Contributing Authors: Joseph Kelly, Sr., DMD, Joseph Kelly, Jr., DMD
In August of 1859, twenty-six men representing several existing dental organizations gathered at Niagara Falls, NY and formed what would become the American Dental Association (ADA). In 2009, 150 years later the ADA boasts 156,000 members who have become an integral part of the health care team in the United States. Today, it is well recognized that complete wellness includes good dental health!
While this column might normally discuss the role of diet and exercise for wellness and the prevention of cardiovascular disease, today it will demonstrate how dental health has a direct relationship to cardiovascular health. Your dentist may be one of the most important health care providers maintaining the health of your heart. If one has periodontal (gum and bone) disease, it may have a detrimental effect on his/her heart and blood vessels. It may be that your dentist can help to keep you healthier by detecting and treating this aspect of your health.
According to the American Heart Association, it is estimated that nearly 80 million Americans had one or more forms of cardiovascular disease in 2004. Cardiovascular disease involves a complex interplay of many risk factors. Controlling or treating periodontal disease may very well help in the treatment of this national health issue. Consequently, people with heart or blood vessel disease who also have periodontal disease may want to discuss coordinated medical-dental treatment with their cardiologist, physician and dentist.
Dentists can readily identify periodontal disease. Thorough examination includes x-ray analysis for bone loss and accumulation of calculus (hard deposits formed by bacteria under the gums), plaque (soft accumulations of bacteria on the teeth and gums), measurement of gum pocket depth around each tooth, evaluation of bleeding during the exam, and gum recession (loss of gum tissue).
Periodontitis is a chronic bacterial infection of the gums and bone that is often unseen. This can lead to tooth loss by weakening the jawbone support around any or all of the teeth in the mouth. More importantly, this constant bacterial assault is in contact with arteries and veins of the jaws which are ultimately in communication with all the blood vessels in the body. Thus the bacteria which are involved in this oral disease may be able to travel anywhere in the body, including to the heart. In addition, the negative immunological effects of this chronic infection may contribute to atherosclerosis (hardening of the arteries).
An article published in the December, 2007 issue of the Journal of Periodontology (JOP), the official publication of the American Academy of Periodontology, suggests that periodontal patients whose bodies show evidence of a reaction to the bacteria associated with gum disease, may have an increased risk of developing cardiovascular disease.
“Although there have been many studies associating gum disease with heart disease, what we have not known is exactly why this happens and under what circumstances,” said JOP editor Kenneth Kornman, DDS, PhD. “The findings of this new analysis of previously published studies suggest that the long-term effect of chronic periodontitis, such as extended bacterial exposure, may be what ultimately leads to cardiovascular disease.”
Research presented last year by Tonetti et al in the New England Journal of Medicine suggests that intensive treatment of periodontal disease may reverse atherosclerosis by improving elasticity of the arteries. This study is important because it furthers understanding of the potential relationship between periodontal disease and heart blood vessel disease. An additional article presented in 2007 in the JOP reported evidence of periodontal bacteria in the coronary arteries in nine out of fifteen patients who had been previously diagnosed with coronary artery disease.
The focus of treatment of periodontal disease lies in the removal of infection. The ultimate goal is to retain all of the teeth in a state of health for a lifetime. The method includes education of the patient as to the cause of the disease and the treatment needed, removal of the bacterial calculus and plaque in the dental office, and making every surface of each tooth accessible to diligent daily cleaning by the patient. Discussing the state of your periodontal health with your physician and dentist may lead to keeping your teeth and making your heart healthier. Complete wellness includes good dental health!
CONTRIBUTING AUTHORS: Joseph T. Kelly, Sr., D.M.D. practices dentistry in Clarks Summit with his son Joseph T. Kelly, Jr., D.M.D.
Total ankle replacement (TAR) is recommended for severe ankle pain which has not responded to conservative treatment: weight loss, activity modification, physical therapy, and anti-inflammatory medication and cortisone injections. Severe ankle pain can result from the following:
Ankle pain can manifest in the shin, ankle, and shin. It usually increases with activity and alleviates with rest. It may occur at night and prevent sleep. This pain is associated with stiffness, limping and functional limitation which significantly affects quality of life.
A TAR is the surgical implantation of an artificial ankle (prosthesis). The worn out joint surfaces of the end of the shin bone (tibia) and the top of the ankle bone (talus) are removed. Extreme care using precise instruments are used to insure a level surface for the implant. A metal and plastic implant is inserted into the prepared bone ends to create a new joint surface. Because the artificial ankle joint has smooth surfaces, like cartilage, complete, or near complete, pain relief is experienced which allows improved motion, enhanced function and less limping.
Ankle replacements have become better designed and more successful. A good candidate is older, less active with an average body weight. Therefore, a poor candidate is young (under 50 years old), active and overweight. For this group with disability and chronic pain an ankle fusion surgery may be more appropriate than a joint replacement.
Predicting the longevity of a TAR on an individual basis is impossible. According to Guido LaPorta, DPM, ankle implants of the 1970’s were not good and resulted in poor outcomes. Those of the 1990’s were good but not great. However, there is an 82 to 90% chance that new TAR’s will last 10-12 years in the appropriate patient.
Recovery following TAR takes 12 weeks. The ankle may be warm/swollen for 3 to 6 months (ice and elevation will help). The ankle will show improvements in function for up to a year. Overall a TAR relieves pain and stiffness, improves mobility and restores quality of life! Instead of limping in pain, you will return to walking painfree and maybe playing golf!
Contributor: Guido LaPorta, DPM, is president of LaPorta and Associates, a podiatric group with several offices in Northeast PA. He is also director of the podiatry residency program at Community Medical Center in Scranton, PA.
SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons
Visit your doctor regularly and listen to your body.
I have been advising my patients to exercise, keep active, and walk as long as they can in order to stay mobile and healthy. However, seniors often tell me activities that require prolonged walking is limited by ankle pain from arthritis. They often ask, “What is arthritis of the ankle?” How does it happen? What can I do about it? I will attempt to answer these questions with the help of local and national experts such as Dr. Guido LaPorta, DPM, The Rothman Institute, and American Academy of Orthopaedic Surgeons.
Your family physician will examine your ankle to determine if you have arthritis. In more advanced cases you may be referred to a specialist such as a podiatrist, orthopedic surgeon or rheumatologist for further examination and treatment. X-rays will show if the joint space between the bones in the ankle is getting narrow from wear and tear arthritis. If rheumatoid arthritis is suspected, blood tests and an MRI may be ordered. The diagnosis will determine if you problem if minor, moderate or severe.
In the early stages your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You and your family physician, podiatrist, orthopedic surgeon or rheumatologist will decide which choices are best.
When conservative measures no longer succeed in controlling pain and deformity, improving strength and function then more aggressive treatment may be necessary.
Contributor: Guido LaPorta, DPM, is president of LaPorta and Associates, a podiatric group. Also, he is chief of the podiatry residency program at Community Medical Center in Scranton, PA.
SOURCES: Rothman Institute, Philadelphia, PA and American Academy of Orthopaedic Surgeons, Guido LaPorta, DPM, Dunmore, PA
Visit your doctor regularly and listen to your body.
Contributing Author: Janet Caputo, PT, OCS
Balance problems are a frequent complication of Parkinson’s disease (PD) and they can lead to falls. A fall can result in a life-altering injury requiring nursing home placement or, even worse, a life-threatening injury that can result in death! Making adjustments to your home to prevent falls as well as practicing strategies to maintain your balance are two important issues for the individual with PD to address.
Falling in your home can be prevented by adhering to the following recommendations. Remove or firmly secure all throw rugs. Minimize clutter to provide adequate walking space between furniture. Avoid using extension cords but, if necessary, they should be secured to the floor with tape. Outdoor lights and indoor nightlights can ensure a well-lighted home in the evening. Using strategically placed light switches and lamps can help provide adequate lighting for negotiating your home at dusk or during the night. Stairs should have rails on both sides. Arrange your activities to reduce the amount of times that you must use the stairs. Wipe up all spills immediately.
Falls in the bathroom can be especially harmful because the surfaces that you would fall on or against are hard (e.g. tub, sink, toilet, and tile floor). Use an elevated toilet seat and/or safety rails or install an elevated toilet to assist standing. Towel racks and toilet tissue holders are not secure enough to provide adequate support when assistance is required to stand from a low surface. Firmly mount grab-bars on the walls to assist you with getting in and out of the tub or shower. The bathtub or shower should be equipped with a non-skid surface (e.g. decals, tape or a mat). Consider extended lever handles on faucets to make them easier to turn. If your balance is significantly impaired, use a shower chair or, for even more security, tub bench. Installing wall-to-wall carpeting in your bathroom will prevent slipping on a wet floor.
You can reduce the possibly of a fall by enhancing your ability to balance. Keep at least one hand free at all times. Use a backpack or fanny pack to carry things. Even though my mom does not have PD she does have balance issues. She cleverly transports items by placing them in a bag with handles so that she can carry them with one hand. Carry lighter loads and make several trips to accomplish a particular task. Consciously swinging your arms and focusing on lifting your feet while walking will help your balance and prevent tripping. Standing with your feet shoulder width apart increases your base of support and also your ability to balance. Minimize distractions by performing one task at a time. Plan ahead and become aware of what movements will be necessary to accomplish a desired activity. After a plan is made, concentrate on the movements you are performing and deliberately execute the desired motions pausing for at least 15 seconds before changing positions. If you become “frozen” or experience an increase in rigidity try to visualize stepping over an object. Freezing most often occurs when you are approaching an object (e.g. chair, bed, toilet, or doorway). Focusing on or thinking about what movements are necessary to accomplish your task can reduce the severity of this symptom. Talking to your feet (i.e. say right, left, right, left, and so on…) may also reduce shuffling or “getting stuck”. When trying to turn around, use a “U-turn” technique instead of pivoting sharply.
Even if all of these recommendations and suggestions are followed, an individual with PD still is at risk for a fall. Therefore, some general safety guidelines are advised: (1) avoid fatigue; if you feel tired, stop your activity and rest, (2) write emergency numbers on stickers and place them on all phone receivers, (3) keep a cordless or cell phone in your pocket at all times. Remember the old adage, “an ounce of prevention is worth a pound of cure.”
Good luck with your exercise program! If you have any questions email Dr. Mackarey at drpmackarey@msn.com.
Janet Caputo, PT, OCS, is a physical therapist specializing in the management of orthopedic and sports injuries with a special interest in vestibular rehab and falls prevention at Mackarey Physical Therapy in downtown Scranton. She is presently a completing her doctor of physical therapy degree at the University of Scranton.
Read Part I of III in this series on exercise and Parkinson's Disease.
Read Part II of III
Contributing Author: Janet Caputo, PT, OCS
Last week we described various forms of exercise to reduce the symptoms associated with Parkinson’s disease (PD). This week we will outline a comprehensive home exercise program for people with PD. We recommend that you begin with the easiest exercises first, slowly introducing the more difficult exercises as your fitness level improves. Try to perform each movement to the best of your ability. If you fatigue easily, try exercising in the morning. Plan to perform your routine 3 times each week. For safety, all exercises can be performed while seated.
Good luck with your exercise program! If you have any questions email Dr. Mackarey at drpmackarey@msn.com.
Janet Caputo, PT, OCS, is a physical therapist specializing in the management of orthopedic and sports injuries with a special interest in vestibular rehab and falls prevention at Mackarey Physical Therapy in downtown Scranton. She is presently a completing her doctor of physical therapy degree at the University of Scranton.
Read Part I of III on exercise and Parkinson's Disease.
Part III of III on exercise and Parkinson’s Disease
Contributing Author: Janet Caputo, PT, OCS
Parkinson’s disease (PD) is a chronic, degenerative disease that leads to slowness of movement, balance disorders, tremors, and difficulty walking. PD results from the loss of dopamine-producing nerve cells in the brain. Dopamine is critical to stimulate the nerves of the muscular system in the body. PD affects approximately 1.5 million people in the USA with 60,000 new cases each year according to the National Parkinson Foundation. Most people know someone affected by PD. PD typically affects those over 65 years of age and only 15% are under 50. However, actor, Michael J. Fox brought national attention to the disease in 1991 when he was only 30 years old. Juvenile Parkinson’s, those diagnosed under the age of 40, is rare and only represens t 7% of all those with PD. Locally, many may know Sarkis Hazzouri, “Uncle Sarkie,” as the ageless handball player and daily exerciser from Weston Field, Downtown Athletic Club, and JCC. Uncle Sarkie was diagnosed with PD two years ago. At age 86 he fights back through daily activities including exercise and physical therapy.
While there is no current cure for PD, exercise can relieve some of its symptoms. Although PD affects an individual’s ability to move, exercise can help keep muscles strong, joints mobile, and tissues flexible. Exercise will not stop PD from progressing but it will improve balance, enhance walking ability, reduce muscle weakness, and minimize joint stiffness. In 2007, a study published in the Journal of Neuroscience revealed that exercise may benefit individuals with PD because exercise encourages the remaining dopamine cells to work harder to produce more dopamine. Also, the researchers discovered that exercise decreases the rate at which dopamine is removed from the brain.
Exercise to improve strength, balance, and flexibility can be performed independently at home or supervised at an exercise facility. Supervised exercise can include physical therapy, recreational therapy, water therapy, yoga, and Tai Chi. Physical therapy can improve walking ability, enhance balance, reduce fatigue, increase strength, promote flexibility and minimize pain. Physical therapy uses movement techniques and strategies as well as various pieces of equipment to enhance an individual’s level of independence and improve his quality of life. Recreational therapy incorporates leisure activities (e.g. golfing and ballroom dancing) to reduce the symptoms and associated limitations of PD. Recreational therapy adapts these activities to meet the specific needs of the person with PD. The modified activities are taught by professionals who have significant knowledge and experience in this area. Water therapy is especially helpful to people with PD because the water provides enough buoyancy to lessen the amount of balance required to perform essential exercises. The cushioning effect of the water allows for freedom of movement while providing the appropriate level of resistance necessary to achieve the desired results. Using a combination of physical and mental exercises, yoga promotes flexibility, reduces stress levels, and increases stamina and strength in individuals with PD. Tai Chi, a total mind and body workout, is a series of individual dance-like movements linked together in a continuous flowing sequence. Particular benefits for people with PD include reduced stress, increased energy, improved concentration and focus, better circulation and muscle tone, and significant improvements in balance.
If you choose the convenience of a home exercise program, consult your physician for recommendations regarding: (1) the types of exercise best suited for you and those which you should avoid, (2) the intensity of the workout, (3) the duration of your workout, and (4) any physical limitations you may have. Your doctor may advise a referral to a healthcare professional to help you create your own personal exercise program.
The type of exercise that works best for you depends on your symptoms, fitness level, and overall health. Your exercise program should address not only strength but also flexibility and endurance and should include all body parts: face, mouth, neck, torso, arms, legs, hands, and feet. Some general exercise suggestions include:
Since individuals with PD are at risk for falling and freezing (becoming rigid), work out in a safe environment and, if possible, when someone is present. Avoid slippery floors, poor lighting, throw rugs, and other potential dangers (e.g. watch out for the pooch because he might want to join in the fun). If you have difficulty balancing, exercise sitting down, lying on the bed or within reach of a grab bar or securely installed rail. Stop and rest if you feel tired during your exercise program since overexertion can make your PD symptoms worse. Join us next week for suggestions on a comprehensive home exercise program.
Janet Caputo, PT, OCS, is a physical therapist specializing in the management of orthopedic and sports injuries with a special interest in vestibular rehab and falls prevention at Mackarey Physical Therapy in downtown Scranton. She is presently a completing her doctor of physical therapy degree at the University of Scranton.
Read Part II on Parkinson’s Disease and exercise
Patrick McKenna, Editor for The Times-Tribune recently sent me copy of a press release regarding a warning from the Centers for Disease Control and Prevention (CDC) that the prevalence of arthritis will increase significantly by 2030. Pat, a true baby boomer, is an exercise and sports enthusiast who is working hard to fight the aging process. He had some serious concerns about this news and asked if I might address this topic in one of my columns.
A recent report from data collected by the CDC indicated that increases in arthritis and other rheumatic conditions are evident. They project a nationwide increase in arthritic conditions from 46 million adults to 67 million adults by 2030. These numbers will have a significant social and economic impact on the United States. Socially, people affected will have greater limitations in activity level and independence. They will rely on others such as family and professional caregivers to a greater degree. Economically, these people will be using more health care dollars for adaptive equipment, medication, rehabilitation, health care staff and joint replacement surgery.
The cause the skyrocketing prevalence of arthritis is multifaceted, according to the Arthritis Foundation. Sedentary lifestyles, obesity, and aging baby boomers are the primary reasons for this trend. The Arthritis Foundation offers several steps to reduce the likelihood of pain and lifestyle limitations from arthritis including education, early diagnosis, diet and exercise for weight control and lifestyle changes.
Osteoarthritis is also known as degenerative arthritis. It is the most common form of arthritis in the knee. It is usually a gradual, slow and progressive process of “wear and tear” to the cartilage in the knee joint which eventually wears down to the bony joint surface. It is most often found in middle-aged and older people and in weight bearing joints such as the hip, knee and ankle.
Rheumatoid Arthritis is a form of inflammatory arthritis in which many joints of the body can be affected. It is very destructive to the cartilage, joint and tissues surrounding the joint. It can occur at any age and usually effects both knees.
Post-Traumatic Arthritis is a form of arthritis that can occur following a trauma or injury to the knee. It is a form of osteoarthritis that is triggered years after a fracture, ligament or cartilage injury.
In the early stages your treatment will be a conservative, nonsurgical approach, which may include; anti-inflammatory medication, orthopedic physical therapy, exercise, activity modifications, supplements, bracing, etc. You and your family physician, orthopedic surgeon or rheumatologist will decide which choices are best.
Visit your doctor regularly and listen to your body.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an affiliated faculty member at the University of Scranton, PT Dept.
Prevent Football Injuries Part II of II: Junior Football Safety Tips
This is the second of two columns intended raise the level of consciousness and to educate coaches, players and parents about the importance of injury prevention. While most high school programs have certified athletic trainers on staff, I am more concerned with the youth football programs. Often, these players are coached by a well-intended, but not well-informed parent without access to trainers or other medical personal at practices and games.
I was fortunate to have a great youth football coach. I remember Dick Holmes, coach of the Central City Indians, as a wonderful man. We worked hard, played hard and always had FUN! Good citizens were developed from our team: Mark Frattali, Scranton physician, Sandy Zanghi, local banker, Rich Goodall, postal supervisor and of course, the honorable Mayor Chris Doherty.
According to the Consumer Product Safety Commission, each year more than 3.5 million sports related injuries in youngster under 15 required medical treatment at a hospital or clinic. One million of those injuries are from football and basketball alone. The American Academy of Pediatrics and the American Academy of Orthopedic Surgeons offers medical information regarding the young athlete (15 and under) and recommendations for injury prevention. High school football is different. Coaches are subject to state regulation (PIAA) and medical personal and athletic trainers are present. However, youth football players may be more vulnerable.
Young athletes are not small adults. Their bones, muscles, tendons and ligaments are still developing and are vulnerable to injury.
Growth plates are sections of bone that are not completely fused. These plates are very vulnerable to injury, especially in contact sports. In some cases, an injury to a growth plate can be very serious.
Size variation in youth football is great. Within one age group, great differences in height, weight, strength, physical and mental maturity varies greatly. Don’t group players based solely on age.
Contact and overuse injuries are common in football. Contact injuries occur from an outside force such as a helmet hitting an ankle. Sprains, fractures, contusions (bumps and bruises) are examples of contact injuries. Overuse injuries occur from repetition. Little league elbow, shoulder or Achilles tendonitis are good examples.
“RICE” Rest, Ice, Compression, Elevation is the best treatment for most minor injuries to provide comfort and prevent further injury until a medical professional is seen.
If the following signs are present, timely medical attention is imperative:
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!”
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an affiliated faculty member at the University of Scranton, PT Dept.
Prevention of Football Injuries Part I of II: HeatstrokeSoon summer football training camps and practice sessions will be in full swing in Northeastern Pennsylvania. I remember all too well, washing down the dust from the practice field at Scranton Memorial Stadium with water from a hose. We were eager to drink ample water to dilute the awful taste of salt tables on a steamy summer day. In spite of limited information available at that time, I must commend coach “Moe” DeCantis and his staff for making sure we had plenty of water breaks.
For the next two weeks, this column will focus on “Prevention of Football Injuries” in an attempt to raise the level of consciousness and to educate coaches, players and parents about the importance of injury prevention. While most high school programs have certified athletic trainers on staff, I am more concerned with the youth football programs. Often, these players are coached by a well-intended, but not well-informed parent without access to trainers or other medical personal at practices and games.
Tony Cantafio, head football coach at Scranton Prep states that in spite of the appearance of intensity on the field, he takes the health and well-being of his players very seriously. He keeps a close eye on players and always defers to his medical staff, lead by Ted Tomaszewski, MD and Jeanne Kowalski MS, ATC for health related decisions.
William Dempsey, MD, Medical Director of the Human Performance Lab at Marywood University and team physician for Lackawanna College Football feels prevention is the best treatment for heat stroke. He feels that overweight and poorly conditioned players should be monitored closely by weighing in before and after practice. A player who loses more than 3% body weight is at risk for heat stroke. These players should be required to take more breaks, with more fluid intake before, during and after practice.
Heat stroke one of the most serious heat-related illnesses. It is the result of long term exposure to the sun to the point which a person cannot sweat enough to lower the body temperature. The elderly and infants are most susceptible. It can be fatal if not managed properly and immediately. Believe it or not, the exact cause of heatstroke is unclear. Prevention is the best treatment because it can strike suddenly and without warning. It can also occur in non athletes at outdoor concerts, outdoor carnivals, or backyard activities. The American Academy of Pediatrics and The American College of Sports Medicine has the following recommendations:
Heat Exhaustion – can be a precursor to heat stroke
DO NOT IGNORE SIGNS OF PLAYER DISTRESS OR POOR PRACTICE MANAGEMENT – YOU MAY SAVE A LIFE! – If you witness signs of a player in distress or signs of poor practice management that may jeopardize the health of an athlete, diplomatically speak up. Use references to educate those in charge to recognize there mistakes and improve conditions. Problems occur not because of malice, but usually because of ignorance.
NEXT MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” Next Week: “Prevention of Football Injuries in Youth Football”
This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com
Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy. Dr. Mackarey is in private practice and is an affiliated faculty member at the University of Scranton, PT Dept.
Each summer in Northeastern Pennsylvania people open their pools for fun in the sun. However, this summer I urge you to look at your pleasure puddle in different light…a health spa! It may very well be the exercise of choice for many people.
Tara Tulaney, recently suffered a knee injury while pole vaulting at Abington Heights High School. She has discovered the benefits of moving her leg in the warm water of her home pool following her knee surgery. Also, long distance runners who often look for cross training methods without joint compression and arthritis sufferers who are often limited in exercise choices by joint pain from compressive forces when bearing weight, can enjoy the buoyancy effects of water. These are good examples of the benefits or water exercise…aerobic and resistive exercise without joint compression.
Most doctors recommend some form of exercise with arthritis. Pain and fatigue are the most limiting factors for the person with arthritis. Pool exercise may be the answer. With proper technique, adequate rest periods, appropriate resistance and repetitions, water exercise can be very effective.
The following are some of the benefits of water exercise:
1. Start Slowly – Don’t Overdo it
2. Submerge the body part that you want to exercise into the water and move it slowly
3. Complete The Range of Motion: Initially 5 times, then 10-15-20-30 times
4. Assess: Determine if you have pain 3-4 hours after you exercise or into the next day. If so you overdid it and make adjustments next time by decreasing repetitions, speed, amount and intensity of exercise.
5. Warm-Up: Make sure you warm up slowly before the exercise with slow and easy movements.
6. Advance Slowly: Add webbed gloves, weighted boots, and buoyant barbells to increase the resistance.
7. Exercises – standing in shallow end of pool
Visit your doctor regularly and listen to your body.
