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The Pharmacologics of Exercise: Yes, Exercise Is Medicine!

It’s been said: “If all the benefits of exercise could be placed in a single pill, it would be the most widely prescribed medication in the world.” Scientific evidence continues to mount supporting the numerous medicinal benefits of exercise. In fact, there’s hardly a disease that I can think of that exercise won’t help in one way or another, be it prevention, treatment, or even cure in some instances.

Meta Slider - HTML Overlay - Pregnant woman holding fitness dumbbells

Prenatal Exercise: Training for the Main Event

Say good-bye to the myth of the “delicate” condition and hello to pregnancy in the 21st Century!

Current research continues to show that women can safely exercise and maintain their fitness level during the perinatal period.  The mom who laces up her sneakers instead of heading to the couch will be rewarded with a healthier pregnancy and a healthier baby.

Pregnant woman doing yoga with a personal trainerPregnancy is a time of excitement, uncertainties, fears, and many profound physical and emotional changes. This “season in life” affords mom a wonderful opportunity to adopt a healthier lifestyle.  Starting an exercise program during pregnancy is a great way to begin and continue this healthier lifestyle for herself and subsequently for her child.  With obesity on the rise in the US, it is important for everyone to increase their current level of physical activity.  This is especially important for pregnant women as the results of obesity and excessive weight gain have been shown to be detrimental to both mom and baby long term.

A Historical Perspective on Prenatal Exercise Guidelines

Moms today are inundated with information regarding pregnancy and exercise. Unfortunately, a great deal of this information is outdated.   It is important for women to have a working knowledge of the most current guidelines so that they can make intelligent choices regarding their exercise programs. For many years, pregnant women were advised to “take it easy” during pregnancy.  Mom was advised to rest and gain weight in order to ensure a healthy pregnancy.  In the 1950’s women were “allowed” to walk a mile a day for exercise and this mile was preferably “broken up” into smaller segments. The American Congress of Obstetrics and Gynecology (ACOG) issued the first formal guidelines for perinatal exercise in 1985 (1).  These guidelines were highly restrictive as they were not based on extensive research and were designed for the majority of pregnant women without regard to pre-pregnancy fitness levels. Four of the original guidelines are highlighted below:

  • Mom should exercise at a heart rate <140 bpm.
  • Strenuous exercise should not exceed 15 minutes
  • Maternal core temperature should not exceed 38 degrees C
  • No supine exercise after the first trimester

A great deal of research involving both sedentary and trained subjects was published

after the release of the 1985 guidelines. This prompted ACOG to publish a revision of the original guidelines in 1994 which lifted specific limitations for prenatal exercise (2).  ACOG said, “There are no data in humans to indicate that pregnant women should limit   exercise intensity and lower target heart rate because of adverse effects.”   In this revision, there was no mention of the 140 bpm maximal heart rate or an exercise limit of fifteen minutes. Women were advised to use the “talk test” and “perceived exertion” as ways to measure exercise intensity. We were making progress!    Although the 1994 guidelines were a refreshing change in the right direction for ACOG, they still did not address the pregnant athlete. In 2002, ACOG published “Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion 267” (3). In this publication, which was reaffirmed in 2009, ACOG recognized that “in the absence of contraindications, pregnant women should be encouraged to engage in regular, moderate intensity physical activity to continue to derive health benefits during their pregnancy as they did prior to pregnancy.” This revision focused more on the athlete as well and was the first formal recommendation by an American physician group to include prenatal exercise. The major points of the 2002 update include:

  • Previously sedentary women and those with any medical or obstetrical problems should obtain medical clearance before embarking on an exercise program; NO PRENATAL CLEARANCE, NO EXERCISE, NO EXCEPTION.
  • Thirty minutes or more of moderate exercise daily, or on most days of the week is recommended. This brought the exercise guideline for pregnancy more in line with the ACSM guidelines for the general population.
  • Competitive and recreational athletes with routine pregnancies can remain active, “listen to their bodies” and modify their exercise routines if medical necessity arises.
  • Physically active women with a history of or risk for preterm labor or fetal growth restriction should reduce their activity in the second and third trimesters.

In 2006, the “ACSM Roundtable Consensus Statement: Impact of Physical Activity During Pregnancy and Postpartum on Chronic Disease Risk” was published (4). This report, based on an analysis of the most current research by a panel of scientific and clinical experts, supported the safety and long term benefits of prenatal and postpartum exercise for both mom and baby. Some of the benefits highlighted in this report and other studies show that exercise:

  • Reduces the risk of preeclampsia (a condition marked by high blood pressure, protein in the urine and marked fluid retention in the mom which can lead to serious maternal and fetal complications).
  • Treats or prevents gestational diabetes, the diabetes of pregnancy. For some women exercise alone may stabilize blood sugar. Moms with gestational diabetes are more prone to Type II diabetes later in life.
  • Helps manage or alleviate pregnancy related musculoskeletal issues. Exercise may help with low back pain, urinary incontinence, abdominal muscle and joint and muscle issues.
  • Links breastfeeding and postpartum weight loss. Weight loss can occur with moderate exercise and caloric restriction without affecting the quantity and quality of breast milk or infant growth.
  • Positively impacts mood and mental health. Exercise is a “mood elevator.”  It reduces stress, fatigue, anxiety and improves self-image.
  • Baby’s health and development: The panel advised that beginning or continuing a prenatal exercise program had both short and long term positive effects.

Beautiful pregnant woman thinking of her babyThe most recent guidelines for prenatal exercise were included in the 2008 US Dept. of Health and Human Services Physical Activity Guidelines (5).  Women who are not currently active should strive for at least 150 minutes of moderate intensity cardiovascular activity per week.  This translates to 30 minutes of exercise 5 days a week, very similar to the ACOG guideline.  They recommend that those women who are currently active may continue their normal routine providing there is an open line of communication with their healthcare providers

The latest research continues to showcase the benefits of prenatal exercise. A 2013 review of the international evidence reinforced the fact that women who engage in prenatal exercise have a decreased risk of developing gestational diabetes and other hypertensive disorders during their pregnancies.  They are also less likely to deliver big babies (> 9 pounds).  Other studies suggest that babies born to active moms are lighter and leaner at 1 and 5 years of age (6). Additional research has supported these findings and has extended the benefits to older children (8-10 year olds) (7).  This is quite significant considering the fact that childhood obesity is on the rise. We now have exciting evidence that the in utero environment of exercising mothers may provide long term effects for their offspring with regards to bodyweight and body fat.  Prenatal exercise may also boost babies’ brain activity.  Canadian research has shown that babies of exercising moms had greater brain activity 8 – 12 days after they were born, as evidenced by an increased ability to process repeated sounds (8).  This was the first study to link prenatal exercise with babies’ brain development.

In 2015, ACOG released two new publications, “Obesity in Pregnancy,” Bulletin Number 156 (9) and “Physical Activity and Exercise During Pregnancy and the Postpartum Period,” Committee Opinion Number 650 (10).   Both publications emphasize the need for regular exercise to prevent or combat excess weight gain and /or obesity in the perinatal population.   Greater than half of the women of childbearing age in the US are overweight or obese. Obesity in pregnancy is associated with significant risks for both mother and baby.  Bulletin 156 authors wrote, “Optimal control of obesity begins before conception.  Weight loss before pregnancy, achieved by surgical or nonsurgical methods, has been shown to the most effective intervention to  improve other health problems.”  The updated Bulletin 156 recommendations include:

  • Behavioral interventions that utilize both diet and exercise can improve postpartum weight loss better than exercise alone
  • BMI should be calculated at the first prenatal visit and used to counsel women on diet and exercise utilizing the Institute of Medicine Guidelines for prenatal weight gain
  • Small preconception weight losses in obese patients can improve pregnancy outcome
  • Losing weight between pregnancies in obese patients may decrease the risk for a large-for-gestational-age baby in a subsequent pregnancy

Pregnant women doing squatting exercise.Pregnancy is an ideal time for maintaining or adopting a healthy lifestyle. Recommendations from ACOG Committee Opinion Number 650, “Physical Activity and Exercise During Pregnancy and the Postpartum Period” include:

  • Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements.
  • A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise.
  • Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.
  • OB-GYN’s and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy. Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered.
  • Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychological well-being.
  • 20-30 minutes of moderate intensity exercise per day, on most or all days, is recommended.
  • Exercise intensity should be monitored by RPE and the “talk test.” Suggested RPE is 13-14 on a 6-20 scale.
  • Women are encouraged to stay well hydrated, avoid long periods of lying supine and cease exercise if they have any warning signs (see below).
  • Women who were sedentary before pregnancy should gradually progress their exercise programming
  • Women who were regular exercisers prior to pregnancy and who have uncomplicated, healthy pregnancies should be able to engage in high-intensity exercise programs, such as jogging and aerobics, with no adverse effects. High-intensity or prolonged exercise in excess of 45 minutes can lead to hypoglycemia; therefore, adequate caloric intake before exercise, or limiting the exercise session, is essential to minimize any risk.\Contact sports, activities with a high risk of falling, scuba diving, sky diving and “hot yoga” are not recommended

Warning Signs and Symptoms to Discontinue Exercise (11)

If a woman experiences any of the following, she should cease exercise and contact her health care provider as soon as possible:

  • Vaginal bleeding or fluid leakage
  • Shortness of breath prior to exertion
  • Pelvic pressure or cramps
  • Dizziness
  • Headache or any vision problem
  • Pain of any kind
  • Uterine contractions
  • Muscle weakness
  • Calf pain or swelling
  • Preterm labor
  • Decreased fetal movement
  • Chest pain
  • Temperature extremes (hot or cold; clammy)
  • Nausea / Vomiting

As a result of almost 30 years of research showing the benefits of prenatal exercise, we have seen a substantial increase in the number of motivated personal trainers who are certified to work with this very special population.  No two pregnancies are the same and no two prenatal fitness programs should be the same.  Trainers certified in perinatal fitness and wellness possess the knowledge and skills to design and implement individualized programs to help mom prepare for the “marathon of labor” and the “tasks of mothering” after the baby is born.

Join Sheila for her upcoming webinar:

 


Sheila Watkins is a perinatal fitness specialist with over 25 years of experience training 2500+ pregnant and new moms, and educating hundreds of fitness instructors, health professionals, and childbirth educators on the rapidly changing field of perinatal fitness. She is the creator of Healthy Moms® Fitness Programs to provide safe and effective group exercise classes and personal training for new and expectant moms, as well as education and training in the field of perinatal exercise for fitness professionals, childbirth educators and other health professionals.

References

  1. ACOG. The ACOG Guidelines for Exercise During Pregnancy and Postpartum; Home Exercise Programs, 1985.
  2. ACOG. Exercise During Pregnancy and the Postpartum Period. ACOG Technical Bulletin, No.189, February 1994.
  3. ACOG. Exercise During Pregnancy and the Postpartum Period, ACOG Committee Opinion, No. 267, Washington, DC: ACOG, January 2002 (reaffirmed in 2009).
  4. Pivarnik, J. et al. American College of Sports Medicine Roundtable Consensus Statement, June 2006.
  5. http://www.cdc.gov/physicalactivity/everyone/guidelines/pregnancy.html
  6. Mudd LM, Owe KM, Mottola MF, Pivarnik JM. Health benefits of physical activity during pregnancy: an International Perspective Med Sci Sports Exerc. 2013 Feb;45(2):268-77.
  7. Pivarnik. J. and Kuffel, E. ACSM Sports Medicine Bulletin; Active Voice: More Maternal Physical Activity May Lead to Leaner Pre-Adolescent Children; June 20, 2010.
  8. http://www.nouvelles.umontreal.ca/udem-news/news/2013-exercise-during-pregnancy-gives-newborn-brain-development-a-head-start.html
  9. ACOG. Obesity in Pregnancy. ACOG Practice Bulletin, No.156, December, 2015.
  10. ACOG. Exercise During Pregnancy and the Postpartum Period, ACOG Committee Opinion, No. 650, December 2015
  11. Watkins, Sheila S. “Healthy Moms@ Perinatal Fitness Instructor Training Manual.” 2013.
caruso1

Why Exercise When You Have Cancer?

Exercise is important for everyone even individuals who have cancer. It is important to understand your body and know what you can do. An Exercise Specialist can help you to figure out an exercise plan that works for you. Everyone is unique and therefore needs an individualized exercise program.

It is important to notify your Exercise Specialist when you have treatments. The exercise program may need to be modified for a few days after treatment. Modification is important to help preserve energy and wellbeing. You may need to do two sets of an exercise instead of three for a training session or two. Exercise can help you to stay strong and relieve stress even if you are only able to do twenty minutes every other day.

There are also some precautions to take. While exercising, you may want to wear gloves. Wearing gloves helps you to keep your hands clean during workouts. This is important because the immune system is already weakened. Wiping equipment before use will also help you to be as clean as possible. It is important to wipe mats and dumbbells as well.

caruso1Start your exercise program slowly and progress when you are ready. Fitness is an individual journey and everyone starts at a different place. It is important to not compare yourself to others and keep focused on your goals. Your exercise prescription will depend on which phase of cancer you are in.

There are many ways that exercise can benefit individuals during treatment such as: maintaining your physical capabilities, lessen nausea, maintaining independence, improve quality of life, control weight, decrease anxiety and depression, and improve self-esteem.

When you are recovering from treatment you may notice that the side effects linger. Your Exercise Specialist will adjust your program according to how you feel. Eventually, you will be able to progress and feel less fatigued. It is important, however, to continue to be active after treatments have been discontinued. Research shows that there is less chance of cancer recurrence in active individuals.


Robyn Caruso is the Founder of The Stress Management Institute for Health and Fitness Professionals. She has 15 years of experience in medical based fitness. Contact Robyn by email at: tsmi.caruso@aol.com

 

References

American Cancer Society (2014). Physical Activity and the Cancer Patient. Retrieved http://www.cancer.org/treatment/survivorshipduringandaftertreatment/stayingactive/physical-activity-and-the-cancer-patient

Web MD (2007). Exercise for Cancer Patients: Fitness After Treatment. Retrieved http://www.webmd.com/cancer/features/exercise-cancer-patients?page=3

 

Exercise: A Must for Both MS Patients to Partake In and Healthcare Providers to Promote

Exercise is an essential component of the Multiple Sclerosis patient’s treatment plan. Unfortunately, until the 1990s, exercise was highly regarded as contraindicated to MS patients. In 1993, the first medicine was approved by the FDA for MS and in 1996; the first research showing the benefits of exercise was published by the University of Utah. These were two major breakthroughs which have given hope to a population consisting of the most common disabling neurological disease of young adults (most common onset between ages 20 and 50).

Multiple Sclerosis is a neuroinflammatory autoimmune disease of the central nervous system (CNS), consisting of the brain, spinal cord and optic nerve.  The immune system attacks the myelin sheath of the nerves which insulates, protects as well as affects the signal speed from the CNS to the affected body part. Presentation of initial symptom of MS include optic nerve inflammation, poor balance (ataxia), dizziness (vertigo), weakness, double vision (diplopia), bladder/bowel dysfunction, pain, sensory loss, cognitive impairment, fatigue (most common) and a host of others including but not limited to gait impairment, depression,  tremors, thermoregulatory dysfunction (autonomic) and spasticity. Because many symptoms are invisible (not outwardly visible), most notably fatigue, pain and cognitive impairment, they can affect confidence, relationships, and discourage patients from seeking treatment or help.

Currently, with more than 16 FDA approved disease modifying treatments, as well as exercise being greatly encouraged by health care providers treating MS, the face of MS is changing for the better. While exercise will not change the course of the disease progression, both aerobic and anaerobic conditioning have greatly helped reduce secondary and tertiary symptoms such as falls, injuries, anxiety/depression, impaired activities of daily living (secondary) and increase self-esteem, and independence while reducing social isolation and family disruption (tertiary).

The benefits of a safe, progressive/adaptive exercise program are improved overall fitness, ability to perform activities of daily living, moods, sense of well-being, strength while decreasing spasticity, fatigue and may prevent a host of co-morbidities. Because MS patients may be less mobile and underweight/overweight, coupled with the possibility of side effects from the use of corticosteroids, it increases the likelihood of developing conditions such as osteoporosis and diabetes mellitus. This is an even a greater reason those affected with MS should work with professionals who understand the disease.

Although many patients are still hesitant to begin an exercise program because of fear of exacerbating their condition, lack of confidence or inability to find professionals skilled to work with them, now is the best time in the history of MS treatment for both patients and professionals to be on the same page. Exercise no longer has to be an activity of an MS patient’s past. It is simply a must of the present and future.


Jeffrey Segal, owner and chief operator of Balanced Personal Training, Inc., since 2004 is a personal trainer, motivational speaker and educator who has been working in the fitness industry for over 20 years. 

At the age of 25, Jeff was diagnosed with Multiple Sclerosis. He was told fitness was not going to be part of his future as an activity. Within a couple of years, Jeff was unable to walk, was visually impaired and barely able to speak.  Rather than succumb to his prognosis, he fought for the life he once knew while burying his head in research. Within a year, not only could he walk, see and speak but he used his knowledge, skills and abilities to physically train others in both sickness and in health with an emphasis on Multiple Sclerosis patients. 

Senior woman exercising with trainer

An Intro to Chronic Conditions for the Fitness Professional

With the future of health being unknown, one thing is known — that Americans are living longer and with age often comes a chronic condition. Living with a chronic disease/condition is often an exhausting and frustrating ordeal.  Too often the person may feel burdened and burned out! When the stress of pain and fatigue, coupled with normal life stresses, the client may feel overwhelmed. When the client is overwhelmed, they often don’t take care of themselves and that only contributes to more fatigue and pain.  Just a few weeks of neglecting themselves can contribute to further disability.  What is the goal of the fitness professional – be positive and supportive and don’t contribute to making they condition worst.

The 3 E’s of Fitness Therapy

Your job as a fitness therapist is the 3 E’s: Educate, Empower and Encourage.

Educate yourself and client about their condition and effects their medications may have on exercise performance. Stay abreast of corrective exercise research. Knowledge is power!

Empower clients to be their own best advocate and to take control of their life not become a victim of their condition. Empower them to take the “dis” out of disability.

Encourage clients about ways to be the best they can be. Think of all methods to foster healthy lifestyles, provide hope and set realistic attainable goals

The purpose of this article is that knowledge is power, and the more you know about a condition, the more you will be an equal partner on your client’s health care team. Not every application is perfect for every client. Always stay alert that what is accepted as a “norm” today can change tomorrow with new research. That is why it is strongly encouraged that your client discuss their fitness plan with their medical professionals. You are not expected to know everything, but you are expected to know when to seek advice!

The Fitness Therapist is first and foremost an educator of the psychomotor domain.

Do NO Harm!

Sometimes clients with a chronic condition will be afraid to embark on an exercise program in fear that it will cause them injury or more pain. They may know intellectually that they should, but the apprehension about what might occur can be paralyzing.  They might tell you I know how I feel now and if I feel worst I might not be able to work or take care of my family.  Your first and foremost job as a fitness therapist is to DO NO harm and NOT make matters worse.  This is why having the client get prior approval and recommendations from their health professional can go a long way in motivating the client. In order to overcome a chronic condition, ask your clients to re-define their paradigm and focus on what they can do rather than what they cannot do! Ask them to think about the benefits of your successes.

Unfortunately, many people with a chronic condition are fearful that exercise may aggravate their condition, so they play it safe and do nothing. Too many people give up on an exercise program long before they experience the benefits of what regular exercise can provide. Be sensitive to your client’s concerns. Never minimize their condition, by saying, “You do not have it so bad I have a friend with ______ and she is doing fine.” What might be a small issue to one person could be a major issue to another. Always start the person where they are at and progress with care from there.

Very often improved fitness empowers the person with a chronic condition to live a richer and fuller life. Ask the client to decide what they want as an end goal of their exercise program and then design the program with small attainable steps to match their goals and abilities. Too often when a person with a chronic condition has lost control of their lives, everybody is telling them what medications to take, what to do and not do. Remind the client that they are the Captain of their wellness ship. You, their doctor and their family can be cheerleaders but they are the Captain.

As their personal trainer, do your best to make their body the best it can be. Never make promises that your program will cure them. Stay alert that many chronic conditions will ebb and flow with periods of exacerbations and remissions. While study after study supports that exercise, when done properly and prudently, produces good outcomes, exercise is never a replacement for medical care.

Regular exercise is therapy for the mind and body.

Some experts project that soon the integration of health care, fitness and wellness will intersect. The anticipated model of wellness and healthcare foresee the role of medicine will be to heal and fitness/wellness to restore health and vitality to those who participate in pro-active lifestyle.

Working definition of Wellness includes attention to the mind, body and spirit.

Today, doctors understand the importance of both passive therapies and rehabilitative exercise. While medical science continues to make great advances in surgical and pharmacologic treatments, exercise physiologists are also proving that simple interventions, such as proper body mechanics and corrective exercise, can play a significant role in decreasing the incidence and severity of orthopedic conditions and other chronic conditions. One of the goals of fitness therapy is to maximize the potential for full function and minimize the chance of re-injury.

Keep in mind that not every exercise is correct for every person or every condition. Depending upon diagnosis, certain movements will not be best for your client. Every program for a person with a chronic condition should be individualized and adapted as needed.

One size does NOT fit all in Fitness Therapy. The cookie cutter approach has no place in fitness therapy! Make the corrective exercise session a positive experience so the client will want to continue to make fitness an important aspect of their treatment plan.

It is important to stay mindful that “Recovery” of a condition may take weeks or even months depending upon the diagnosis or severity of the problem. Also, in the case of some chronic conditions, maintaining is all that can be hoped for. Slow and steady is the best approach. Progressing too quickly will only set the person up for re-injury. As the client embarks on the recovery process, you need to encourage clients to be their own health advocate and wellness trainer.

Exercise: The Miracle Cure All?

It can:

  • reduce cardiac mortality by 30%
  • improve self-image
  • reduce prostate cancer progression by 50%
  • assist in decreasing hypertension
  • reduce the risk of type-2 diabetes by greater than 50 %
  • reduce bowel cancer by 45%.

For more information see aomrc.org.uk/publications/reports.

Some General Guidelines for Working with Clients with Chronic Conditions

The world of health and fitness is a complex one. Lack of exercise contributes to diabetes, high blood pressure and other assorted sedentary health concerns, but too much exercise causes overstress and injury to joints and muscles. While exercise can make us feel good, too much can bring on pain and soreness. The answer is to train smart. If a client is hurting, let them know it is OK to back off.

  1. Consider asking the client to consult their health professional for suggestions regarding exercise and their condition. The information given by their health professional supersedes the information in any textbook, because the health professional is familiar with their unique situation.
  2. Perform their exercise program when they are having the least amount of pain/discomfort. Teach the client to listen to your body and heed what it says. Keep in mind the 2-hour rule; if the client hurts more 2 hours post-exercise, back off until they are pain-free, but don’t quit. Avoid any activity that aggravates your client’s condition. If they say, “I am fatigued”, don’t force one more repetition.  If they say, after a workout, “I hurt!” Back off!
  3. Never allow the client to mask pain with pills or lotions. Pain is the body’s way of informing them that something is going on inside. To prevent a re-injury or unnecessary pain, execute motions in a pain-free range of motion with proper form. If you suspect a re-injury, ask them to schedule an appointment with their doctor. If you suspect the person is abusing pain medications, seek advice. The client is more important than any exercise program!
  4. Encourage them to carry ID and medical information with them to sessions.
  5. Always teach and ideal proper posture and proper body mechanics in all movements when possible given their health status.

Exercise Do’s And Don’ts for Your Clients

  • DO carry identification when you exercise.
  • DO check heart rate before, during, and after exercise.
  • DO listen to your body, if it hurts, STOP!
  • Do prepare the body for movement and stretch and relax after a session.
  • DO drink plenty of water before, during, and after each exercise session.
  • DO consider solitary versus social aspects of your chosen program.
  • Do teach mindfulness when exercising.
  • DON’T bounce when stretching, and stop a stretch if it hurts.
  • DONT squeeze a week’s worth of exercise into one day.
  • DON’T overestimate your client’s capacity to exercise. However, DON’T underestimate it either. Remind the client that the body is designed for movement, but let it adapt slowly and gradually.
  • DON’T allow the person to hold their breath during exercise.
  • DON’T allow the person to go directly into a sauna, hot whirlpool (Jacuzzi), or steam bath after exercising.
  • DON’T use perspiration (sweating) as an indication of how good (or bad) your workout is: we all perspire at different rates and in different amounts.

Reprinted with permission from Karl Knopf.


Karl Knopf, Ed.D, was the Director of The Fitness Therapy Program at Foothill College for almost 40 years. He has worked in almost every aspect of the industry from personal trainer and therapist to consultant to major Universities such as Stanford, Univ. of North Carolina, and the Univ. of California well as the State of California and numerous professional organizations. Dr. Knopf was the President and Founder of Fitness Educators Of Older Adults for 15 years. Currently, he is the director of ISSA’s Fitness Therapy and Senior Fitness Programs and writer. Dr. Knopf has authored numerous articles, and written more than 17 books including topics on Water Exercise, Weights for 50 Plus to Fitness Therapy.

 

Reference:

Arthritis Today Sept/Oct 2015

feet sneakers

The Feet: The Body’s Foundation

The feet are one of the most overused and taken for granted parts of the body. Since the feet are the foundation for the rest of the body, it would only be logical to begin developing strong, aligned, and full functioning feet from the start when developing a personalized fitness program. The feet should be a priority for developing sound fitness education in order to prevent injuries. Most fitness and sport injuries usually involve the feet. Even when the injury is to the knee, hip or back it can usually be traced back to a misaligned foot pattern.

In the fitness and wellness world there is hardly ever a designated focus on the feet. Since the feet are involved in almost all fitness activities it would make sense that starting with a careful assessment of a person’s feet would be the best place to start. Observing how a person stands, walks, runs, and moves normally can tell you why a person might have a hip, knee, or lower back problem. People who have difficulty with balance almost always have a foot alignment and gait which cannot support the body in movement. Maintaining and working foot function is crucial for insuring continuous mobility, and independence in populations who are handi-capped, have had strokes, who have M.S. or Parkinson’s, or diabetes.

Feet often are good indicators for what is going on in other parts of the body. Abnormalities or pain in the feet can often be a precursor for more serious health conditions. This means that we as wellness practitioners and fitness experts need to pay attention to the feet so much more than is commonly done today.

As wellness/fitness educators it makes sense to understand the anatomy of the feet. It is easy to understand and be able to explain to clients that there are three posterior muscles which go into the plantar foot, three muscles into the dorsal foot. There are three muscles which attach at the calcaneus stabilizing the ankle, heel and lower leg to knee. Both the tibialis posterior and anterior are major stabilizers and the flexors and extensors can only reach their insertions based on the full function of these two muscles. It is not difficult to give people simple and clear understandings of these basic muscles and how they need to be in balance in order for the muscles of the legs to work correctly.

Throughout the body we train muscle groups and chains to function and support the body in movement. These muscles are largely unrestricted by outside forces. Only in the feet are the muscle insertions cut off and thus, restrict the muscles from their full function.

This means that over time the muscle chains will slowly contract upward from these restricted insertions. Wearing shoes to train restricts full function of the feet and legs. This in no way means you should train people barefoot, however, it does mean that part of each training session should be focusing on the feet without shoes worn.

Here are simple facts about the feet:

  • There are 52 bones in your feet which makes up 1/4 of the bones in your body. This means that it pays to focus on the anatomy of the feet and to best understand how to transfer weight through them.
  • Each foot has 26 bones, 33 joints, 107 ligaments, and 19 muscles and tendons which are supposed to hold the structure and allow it to move the rest of the body. The more you can analyze a person’s gait and standing position and observe which muscles are not being used properly and where weight is impacting and damaging the foot, the easier it can become to correct the problem and prevent injuries.
  • 75% of all Americans will experience foot problems at some point in their lives. This is epidemic. More people are living active lives and more foot injuries are occurring annually. Starting at the feet is essential for avoiding foot injuries.
  • With a foot injury, without education about how to change the way a person is using his feet, the injury will continue to occur and worsen with time. Using orthotics and other devices does not re-educate the feet. They are temporary fixes. Over time a person will continue to breakdown in the same pattern while weight bearing into the orthotic.
  • When walking the feet receive more pressure into them than the actual weight of a person and when running it can be up to four times the weight of a person. Learning how to use the entire foot when walking allows a transfer of weight throughout the foot. This can mean a person stops walking into the same point repetitively breaking down. Weight needs to be transferred equally through the feet.
  • Only a small percentage of people are actually born with foot problems. People blame foot problems on their genetics. Genetics in the feet as well as in any other structural part of the body can be identified and improved upon to avoid repeating the family pattern.

Bringing the Best Foot Practices into the Medical Fitness Community

It is important to bring the feet into your client’s fitness/wellness program. Learn how to break foot education down so it is mindful and allows a person the ability to understand how to use his/her feet. Here are some pointers:

  • Observe how your client stands, walks, and runs to see the most used foot pattern.
  • Observe where this pattern might be repetitively stressing and impacting the joints of the feet and above in the body.
  • Teach a client how to walk and stand in parallel with feet at hips distance a part.
  • Train people how to transfer their weight from the heels, through the outside of the feet, through the transverse arch from lateral foot to medial, from fifth toe to big toe. The knee must stay in line with the middle foot when the big toe presses down into the floor.
  • Explain what pronation and supination are. Explain the difference between pronation and collapsing the feet medial breaking down the arch.
  • Train clients how to activate and strengthen and stretch their toes.
  • If your client is weight bearing into the medial knee, focus on the feet to realign the knees and avoid a knee injury.
  • The more you bring a foot practice into your program, the better your results will be and the less injuries will be experienced.

Learn more from Yamuna on this topic! Join her for the upcoming MedFit webinar, How to Rebuild Healthy Foot Function


Yamuna Zake is a visionary healer dedicated to demystifying the body and providing simple, powerful tools that make lifelong fitness and well-being a reality for everyone. She has developed her deep knowledge of how the body works over forty years, starting at sixteen, when she became a certified hatha yoga instructor. She is the founder of Yamuna, a leading source of education for teachers, therapists, and fitness instructors interested in expanding their knowledge in BodySustainability which can enhance their core expertise, and often lead to a longer term interest in becoming a certified Yamuna instructor.

*Information taken from Illinois Pediatric Medical association – Simple facts*Yamuna Foot Fitness Training Manuals – Bringing best foot Practices

Walking-Sneakers

A Clearer Vision in Training

As fitness professionals, what we can expect is the unexpected. Often the last person we think may send an inquiry, does. If you’re like me and the majority of your training is in-home, you often get the privilege to work with so many you may not otherwise in a traditional gym or studio setting.

The Unexpected Client

While I was used to receiving various inquiries from those with different chronic conditions or disease, disabilities and other limiting factors, the one I didn’t anticipate was a blind client. The first thing I did before responding was see what trainers in my area may be willing to work with this individual, no response, no one was interested. My first thought was my “scope of practice”. Surely this wasn’t in that category for me. While I took time to reflect on how I could possibly help this person, I did some asking around to a well-respected fitness professional not in my area. I asked him, “How do you train a blind person?” He responded by saying, “I have never had the chance to do that but I would say you train him just like anyone else.” That made complete sense to me in that moment. What I didn’t know I would research. Next, I would fully disclose that I did not have prior experience with training a blind person, but I would be happy to take him on. So, I did.

Learning Curve

In researching training the blind community and speaking with a few people in various agencies, I couldn’t get much beyond the science and statistics. No methods, no accommodations, no modifications, no advice, not much to guide me. I did learn about Orientation and Mobility Specialists and while that was needed in the beginning for my client, it was not needed for him to have at the time for the training to take place.

You adjust everything you know about training. A huge eye opener for me was learning that I had a vision dependency on cueing. My verbal cueing was subpar. Too often I was used to saying, “Watch me first, then you try,” then correcting form as needed. In programming for my client, I needed to better learn to be descriptive so that what he could not see, he could imagine in the mind. It had to make sense.

Tips

What helped me to make progress, not just with my blind client but in general, was to really read the descriptions of exercise, movement and anatomy. Even if I had to read it continuously to better explain, that is what I did. When something didn’t make sense, we just eliminated it and found a better option.

Learning to count steps was another big deal. It was critical to know how to express inches, feet, yards when walking or moving around. For example, we are 2 yards from your driveway, in 2 feet there is a table, it is 35 steps to your mailbox.

Blindfold yourself. Close your eyes when exercising. Have another trainer, family member or friend, tell you some of the exercises that you find hard to describe and learn from those examples. Get a real feel for what your client may experience. Learn how they use their cane and the types of canes (sticks). One wealth of information came to me from a blind athlete. He took time to talk to me and just reinforce how important it is for my client to be independent.

Announce what you’re doing before you do it. It’s the same with asking to touch a client, “Is it okay if I touch your elbow?” Or, “I am going to pick up these dumbbells.”

Challenges

Learning to not be so protective, smothering and motherly, as was my nature as a mother of five. I was scared every moment, what if my client falls, trips, bumps into the wall, anything. I felt I had to always be on guard and with the slightest change in movement or awkward movement, I would have my arm ready to catch if I needed. Too much! It was very helpful that a few times I had another trainer in training (my husband) come along with me and he brought it to my attention. I told him, I know I can do it, but what if something happens? He said, it just will and I can’t spend every minute in protection mode. It’s not good for me or the independence of my client.

Programming always changed. There were days we just walked because that was as much as my client could handle. Cancellations due to various reasons required me to step up and not be taken advantage of as well. Adapting to all of that and being patient in what my client needed took time.

Addictions (substance abuse). While I won’t get into much depth on this topic, there were many other challenges within this area that I was exposed to and needed to refer out and gain help for. Again, it was the unexpected.

Nutrition problems. Making sure my client was eating, what and when. There were many discussions we had regarding proper nutrition. Much of it would lead back to other barriers, such a cigarettes or substance abuse. It required other professional intervention, as I am not a Registered Dietitian, but we did review general eating habits and good vs bad. Occasionally, we got it just right.

Dawn working with her client

The Workouts

While the primary goal was weight loss and increased strength for my client, we tackled everything. We incorporated cardiovascular activities and ones we did often were running together with a rope (tether), jumping jacks, and walking. But every part of the programming goals were to incorporate functional exercises which all required flexibility, balance, core, resistance, strength training, and what my client could focus on doing alone. We used dumbbells, resistance bands, sandbells, medicine balls, jump ropes, tires, picnic table, stairs, Airex pad and simply bodyweight. The most important use of all the exercise was in how it would further benefit my client and the goals we set. Nothing should be useless training.

In closing

While there is so much more to be said on how I trained my blind client, the most important message to relay is to not be afraid of what you can’t do, but do what you can. We should always ask questions, always expand our knowledge and do what we as fitness professionals are here for — to assist in living a healthier, active lifestyle. We can’t promise the moon, but it is our responsibility to do the very best we can within our scope, and what we are hired for. If you’re doing that, than you are probably doing it well.


Dawn Baker is an Independent Contractor Personal Trainer, founder of One Accord Fitness LLC and has been changing lives in the fitness industry for 6 years.

Senior Man On Cross Trainer In Gym

Exercise and Wellness and Their Role in Injury Reduction and Prevention

For many exercise professionals, the goal of training and educating clients is to improve health, increase strength and performance, and improve fitness parameters. The concept of reducing injuries may not be high on their radar screens.

Active seniorsHowever, in American business, the aspect of doing anything that will reduce injuries (and health insurance costs) is of utmost importance. So much so that many businesses, universities, and manufacturing companies are hiring wellness professionals as part of their efforts to reduce heath care costs.

One aspect of providing a wellness program to companies is to define your services. Will you be performing ergonomic analysis?
Is a comprehensive stretching program part of your offerings?
Will employees be able to train in a health club environment?
Will there be any post-rehab therapy services available?

Many wellness programs segregate their services from ergonomics – which is a certified practitioner who may perform intrinsic (body mechanics), or extrinsic ergonomics (fitting proper equipment to the employee). Wellness programs are also not athletic training or rehabilitation, but may incorporate some of the elements of each of these disciplines.

Wellness services concentrate on sound basic exercise, stress management, aerobic conditioning (walking/machines), massage therapy, weight management, smoking cessation, and general health services (coaching, phone follow ups, etc.).

Perhaps the most important aspect of wellness programs (other than great instruction) is defining outcomes. HOW will employees lose weight? Will gaining core strength reduce total lost days? Can stretching and balancing programs reduce total medical payments for low back pain?

Outcomes will make a program successful. Results from university programs show that regular exercise programs may reduce back pain levels by up to 50%. Workers who have less pain won’t mind coming into the office more often. These same programs help reduce total low back injuries (many by over 75%).  Most importantly – these programs save money. From the Steelcase programs in the mid-1980s to programs today – people who are actively engaged in regular exercise, range of motion, massage therapy (chair massage), core training, balance training, nutritional intervention, relaxation training, smoking cessation, and regular health monitoring (body weight, body fat, blood pressure, specific blood lab values) improve health, reduce health risks, and save appreciable dollars over companies that do not provide these services. It is not uncommon for the return on investment to be higher than 4:1. This is remarkable considering most wellness programs have a modest budget.

Speaking of a modest budget – many wellness programs can be done well even if inexpensively. For a staff of 200 employees – approximately $2,500-3,000 can be spent on fitness balls, rubber tubing, dumb bells, stretch mats, and flyers can suffice to produce good results. Other equipment that may be used would include relaxation CDs, or a machine called Resp E Rate, which is a biofeedback unit that works to reduce heart rate through specific music programming. TENS units and chair massage may be used for pain management. Although these modalities are usually found in a PT office, they can be used anywhere where staff experience chronic pain levels that are not threatening.

Doctor showing a woman a part of a spineThe power of the wellness practitioner may also be the power to refer. When an employee experiences high levels of pain, depression or anxiety, or an injury or condition (blood pressure) that will not normalize – they need to be referred to medical personnel. It’s actually a great feeling to have a network of providers that can assist in bringing an employee to a more healthful and productive place in their work status.

In closing – the field of injury reduction and prevention is one of the fastest growing areas of health promotion – and should be investigated thoroughly. Some resources below may give wellness instructors some insight into the area of injuries, safety, and certifications. Remember, too that employers in private sectors companies may pay well for services that save them money. This is yet another reason to look into this interesting and challenging health promotion field of the future.


Eric Durak is President of MedHealthFit – a health care education and consulting company in Santa Barbara, CA. A 25 year veteran of the health and fitness industry, he has worked in health clubs, medical research, continuing education, and business development. Among his programs include The Cancer Fit-CARE Program, Exercise Medicine, The Insurance Reimbursement Guide, and Wellness @ Home Series for home care wellness.

Resources: www.resperate.com; www.stretchwell.com

pain frustration

Chronic Pain – Healing with Release

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 USA alone 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:

  • Headache—$14 billion, only $1 billion of which consists of health care costs (Hu et al., 1999), partly because most people with migraine stop seeking medical care for the condition (Silberstein, 2010)
  • Arthritis—$189 billion, less than half ($81 billion) of which is for health care costs (Yelin et al., 2007)
  • Spine problems—$2,500 average in incremental medical costs (Martin et al., 2008); and low back problems—$30 billion (Soni, 2010) Opioid pain medication use presents serious risks, including overdose and opioid use disorder
  • Between 1999 and 2015, more than 183,000 people in USA died from overdoses related to opioids.

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:

  • Chronically hard, tight muscles
  • Chronic tightness or chronic inflammation of a tendon(tendinosis)
  • Chronic joint tension or chronic inflammation
  • Limited range of motion in a joint
  • Impingement of a nerve resulting in numbness or a tingling sensation
  • Compression of a disc resulting in neck or back pain
  • Muscle weakness in one area especially if the muscle feels tight
  • Consistent muscle cramping
  • Joint instability while performing daily tasks
  • Recurring muscle strain or injury to the same muscles

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:

  1. To balance function of sensory-motor cortex via sensory stimulation mental imagery (sometimes called visualization, guided imagery), progressive muscular relaxation and control breathing. Result is relaxed but alert state of awareness.
  2. To enhance sensory integration/ awareness of somatic movement (movement regulated by feeling, mental imagery, sensation). Result is ability to perform somatic/ intuitive movement.
  3. Ability to perform conscious exercises – via mental imagery, sensation. Positive result is in neuro muscular conditioning/ function – postural improvement, balance, coordination, flexibility and agility.

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.

  • Exercise is performed with controlled breathing that utilizes full inhalations and full exhalations that follow a specific number of counts or rhythm. The goal is to learn how to breathe at a pace of 6 breaths a minute, about 3 or 4 seconds inhaling and 6 or 7 seconds exhaling. Once we have the slow, deep breathing accomplished, we don’t have to worry about counting and imagine breathing out any tension in the body or thoughts that get in the way of comfort and relaxation. The benefit of the water environment is tremendous. Hydraulic pressure increases human vital capacity in shoulder depth immersion 7x more than air, which promotes deep breathing and natural relaxation.
  • Exercise is performed with proper form or in precision. Quality of movement counts more than quantity in a mind-body exercise. Precision requires mental control. The mind has to be wholly focused on the purpose of the exercises as you perform them. The sensation of water on the skin is enhancing biofeedback’s, which helps with proper form greatly.
  • Neuromuscular exercise always involves the control and balance of your own body-weight. In water exercise we have interplay between gravity and buoyancy, weight and weightlessness. Control of the body can become challenging and at the same time very beneficial for overall success. By implementing movement patterns in a variety of directions, we stimulate and enhance balance, coordination, and flexibility, and inspire the neuromuscular system to become more expansive and creative. Moving in different speeds is an aspect of our physical capabilities that must be practiced in order to maintain a sense of health and well-being.
  • Releasing Movement is performed with intense concentration on yourself, in the present moment. The mind-body exerciser is focusing on his/her body rather than on the instructor, or on other participants. One should never be day dreaming about other things. The point-of-focus in a self- sensing exercise will differ from most other forms of physical exercise. One should be thinking about stabilizing, or anchoring, the area of the body that is NOT in motion. This is contrary to the usual Western method of trying to isolate the muscles that we perceive to be performing the movement.

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.

Join Dr. Sykorova Pritz for her upcoming webinar, Pain-Free Movement Techniques.


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.

Resources:

  1. BURDENKO I, MILLER J. (2001) Defying Gravity. www.Burdenko.com.
  2. GREGOR T., SYKOROVA PRITZ M.: (2008) Pain management and psychophysical     conditioning through water exercise. Revue Mediciny v praxi, Bratislava, MAURO Slovakia s.r.o. Rocnik 6, cislo 1, 2008, s.29, 30, 38 ISSN 1336-202X
  3. Discovery writers. (2013): Mind – Body Exercise Connection. Discovery Fit &Health; http://health.howstuffworks.com/wellness/diet-fitness/information/mind-body-exercise-connection.htm
  4. INSTITUTE of MEDICINE (2011): Relieving Pain in America. A Blueprint for Transforming Prevention, Care, Education, and Research
  5. JOHNSON, L.S.(2009):”Therapist’s Guide to Posttraumatic Stress Disorder Intervention”, Academic Press is an imprint of Elsevier, San Diego, California, USA.Page146-148, ISBN:978-0-12-374851-5
  6. RAMSEY L. (2018): As America fights opioid addiction, the healthcare system is failing people who live with chronic pain: http://www.businessinsider.com/people-with-chronic-pain-during-opioid-crisis-2018-1
  7. SYKOROVA PRITZ, M. (2007):” The effect of water exercise on selected aspects of overall health on a fibromyalgia population”. Aquatic Fitness Research Journal, October 2007, Volume 4, Issue 2, Nokomis, Florida, USA: Aquatic Exercise Association. page. 6-13
  8. SYKOROVA PRITZ, M. (2018):” Healing with Release” AKWA: Volume 32, No 2;  Brunswick GA. USA; Aquatic Exercise Association, page 31-33,ISSN: 1536-5549
  9. STOLNICK, D.:  (2000-2008) Looking for joint pain relief. Vilage Inc.
  10. VAN HOUDENHOVE, B, – EGLE, U, – LUYTEN, P. (2005): “The role of life stress in fibromyalgia”, Curr Rheumatol Rep. 2005 Oct; 7(5):365-70.
  11. THEARMAN, B.H.: (2007) Simple solutions to Chronic Pain. New Habringer Publication, Inc. ISBN-13: 978-1-57224-482-5.

NOTE: To learn more about SykorovaSynchro Method, it is recommended that you take the course “Application of Water Exercise for Health Fitness Professionals Specializing in Pain Management.” to increase your knowledge and skills.  For more information, log on to www.FitnessLearningSystems.com.