It is a common injury, with 2 million acute ankle sprains happening each year in the US! In addition, it is the most common injury suffered by college athletes making up 15% of all injuries in this population.
When it comes to managing chronic pain due to past injuries, most of us are familiar with common modalities like oral medication, topical analgesic gels, acupuncture, massage, pain therapy machines, meditation/mindfulness, or even surgery. However, did you know that exercising regularly is also an effective tool to manage chronic pain?
Treating pain mainly falls into 2 categories:
Passive treatment includes treatments that are performed on you such as ultrasound, infrared rays, needling, and manual therapy such as massage or chiropractic manipulation. The therapist is in control during this type of treatment and it mainly focuses on acute pain relief. It does not address or correct the cause of the pain. Brief pain-free periods may ensue, but passive treatment rarely increases the likelihood of complete recovery. For most, one of the main reasons is because people rely too much on passive treatment alone. Passive treatment is usually recommended during the early stage of rehab or for acute pain to help regain minimal functionality, to promote early stages of healing, and to break the vicious pain-cycle.
Active treatment requires you to be physically involved in the process while working towards a cure to pain. Some active treatments include stretching, a corrective exercise program, and resistance training. However, it is extremely important that you are given the correct active treatment program that is relevant to your injury or condition as well as your goals. Correct exercises are able to address the root of the problem and may even prevent injuries. Active treatment is salient in the mid to late stages of rehab when one is nearly back to full functional capacity. The key is to strike a balance between passive and active therapies to best suit the type of chronic pain.
In order to treat chronic pain, it is important to understand that pain is a complex and individualized experience. Moreover, physical exercise may seem counterintuitive when you’re already suffering from pain, but whether your pain is intermittent or constant, adopting exercise as part of your active treatment can play an important role in managing pain for the long run.
Here are the 7 reasons why exercise is essential to manage chronic pain:
Athletes tend to report higher resilience towards pain compared to people who are sedentary. Studies have shown that active individuals are also likely to perceive pain differently. People who perform aerobic exercise or resistance training regularly, may develop the ability to adapt and desensitize the sensation of pain, thereby altering their pain tolerance in the process.
Recurring injuries can happen when an excessive load surpasses the tissue tolerance level. Excessive load can come in many forms such as lifting up a pail of water, gardening, or from over-training. Gradually performing optimal exercises coupled with rest can stimulate and improve tissue tolerance margin. An increased threshold can help prevent an injury from reoccurring.
Source: McGill, Stuart; (2017). Ultimate Back Fitness and Performance. Backfit Pro Inc.
Frequent exercise is associated with enhancement of the cardiovascular system. Aside from reducing risk of heart disease, increased blood flow raises the oxygen levels and helps deliver key nutrients within the body that are essential for cellular healing and reparation of injured tissues.
People living with chronic pain may experience severe disturbances in their psychological state. One can become anxious, depressed or stressed due to physical limitations. Therapeutic exercise can help elevate mood by releasing feel-good hormones such as endorphins and dopamine while at the same time reducing stress due to the release of hormones such as cortisol.
Common injuries such as chronic lower back pain can be caused by many factors like continuous poor movement, muscle imbalances or past traumatic injuries. Exercise can help tackle the root of the problem by identifying compensating movements or muscle weakness through a series of assessments and resolve them with an exercise program.
“Use it or lose it” is a popular phrase used by physical therapists and exercise professionals when it comes to exercise. The connective tissues that move our body and support the joints are muscles. When the muscle stop being challenged, they lose function and strength. Over time, this weakens muscles and exposes the musculoskeletal structure to potential harm.
In addition to strengthening muscles and improving overall health, exercise can also enhance motor skills by stimulating the connection between the central nervous system and the muscles. Neuromuscular training helps improve balance, stability, proprioception and joint control. This can translate to pain-free movement and a decreased risk for falls. Practicing quality movements via routined exercise can boost functional capacity to perform various activities of daily living without fear of injuries.
Regular exercise that encompasses both aerobics and strength training is strongly recommended because it is both healthy and effective to decrease chronic pain. However, be sure to seek the advice of a certified medical fitness professional to help you design an appropriate pain management strategy that is appropriate for your condition.
Ke Wynn Lee is an author and an international award-winning corrective exercise specialist who currently owns and operates a private Medical Fitness Center in Penang. Apart from coaching, he also conducts workshops and actively contributes articles related to corrective exercise, fitness & health to online media and local magazines.
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People faced with the day in day out experience of ongoing muscle and joint pain often develop mental habits to help them cope that can actually make their condition worse.1 Emotions such as anger, depression and/or making comparisons to how things used to be before the physical problem began, distracts the brain temporarily to help override current sensations of pain. While these mental habits can provide fleeting relief, they also serve to prolong chronic pain conditions by changing brain chemistry and altering the mind and body’s response to pain.
Healing with release is based on the fundamental idea, backed by research, that stress, tension and trauma are both psychological and physical. Twentieth-century science is moving forward to a better understanding of the body’s deterioration. Hans Selye recognized that physiological disease could arise from psychological causes, such as stress (Somatic viewpoint). The pathology of chronic pain is associated with numerous losses such as a decline in physical fitness, disturbance of sleep, strained relationships, loss of energy and fatigue. Social isolation, loneliness and anger are often evident in people suffering from chronic pain. These negative emotions exacerbate pain and increase suffering. An estimated 33 to 35 million U.S. adults are likely to experience depression at some point during their lives.
In 2011, in the USA alone, a hundred million Americans suffer with chronic pain and the cost of lost wages translated to $ 600 billion due to employees with chronic pain calling in sick because of a pain–related condition such as:
By having a flexible spine with strong hips and thighs, the human body is ideally designed for movement such as walking, running, squatting, and claiming- throwing objects and swimming. Unfortunately, during the course of a person’s life, the sensory-motor nervous system continually responds to daily stresses and traumas with specific muscular reflexes. These reflexes, triggered repeatedly, create habitual muscular contractions which cannot be relaxed–at least not voluntarily.
If stressed, traumatized, overused and repetitively used muscles are required to continue to work, the muscle begins to tighten. Once this happens the contraction of the muscle constricts the blood vessels. This reduction of blood flow reduces the oxygen to the tissue. Once a tissue is oxygen deprived, it will shut down and tighten more. This creates a negative pattern of tension, oxygen deprivation, and more tension that ultimately results in rigid muscle tone. This results in one’s postural misalignment and muscular asymmetry with symptoms such as:
Muscles needed to perform regular, daily tasks (such as sitting and standing) are what we call “functional muscles”. It is more important in daily life to have functional muscles than it is to have big, hard muscles. Functional muscles require more endurance than pure strength. The focus of restoring to maintain a healthy body is to increase the endurance of those muscles which are needed to function throughout the day.
The exercises which safely activate a natural reflex mechanism calming down the nervous system which releases muscular tension are based on restoring blood flow and oxygen to tissue.
Muscular tension release can be done by manual pressure that is applied to the most superficial layer of tissue where dysfunction appears (pain, tension or rigidity). Once the tight tissue is stimulated, blood flow to the area increases and the tight tissue will become suppler. This allows the therapist to access the next layer of tissue without applying excessive pressure. This pattern is repeated until all layers of dysfunctional tissue are restored and the tight, rigid tissue is replaced with supple and mobile tissue. Supple and mobile tissue will be free of pain and have a greater range of motion.
The ability to release muscular tension independently one must learn how to align their body and mind while experiencing an alert but relax state of awareness. The SykorovaSynchro Method℠ is a phenomenal educational tool with positive impacts to patients mentally, physically and emotionally and has three stages/ progressive levels:
Research has shown that when we imagine an experience, we often have similar mental and physical responses to those we have when the event actually happens. For example, if one recalls an upsetting or frightening experience, she/he may feel their heart beating faster, may begin to sweat, and hands may become cold and clammy.
In life it is very important to minimize the negative effects and maximize the healthy, healing aspects of the mind–body connection. Each person has a unique capacity for getting better, healthier, achieving peak performance and recovering from injury.
The mind-body connection means that one can learn to use his/her thoughts to positively influence the body’s physical responses, to create abilities to be aware of their own thoughts and actions in the present, without judging them self.
Physical activity has the potential to be not just an activity of the body, but a whole body-mind-spirit system. Exercise can create a unique, beneficial mental state; and the positive mental state can enhance the benefit of exercise as a part of muscular release tension plan, which reinforces the perception that exercise is just an out of body experience. We have to remember, that our bodies are made to feel good and has abilities to heal.
A unique water exercise program based and structured on those principles will teach you to release tension, increase mobility and build endurance in muscles, tendons and joints. Those physical exercises are performed with an intense focus to utilize four principles such as breathing, proper form, control and concentration.
Working as a health-fitness professional for the past 30 years, I am sensitive to the overall health of students/clients, and I continue to put research developments into practice. The focus in fitness these days for “Active Aging”, “Athletic Recovery”, “Chronic Pain Management”, “Healing with Release” are functional exercises – exercises that simultaneously use multiple muscles and joints to improve muscular endurance, overall strength, coordination, balance, posture and agility – to get a challenging, effective and fun full-body functional workout as well as prepare the body for every day, real world activities.
Reprinted with permission from Dr. Maria Sykorova Pritz and the Aquatic Exercise Association (AEA). The AEA is the leading educational agency in water fitness and is reaching health-fitness professionals in aquatic field. This article first appeared in the August/September 2018 issue of their AKWA magazine.
Dr. Maria Sykorova Pritz Ed.D earned her doctorate in education (specialty in Physical Education and Sports) from University Comenius in Bratislava, Slovakia. Maria is an ATRI faculty member, member of AEA Research Council, author of health fitness articles and FLS CE class, presenter for national and international fitness conferences. In her 32 years of professional career Maria is combining academic knowledge with hands on experience in functional fitness, pain management via land based and aquatic fitness. Maria’s unique training method (SykorovaSynchro Method℠) involves integration of multidisplinery techniques to achieve overall health and optimized performance. Maria is an ATRI faculty member, member of the AEA Research Committee, FLS continuing education developer, author and presenter.
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Did the title of this article capture your attention? It should because surgery, no matter how big or small, is serious business. The type of surgery this article is speaking to is orthopedic surgery. This means surgery due to pain, disease, and dysfunction in your muscles, tendons, ligaments, bones, and joints.
Maybe you, or someone you care about, have been told that surgery is necessary. You have done what the doctor suggested. You tried Physical Therapy. You went beyond that, and tried massage, acupuncture, chiropractic, drugs, and other alternative interventions. Why would avoiding a surgery even come into your mind? You are in pain, the doctor said you need it and that should be the end of the discussion right?
It’s a tough decision with uncertain consequences. Second and third opinions are recommended.
There might be several reasons why you want to avoid it; the thought of someone going in and “cutting you” (surgery is really a controlled injury), the risks associated with being put under anesthesia, the long recovery time and disruption to your life routine post surgery, you know someone that had surgery and months later are still not feeling much better, or they may be suffering complications from the surgery itself.
You have doubts.
Maybe you have read the recent research that concluded that a very common surgical procedure on knees actually showed more long term harm than good. (1)
Have you read the research that shows that there are many individuals with a diagnosable orthopedic disease that don’t report pain? And there is research that shows that some report pain and nothing can be found wrong that directly explains the pain. (2) (3)
Maybe you will need the surgery. But is there one more conservative non-surgical alternative that you haven’t tried yet?
There is… Exercise.
But wait, you already did exercises at the physical therapy clinic. Even the chiropractor gave you some stretches and rubber bands to tug on and that didn’t work.
Here is the problem. All exercise is not created equal. What may work for one person doesn’t work for another. Why is that?
Because every pain situation, just like people, is unique.
Pain is a word. When you choose to use the word pain to describe a sensation in your body you are clearly elevating the level of concern you have for the sensation.
Pain is not a thing like a brick, cat, glove, or car. Pain is the brain’s conclusion about all of the information it is receiving and processing from within the body moment-to-moment.
If you are considering surgery because you are experiencing a sensation that you choose to use the word pain to describe, then in a sense you are having surgery to remove the pain right? Which is weird because pain isn’t a thing to be removed, as it is simply a word chosen to describe a subjective conclusion based on bodily information. So a surgeon doesn’t remove pain with a scalpel, they remove the body part that they think is causing the pain. Sometimes this works great. Sometimes it doesn’t. See previous references.
What the surgeon is doing, what the drugs are doing, what the spinal manipulations are doing, are changing, or at least trying to change, the information that the body is producing to see if changing the information that way will lead to a new conclusion of the brain.
Change the information and possibly change the conclusion.
Back to the exercise thing.
What is exercise? It is stimulation to, and of, the body that changes the information within it. Sometimes those changes are short term and sometimes they can be of a longer term.
But you tried exercise in physical therapy and with the chiropractor and it didn’t help.
As stated earlier not all exercise is equal. Often exercises are just given to work on the area of the body that hurts. This might not be the best way to change the information. Exercise has very specific influences on the body depending on HOW you do it. The old adage “Just Do It” is painfully inaccurate advice. We need to know the quantity but also need to know the quality of your experience with different exercises.
Pain is a subjective experience that, at least right now, does not have an objective measurement like temperature, pressure, and distance. Your pain is totally unique to you and cannot be experienced by anyone else. Pain has a component of quality associated with it. It certainly can have a cause like when you break a bone, cut of your skin, tear a muscle, or sprain a ligament. But sometimes the cause is not so clear-cut.
So what am I proposing? What could be the thing that you haven’t tried yet?
A different approach. A totally different strategy. A more precise HOW.
I am talking about exercise that is highly catered and highly specific to your unique body.
Your body has its own unique history, a unique genetic profile, a unique combination of diseases and dysfunction, all of which confluence towards a unique problem. This requires a completely unique solution. A completely unique HOW.
This unique strategy and HOW is based on some simple concepts.
If number 4 is true then it stands to reason that any part of your body’s information generation and processing can affect any other part’s information. You may good at contraction shortening but are not so good at contraction lengthening.
If number 5 is true then a good way to see if you actually have control and assess the information control is my assessing your ability to do number 3.
Given the fact that your body is completely unique from any other body, this means that any strategy and HOW must be created to explore your unique information control system and any influences between parts. See number 6.
This is what Muscle System Specialists are trained to do. To systematically explore your information control by assessing your muscles’ ability to hold joint positions and change joint positions via lengthening or shortening contractions. This tells us about the quality of you information generation and processing.
The challenge is to find those places and conditions. You have roughly 600+ muscles and are capable of being in a dizzying array of positions and motions.
It’s okay – we have a process to explore your unique body’s abilities and start discovering the solutions it needs in order to change its control, to change the quality of information within it that just might lead to a change a reduction in pain.
Can you avoid surgery? Maybe. You have to decide if it’s worth some time and effort to exhaust conservative non-surgical options. Always speak with your doctors regarding this important decision.
Greg Mack is a gold-certified ACE Medical Exercise Specialist and an ACE Certified Personal Trainer. He is the founder and CEO of the corporation Fitness Opportunities. Inc. dba as Physicians Fitness and Exercise Professional Education. He is also a founding partner in the Muscle System Consortia. Greg has operated out of chiropractic clinics, outpatient physical therapy clinics, a community hospital, large gyms, and health clubs, as well operating private studios. His experience in working in such diverse venues enhanced his awareness of the wide gulf that exists between the medical community and fitness facilities, particularly for those individuals trying to recover from, and manage, a diagnosed disease.
Charlie Rowe, CMSS joined Physicians Fitness in the fall of 2007 after spending 9 years as the Senior Personal Trainer at Oak Hill Country Club in Rochester, New York. He has also worked within an outpatient Physical Therapy Clinic coordinating care with the Physical Therapist since joining Physicians Fitness. Charlie has earned the Cooper Clinic’s Certified Personal Trainer, the NSCA’s Certified Strength and Conditioning Specialist, the American College of Sports Medicine Certified Health Fitness Specialist, Resistance Training Specialist Master Level, and American Council on Exercise Certified Orthopedic Exercise Specialist Certifications.
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This is part 2 in a series. Click here to read part 1.
In Part 1 of this series, we discussed the dilemma of back pain that persists despite your persistent efforts to solve the problem. You’ve been prescribed medication, exercise, and a myriad of methods to “stretch” and “loosen” your muscles, but no avail. You must be a lost cause . . . right?
Maybe not.
It’s not your effort that’s lacking; perhaps it’s your strategy of solving the problem that’s in need of some tweaking.
In Part 1 we established that the body operates as a system: an interconnected, interacting, interdependent set of parts designed to achieve a goal– and in the case of the human body, the goal is production of high-quality movement for the sake of survival. Part of its genius, in my opinion, is in its sophisticated setup for communication within itself: the body is one continuous, cohesive system with a built-in mechanism that allows for every part to be aware of, and work with, the other parts to achieve the goal of operating efficiently. The human body is a truly amazing system!
Every body movement is a whole-body task that requires an internal, whole-body solution. Your muscles are an interconnected, interacting, interdependent system, constantly communicating back and forth, working together to create and control movement. All of your muscles are involved in one way or another in any bodily event.
Conversely, an issue with low-quality muscle function in any area of your system has the inherent potential to affect the performance quality—and your brain’s conclusion about how you feel– in any other area of your system.
Let’s apply this Systems Approach to form a new strategy to address your back pain.
The fact that your back is where you feel muscle pain and tightness doesn’t necessarily mean your back itself is the problem. The standard Western medicine approach subscribes to the philosophy of “Local pain means a local problem, which requires a local solution”, but this isn’t always the case.
Imagine you start your car in the morning, and the “check engine” light pops up. What’s wrong with your car? Is the “check engine” light itself the problem? No– the “check engine” light is an indicator, a safety mechanism built into your car’s system to alert you of a problem somewhere in the car’s system that needs to be addressed.
Likewise, pain you experience with movement is simply an indicator that there’s low-quality function somewhere in your muscle system . . . but not necessarily at the specific location you feel the pain. The pain is just symptom, the downstream result of poor quality. The pain itself is not the problem to be solved; the low-quality control is the problem! Instead of focusing directly on the part where you feel pain, my work focus is on the quality of your position control. Any area of the body with low-quality muscular control can contribute to a problem with movement, pain, tightness, or discomfort you are experiencing in any other area of their body.
While the work of a Certified Muscle System Specialist™ and the work of a physical therapist may look similar, the philosophy and thought process differ greatly. Physical therapy generally focuses on a patient’s complaint of pain or tightness, and as a result the therapy is almost always performed on or around the area of the patient’s pain. The physical therapy approach often subscribes to the philosophy of “local problem, local solution” we discussed earlier.
The same goes for massage therapy, stretching, chiropractic, pain medication, and other traditional options for treatment of muscle pain and tightness. The “local problem, local solution” approach focuses on the pain instead of on the quality of your muscle function as a cohesive, dynamic system. Chasing “the pain” is rarely an effective problem-solving method. This is the reason why using generic protocols and pre-packaged plans to “treat back pain” are not effective. This is also why “strengthen your core” isn’t always the panacea for back pain we’re led to believe https://thefitnessequation.com/soma-carisoprodol/.
So . . . you’ve completed physical therapy, diligently taken your medication, foam rolled the “tight” area every day . . . but your “check engine” light is still on. So, how can you understand what your system needs to turn it off?
Find a “systems mechanic” for your muscle system.
Work with a practitioner who is able to look under the hood, run a battery of diagnostics, find areas of low-quality function throughout your muscle system, and prescribe a system-wide plan to remedy the problem and put into place an ongoing maintenance process (like getting regular oil changes and maintenance on your car) so you can keep your system running at its optimal operating potential.
This is the role of a Certified Muscle System Specialist™– we’re muscle system mechanics! As we help you improve control throughout your system, we can elicit a significant, positive effect on how your entire body feels and moves. Our clients are often surprised that improving muscle control in an area can lessen pain they were experiencing at a different location of their body!
So the next time you’re feeling muscle pain and tightness—or any change in the quality of how your muscles move and feel– remember that the whole is greater than the sum of its parts. The strategy you’re using to take care of your system matters!
If you’re interested in learning more about how a Certified Muscle System Specialist™ can help you move better, feel better, and live better, click here.
To find a Certified Muscle System Specialist™ near you, see our list of practitioners throughout the U.S. and Canada.
If you’re a fitness practitioner who is interested in learning more about how to become a Certified Muscle System Specialist™, visit us at www.exerciseproed.com.
Originally published on Physicians Fitness. Republished with permission.
Jessica Cahen, M.S., CMSS, ACE-CMES, RTS is a Course Facilitator for Exercise Professional Education, a rapidly-growing Continuing Education company for exercise professionals, offering the Certified Muscle System Specialist™ course as well as custom-tailored CEC courses for groups upon request.
Jessica holds a Masters Degree in Clinical Exercise Physiology and the Certified Muscle System Specialist™ designation. She has also earned the distinction of being one of only a handful of ACE Certified Medical Exercise Specialists in the Midwest. She practices as a Certified Muscle System Specialist™ at Physicians Fitness in Columbus, OH.
Do you ever have pain in your muscles and joints when you move around? I did… and still sometimes do! I started my career as a Personal Trainer 20 years ago at Oak Hill Country Club in Rochester, New York . . .
You have back pain, and you’re determined to beat it. You’ve been to your doctor and received pain and anti-inflammatory meds. You’ve been to massage therapy to relax the tight muscles….
Hey! Did you know that all pain is all in your head? It doesn’t mean you don’t have real pain when something to cause pain happens, or that chronic pain is not real. Feelings of pain are very real and are initiated by the brain for a very important basic reason…to keep you safe.
The study of the neuroscience of pain has changed considerably in the past 10 years. It is now believed that the sensation of pain is a necessary function that warns the body of potential pain or of actual injury. The process starts with the nociceptor detecting a potentially painful stimulus from the skin or an internal organ. Neurotransmitters (chemical messengers) transmit the signals through the nervous system and spinal cord to the brain. In essence, how the brain processes the signals causes an appropriate or inappropriate pain response.
One example is a child falling and skinning his knees. He gets up and continues to play as if nothing happened. Then another child or adult reacts to the blood running down his legs, he looks, his brain responds differently to the neurological stimulus, and suddenly there is pain. Initially the brain did not register the experience as painful, however the next time the child falls, he will probably immediately register the skinned knees as painful. Experience plays a role in the pain response.
The pain response can also be overridden by the brain in circumstances that are life threatening. For example, a soldier who runs to safety with a serious gun-shot wound. The brain, due to past experience, can conversely register the event as much more painful or life threatening than necessary. For example, someone who was bitten by a poisonous snake may brush it off as being scratched by a stick, until they realize they have a life-threatening injury. But the next time they get scratched by a stick, they may respond as if they were bitten by a poisonous snake.
According to Elliot Krane in his Ted Talk “The Mystery of Chronic Pain,” after an injury or surgery, the nervous system can sometimes get what is going on wrong. Approximately ten percent of the time, the nerves and glial cells (play a vital role in modulation, amplification, and distortion of sensory experiences) that interact in the pain response develop into a feedback loop that can become distorted. This altered feedback can make chronic pain become its own disease.
Dr. Maria Sykorova-Pritz in her course “Application of Water Exercise for Pain Management” describes how chronic pain is not simple, but very complicated. The body, mind, emotions, and behavior can become entwined in the chronic pain cycle. Pain medication is often prescribed for chronic pain. Rampant prescription of pain medication is believed to play a large role in the opioid epidemic in the United States. Although pain medication is often prescribed for chronic pain, it does nothing to unravel the combination of physical, emotional, and behavioral factors that are now believed to cause chronic pain .
There is growing evidence that chronic pain is caused by multiple factors including cognitive, physiological, and behavioral factors. If you are working with clients or interacting with a family member with chronic pain, it is important to understand that it is not just simply a physiological response to pain. It is important to effectively influence a client’s attitude, cultural background and belief system-which influences social norms and perceived behavioral control. To achieve the highest positive health/fitness results among the chronic pain population, it is important to know and understand your client as a whole person.
As we start to look for alternative ways to deal with chronic pain and its aftermath, a combination of physical therapy/exercise and emotional/behavioral counseling is emerging as the tools of choice. Using the practice of yoga and water therapy/exercise to relieve and even cure chronic pain are proving to be viable and more effective alternatives than pain medication. Statistics from the Institute of Medicine indicate that more than 100 million Americans suffer with chronic pain, thus creating a viable niche for those wishing to work with clients with chronic pain. Now that more is known about chronic pain, its potential causes, the chronic pain cycle, and how to treat it effectively, education is key to working with this population in need. Proper treatment and compassion for chronic pain sufferers can help end the opioid crisis and help people beat chronic pain to live pain free lives without addiction and suffering.
For more information about the psychology and treatment of chronic pain management, see Dr. Maria Sykorova-Pritz’s continuing education course “Application of Water Exercise for Pain Management.”
Compiled by June Chewning. June M. Chewning BS, MA has been in the fitness industry since 1978 serving as a physical education teacher, group fitness instructor, personal trainer, gym owner, master trainer, adjunct college professor, curriculum formatter and developer, and education consultant. She is the education specialist at Fitness Learning Systems, a continuing education company.
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