections. Steroid injections reduce swelling and thereby alleviate pain and decrease joint stiffness. Hyaluronic acid injections are known as "viscosupplementation" and help lubricate the joint similar to the way W40 works on mechanic joints.

If all non-surgical options are exhausted your physician will suggest either a total shoulder replacement (arthroplasty) or a partial replacement in which only the head of the humerus is replaced (hemiarthroplasty). Both these surgeries are performed to treat osteoarthritis of the Glenohumeral joint. The removal of a small section of the end of the collarbone known as resection arthroplasty is the common surgical choice to treat osteoarthritis of the AC joint.

In recent years stem cell research has created new hope for osteoarthritis patients. In the last years stem cells who help heal and regrow cartilage were used in the repair of small cartilage defects. Currently studies are ongoing to explore whether the same treatment can help grow whole joint surfaces such as knees and hips in a lab to resurface the degenerated joint. For now this is still science fiction but there is a great deal of optimism and reason to be hopeful.

Many of my arthritic clients ask whether exercising is beneficial and whether I would recommend exercising while in pain. My answer to both questions is YES.

Our joints need movement! Movement nourishes and promotes joint health. Maintaining strong muscles will help support the weakened joint structure and reduce joint stress as you move. Stretching muscles and utilizing gentle mobilization exercises will help maintain good functional range of motion allowing for optimal use of the joint. Cardio-vascular exercises help in the prevention of diseases commonly known to be associated with inactivity and manage body weight therefore reducing impact on spine and joints. In addition learning meditation and relaxation techniques have shown to reduce stress and pain.

The exercise choices and the workloads when exercising with osteoarthritis depend on the severity of the disease as well a the timing. Workloads and work-out intensities have to be reduced when training an arthritic joint. Certain exercises might require modifications or need to be avoided all together in order to reduce the risk of causing aggravation. During an acute phase of inflammation one should further reduce or even eliminate the workload and focus instead on flexibility and mobility exercises working around the pain rather than through the pain.

Exercise suggestions for Shoulder OA:

Overhead Shoulder Stretch:

Stand with feet shoulder wide apart, arms hanging in front of body. Interlock fingers with palms facing down. Stretch arms straight overhead with fingers interlocked and palms facing ceiling.

Hold stretch for 20-30 seconds
2-3 Repetitions

Crossover Shoulder Stretch:

Stand with feet shoulder wide apart. Reach with one arm across opposite shoulder bending elbow. Gently push elbow further towards opposite shoulder.

Hold stretch for 20-30 seconds
Repeat 2-3 times each side










Towel Shoulder Stretch

Feet shoulder wide apart. Hold towel in one hand, drop it down the spine, Grab low end with other hand and gently pull top hand down behind head.

Hold stretch 20-30 seconds
Repeat 2-3 times each side









Shoulder Blade Pinch:

Stand with feet shoulder wide apart. Draw shoulders down and back until you feel your shoulder blades pinch in the back.

Hold for 5-10 seconds
Repeat 5-10 times









Rotator Cuff Strengthening
External Rotation

Stand with feet shoulder wide apart. Arms bend by your side at 90 degree angle. Grab elastic band with one hand and rotate outward. .

Repeat 10-20 times each side

Internal Rotation

Same position as before but this time arm rotates inward

Repeat 10-20 times each side.








These exercise are only a small selection and might not be suitable for everyone. Please talk to your physician and/or physical therapist before starting any exercise program.

I hope this short article is helping you understand your own condition or that of someone close to you. If you have any comments or questions please don't hesitate to email me.

Best,

Hartmut

References:

Web Md: http://www.webmd.com/osteoarthritis/guide/shoulder-osteoarthritis-degenerative-arthritis-shoulder

American Academy of Family Physicians: http://www.aafp.org/afp/2008/0901/p605.html

About.com: http://osteoarthritis.about.com/od/shoulderosteoarthritis/a/shoulder_OA.htm

Arthritis Health: http://www.arthritis-health.com/types/osteoarthritis/shoulder-osteoarthritis-treatment

NCBI: http://www.ncbi.nlm.nih.gov/pubmed/23190869

Science Daily: http://www.sciencedaily.com/releases/2013/01/130124163246.htm

Chicago Tribune: http://articles.chicagotribune.com/2013-04-24/health/sc-health-0424-arthritis-stem-cells-20130424_1_stem-cells-farshid-guilak-cartilage

Arthritis Foundation: http://www.arthritis.org/conditions-treatments/disease-center/osteoarthritis/

Warm-Up and Cool -Down: Why and How

Dear Friend,

I wish you and your family a Healthy and Happy 2013.

Yesterday I watched my son's High School soccer game. As so often, my observations triggered a new blog. During the middle of the game one of my son's teammates, who just a few minutes earlier had entered the game as a sub, went down on to the pitch in a great deal of pain. No one knew exactly why. I thought it was the lack of proper warm-up before he entered the game that caused the injury. Turns out I was wrong. Upon further examination the boy showed all classical symptoms of Sciatica. However having observed his warm-up prior to coming into the game made me want to write a blog discussing the changes that have taken place over the past 4-5 years with respect to warm-up and cool-down and the scientific reasoning behind these changes.

The right warm-up and a proper cool-down need to be essential parts of every work-out and athletic competition. Correctly done they help minimize the risk for injury, increase physical performance and help with recovery after the competition or work-out.

The preferred warm-up of the past and that of my son's teammate included some form of gradually increased cardio vascular activity ( in his case way too little) like running, cycling, swimming etc. to increase the body's core temperature and blood circulation within the muscles. This phase was followed by static stretches to increase flexibility and range of motion (prolonged stretches that are used to increase the length of soft tissue and flexibility of the muscle). This warm-up procedure is flawed in at least two ways.

1. Static stretching is a very inactive warm-up method which leads to a decrease in muscle and body-core temperature that had just been elevated during the first phase of the warm-up. Therefore rendering the cardio-vascular warm-up part worthless. Reducing muscle temperature and core-temperature reduces physical performance ability (reduced oxygen supply, reduced neurological activation level) and increases risk of soft tissue injury as a colder muscle is less pliable/flexible and tears easier.
2. Besides that, several recent studies have shown that static stretches reduce the muscles ability to contract forcefully leaving that stretched out muscle weakened for up to an hour. This muscle weakness leads to an increased risk for injury and a muscle performance reduction.

Does this mean static stretches should be avoided all together? The answer is no. Static stretches are still a vital part of an athletes overall training. They do increase flexibility and improve joint biomechanics thereby reducing risk for injury to soft tissue and joints. Static stretches should based on today's knowledge be performed as part of a cool-down procedure and/or be done on off days.

Lately we are leaning more and more towards sports specific dynamic warm-up programs. These dynamic warm-ups focus more on the neuromuscular systems of the muscle. Dynamic warm-ups help with short term flexibility gains and lead to more adequate protective reflex responses from the Golgi Tendon Organs without compromising the strength of the muscle. Golgi Tendon Organs are lying deep within the muscles and protect the muscles from being overstretched. If not properly prepared and activated during warm-up these organs often over react during sports activities leading to muscle strains. Dynamic warm-up protocols help dampen the reaction of the Golgi Tendon Organs leading to improved muscle performance.

To properly warm-up I suggest you continue to start the same way you used to. Brisk walking, jogging or cycling etc. will help increase core and muscle temperature, improve oxygenation of muscle, and get your metabolic and nervous systems ready for action. After that skip the static stretches and move into dynamic sports specific exercises such as high knee jogging, butt kickers, multi directional lunges, bear walks, leg swings, arm circles etc.

After completing your work-out or competition slowly turn the system back down by gradually decreasing the intensity. Slow jogging and static stretches are a good way of returning physically and mentally to a real life activity level.

I hope I was able to shed some light on the recent changes to Warm-Up and Performance Readiness. As always, if you have any questions or comments please feel free to contact me.

A Sante,
Hartmut




Sources:
Mayo Clinic: http://www.mayoclinic.com/health/exercise/SM00067
Journal of Strength and Conditioning Research. ” 2008:
http://hpcsport.com/publications/staticstretching2.pdf
About.com: http://sportsmedicine.about.com/cs/injuryprevention/a/aa071001a.htm
IDEA: http://www.ideafit.com/fitness-library/pre-run-stretch-hampers-endurance

Holiday Tips

Dear Friend,

My apologies for letting too much time pass since the last blog, but family commitments do come first.

The Holiday Season is upon us with the first feast done and the second and third on the way. Every year I face similar questions: "How can I ensure the number on the scale doesn't go up" or "how can I win the "Battle of the Bulge" before it defeats me?" My answer remains the same, prepare and stay real.

The Holiday Season is most certainly a tough time to lose or even maintain current weight, and your goal should not be deprivation as temptations loom everywhere.  Instead try to maintain your weight and your workout schedule AS MUCH AS POSSIBLE.  It is unrealistic to expect to work-out as much as one would during other times of the year. Holiday parties with friends and colleagues, traveling and shopping consumes the time usually dedicated to your normal work-out routine.  However, exercise activities can still be integrated in many different ways.  Avoiding the ever so coveted close parking spot at the mall, or using the stairs instead of the elevator, will burn a few extra calories which can definitely accumulate to a measurable difference on January 2.  Family activities such as walks after holiday dinners or the traditional football game in the backyard are fun and are an excellent alternative to popping bonbons while sinking into a sofa and watching TV. 

Of course this is the season to be jolly and I love chocolates and all the other goodies abundantly and ubiquitously available.  Just establish a Holiday Game Plan and stick to it!  Make sure you provide the healthy fall back option when invited to a pot luck party. Arriving at the buffet fill your plate on the first round with healthy and low calorie food choices such as veggies and fruits. The second round opt for some lean meat or fish dishes and go easy on the deserts by the 3rd round. Any good host/hostess ensures that your wine glass is full at all time, so make sure you leave a sip to discourage any refills until you are ready for more.  Add a glass of water after each alcoholic beverage to further reduce the party calories.

Another hot topic at the end of each year is the Personal Training question. Can I afford Personal Training?  Will I realize a true benefit?  How do I choose the right Trainer?  A Personal Trainer can be a great ally in the prevention and reversal of holiday expansion.  He or She will hold you accountable to an agreed-upon work-out schedule. Pricing for trainers varies greatly depending on the area in which you live, the qualifications and experience of your trainer as well as travel time and expense.  As a Personal Fitness Trainer, I strongly believe in the benefit of enhanced quality of life, that fitness training provides whether through a PFT or on one’s own efforts.  I have personally experienced the difference a good trainer can make in my own athletic endeavors.  I’ve also had the pleasure of influencing positive impacts of many of my clients’ health and wellness. 

For guidance on how to select a Personal Fitness Trainer, visit a blog I wrote in January of 2011 titled Happy New Year: How to choose a Fitness Trainer.

Have a wonderful Holiday Season and a healthy, wealthy and joyful 2013!

Hartmut

Childhood Obesity - Let's face the challenge

Dear Friends,

after taking a break I am coming back to you with a blog that addresses the fitness needs of an age group opposite to those I wrote about last time, our children and adolescents. Childhood obesity has according to the CDC (Center for Disease Control) tripled over the past 30 years, increasing from 7% in 1980 to 20% in 2008 among 6-11 year old kids and in the same time period increasing from 5% to 18% among the adolescents (age 12-19). One third of all children 6-19 were overweight. Healthy weight, over weight and obesity are defined in children and teenagers with the help of the BMI (Body Mass Index - relationship between body height and body weight) in addition age and sex are taken into mathematical consideration. Children among the 5th-85th percentile are considered "healthy weight", 85th-less than 95th percentile are considered "over weight", and those 95th percentile and higher are labeled "obese".

The effects of being over weight and obese have immediate and long term health consequences.

Early heath effects:

• Increased risk of cardio-vascular disease (due to hypertension and hyperlipidemia).
• Increase in pre-diabetic conditions
• Extra weight is also hard on joints and bones creating early onsets of osteo-arthritis.
• Being out of shape and furthermore leads in many to being ostracized and suffer from poor self-esteem.

Overweight adolescents have a 70% chance of becoming overweight or obese adults. This chance increases to 80% if one or more of the parent/s is/are overweight or obese.

Health consequences later in live include:

• Increased risks for type 2 diabetes
• Increased risk for heart attacks and strokes
• Greater rate of osteoarthritis
• Increased risk for many forms of cancer

How can I as a parent prevent my child from growing overweight or obese or help him/her when already overweight?

In the vast majority of cases childhood obesity  is a result of caloric imbalance. Too many calories are being consumed while too little calories are being used for physical activities. In plain English; most children spend too much time in front of TV and computer screens while consuming high caloric foods of very little or no nutritional value. Educating your youngster on healthy dietary choices, limiting his/her screen time and encouraging physical activity by being a role model and activity partner goes a long way in the prevention and treatment of childhood obesity. When addressing the need for more physical activity please realize that sending your child outdoors is not enough to encourage physical activity. You going to the pool, playground or neighborhood park together and engaging your child goes a lot further. Another mistake parents make when choosing a physical activity for their kids is to integrate them into their own routines i.e. jogging. When deciding on a specific activity for your child please take his/her age and physical developmental stage into consideration. Jogging might be a good choice for a 16 year old adolescent (if it isn't painful due to the extra weight), but is certainly utterly boring for a 5 or 6 six year old kid. In addition, young children up to age 12 are metabolically "High Speed Stop and Go Engines". Next time you have a chance observe little kids on a playground. They most likely go in short spurts to full exhaustion, recover and go full blast again. Chose playful forms of activities in younger years and continue on with more organized forms of exercising as your child grows up to be a teenager.

To give yourself and your child a better chance to be successful in dealing with her/his weight issues make sure your whole family is on board and ready to support each other in living a healthier live.

Helpful websites:

http://www.nourishinteractive.com/healthy-living/family-nutrition-exercise-facts/childhood-obesity/childhood-obesity-prevention-websites-childhood-resources

http://www.letsmove.gov/


http://www.shapingamericasyouth.org/Default.aspx


As always, your questions, comments and suggestions are appreciated.


In good health,
Hartmut

Sources:
www.mayoclinic.com/health/childhood-obesity/
http://www.cdc.gov/healthyyouth/obesity/facts.htm
http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html
http://backinform.com/services.php#fit4kids

IT Band Syndrome

Dear Friends,

today I want to address a very common and painful condition effecting the outside of thighs, hips and knees. The Iliotibial Band (IT Band) runs from the hip (ilia crest) along the outside of the thigh attaching to the tibia (shinbone) just below the knee. It stabilizes the knee and coordinates muscle activity while moving. This band can become irritated and inflamed causing pain at hip and knee.

IT Band Syndrome (ITBS) is common in long distance runners, cyclist and tennis players caused most often by

• overuse/over training
• increasing workload/distance to soon
• returning from an injury before healed
• training errors
• poor biomechanics or anatomical problems

While the first three causes are pretty much self explanatory the last two might need elaboration. Training errors amongst runners can include running on the same side of the road or on the track in the same direction. By keeping same leg on the inside turn  you are causing excessive stress on the outside leg. Most roads are crowned, meaning the surface slopes to the outside edges causing a lateral pelvic tilt. Other biomechanic problems include super pronation, bow legs and significant leg length discrepancies.

The cardinal symptom of ITBS is knee pain as the IT Band slides across the femoral condyle on the outside of the knee. Pain can extend along the thigh up to the hip. Pain typically is worse at heel strike while running and when ascending/descending on stairs, or getting up from seated position.

Treatment of this condition initially involves Rest, Ice, Compression and Elevation (RICE) in combination with Physical Therapy, stretches  and mobilization of IT Band. In addition Non Steroidal Anti Inflammatory drugs might be prescribed or in severe cases Cortisone Injections given.

Even though there are only insufficient randomized, controlled trials as to which particular exercises are most beneficial in reducing the IT Band Syndrome and prevent recurrence some studies amongst specific groups of patients (i.e. long distance runner) seem to indicate that stretching the IT Band, mobilization of the IT Band and single leg strengthening exercises have been successful in the secondary prevention of ITBS.

Here are some recommended exercises I'd like to share with you:

1. Standing ITB stretch
2. Advanced ITB stretch (Pigeon Pose)
3. Foam Roller ITB mobilization
4. Hip Hike on step
5. Single Leg Squat
6. Side Lying Hip Abduction

Since ITBS is most often caused by overuse cross training can be successful in reducing the risk of acquiring such injury.

I hope this little bit of information was helpful and will keep your IT Band in great shape.

A Sante,
Hartmut

References:
About.com Sports Medicine
emedicinehealth.com
VHI's Evidence-Based Exercise Prescription Newsletter

Osteoporosis: maintain and recreate bone density

This blog is focusing on one of the most common health problems among my older female clients/patients, Osteoporosis.


Overview
Osteoporosis is the most common bone disease in women over 50 in the US. A loss of bone density occurs when the body doesn't form enough new bone or reabsorbs too much old bone or both. This is caused by a lack of calcium and phosphate, two minerals vital to bone formation. Other causes include:

• chronic rheumatoid arthritis
• corticosteroid use
• Hyperparathyroidism
• bed confinement
• Vitamin D deficiency
• alcohol abuse and more

Symptoms include bone pain, fractures without or little impact/trauma, stooped posture (hyper kyphosis) and significant loss in height (6 inches or more).

Bone density loss is commonly diagnosed by performing a bone density test. The dual energy x-ray absorptiometry scans are comparing the patients levels with those of a healthy young woman (T Score) and with those of the patient's peers (Z Score). Negative T-Scores indicate the loss of bone mass with values from -1.0 to -2.5 being diagnosed as Osteopenia (milder form) and values of -2.5 and lower being considered Osteoporosis.

A treatment plan is trying to stop further bone density loss, increase bone density and manage the associated pain. The patient is typically using calcium and vitamin D supplements and medications such as Fosamax, Actonel, Boniva, and Reclast that are designed to increase bone density. In addition patients with low bone densities need to be educated on the importance of impact exercising and be put on an appropriate exercise program


Why is weight bearing and loaded exercising important? Bone is considered a bradytrophic tissue, meaning it has very little or no direct blood supply. It absorbs nutrition like a sponge absorbs water. You squeeze the sponge for maximum absorption. Compressing the bone through weight bearing- and impact exercises accomplishes the same. Studies performed among women with Osteoporosis and Osteopenia showed significant better outcomes in those that were involved in exercise programs involving weight bearing exercises and loading stresses. It needs to be mentioned though that patients with severe Osteoporosis are at a very high risk for hip, wrist and vertebra fractures. High impact exercises have to be avoided at this stage. Exercising under the supervision of an experienced trainer or Physical Therapist is highly recommended.


Exercises I recommend to my patients include but are not limited to:

• Lunges
• Squats
• Step-ups
• Jumps (milder stages)
• Hip Abduction (short lever in severe cases)
• modified Push-Ups
• Supine Posterior Pelvic Tilts
• Supine Bridging etc.

I hope this blog is offering some insights into the problem of bone density loss and the importance of exercise to treat this disease. As always, please feel free to contact me with questions and comments. Please like BACK IN FORM on Facebook (www.facebook.com/backinform) and follow our tweet on Twitter.

A sante,

Hartmut