Exercise Physiology

Archive for Exercise Physiology

Boston University Center for Neurorehabilitation: A Novel Mobile Intervention For People With Parkinson’s Disease

In 2013, when we were a brand new m-health company, we had the good fortune to meet Terry Ellis, PhD, Director of the Center for Neurorehabilitation at Boston University. Dr. Ellis was an early investigator in the value of digital interventions, and saw an opportunity to partner with Wellpepper so that her team could focus on the new care models, and Wellpepper could focus on the technology. The first building blocks in the Wellpepper platform aligned closely with outpatient rehabilitation, and Dr Ellis and team wanted to prove that people who had Parkinson disease could improve strength and mobility without costly in-person visits. At Wellpepper, we also had an interest in proving that mobile health can improve outcomes, and also that those 50 plus could use mobile technology.

Persons with Parkinson Disease (PD) have been described as 29% less active than older adults without PD, and see a 12% decline in mobility for each year after their first diagnosis with the disease. In-person interventions with physical therapists can help, but in the usual care condition, a person has one in-person assessment at The Center for Neurorehabilitation, and may not be seen again for 6 months to a year, during which time there was a decline in mobility. Dr Ellis and team were looking for a way to prove out a novel intervention that could improve outcomes for these patients.

Patient Experience

This video does a great job of showing the patient experience, both with the clinician and while using the application at home.

User Journey from Wellpepper on Vimeo.


While Dr. Ellis and team are still analyzing additional data, and will be submitting to a peer-reviewed journal, and are exploring expanded studies on the topic, we can share some very promising results.

  • This study revealed that using mobile health technology to remotely monitor and adapt exercise programs between bouts of care in persons with Parkinson disease was feasible and acceptable.
  • On average, subjects engaged with the app every week for 85% (+/- 20%) of the weeks with an 87% satisfaction rating.
  • Significant improvements in physical activity, walking and balance measures were observed over 12 months.
  • People who showed lower exercise self-efficacy at the beginning of the study saw the greatest gains.


  • This technology used the Wellpepper platform, clinic application for iPad, and patient application for iOS. Requirements were for ease of use for both clinicans and patients. Features include the ability to record custom video of patients doing their exercises, for patients to record results, and for patients and providers to message securely with each other.
  • Fitbit was used for patients to track non-exercise activity, and this was the first integration of a consumer exercise tracker with the Wellpepper platform.
  • The entire Wellpepper platform is built on Amazon Web Services, in a HIPAA secure manner, which was a requirement for the study. No data was stored on mobile devices and all personal health information was encrypted in transit and at rest.
  • The Boston University team required a monthly data extract of all patient-generated data for their analysis purposes.
  • Post study, we were able to analyze anonymized patient-provider messages using a machine learned message classifier, and have presented this data at digital health conferences.

The positive preliminary results of this study, lead to a larger study with seniors at risk of falls, lead by principal investigator Jonathan Bean, MD from Harvard Medical School. Details of this intervention are available here. While Dr Bean is also in the process of submitting to a peer-reviewed journal, his assessment is that outcomes exceeded clinically significant measures.

We are looking forward to sharing more about the results of both of these studies when they are publicly available in peer-reviewed journals. If you are a researcher who would like to know more, contact us and we may be able to put you in touch with the study leads.

Posted in: Clinical Research, Exercise Physiology, Healthcare Technology, Healthcare transformation, M-health

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EvergreenHealth: Evolving Care Outside The Clinic for Better Outcomes

In 2016 we formally announced our collaboration with EvergreenHealth to deliver interactive care plans for Total Joint Replacement.

“Across our organization, we strive to be a trusted source for innovative care solutions for our patients and families, and our partnership with Wellpepper helps us deliver on that commitment,” said EvergreenHealth CEO Bob Malte. “Since we began using Wellpepper in 2014, we’ve seen how the solution enhances the interaction between patients and providers and ultimately leads to optimal recovery and the best possible outcomes for our patients.”

EvergreenHealth is an integrated health care system that serves nearly 1 million residents in King and Snohomish counties in Washington State, and offers a breadth of services and programs that is among the most comprehensive in the region. More than 1,300 physicians provide clinical excellence in over 80 specialties, including heart and vascular care, oncology, surgical care, orthopedics, neurosciences, women’s and children’s services, pulmonary care and home care and hospice services. With expansion into more rural areas, and a catchment area that serves Seattle’s ‘eastside’ home to Microsoft and other major technology companies, delivering virtual care is both an imperative for an an expectation of EvergreenHealth patients.

Since our initial announcement, we’ve seen thousands of patients complete care plans and outcome surveys, and expanded within the musculoskeletal service line to include preventive care, spine surgery, and general rehabilitation.

User Experience

EvergreenHealth has a white labeled version of the Wellpepper patient application called MyEvergreen and available in Android and Apple App Stores. Clinicians use the Wellpepper clinic portal, and receive alerts to their email inbox if patients report any issues or unexpected outcomes.

EvergreenHealth has deployed care plans based on their own clinical best practices. 


  • Thousands of patients have used Wellpepper interactive care plans at EvergreenHealth
  • Interactive care plan users show higher scores on standardized outcome reports than those tracking outcomes without an interactive care plan
  • EvergreenHealth patients show a higher engagement level than Wellpepper’s overall 70% engagement

I would not want to have another knee surgery without the app. I was 81 and it wasn’t hard for me at all!

Total Knee Replacement Patient at EvergreenHealth


This deployment used a white labeled Android and iOS application for patients, and a clinic portal for clinicians. Patient invitation is synched with the Cerner medical records software using an ADT feed. Clinicians are notified of patients requiring additional help with an email alert. Wellpepper’s entire HIPAA secure platform was leveraged for this implementation, and EvergreenHealth deployed custom care plans based on their own best practices. They continue to add innovative features as they are added to the Wellpepper platform.

Posted in: Exercise Physiology, Healthcare costs, Healthcare Technology, HIPAA, Interoperability, M-health, Outcomes, patient engagement, Prehabilitation, Seattle

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Translating Evidence-Based Interventions to Practice: Falls Prevention and Otago

APTA CSM 2015 Session Recap: Falls Prevention: Otago Program and Behavior Change


Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

The fact that a session entitled “Falls Prevention: Otago Program and Behavior Change “ ended up in the Health Administration /Policy track at APTA CSM 2015 reinforces that we have a long way to go on translating outcomes-based research into care plans. Otago is a proven and effective set of preventative exercises and care for community-dwelling yet frail adults which improves balance and prevents falls risk. It was developed in New Zealand, at the University of Otago over 14 years ago, and prescribes a set of balance and strength exercises that the patient completes independently over 12 months.

Recommended physical therapy visits to access, teach, monitor, and kick-start patient adherence are to occur over 6-8 weeks and after that patients are encouraged to self-manage, and herein lies the reason that this session is in health policy and administration: this is longer than most insurance covers, and there are not currently enough incentives for remote patient monitoring. However, according to presenter Tiffany Schubert, Otago shows an ROI of $1.25 of every dollar invested as it prevents patients from falling which results deterioration to the patient and further burden on the health system.

Barriers to implementing Otago in the US stem largely from reimbursement and the current incident-based payment model that does not facilitate managing patients over a long period of time. As a result, Otago expert and presenter Tiffany Schubert presented an abridged version that might be easier to fit into current payment models.

Delivering Otago: Calendar view

Delivering Otago: Calendar view

However she is also on a crusade to collect outcomes data for Otago in the US so that these barriers can be overcome as the barriers are not just reimbursement. Clinicians have preconceived notions that patients won’t adhere to plans. Tiffany challenges these misconceptions by asking “are you sure or is it your patients just don’t understand.” We’ve definitely seen this with patients we’ve interviewed: they do want to be adherent to their plans but they find out when they get home that they forgot or are confused. Otago and systems like it work well when there is remote support for the patient.

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

Given that Otago requires a high-level of patient self-efficacy, understanding factors that impact behavior change is key in driving long-term outcomes and adherence. Hence, the second half of this presentation, from Mary Altpeter focused on strategies to help patients develop self-management skills to complete the independent part of the program. One of the big misconceptions, that we hear frequently from healthcare providers (and definitely from many of the sensor and tracker vendors), is that knowledge is sufficient to effect change. It’s not, many other factors weigh in including readiness to change and social influences. Understanding more about the patient’s own journey and the patient’s barriers and readiness to change can make a big difference in this area. Also understanding the patient’s goals is crucial and personalizing their risk of not changing their behavior.

Breaking behavior change down into stages can really help move the patient along a path. In this session, Altpeter outlined a 5 stage model to affect patient behavior.

6-Stage Behavior Change Model

6-Stage Behavior Change Model

Understanding that while your assessment may show that the patient is at risk for falls, the patient may not have internalized this. First step is to plant the seed of doubt while the patient is in what is called the “Pre-Contemplation” stage. You can do this by personalizing the risk.

In a falls scenario, patients are not actually worried about falls risk. This sounds counter intuitive, but patient goals are usually not functional goals they are life goals. (We can attest to this from the goals patients set in Wellpepper.) So, the patient may be worried about losing their driver’s license which might happen if they had limited mobility. This is moving to patient-centered goals from clinical goals which personalizes the risk. Find out what the patient might be afraid of losing and this can start to plant the seed of doubt that they might be at risk for falls.

During the Contemplation phase the healthcare professional can help the patient break down what it might look like to be able to embark on a program. What might be their barriers or sticking points to do so? When might they do it? This isn’t about making a plan it’s about facilitating the patient in thinking that a plan might be possible.

The next phase Preparation, occurs when the patient has demonstrated that he or she is ready to change, and this is where we can examine the nuts and bolts, breaking down what may seem like a daunting task (adhering to a program for 12 years), into something manageable. Here is where you help the come up with plans to overcome the barriers you identified. One key barrier is often fear of relapse: that is that when a patient stops doing the plan, they can’t get back on the wagon, so to speak. Making it okay to “start over” is a great way to encourage patients.

During the preparation phase you may also want to help the patient break down the program into smaller goals and manageable chunks so they can see progress during the program. Also help the patient identify rewards that will help drive their adherence. These are both important steps when helping with a large and often intangible goal.

Action is putting the plan into place. Here your main role is to support the patient, help them continue to overcome barriers, and be a cheerleader to keep them going in the case of a relapse.

The final stage is Maintenance (which includes dealing with Relapse). Pointing out the patient progress, possibly by completing another falls assessment and showing the difference is a great way to reinforce that the program worked and it’s worth continuing. Also ask the patient to remember what fears they had before the program and whether they feel that now. Simply shining a light on their own experience can help a lot here.

With an aging population, and rising health costs, translating valuable and proven research like the information in this session into clinical practice is key. Given that the average time from research to implementation is 17 years, and that Otago was invented 14 years ago, we can only hope to see widespread adoption by 2018. That’s also in-line with CMS’s new requirements for 50% of Medicare spend being for new value and outcome-based models. It’s time right?

Posted in: Adherence, Aging, Behavior Change, Exercise Physiology, Healthcare Disruption, Healthcare transformation, Physical Therapy, Rehabilitation Business

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Get Your Engines Ready for CSM 2015 Indianapolis

CSM2015Marquee_960x222I’m not a physical therapist, healthcare professional, nor do I play one on TV, but I can’t wait for my third American Physical Therapy Association conference. While I’ll be spending most of my time at our booth (2114 if you’re looking) on the exhibition floor, I’ve managed to find a shortlist of 46 sessions I’d like to attend, and this is from someone who is not looking for clinical practice sessions.

Screen Shot 2015-01-27 at 11.10.50 AMNext week over 10,000 physical therapists, doctors of physical therapy, PhD researchers, and students will converge on Indianapolis (yes, in winter) for the annual American Physical Therapy Association Combined Sections Meeting. The Combined Sections Meeting or CSM as it’s often referred to (we do love our acronyms in healthcare) combines all the interest groups and professional associations within the association including private practice, oncology, neurology, homecare, acute care, orthopedics, sports medicine, and students and academic researchers. The result is a diversity of topics that represent the major trends in healthcare today including: concussions in youth sports; the impact of the Affordable Care Act on practice; high-intensity interval training; caring for an aging population; managing chronic disease; preventative medicine, health and wellness; healthcare technology; and the psychology of pain.

See for yourself in a selection of some of the 46 sessions we’ve flagged:

Sports Concussions in Youth: The Role of PT for a Surging Population

Transforming Physical Therapy Practice for Healthcare Reform

Exercise Prescription for the Older Adult With Multiple Chronic Conditions

Getting Patients Into Cardiac Rehab and Other Wellness Programs and Keeping Them Exercising After Rehab

Google Glass in Physical Therapy Education and Clinical Practice

High-Intensity Interval Training: Rehab Considerations for Health and Cardiovascular Risk

Practice Issues Forum: Does Medicare Really Cover Maintenance Therapy?

I Have Arthritis. Is My Running Career Over? Evidence-Based Management of the Runner With Osteoarthritis

Called to Care: Integration of Positive Psychology

Integrating Physical Therapy in Emerging Health Care Models

Virtual Reality and Serious Game-Based Rehabilitation for Injured Service Members

Of course, our most anticipated session will be “Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions” where Dr. Terry Ellis Director of the Center for Neurorehabilitation and a Associate Professor at Boston University will be presenting the results of a study where they used Wellpepper and Fitbit to improve adherence to home exercise programs for people with Parkinson’s disease. For a sneak preview of what she will present, see this article from Inside Sargent Magazine.

As in 2013 and 2014, we will do our best to blog about as many sessions as we can so that if you can’t make it to the conference this year, you can still experience some of the flavor.

If you’re going to CSM, what sessions are you looking forward to most?

Posted in: Adherence, Aging, Exercise Physiology, Health Regulations, Physical Therapy, Prehabilitation, Rehabilitation Business, Sports Medicine

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You Too Can Be An Orthopedic Surgeon

This past weekend I performed arthroscopic surgery on a knee and extracted a sponge that was clogging up the joint. Sounds scary doesn’t it? It was great fun, part of the open house at UW Medicine’s new Sports Medicine Center at Husky Stadium in Seattle. The newly opened clinic has been operating for about a month, but this was an opportunity for the general public to see what it was all about.

The open house was framed around a “Passport to Health” and participants visited various stations staffed by doctors, physical therapists, and radiologists. At each stop, experts explained procedures and benefits, and answered questions from attendees. Volunteers from some of the UW sports teams acted as guinea pigs for some of the treatments.

Specialties in the clinic and stops along the tour included:


    • Anti-gravity treadmill

      Anti-gravity treadmill

      Dr. Ashwin Rao explaining platelet-rich plasma therapy

      Dr. Ashwin Rao explaining platelet-rich plasma therapy

      Running Medicine: Here we saw how the anti-gravity treadmill can help both running performance and rehabilitation.

    • Sports Performance and Rehabilitation: In the “gym” area of the center, physical therapists discussed how they help improve performance and restore function using exercise and equipment including a full Pilates set up.
    • Soft-tissue Injuries: The focus was on preventative measures and bringing people back to full performance.
    • MSK Ultrasound: Ultrasound technology has come a long way from fuzzy gray images. In this session we saw how ultrasound can be used to access and diagnose nerve damage using Doppler technology to show nerves and blood vessels.
Dr Elena Jelsing demonstrating MSK Ultrasound

Dr Elena Jelsing demonstrating MSK Ultrasound

  • Platelet Rich Plasma: This technique involves injecting a patient’s plasma back into a troubled area to help repair and regenerate cells. It’s particularly helpful for nagging tendon injuries, although physical therapy is recommended first if it’s an acute injury.
  • Minimally Invasive Surgery (Knee and Shoulder demonstrations): I don’t want to say this was the most fun, but it was, as participants were guided in performing arthroscopy surgery on a dummy knee or shoulder joint.
  • Sudden Cardiac Arrest: The focus of this stop was prevention. Young athletes are at the highest risk for sudden cardiac arrest and UW is leading the way by offering screenings to high school teams around Puget Sound.
Shoulder Surgery Dummy

Shoulder Surgery Dummy

Visitor performing shoulder surgery

Visitor performing shoulder surgery

In some cases, tour participants received minor consultations, like one woman who had an MSK ultrasound. In addition to providing education and showcasing the clinic’s staff and new technologies, the event generated new patients for the clinic. The tour conveniently ended at reception where many people were seen booking appointments.

The opening of a new clinic like UW Sports Medicine at Husky Stadium provides the perfect time to engage patients. However, maybe adding a new service or technology could provide you with the opportunity to invite the public in for a tour of your facilities. Or maybe it’s a patient appreciation thank-you event. Any opportunity to engage with patients is an opportunity to help educate them to take charge of their own health, and let them know that you’re there when they need help.

Posted in: Exercise Physiology, Rehabilitation Business, Sports Medicine

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Taking Preventative Medicine to the Store

Storefront health clinics, patient engagement, and community outreach are all touted as great new innovations in healthcare. Well, today we found a great example that includes all three and was established over 3 decades ago yet continues to engage patients today. And it takes place somewhere you might not expect: a shoe store.

Over 30 years ago Dr. William Warnekros, a podiatrist from Seattle, approached running store Super Jock N Jill founder Laurel James with the idea that he have “office hours” in the store every Thursday night where he would answer questions and do screenings. Dr. Warnekros believed that by doing this he could provide a community service, practice preventative medicine, and also create referrals to his clinic. At the time, running had not gained the popularity it has now, so there was limited information for runners on how to prevent injury.

Events at Super Jock N Jill

Events at Super Jock N Jill

The relationship between the podatrist and the store proved to be symbiotic, where staff became more educated in biomechanics from Dr. Warnekros and he learned about the different types of running shoes on the market. Together, they were practicing preventative medicine by making sure runners received the best advice and the right shoe for their style. Dr. Warnekros recalls that at the time the most common injuries he saw through the store  were plantar facitis, achilles issues, tendonitis, ingrown toenails, stress fractures.

In addition to these  “Medical Nights” at the store, Dr. Warnekros also visited community centers every Saturday to lecture on preventing running and athletic injuries. When I asked Dr. Warnekros why he did all this, he said that “outreach and community service helped me generate the type of patients I wanted to see, rather than relying only on referrals.” Sometimes we forget how simple community engagement can be, and while social media enables us to reach the world, often the best way to reach the community is face-to-face.

The Injury Wall at Super Jock N Jill

The Injury Wall at Super Jock N Jill

Since its inception, the Medical Nights program has proven so popular it’s been expanded to two nights per week, and features podiatrists, sports medicine doctors, physical therapists, and massage practionners from over 25 local clinics on a rotating schedule.

Rim Veitas from University of Washington Medicine at Super Jock N Jill

Rim Veitas from University of Washington Medicine at Super Jock N Jill

On the night I attended, Rim Veitas, a physical therapist from the University of Washington’s Roosevelt Exercise Training Center Clinic was the attending healthcare professional. He had a treatment table set up, conveniently near Super Jock n Jill’s selection of injury aids.

I was surprised to see that Rim spent between 15 and 20 minutes with each client. When I asked him about it, he said that he did it because he loved treating people. (Sadly, he said he especially loved treating people when he didn’t have to fill out all the insurance or Medicare paperwork after.) Rim wasn’t sure that the University of Washington received a lot of new clients from participating in the Medical Night program, so for him it really was a labor of love and community outreach. I suspect that other clinics that might not be as well-known as the University of Washington see a lot of referrals from this program, and that for them it’s both goodwill and good business, just like Dr. Warnekros’ original intention.

In addition to interviewing Dr. Warnekros, Rim, and the Super Jock N Jill staff about the Medical Nights program, I decided to participate. I have tight hamstrings. I come by them naturally as a short person, and running tightens them further. I thought that might be the reason that after longer runs I had a clicking in my achilles. Rim did a few assessments, and pointed out that I had unusually tight ankle joints. He gave me some exercises and said if I did them, I could become a faster runner. (I assume they will also improve my Downward Dog.) I’ll try it!

If you’re in Seattle and want to know more about your running style or if you’ve been struggling with an injury, definitely stop by Super Jock N Jill Medical Nights. You might get some tips or establish a long-term relationship with a new healthcare provider. If you’re not in Seattle, take a look for events in your area or maybe start one yourself!

Posted in: Exercise Physiology, Rehabilitation Business

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Getting the Most Out of Your Golf Game

Ah golf. I love this game. It can be such a frustrating sport, but nothing can beat the feeling of a well struck ball or the sound of the ball hitting the green. I don’t get out nearly as often I would like, but when I do I fully enjoy what the sport provides: a solid four hours of time with good friends out in the beautiful outdoors. When I can find the time to squeeze in a round I want nothing to get in the way. So when I heard that Sitka Wellness was putting on a Golf Workshop to learn how to get the most out of your game and prevent injuries, I grabbed a friend and we went to go and check it out.

Sitka Wellness is a full-service physiotherapy and wellness clinic located in the heart of downtown Vancouver. Along with physiotherapy services, Sitka offers group Yoga and Pilates classes as well as Personal Training. The instructors work closely with the therapists to tailor programs to each individual’s needs. What we love most about Sitka, besides their integrated approach to health, is that they put on monthly community workshops that anyone can attend. They range from managing chronic pain to training for your first 10k. Anne attended a workshop on minimalist running last month.

images (1)Jason Lee, Registered Physiotherapist and TPI Certified Golf Fitness Professional started off the workshop by discussing some of the basic functional movements required to perform a golf swing such as squats, pelvic tilts and trunk rotations. Jason used the example of balancing on one leg. If you weren’t able to perform this simple movement, then you wouldn’t be able to follow through correctly by finishing with all your weight on your front leg. Flexibility, strength, coordination, balance and endurance are all important factors in maximizing your performance. A physical therapist can help you break down your movements and determine where you might need to focus your energy and improve.


The Reverse Spine Angle. The number one cause of lower back pain in golf.

Jason then walked us through these simple recommendations for avoiding injury.

1. Improving physical conditioning before the season starts

2. Warm up before you play, minimum 15 minutes

3. Using a push cart instead of carrying your clubs

4. Engage your core before your swing

5. Rotate through the hips instead of lateral sliding during your backswing

6. Avoid excessive extension as you finish your swing



Using the foam roller in this position can help open up tight chest muscles caused by sitting at a desk all day.

Tip #4  really stood out for me. I know engaging my core is one of my weaknesses and this is where Irene Lugsdin (a Pilates instructor at Sitka) came to the rescue. Pilates is an approach to exercise that focuses on the deep stabilizing muscles of the body or the core. Irene took us through some simple exercises that would help strengthen and lengthen the spine and that would facilitate the flexibility and mobility needed to enhance our golf swings. Irene described Pilates as breath with movement and so we focused on how your breath could help you engage your core but also infuse your swing with a fluid tempo. She also explained that golf is an asymmetrical sport while Pilates is all about symmetry and balance hence the reason these two activities are an excellent combination.

I really enjoyed the workshop. Jason and Irene were both very knowledgeable and engaging speakers. It was great to be able to breakdown the golf swing and really think about the mechanics and the movements/muscles required.  My friend Carla, who came along and who is an avid golfer, was surprised to see the Physiotherapist and Pilates instructor working together. She had never imagined such collaboration between the two practices, but after attending the workshop she thought that it made absolute sense.

Sitka offers comprehensive golf swing assessments where a physiotherapist will look for any dysfunctional movement patterns that could be limiting your performance. The 1 hour golf screen includes a walk through your injury history, a series of functional movement tests as well as a swing characteristic analysis using 2D video.  Once the assessment is complete, the PT can then work with you on an exercise program focused on improving any physical deficiencies that need to addressed. They will even work with and communicate with any golf instructors or personal trainers you might be working with outside the clinic.

We have noticed that many physical therapy clinics offer screening services for golf  and other sports such as Running, Tennis, Softball/Baseball and Cycling.  Working with a Physical Therapist is an excellent way to learn how to take care of and get the most out of your body no matter what you want to do.  I know that I am excited to take my new tips and tricks to golf course. I might even have a chance at beating Carla!

Posted in: Exercise Physiology, Rehabilitation Business

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Data-Driven Exercise for the Disabled

Machines can be used by able-bodied and disabled athletes

Machines can be used by able-bodied and disabled athletes

A few weeks ago, I had the opportunity to visit the PARC facility at the ICORD Spinal Cord Research Centre in Vancouver, BC with our guest blogger Lynda Bennett. Lynda is participating in an exercise study for people with spinal cord injuries and she wanted to show me around. The study is in pilot stage right now and has less than 50 participants all of whom have spinal cord injuries. Lynda doesn’t actually have an injury, she was born with Spina Bifida. However, she has recently started using an electric chair and is concerned about keeping up her core and upper body strength, especially for transfers from the chair. The pilot study is looking for positive outcomes associated with regular and increasing levels of exercise in people with spinal cord injury.

All machines track workouts using a SmartCard system

All machines track workouts using a SmartCard system

The equipment at the facility looks like that at any gym, however there are two key differences. Each machine is adapted so that a person can access it from a wheelchair. Actually the machines are designed both for able-bodied and disabled users and ICORD employees are allowed to use the gym if the study isn’t actively using it. If a machine has a seat, which an able-bodied person might use, it swings away to enable someone to wheel up to it. The other difference is that each machine is fitted with a smart card reader. Study participants enter their cards to start the weight program. The machines use air-pressure to provide resistance, and the resistance is increased automatically based on previous day’s activities. All the data is collected and can be reviewed by researchers. You can think of it as ‘quantified-self’ but with extremely expensive quantification.

Super Mario on Weight Machine

Playing Super Mario provides motivation

While Lynda enjoyed her workouts and meeting with others at the facility, she would have liked to have seen active rather than passive goal setting. She wanted the goals to be translated into something that she needed to do in everyday life.  “to be able to transfer from your chair to a truck, you’ll need X amount of core body strength.” As the study is designed, she is increasing the amount of weight but doesn’t know what outcomes this will provide in her daily life.

“I’d like to see how I am progressing towards a goal rather than try to correlate the increased weights to some improvement myself.”

Since this is just a pilot, and they are trying to keep the research relatively open to start, this might be able to be designed into future research.

Unfortunately, the pilot study isn’t guaranteed to go to a large scale study. The initial funding was used to set up the facility, and additional funding will be required to expand beyond the pilot. However, pilot organizers are hoping once they get enough data and can start to form hypotheses, they will attract the interest of the many researchers in the labs upstairs at ICORD, who are working with cells and microscopes but not as often with real human subjects like the people who volunteered for this study. Facilities like PARC and the data they collect can go a long way to bridge the gap between research and human outcomes.

Posted in: Exercise Physiology, Healthcare motivation, Healthcare Technology

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How To Become a Minimalist Runner

Last week I attended a free seminar at Sitka Physio & Wellness in Vancouver, BC, about how to avoid runner’s injuries with a focus on the mechanics of minimalist running. We also blogged about offering seminars like this as a best practice.

Physical Therapist Elisabeth Mclatchie

Physical Therapist Elisabeth Mclatchie. Source Sitka Physio & Wellness

The seminar by physical therapist Elizabeth McLatchie, started with an overview of why people get injured: repeated mechanical stress to tissues. She then talked about how the main goal of minimalist running and the new minimalist or barefoot shoes is to change the mechanics to avoid injury.  I’ve read a lot about minimalist shoes and have talked to a few runners about them, but this clinic really helped me understand what they are trying to accomplish and why: more efficient movement, and encouraging a mid-foot strike rather than a heel strike, with the long-term goal of avoiding injury.

Challenges with Traditional Shoes

Challenges with Traditional Shoes

When a runner heel strikes, his or her center of gravity is off, resulting in more force on the body and more energy spent. Heel striking also affects cadence (how quickly you can move from one foot to another) because you are spending more time transferring weight across the foot, rather than touching down and lifting off. While minimalist shoes attempt to change the way people run, people can be trained to run differently in any type of shoe. 90% of runners will heel strike in traditional shoes. Unfortunately there’s a group of about 10% of runners that will heel strike regardless of shoe.  Heel striking and overuse are key causes of injuries, and over 80% of runners will be injured during their running careers.

As an example, we were shown video of a runner who regularly runs 50K races running in shoes, barefoot, and at different cadences. Running barefoot (on a treadmill) helped her to increase her cadence to 180 beats with minimal effort. For more effective running, runners should strive to be light on their feet and run at a 180 cadence. (Note that this may take some working up to: recommendations for switching to a minimalist style and shoes suggest 9-12 months for the full transition.)

Elisabeth recommended a phased approach to switching to a minimalist style, and for those wanting to try barefoot shoes, to phase in the change over 9-12 months. She also stressed that you don’t necessarily need to move to minimalist shoes to change running styles, and that there are many types of shoes. Minimalist doesn’t equal no support and no padding, it just means less rise in the heel of the shoe. For those who had further questions, she recommended talking to either an expert at a dedicated running store or a physical therapist, who could also perform a gait analysis. Elizabeth finished off the talk by demonstrating some ABCD drills, which are recommended ‘active stretch’ warm-ups for runners and talked about the lack of consensus on stretching in general.

The most important takeaways from the talk were about how to avoid overuse injuries:

  • Avoid repeated mechanical stress: you can do this by varying terrain, speed, intensity, and distance
  • Improve efficiency: change your running style to mid-foot strike from heel strike
  • Find your cadence: running at 180 cadence and being light on feet will minimize reaction force from the ground and therefore energy loss.

Elizabeth was an engaging and enthusiastic speaker who truly cared about imparting her knowledge. Her passion for her profession shone through in the presentation.

For more on the topic of ‘barefoot’ or minimalist running:

Posted in: Exercise Physiology, Rehabilitation Business

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Five Best Practices For Community Outreach for Physical Therapy Clinics

In our recent study, we found that 96% of physical therapy clinics offer additional services beyond physical therapy. The most popular were the following:

Popular Services

One clinic owner we spoke to said that his business didn’t become profitable until he started offering additional services. While this is definitely not true for everyone, we’ve seen a promising trend with physical therapists talking about how they can help manage the whole health of the individual, and this includes offering additional services. When we saw a post on Twitter advertising a minimalist running clinic at Sitka Physio & Wellness in Vancouver, BC, we thought we’d check it out, both for our own education, we’re all runners at Wellpepper and love learning how to improve, and of course for the blog.

Sitka Physio & Wellness

Sitka Physio & Wellness Reception

Sitka Physio & Wellness is located in the Fairmont Hotel Vancouver, which isn’t a typical location for a rehab center, but makes perfect sense for a wellness clinic, where hotel patrons and local business people might stop in. The clinic itself is beautiful: clean and airy, it definitely connotes health and wellness. We were positively greeted as soon as we came in. We’ve visited our fair share of clinics since starting Wellpepper, and this is definitely one you’d want to visit even if you weren’t injured.

The seminar itself, by physical therapist Elizabeth McLatchie, focused on basic education minimalist running. It was so full of great information that we’ve covered the content in a separate blog post. Many of the attendees were already familiar with Sitka Physio & Wellness from their weekly running club that Elizabeth mentioned. (Interestingly, and reflecting the demographics of runners, the audience was predominantly female.)

Selection of minimalist shoes

Selection of minimalist shoes

I talked to both Elizabeth and clinic owner Helen Ries after the session and learned that they offer these type of community outreach classes monthly. Elizabeth said that the physios all volunteer to do the sessions and she had to wait 8 months to get on the calendar because their were so many other sessions booked. She said she loves sharing her knowledge and would definitely volunteer to do more sessions. Upcoming sessions include Pilates for pelvic floor control and golf swing analysis.

Some of the best practices we noted in the session:

  1. Elizabeth did a great job of providing examples and breaking down more complex concepts into something we could understand.
  2. The session was focused on preventing injuries, which changes the conversation that someone might have with their physical therapist, and enables the clinic to emphasize their wellness services.
  3. She engaged with the broader running community. The clinic featured shoes from local businesses that focus on the running community. This provides a potential symbiotic relationship: if a runner is looking for new shoes because of an injury or issue the store could refer this person back to Sitka, and of course, Sitka referred to these stores, as experts in shoe fitting.
  4. The session targeted an audience that needed to engage with physical therapy. Over 80% of serious runners will face injury at some point. Why not establish a relationship with them before they “need” you?
  5. Suggestions of how to further engage with your physical therapist, for example, for a gait analysis were presented within the context of the overall session. Elizabeth also recommended that if people were interested in what type of shoes might work for their running style that they consult their physical therapist. Both of these services furthered the idea that physical therapists are there to help you stay well, not just for episodic treatment.

Offering sessions like this are a great way to market your clinic and services, first you get people into the clinic, second you help educate them on the importance of proper movement, and third you can educate them on other services you might be able to offer them. We’d love to see more clinics offering these types of services, and you can bet that we’ll be back for more sessions at Sitka Physio and Wellness. Jacquie needs to fix her golf swing. 😉

Posted in: Exercise Physiology, Rehabilitation Business

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Abreast In A Boat

This weekend marks the 25th anniversary of the Vancouver Dragon Boat festival, the biggest festival of its type in North America. Over 100,000 people will watch 180 teams racing to the finish. Dragon boating started over 2000 years ago in China as a fertility ritual held during summer solstice. Today there are dragon boat races across the globe, including North America, Europe, and of course Asia. Dragon boating promotes team work and discipline as the crew typically consists of 22 people: 10 pairs of paddlers, a caller at the front of the boat and a steerer at the rear.

Dragon Boat Racing from Wikimedia.org

In Vancouver, one of the most colorful and long-paddling teams, A Breast In A Boat, is made up of breast cancer survivors. In 1996 Dr. Don Mackenzie, professor of Kineseology at the University of British Columbia, posted an ad looking for breast cancer survivors to participate in an exercise study. At the time, the common understanding was that women who had treatment for breast cancer should refrain from upper body exercise to avoid the risk of developing chronic lymphedema  which is a permanent and sometimes incapacitating swelling of the arm that can be caused by damage to or removal of the lymph nodes, which often occurs in cancer treatment. Although this was the wisdom of the time, there was actually no research to support the fear. Dr. Mackenzie’s studies in the area of exercise rehabilitation led him to believe that the current thinking might be wrong. Dragon boating is mainly a core and upper body workout, so it provided the perfect way to test the theory. Dr. Mackenzie formed a team in February 1996, and the team named itself Abreast in a Boat.

In 1998, Dr Mackenzie was able to publish a research study on the project in the Canadian Medical Association Journal on the success of the project, observing:

How important is the Abreast in a Boat project? It is an approach to promoting health and raising breast cancer awareness that is driven by women with the disease. It reaches out to other women and offers them a message of hope and support. It is helping to change attitudes toward “life after breast cancer,” and it encourages women to lead full and active lives. It is making a difference.

Breast cancer survivors dragon boat teams

Breast cancer survivors dragon boat teams

What’s interesting about this study is that 15 years later, there is still not enough widespread evidence for the value of physical therapy after cancer treatment, in particular for recovery of muscle weakness from radiation. A lot more could be done to educate on both the value and the necessity for physical therapy to help patients gain back strength, abilities, and hope.

Today there are more than 116 breast cancer survivor dragon boat teams worldwide including 41 in Canada, 29 in Australia, and 24 in the United States. So, if you’re out watching in Vancouver or the rest of the globe this weekend, cheer a bit harder for the ladies in pink. They have paddled farther than you’ll know.

To read more:

Abreast in a Boat

Machestic Dragons

Rio Tinto Vancouver Dragon Boat Festival


Posted in: Exercise Physiology, Healthcare Disruption, Healthcare motivation

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Breaking the Barriers to Exercise

Last Friday, May 3rd I attended the IDEA Personal Trainer Institute Conference in Seattle.  IDEA is a conference for personal trainers to come together and get comprehensive, in-depth training from some of the top fitness professionals in the world. Sessions ranged from full-on workout sessions (TRX, Kettle Bell training) to lectures on motivating clients, and running a successful fitness business.  I had the opportunity to attend a session presented by Rodney Corn from PTA Global entitled “Breaking the Barriers to Exercise” in which he discussed how to motivate non-exercisers to get active.

1gf4g Rodney started off the session by asking: “What do you consider exercise?” Now in a room full of personal trainers you can imagine that there were visions of some pretty intense and vigorous exercise. To be fair, the morning sessions looked something like the video you see on the left.  He then asked the room to go through a series of movements. He had us pick up a medicine ball and carry it to the other end of the conference room. Then he had us roll an exercise ball to the other end of the conference room. Pretty easy and non-strenuous movements.  “Was this exercise?” From the expressions of the majority of the people in the room I would say most thought NO.

Exercise is movement.  It is generally defined as movement that is planned, structured, and repetitive for the purpose of conditioning any part of the body. The industry’s  standard for exercise is a minimum of 150 minutes of moderate exercise or 75 minutes of intense exercise per week.  For increased benefits the recommendation is 300 minutes of moderate exercise or 150 minutes of intense exercise per week.

In the following video Dr. Joan Vernikos, looks to simplify the idea of exercise stating:

“The key to lifelong health is more than just traditional gym exercise. The answer is to rediscover a lifestyle of constant, natural, low intensity, non-exercise movement that uses the gravity vector throughout the day.”

So if exercise is so simple, then why aren’t more people doing it? The situation today is pretty dire:

  •  1.6 billion people are overweight or obese in the world
  • 60% of people worldwide don’t get sufficient exercise
  • 70% of the US population is overweight or obese
  • Less than 20% of people get the recommended amount of physical activity
  • 25% of US population does ZERO physical activity

There are more fitness facilities, personal trainers and education than ever, yet there is also less participation in exercise and more disease than ever before. What are the barriers to exercise? Why are so many people remaining inactive? Rodney suggested there are two major obstacles: Pre-existing level of activity and the suggested time required to exercise.

Dr. Roy Sugarman, Neuropsychologist states: “People need the reward of micro-goal successes to avoid ambivalence about the big goals”.   So breaking down daily activities into smaller, shorter bouts and intervals would be much easier for the sedentary populace to digest. Protocols for non-exercisers and beginners should be just 5 to 10 minutes in length. It has been scientifically proven even short intervals (5-10 min) of activity can have a physical and mental benefit.

At this point of the lecture you could hear the collective sigh of the trainers in the room.  Really? Only 5-10 minutes? Personal trainers are used to pushing people to their limits. They turn even the average Joe into an athlete. How can 10 minutes be enough? Rodney hammered home the point by saying:

“People are more likely to change when they have a sense of control, can manage the process and see some quick micro results.”

Trainers should match exercises and programs specifically to the client by knowing their personality, behavior patterns and motivation. They should ensure that the program gives the client a sense of control and that the length of exercise is short enough to facilitate change. The fact is, the more often you can get someone to do an activity, the more likely you are able to help them establish a new habit. If the program is overwhelming for an individual, they just won’t do the exercises. Training programs need to be appealing, nonthreatening and most of all – achievable.

The fitness industry is not designed to meet the needs of the sedentary population because the fitness industry’s idea of exercise is too high. The reality is that any movement is exercise and for some just doing simple movements around the house is where they need to start. As Dr Joan Vernikos says: “Sitting kills, movement heals”. Helping someone get in the habit of performing even the simplest of movements can move them towards a more healthy and active lifestyle.

At Wellpepper, we motivate behavior change by giving clients detailed instructions, reminders, and motivational prompts to remember to do their exercises. Many professionals we have worked with recognize that when it comes to motivation, sometimes less is more.  However, some have asked how many exercises can you prescribe to clients with Wellpepper? The answer is as many as you like,  but the trick is to find that magic amount for the end customer. What will drive them to change?

Posted in: Exercise Physiology, Healthcare motivation

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Encouraging Exercise for Injury Prevention

Washington Physical Therapy Conference Spring 2013Last weekend Wellpepper attended two conferences, the Washington Physical Therapy Association Conference in Spokane, Washington and the Physical Therapy Association of British Columbia Annual General Meeting in Vancouver, BC. It was amazing to introduce Wellpepper to so many new faces and to hear feedback. We were too busy at both conferences to take advantage of the information and other activities however, we did manage to attend one talk  “Recreational and Elite Athletes:  Can we really prevent injuries?”  by Rick Celebrini. Dr Celebrini is the head of sports medicine and science for the Vancouver Whitecaps MLS team, and former physiotherapist for the Canadian Olympic Ski Team. He became interested in physiotherapy after breaking his food during his teen years as a high-level soccer player.

Dr Celebrini started his talk with some statistics about injuries. Injuries cost the MLS $7M in 2012. Considering that MLS players are not the highest paid professional athletes, you can only imagine what this might be in other sports. He also shared that sport and recreational injuries can cause osteoarthritis later in life. Then he focused on one of the most common sport injuries: ACL tear. The ACL tear will take an athlete out of commission for 8-12 months and is estimated to cost the US healthcare system $2B a year. Women are 4-6 times more likely to have an ACL tear and have a greater risk of osteoarthritis. The major cause of ACL tear is changing direction. 70% of injuries are non-contact, that is they are incurred by the athlete him or her self by changing direction or landing incorrectly: if the knee is close to extension, and the foot moves outside the center mass, this becomes a perfect situation for an ACL tear. This situation of imbalance can result from extrinsic or intrinsic factors. Extrinsic factors are things like weather, footwear, equipment. Intrinsic factors are related to things about the person: How does the person move? Is the person tired? What is their mood? When Dr. Celebrini had his injuries, he remembers that he was tired and felt he shouldn’t have been playing. These types of factors change on a daily basis.

It turns out however, that a study in 1986 proved how to prevent ACL tears. In particular changing how deceleration happens and making rounded turns instead of sharp changes of direction are two key factors. However, in all this time, there has been no change in the number of ACL injuries. The reason for this: human nature. He cited a study where physical therapists were brought in to help professional athletes with preventative techniques and exercises for ACL. As soon as the PTs left, and the coaches and players were on their own, only 50% had compliance with the program. Physiotherapy Association of British Columbia

Dr. Celebrini believes that we don’t need to do any more research into how to prevent ACL tears. What he’d like to see is the translation of the research into a practical application for people. That is, focusing on how to motivate them to change their behaviors for the better. He thinks there’s a gap between academic research and practical application. Even the Whitecaps, who rely on their bodies being healthy and functional for their careers, don’t do their preventative exercises.

Dr. Celebrini had some suggestions for this:

  • How do you fit preventative exercises into the schedule? He gave the example that the Whitecaps players would not want to spend 30 minutes pre-game doing preventative exercises, they would want to be warming up for key skills they’d need in the game.  Can you include exercises in the warm-up without detracting from other exercises they need to do? 
  • What is the player’s motivation? Can you tap into their desire to have a long career?
  • How do you make it sport specific? Can the exercises be adapted to have relevance to the specific sports?
  • Make sure that the decision makers are bought off. In the study he mentioned, the coaches weren’t on board and didn’t continue the program after the physical therapists left.

Finally he stressed the need for the research to include implementation. Researchers should collaborate with athletes, sports psychologists, and coaches, to translate the research into practice. At Wellpepper we’re working with physical therapists, behavior researchers, and patients to try to solve these challenges in getting people to do what’s good for them, so we were really happy to hear this message!


Posted in: Exercise Physiology, Rehabilitation Business

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The Value of Physical Therapy

We’ve participated in quite a few #solvePT tweetchats, and a recurring theme is the need for the physical therapy profession to better market the profession both to consumers and within healthcare as a whole. What’s interesting is that within our experience, everyone we know has seen a physical therapist at one point or another, and seen benefit. Of course, we are active ourselves and so are our friends. We also fall into that category of people who want to remain fit and active as we age.

Once, people did not see a doctor until they could barely get around. “Now patients will say: ‘I can’t exercise. I can’t ride my stationary bike or regular bike or go for walks of one or two or three miles,’ ” said Dr. Mark W. Pagnano, an orthopedist at the Mayo Clinic in Minnesota. NY Times

However, keeping in mind that everyone is not like us, we thought we’d explore the concept of the value of physical therapy and exercise in a few blog posts. Recently, we met with an MD who on the one hand was a huge proponent of preventative medicine, and on the other hand was a bit dismissive of physical therapy. However, he swore by his personal trainer so he definitely sees the value of exercise.

Search for “the value of physical therapy” and the fifth result is:

It may be stated with little fear of contradiction that there is no field of therapeutics less understood and less frequently employed by internists than physical therapy. There are several reasons that account for this unfortunate state of affairs which has its inception in our medical schools. http://jama.jamanetwork.com/article.aspx?articleid=252288

It’s from 1941, so hopefully sentiments have changed a bit, but the fact that it’s in the top search results is a bit disturbing. A much better resource has been developed by the Canadian Physiotherapy Association, where they outline the types of conditions and interventions where physical therapy can help.

Here’s the list, with links to evidence on how physical therapy can help in each one of these cases.

Tracking exercises in Wellpepper

Tracking exercises in Wellpepper

If you’re like us, accidents and sports injuries are the first areas that come to mind. However, where physical therapy can really shine is in preventative treatments for things like falls and low back pain. Did you know that low back pain causes almost as many work absences as the common cold? Management of chronic disease is also an area where physical therapy can add value. Diseases like arthritis, multiple sclerosis, and Parkinson’s can all be managed through regular movement and exercise. Keeping people moving is key to keeping them from getting worse. We’re working with researchers using Wellpepper for Parkinson’s management and we are hoping the findings can be applied more broadly to chronic disease management.

Recovery from disease is another area, stroke, heart disease, and cancer all need physical therapy to help regain quality of life. The first two are obvious. Healthcare professionals are just starting to realize the toll that cancer treatments take, and are prescribing physical therapy as part of a recovery program. Often people are so weakened that they need help to get muscles back to where they were.

In our experience, people who have been helped by exercise prescription understand the value. The challenge seems to be not enough people know about the possibilities. Direct access, which enables people to see a physical therapist without a doctor’s referral, can help this tremendously. However, in order for people and the profession to see the benefits of direct access, there needs to be more awareness of when it could help.

Posted in: Exercise Physiology, Managing Chronic Disease, Rehabilitation Business

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Prescribing Exercise

Maybe it’s because at Wellpepper we’re quite active–a recent weekend saw us running, skiing and snowboarding, and rock climbing–but it’s a bit surprising to us that the merits of exercise as a prescription for health are still being proven.

Cross country skiing is a great workout!

Cross country skiing is a great workout!

For example, it’s not regular practice for doctors to tell people to get active. However, many doctors are not active themselves and if they don’t have the experience, then it’s hard for them to recommend the benefits. The US Center for Disease Control recently collated results from a number of studies that showed that doctors who exercise themselves are more likely to prescribe exercise.

The findings showed that active physicians were two to five times more likely to recommend fitness regimens than those doctors who led physically inactive lives. Link to full story.

The NHS in Scotland is piloting an intervention where doctors recommend and prescribe physical activity. Again, a very helpful intervention, but why is it a pilot and not a practice?

Increasing physical activity is a simple, cheap and highly effective way of both staying healthy if you are well, and reducing the health risks of many chronic conditions like diabetes and heart disease. It works at any age. RCGP Scotland is happy to support this initiative, which will give GPs vital information on how to help patients increase activity and improve their health. John Gillies, Chair of Royal College of General Practitioners Scotland. Link to full story

The problem seems to start earlier. The British Journal of Sports Medicine reports that doctors are not taught about the benefits of exercise.

This gap in knowledge means that future doctors will have insufficient knowledge to effectively promote physical activity to their patients, which results in a failure to help combating serious diseases that are linked to insufficient exercise according to the study authors. Link to full story

First Lady Michelle Obama’s “Let’s Move” initiative pinpoints that the problem actually starts a lot earlier.

Thirty years ago, most people led lives that kept them at a healthy weight. Kids walked to and from school every day, ran around at recess, participated in gym class, and played for hours after school before dinner. Meals were home-cooked with reasonable portion sizes and there was always a vegetable on the plate. Eating fast food was rare and snacking between meals was an occasional treat.

This is in contrast to the current situation where diets regularly include junk and where kids are driven to and from school and scheduled appointments. The Let’s Move campaign is looking to change this situation through education on healthy habits: eating well and exercising. Great campaign, just sad that we got to this state.

At Wellpepper we were fortunate to have had active parents, role models, and the encouragement “to get outside when the sun was shining” from a young age.  Added to that the wisdom of Hal and Joanne at Participaction to help instill good habits in our formative years. 😉

We’re building a healthcare technology business starting from exercise program prescription and adherence. It’s been surprising to us that the benefits still need to be proven, but we’re looking forward to helping in that area through the data we collect and resarchers we’re working with.

As Hal and Joanne say, until next time “Keep fit and have fun.”

Posted in: Exercise Physiology, Managing Chronic Disease

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