Benefits of Physical Activity, some thoughts about Intensity and How to Cut Your Risk of Premature Death by 33%

So I’ve been researching the benefits of physical activity on healthy aging a lot lately. Of course, as a PT, I’m well-aware that exercise is good and we should all be doing it, but I’ve been doing a deeper dig lately into the actual specific effects on our health as I develop my therapy programs. Beyond identifying the benefits, the next step is learning how acheive them. This has led me to topic of intensity. Yes, for those of you who know me, you can stop your snickering, I’m aware I can be a *little* intense sometimes and you may find the idea of me actually having to put research into this topic a little amusing. But in reality, the topic of intensity is actually quite pertinent to healthy aging. You see, the older adult is chronically underdosed in exercise intensity by well-meaning therapy clinicians and the medical profession in general when it comes to exercise prescription. Underdosing translates into wasted efforts, and poorer health outcomes. I want better for my patients.

The first step in understanding how to better prescribe exercise to promote health and wellness in the older adult is to understand what is required to achieve said benefits. The CDC issued a well-researched and thoroughly detailed 117 page document in 2018 entitled ‘Physical Activity Guidelines for Americans,’ and after reading all 117 pages, I started wondering if I am I even getting enough exercise at an adequate intensity. While you’re more than welcome to read the document in it’s entirety yourself, for those of you satisfied by a summary, I’ll share a brief cliff-notes of the relevant details here.

• Americans do not exercise enough. The average American sits for 55% of their waking time, or around 7.7 hours hours per day. This number only increases in the older adult. The average 70-85 year old American sits for 9 hours per day. This doesn’t take into account time spent SLEEPING.

• 28% of adults over the age of 50 are physically inactive. Physical activity levels are graded from Inactive, to Insufficiently Active, to Active, to Highly Active. Adults who are physically inactive do not get any moderate or vigorous physical activity beyond the basic movements involved with daily life. Insufficiently active adults exercise, but at less than the recommended amount. Active adults hit their target movement goals and Highly Active adults surpass them.

• Inactivity is 30% higher in those with a chronic disease. 6 in 10 Americans live with at least 1 chronic disease. 4 in 10 have two or more.

• To qualify as Active, you must regularly participate in the recommended level of exercise as described in the Physical Activity Guidelines for Americans. These guidelines state that to get optimal health benefits from physical activity, you should:

  • Perform 150 to 300 minutes of moderate intensity physical activity per week.

  • Participate in regular moderately challenging strengthening activities at least twice per week that target all the major muscle groups.

  • For older adults, the Guideline goes on to suggest every older adult should include balance training as part of their regular, weekly multicomponent exercise routine.

Where do you fall ? Are you Inactive, Insufficiently Active, Active or Highly Active? Could you do better?

And now for the good news. IF you are able to participate in this level of activity, you will not only be 33% less likely to die of unnatural causes, but you also reduce your chances of developing or experiencing:

• Dementia, by 30%

• Hip fractures, by 68%

• Cardiovascular disease, by 35%

• Type II diabetes, by up to 40%

• Colon cancer, by 30%

• Breast cancer by 20%

If this isn’t enough to convince you, regular physical activity has further health benefits on your cardiovascular system, pulmonary system, muscle, joint and bone health, neurological function and emotional health, helps you sleep, has a large role to play in weight management and can reduce your risk of falls, and falls-related injuries significantly. And also, it improves your quality of life. Yes, this has actually been proven.

So back to the question I found myself posing earlier. Am I getting enough physical activity to garner me all of these health benefits? I mean, I’m an active person, and I pretty much never sit still. I try to exercise throughout the week, though some weeks I’m better than others. Some days I cycle, but others I just feel like taking a walk or doing some yoga, and I try to respect what my body tells me I need. Before you, too, try to figure out whether you getting enough exercise, I want to take a moment to explain the concept of Intensity. What is ‘moderately intense’ physical activity anyways?

Exercise Intensity

A general description of exercise intensity is how hard you have to work to perform an activity. It can be further broken down system-specifically, in regards to how hard you heart has to work, how hard your lungs have to work and how hard your muscles have to pump to make the activity happen, but in a general sense, exercise intensity refers to how taxing the activity is on your body. The most specific way to measure intensity (without a whole bunch of treadmills, EKG tabs and pulmonary function tests) is to determine the percent your heart is working of its maximum capacity. You can use an online calculator, or do some simple math (220-your age) to determine your maximum heart rate, then multiply by the desired intensity to calculate your intensity range. Per the CDC, intensity ranges per percent of heart rate maximum are as follows:

• Light Intensity is activity that places you at 50-64% of your heart rate maximum.

• Moderate Intensity is activity that places you at 64-76% of your heart rate maximum.

• Vigorous Intensity is activity that places you 77 - 93% of your heart rate maximum.

Now of course, there are all sorts of variables that go into your true heart rate maximum, and your ability for your body to reach these levels (use of beta blockers is a big one!), but to give you a sense of what this translates to, for an average 50-year old, the heart rate range for light intensity is 85-106 beats per minute, for moderate intensity is 109-129 beats per minute, and for vigorous intensity is 130 - 158 beats per minute. For a 75 year old, these values drop; for light intensity the range is 72-92 beats per minute, for moderate intensity the range is 93-110 beats per minute and for vigorous activity the range is 111 - 134 beats per minute. As you would expect, this means that the same active I perform at 37 years old, would likely be more taxing for someone who is 50, and even more taxing for someone who is 75. This means exercise prescription for the older adult cannot be a simple cookie-cutter exercise class or online program. It requires an educated health profession (a PT perhaps…) to take into account all the health variables that may determine what your personal exertion ranges can and should be.

There are also a few subjective, but frequently, more useful measures to gauge intensity. The measure I use most frequently is called the Rate of Perceived Exertion Scale, or RPE. While the original tool used a 6-20 scale to self-report level of perceived exertion, a modified version has since been validated and uses instead self-rating on a 0-10 scale. I find this is more user-friendly for my patients, and I use it more often. When I use this scale, I explain 0/10 is when you are completely at rest, and 10/10 is running a marathon and you couldn’t possibly take another step. 5/10 is working hard, but you can maintain this level of exertion. This scale has been validated to correlate well with intensity as measured by heart rate ranges as above, and can be used in lieu of this measure of intensity for general purposes. To gauge how intense your physical activity with this modified RPE scale:

• 0-3 reflects a subjective experience of light intensity (rest, little to no fatigue or comfortable level of activity with slightly evaluated breathing rate - you should still be able to carry on a regular conversation)

• 4-6 reflects a subjective experience of moderate intensity (moderate, walking a brisk to rushed pace, breathing more deeply and level of activity more difficult to maintain - you should be able to talk, but not sing)

• 7-10 reflects a subjective experience of vigorous intensity (very strong, difficult to maintain level of activity, could not sustain for long, can barely talk)

So, if you find yourself in a session with me, wondering why the heck this PT lady is making you run around your house or get up and down from your chair so many times in a row, or even *gasp* lift weights (‘I’m 80-years old, why in the world does this chick have me deadlifting?’) it is because I am trying to get you what you deserve - the benefits of moderately intense physical activity and the most effective therapy treatment possible. The days of ankle pumps and seated exercise are behind us. We know better. You deserve therapy that not only fixes your pain and dysfunction, but helps you adopt a lifestyle that promotes health and wellness in more meaningful ways. And that takes participation in moderately intense, multicomponent regular physical activity. But your hard work will pay dividends; you will decrease your chances of developing disease and can increase your lifespan. Seems like a fair trade, right?

Getting your 150…

So back to me. With these thoughts in mind, I decided to check myself and see whether I am actually getting the recommended level of physical activity each week. I mean, if I can’t practice what I preach, what business do I have giving other people health and fitness advice? While I track my activity on my Apple Watch intermittently, I don’t often circle back to see what my weekly numbers are. I decided last week track my activity each time I exercised, and see where I wound up for the week. While I got plenty of exercise minutes, I was surprised to see how many of them didn’t qualify as moderately intense physical activity. Now, fortunately, this is likely reflective that I am in good cardiovascular health, and my never-stop-moving baseline level of activity doesn’t pose a physical challenge for me beyond light intensity. But that said, level of physical activity is person-specific; even if I’m active for the recommended number of minutes per week, if they aren’t at ‘moderate’ or higher level of intensity, I’m not going to get health benefits associated with an ‘Active’ lifestyle. All said and done, last week I worked out for 222 minutes. I only tracked my specific work out times, as I assumed none of my busy-body daily movements would be high enough to register as moderate activity. Of those 222 minutes, 155 of them qualified as moderately intense, while 68 of them registered as light. 2 of my workouts were bike rides, 2 of them were strengthening sessions and 1 was a 3 mile brisk walk around a local state park. So what did I take from my experiment? Of my five workout sessions, 30% of the time spent was not intense enough to garner the health benefits I am striving to achieve. And this is not to say that the light exercise I performed wasn’t worthwhile - some of was time spent in warm up, some of was walking that I do just to relax and some if it is the stretching and flexibility work I use to keep my back from bothering me. But, on the other hand, I barely broke the recommended minimum for moderate physical activity! I could absolutely be doing more. And I know I’m not the only one who struggles with this. I’ve heard from so many friends, colleagues and acquaintances that this year in particular, has made getting adequate levels of physical activity even harder. Many of us rely on getting out and going to work for our regular physical activity. Staying home has had a tremendous impact on all our our lives and daily rhythms. But with the stress of pandemic life higher than ever (oh dear god...school starts next week), it is even more important that we prioritize ‘getting our 150’ to help balance out the chronic stress and immobility that has unfortunately, become part of this pandemic life.

If someone told you there was a way to reduce your risk of dying early by 33%, wouldn’t you take it???

So back to you. How are you going to get your 150 this week? Do you need help? Extra motivation? Guidance? Have questions? I’ll post how I get my 150 each week if you post me yours. Keep an eye on my Facebook each week for a Getting Your 150 thread and share with me your plans, workout pictures and stats and lets celebrate together when we hit our goals. But don’t forget - something is better than nothing, so even if you start small, share your victories with me and I’ll root you on.

Need some extra help? Exercise is for everyone, even if you’re young, old, limited or living with a disability. My job as a physical therapist is to make exercise accessible. I am an expert at making exercise safe and efficient and enjoyable for people of all ages and abilities. I offer 1:1 Wellness Training and ongoing community education as part of my efforts to offer health promotion on a greater scale than I can with physical therapy alone. Check out these links to learn more.

HAE/FIT 1:1 Fitness Training

HAE/ED Community Seminars

Coffee Talks with Katie (Doctor of Physical Therapy)

References:

CDC Physical Activity Guidelines 2018

CDC Physical Activity Guidelines Executive Summary

ncbi.nlm.nih.gov/pmc/articles/PMC3527832/

CDC Physical Inactivity Among Adults

Treatment Tuesday: focus on Osteoporosis

WHAT IS OSTEOPEROSIS?

Osteoporosis is a disorder of progressive bone loss. While all bones normally cycle through a series of bone degradation (resorption) and new bone creation (deposition), bone loss occurs when the rate of bone resorption becomes faster than the rate of bone deposition. While we all experience age-related bone loss beginning around age 35, bone tissue deterioration can become pathological when it progresses < 1 ‘standard deviation’ (SD) from normal. Osteopenia is defined as between 1-1.25 SD below normal or a T score (measure of bone density) between -1 to 1.25. Osteoporosis is defined when bone density drops 2.5 SD or more below normal, or T score falls below - 2.5. Symptoms of low bone density typically include increased risk of fracture, increased thoracic kyphosis and pain. Osteoporosis can impact breathing and digestion if/when structural changes affect posture and spinal structure. Women are at higher risk for bone loss than men; women are 8x more likely to experience Type I osteoporosis(postmenopausal and related to loss of estrogen), and 2x more likely to experience type II (senile osteoporosis that occurs after 70 years old).

You can decrease your risk of developing Osteoporosis and/or improve your management of this disease by making certain changes in your lifestyle and activity:

✓ Participate in Regular Aerobic Activity and Strengthening: Participation in moderate to high intensity weight bearing aerobic exercise with a cyclical movement pattern has been shown to be beneficial to people with osteoporosis. Strengthening improves bone mass by the transfer of mechanical stress to bone via tendons and reduces your risk of falls.

✓ Improve your Balance and Reduce your Risk of Falls: Given the increased risk of facture in the setting of osteoporosis, it is critical to improve your balance and stay on your feet. Additionally, learning how to fall properly can protect your spine and joints in the case that you do lose your balance. Consult a physical therapist to determine how to best address these issues and incorporate a balance program as part of your normal routine.

✓ Postural Awareness and Use of Proper Body Mechanics: If you have already been diagnosed with osteopenia or osteoporosis, it is important to use proper posture and body mechanics to protect your spine and reduce risk of compression fractures. Excessive spinal flexion (bending forward) and twisting motions can increase risk of these types of fractures. Avoid activities that require these movement patterns and focus instead on spinal extension (leaning back) and improving your neutral posture and postural control.

✓ Follow any Medication and Diet Recommendations Provided by your Doctor: There are many good, effective pharmacologic treatments available for the treatment of osteopenia and osteoporosis. Your doctor may prescribe dietary supplements or bisphosphonates to slow bone degradation and encourage new bone deposition. Follow your doctor’s directions and make regular follow-ups routine.

BENEFITS OF EXERCISE

✓ Improved bone density

✓ Decreased risk of falls and fracture associated with falls

✓ Improved aerobic capacity, oxygen utilization, blood pressure and improved cardiac efficiency

✓ Improved sleep, mood and decreased daytime fatigue

✓ Improved weight management

CAUTIONS AND CONTRAINDICATIONS

While it is safe to exercise with osteoporosis, you should avoid high impact activities and exercises that involve twisting of the spine. This can protect your vertebrae from compression fracture.

Further Reading and Resources

Choose PT Guide to Osteopenia

Choose PT Guide to Compression Fractures

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Treatment Tuesday: Focus on Low Back Pain

🩺It's Treatment Tuesday here at HAE🩺

With my goal of promotion of healthy aging for the patients I treat, I also think it's important to share information on a larger scale. Each Tuesday, I will review either new literature or established best-practice standards that address the best treatment for a particular disease, disorder or dysfunction. To kick things off, I choose a problem I'd be willing to bet we've all experienced a time or two....Low Back Pain.

While Low Back Pain is common, it is often mistreated. Here is a review of the recommended, most effective treatments, treatments options that are sometimes appropriate, and lastly, the few that are least appropriate and often less helpful. Primary source of this information collected from ChoosePT.com, a patient education resource guide from the APTA. See links below for more information.

RECOMMENDED: 

🟢 Movement: While it may be tempting to stay in whatever posture doesn't bother your back, the more effective treatment  is movement. Try to move more in ways you can tolerate - walking, swimming, cycling or simply gentle stretching can help alleviate and prevent low back pain. Consult a Physical Therapist to help you establish a physical activity plan that is safe and effective at reducing low back pain.

🟢 Education: Low Back Pain can commonly be attributed to muscle imbalances within the trunk, legs and along the spine. When you combine that with prolonged sitting, standing or repetitive motions, you get pain and dysfunction. Learning about your imbalances and about proper posture can help you take control of your low back pain.

🟢 Cognitive-Behavioral Therapy: This type of therapy (using your behavior to retraining your brain to respond in an alternative way to a stimulus) has been proven effective for any type of chronic pain. Next time you have a painful experience, notice what your response is. Do you get immediately anxious? If it happens, take that opportunity to focus on your breathing, instead of your anxiety. While you take time to be aware of your symptoms, take 5-10 slow deep breaths instead of turning to panic or googling what to do. This 'changing the conversation' can help your brain begin to dampen the response to the pain stimulus instead of turning to panic.

SOMETIMES APPROPRIATE:

🟡 Yoga: With a focus on controlled breath with movement and on core activation, yoga can be a helpful adjunct to your low back pain treatment plan.

🟡 Massage: While massage may give you some short term relief, evidence has shown movement-based therapy is more beneficial in the long term.

🟡 Acupuncture: Results of acupuncture for low back pain relief is similar to those associated with massage; while it may be helpful on the short term, it should be combined with recommended treatments for long term relief.

🟡 Spinal Manipulation: As with massage and acupuncture, spinal manipulation may help initially with function, but should also be combined with exercise and movement-based treatments.

RARELY APPROPRIATE:

🟠 Opioids: The CDC recommends use of opioid medications only for chronic pain that has been resistant to other recommended treatments. They are less effective and have considerable side effects.

🟠 Heat: Everyone loves to throw on a heat pack, but there is limited evidence of any long term benefit. Ice may be a better choice, but regardless, any use of modalities should be used in combination with recommended treatments.

🟠 Imaging Scans: Evidenced has shown that imaging like x-rays and MRI's is not necessary to diagnose and treat low back pain. It can also lead to unnecessary treatment.

🟠 Spinal Injections: Evidence has not found any long term benefit from spinal injections and it does not reduce the likelihood of surgery.

🟠 Surgery: Surgical intervention is not necessary or recommended for most types of low back pain.

NOT RECOMMENDED: 

🟠 Bed Rest: Not only is bed rest ineffective, it will likely make back pain worse. Try to move, in ways that are comfortable instead. 

To learn more about the best practice guidelines for the treatment of low back pain, check out these links:

Choose PT Guide to Low Back Pain:

https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-low-back-pain

Choose PT Recommended Treatments for Low Back Pain:

https://www.choosept.com/resources/detail/recommended-treatments-low-back-pain-2

Choose PT Five Common Myths About Low Back Pain:

https://www.choosept.com/resources/detail/5-common-myths-about-low-back-pain

Michael J. Fox Foundation Research Update

I had the opportunity to sit in on a Michael J Fox Foundation research update this week, presented by Rachel Bulmer and Melanie Demakis, and wanted to share some updates with you that they shared with us. For those of you unfamiliar with the Michael J. Fox Foundation, they provide financial support to researchers working not only to advance the treatment of Parkinson’s Disease, but to find a cure. 

While I’ve always tried to stay up to date on management of the patient with Parkinson’s to provide the best standard of care for my own patients, I also have personal interest in the topic as my mother is living with Parkinson’s disease. This webinar was a great opportunity to hear about current state of genetic research and also to learn about some recently approved pharmacological interventions.

Genetic Trials

The presenters discussed the importance of finding a concrete biomarker for Parkinson’s disease. A biomarker is a quantitative measurement tool that enables researchers to more definitively determine efficacy of a treatment in testing, and also better identify the current stage of a person’s disease.  As there is no current validated biomarker for Parkinson’s disease, researchers have to rely primarily on clinical observation and functional outcome measures to determine whether a new medication or genetic treatment has made a significant and clinically relevant difference. They are able to perform brain scans that show some degree of dopamine loss, but this value is difficult to standardize and has not been used in a validated way as of yet. 

They discussed three areas of genetic research that are potentially relevant to finding a better treatment, or possibly a cure, for Parkinson’s disease. Alpha-synuclein protein is one of these areas of interest. Located in the brain, mutation or overexpression of this protein is believed to play a role in the development and progression of Parkinson’s disease. This protein essentially folds into clumps, leaving Lewy Body deposits, which slow the transmission of dopamine within the brain, leading to the motor effects we see in patients with Parkinson’s disease. There are presently 13 Phase 1 to 2 trials investigating how to slow or prevent the expression of alpha-synuclein, in turn, slowing or stopping the progression of the disease.

The other two genetic avenues they presented were related to the genetic markers GBA and LRRK 2. With 6 GBA trials, and 3 LRRK 2 trials already in progress, two large companies, Biogen and Denali, just announced they will be combining efforts to support a Phase 2 LRRK 2 trial. This is significant, as with promised financing of $1,000,000,000, their support to the project speaks to their belief that this research may be particularly promising. 

Pharmacological Treatments

The presenters also reported on three new medications that have recently hit the market. Interestingly, all three share a common goal - to reduce the experience of off-times, while each one approaches the problem in different ways. Kynmobi, a thin-film apomorphine strip can be taken sublingually as a rescue drug during off times. Ongentys, a COMT inhibitor, is also taken by mouth in pill form once daily, and though slightly older news, they also mentioned Inbrija, an orally-inhaled form of levodopa, which can be through an inhaler on as as-needed basis to reduce off-times as well.

Lastly, they touched upon the importance of volunteering for clinical trials, whether as a healthy control, or a person with Parkinson’s. You can access their trial database here and learn more about these opportunities. 

I thought this was a great over-coffee opportunity to hear about the latest progress in Parkinson’s Disease research. You can see more webinars from Michael J. Fox Foundation here. If you would like to support this wonderful foundation, you can make a donation here.

the HAE Senior Fitness Assessment

Curious how you stack up against the competition or just want to find out if there are areas you could improve on. Sign up for a HAE Senior Fitness Assessment. On the day of your assessment, I will meet with you in your home to discuss your goals, your health history and will perform a thorough physical fitness assessment that day.  Here are some of the areas I will be assessing:

Past Medical History and Current Conditions: I will review your pertinent health history, discuss with you any concerns you have about your current medical conditions, within the scope of my practice, and provide education on conditions that you may benefit from understanding better. If I feel like you could benefit from any specialist referrals, I will provide this feedback to you and your medical team.

Assessment of Goals: For your Wellness plan to be effective, it must start with you. We will discuss what your goals are at present and for the future. These goals can be anything from being able to get up from the ground with more ease, to participating in your favorite hobbies and leisure activities with less limitation. I will use this information to help with development of your Wellness plan and our success together is measured by your progress in these areas.

Clinical Assessment: I will then perform a thorough physical assessment of your areas of strength and any areas of potential weakness. I will perform tests and measures to assess the following areas:

o   Cardiovascular and Pulmonary Health

o   Functional Strength, Power and Muscle Endurance

o   Flexibility and Range of Motion

o   Aerobic Capacity and Activity Tolerance

o   Balance and Coordination

Functional Outcome Measures: By utilizing outcome measures with predetermined age-matched norms and cut-off scores that indicate associated fall risk and other functional outcomes, I can better gauge where you are at present, and where I hope you will be when by the time we finish. I use tests like the 6 Minute Walk, 2 Minute Step, Berg Balance Scale, Functional Gait Assessment, 30 Second Sit to Stand, Arm Curl Test, and the Activities Specific Balance Scale among others to help me set more specific goals for you, and to help illustrate for you where you land currently on the spectrum of health and fitness. I will provide you with your scores, and we will reassess these as you progress with your Wellness program.

Development of Your Wellness Plan

After careful review of your medical history, and after we address any pertinent current medical issues, I will review specific guidelines for physical activity and provide you with education on any relevant precautions or contraindications for exercise. I will then review your individualized Wellness plan and we will determine together how you would like me to help you along your journey. Visits can be made in person or virtually, and at a frequency that you and I decide together would be most beneficial.

While our routine may vary, and all Wellness programs are individualized, there are certain types of workouts I find most beneficial to my clients. All of your workouts can be done in your home with whatever equipment you have on hand, or no equipment at all. Here is an overview of some of the different types of workouts you can expect to try:

Functional Strengthening: I believe in performing exercises and activities that are designed to directly improve your ability to function. This means choosing activities that strengthen your body in ways it must move to perform functional mobility and everyday activities. Typically, these movements fall into seven categories: Pushing, Pulling, Hinging, Squatting, Lunging and Core Work and Twists. While these are the same types of patterns you may expect to see heavy weightlifters performing, I modify these to reflect the types of activities you perform during your everyday life. You perform a squat every time you get up and down from a chair or the toilet. Stairs require a form of lunging and you hinge every time you must retrieve an item from the ground.  Pushing happens when you rise from bed, and you pull often when get in and out of the car. Your core is active during every one of these activities and twisting is a part of everything you do – rarely do these actions happen in isolation or as straight plane. By getting away from the traditional single limb strength protocols (bicep curls, knee extensions) and focusing on the multi-body part, big muscle group motions that translate to increased function, your workouts will not only be more effective, but more efficient. To read more about the benefits of functional strengthening, check out this blog post I wrote about it here.

High Intensity Training and EMOM-Style Workouts: To get maximum benefit from your workouts, you must be working intensely. And while this doesn’t necessarily mean you have to be dripping sweat or exhausted, it does mean I will find ways to get you moving and keep you moving so your heart rate stays up and you get a cardiovascular benefit even during your strengthening. I do this frequently by incorporating low impact aerobic intervals into your strength sessions, or using Every Minute on the Minute (EMOM) style workouts that use strength activities performed at more intense speeds and efforts to achieve the same effect. 

Low Intensity (LISS) and Moderate Intensity (MISS) Steady State Cardio: While it may sound simple, there are so many benefits from participating in regular low to moderate intensity aerobic exercise, that it has a role in a every Wellness program I create. This is the place where you get to choose how you move; if you like to walk, I will help you create a walking program. If you like to dance, we will find a way for you to find your groove. If you want to get on a bike, we can do that too. The only guideline I have your LISS or MISS workouts is you pick something you like to do, that feels good for your body.

Balance, Coordination and Agility:  I rarely meet someone who couldn’t benefit from work on their balance. I will create a balance program specifically for you that starts with the areas I find deficit during your assessment. It will start easy, and progress to keep you challenged, with activities modified to present challenges to your static, dynamic and walking balance all designed to encourage more instinctive and effective use of your balance strategies when needed.  

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