Category Archives: Injury treatment

Low back pain: why and what to do about it

by Thommy Chui, PT, OCS, CSCS, TPI CGFI MP2

What does it mean when someone says I threw my back out? Was it spring cleaning and this person decided, I  don’t want it anymore?

As a Physical therapist, all too often I hear the phrase” I threw my back out”, followed by… “all I’ve done for the last week is lie down, take pain medication, and rest.  I didn’t want to make it worse.”

Our human anatomy and physiology was developed to move, however our increasingly sedentary work duties and lifestyles have done quite the opposite. Whether it’s sitting watching TV, sitting in front of a computer station for hours without breaks, sitting in meetings , or traveling by car or airplane to then sit in meetings, we just aren’t moving as much anymore.

Studies have shown that prolonged sitting can contribute to decreased disc height in our lower back.  Additionally, extensive sitting produces overly tight hip muscles and weakness in the low back and gluteal muscles.   The result is an imbalance in our core stability.

The most common non-traumatic ways in which people injure their lower back is by bending, standing from a chair, turning or twisting. This is when we “throw our backs out.” What does this mean? It means that since we have an imbalance in our core stabilization, our muscles are not working in harmony. Specific muscles around our spine end up compensating and can progressively become overworked, setting the stage for injury.  The pain we feel initially is usually  tension or spasms of these overworked muscles.  Remember the root of the problem is weakness and inadequate stability caused by not moving enough.—so the last thing you should to do when your back is sore or in pain is lie down and not move!

Research shows that continued mobility in pain free ranges in combination with modification of activities helps decrease pain significantly.

Below are some recommendations for strength and mobility exercises along with safe techniques for getting in/out of bed and standing up from chairs without exacerbating your back pain. Try these the next time you have back pain and it may help avoid a trip to your doctor’s office.

LOG ROLL (4 steps):

log roll 1 crop

log roll 2 crop

log roll 3 crop

log roll 4 crop


hip hinge crop


squat crop


LTR 1 crop

LTR 2 crop


front plank crop


side plank crop


bridge crop


–          O’sullivan, K et al. “Lumbar posture and trunk muscle activation during a typing task when sitting on a novel dynamic ergonomic chair.” Ergonomics. 2012;55(12):1586-95. doi: 10.1080/00140139.2012.721521. Epub 2012 Sep 25.

–          Zemp, RIn vivo spinal posture during upright and reclined sitting in an office chair.” Biomed Res Int. 2013;2013:916045. doi: 10.1155/2013/916045. Epub 2013 Sep 24.

–          Lee SH, et al “The change of whole lumbar segmental motion according to the mobility of degenerated disc in the lower lumbar spine: a kinetic MRI study.” Eur Spine J. 2014 Mar 28.

–          Kline JB et al. “Core strength training using a combination of home exercises and a dynamic sling system for the management of low back pain in pre-professional ballet dancers: a case series.”J Dance Med Sci. 2013;17(1):24-33.

Do This, Not That

by Colleen Morgan, PT, MS, OCS, CSCS

Whether you are a weekend warrior or competitive athlete,

a life-long “gym rat” or exercise newbie, it’s important to know which gym exercises are worth your time and energy.  Learn what exercises most physical therapists would categorize as worthless (perhaps even downright dangerous) and explore some healthy alternatives in our recurring blog column “Do This, Not That!”

Do This!

Not That!

Planks are the perfect “whole body” exercise as muscles from your head to your toes are contracting to keep you stable.  They also effectively recruit your “core” which includes the muscles of your abdominals, buttocks, shoulder blades and spine.  Hit the floor and hold this position as straight as a plank! Full sit ups emphasize your rectus abdominus (aka your six pack muscle) which connects the base of your ribcage to your pubic bone.  This muscle has no attachments to your low back.  In fact, as you perform a sit up, the rectus abdominus compressed your spine, creating excessive loads to the discs.  Those with a history of low back pain should stick to crunches as they are less stressful to the spine.
 image017  image020

Tom House Shoulder Exercises

No more excuses!

Now you won’t need equipment to do shoulder exercises.

In fact, these exercises are better than lifting weights at the gym.  Tom House has developed a series of stability exercises for the shoulder that have been used by hundreds of successful athletes including Drew Brees and Nolan Ryan.  Whether you are recovering from injury, working to prevent injury, or trying to improve performance in an overhead sport, these exercises are for you.

Check them out!

Bracing for action: Are ankle braces effective for volleyball players?

Ankle sprains are the most common recreational sports injury, with ankle injuries making up about 25% of all adult sports injuries. To combat ankle sprains, ankle braces have become popular in sports that require jumping and cutting. In volleyball, ankles account for about 40% of all injuries. Volleyball players in particular have embraced the use of prophylactic ankle braces, with some coaches making ankle bracing mandatory for their players. With rates that high, who wouldn’t want to protect their ankles? But are braces really effective in reducing the risk of ankle sprains? We’re going to answer some frequently asked questions about ankle braces, based on the most current literature available.

Do ankle braces prevent injury?

In healthy, active people without a history of ankle sprains, studies have not shown a benefit to wearing prophylactic braces (those intended to prevent injury). Most studies do not report injury severity, so it is certainly possible that braces affect the severity of sprains—unfortunately there just isn’t good data out there to support it.

Do ankle braces prevent re-injury?

It does appear that braces are effective for ankles that have been sprained before, especially within the first year after injury. Ankle sprain rates double in the 1-2 years following a sprain. Furthermore, 30-50% of people who sprain their ankle develop chronic instability. Prevention of reinjury following a sprain is therefore vital, and several studies have shown that bracing does reduce the risk of reinjury. It is less clear if long-term use of bracing is necessary for injury prevention. A combination of bracing with specific ankle exercises is likely the best course of action in preventing re-injury. Read on for further information.

Does the type of brace matter?

Probably not. However, braces may vary in the type of support they offer. For example, lace-up braces add stability both on the sides and in the front and back, while stirrup type braces (such as Active Ankle) only support the ankle on the sides. This won’t make a difference in most people– as the majority of ankle sprains are inversion/lateral sprains– but if you have anterior/posterior instability it may make a difference. The second way braces work is by increasing proprioception and feedback to your sensory and musculoskeletal systems. Proprioception is your brain/body’s unconscious awareness of a joint’s location in space. Increased proprioception helps your muscles react faster and stronger when they are needed to support your ankle against a potentially injuring force. All types of braces will help give proprioceptive input. To date, studies looking at type of brace haven’t agreed upon the superiority of one brace type over another in injury prevention.

Will ankle bracing hurt my ankles?

There is currently no evidence supportive of ankle weakness or loss of function stemming from the use of ankle bracing. Contrary to the beliefs of some avid non-bracers, braces won’t weaken your lateral ankle muscles or cause them to ‘get lazy’ and stop working.

Will ankle bracing hurt my knees?

Probably not.  There is evidence to show that ankle injury rates increase with knee bracing, however no similar conclusions have been made linking knee injury rates to ankle bracing. Some lab studies have shown slight increases in knee rotation with ankle bracing versus without. It makes sense that if you restrict movement enough at one joint, other joints may compensate with extra movement. However, current studies are not substantial enough for this to factor into recommendations about ankle bracing.

Will ankle bracing hurt my vertical jump?

It shouldn’t. Several studies have shown that ankle bracing does not impair physical performance in activities like jumping, running, or agility. In other words, no looking down at your ankle brace in disbelief after burying that perfect set into the net during your company’s picnic volleyball game.

What are some other options to prevent ankle sprains?

Training: Training is a key component of staying healthy as an athlete, but often athletes forget to train their ankles. Incorporating ankle exercises can be as easy as trying to stand on one leg and balance. Once that’s easy, try balancing while doing arm exercises, standing on an unstable surface, or closing your eyes. You can also try leg exercises like squats, lunges, or side leg lifts on a BOSU or balance board. Agility and jump training programs, including training yourself to land from jumps with good body mechanics, may also improve your ankle strength and stability. Keep in mind that even the best training programs take 8-12 weeks to show benefits. If you’re coming off of a recent ankle sprain, you may benefit from the advice of a physical therapist to progress your exercises at a reasonable pace while your ankle heals.

Footwear: There has not been evidence that high tops or other shoe designs prevent ankle sprains. However, supportive shoes without too much wear and tear are important. Some minimalist footwear and shoes like shape-ups may promote increased movement in your foot and ankle. This may help strengthen your foot muscles during regular activities or running, but may also increase your risk of injury during jumping and landing, so keep those off the court.

Taping: Taping may provide a similar effect to bracing in the proprioception department, and has been proven to be about as effective to bracing to prevent re-injury. However, the mechanical stability of taping has been shown to decrease quickly: within 10 minutes of activity after taping, it is already 40% less effective mechanically, and may provide negligible support within an hour. Taping is also time consuming and requires a trained professional for optimal results. However, if you leave your brace at home, taping may be an alternative to bracing that is helpful in preventing reinjury.

Here are a few other things to consider when deciding whether or not to use an ankle brace:

-Most volleyball players have a ‘dominant ankle’, the ankle opposite their hitting arm. This ankle is more likely to be injured because they land on it more often. Setters may be at risk for more ankle sprains on the right because that is the ankle closest to the net, increasing risk for under the net contact after jump sets.

-If you play indoor and outdoor volleyball, consider that you may not be able to use bracing on the beach or grass, but should definitely be working on ankle strengthening and stability exercises to prevent injury outdoors.

-In almost all cases, bracing is not going to provide enough support to prevent a sprain when one player lands in a bad position on another player’s foot after jumping high off of the ground. The forces are just too high for the brace to control.

Recommended Reading

Verhagen EA, Bay K. Optimising ankle sprain prevention: a critical review and practical appraisal of the literature. Br J Sports Med. 2010 Dec;44(15):1082-8.

Dizon JM, Reyes JJ. A systematic review on the effectiveness of external ankle supports in the prevention of inversion ankle sprains among elite and recreational players. J Sci Med Sport. 2010;13(3):309-17.

Study Designs (publishing date TBD)

Janssen KW, van Mechelen W, Verhagen EA. Ankles back in randomized controlled trial (ABrCt): braces versus neuromuscular exercises for the secondary prevention of ankle sprains. Design of a randomised controlled trial. BMC Musculoskelet Disord. 2011; 27;12:210.

Janssen KW, van der Wees PJ, Rowe BH, de Bie R, van Mechelen W, Verhagen E. Interventions for preventing ankle ligament injuries. Cochrane Database of Systematic Reviews. 2011; Issue 12.

Additional References

Frey C, Feder KS, Sleight J. Prophylactic ankle brace use in high school volleyball players: a prospective study. Foot Ankle Int. 2010;31(4):296-300.

Hübscher M, Zech A, Pfeifer K, Hänsel F, Vogt L, Banzer W. Neuromuscular training for sports injury prevention: a systematic review. Med Sci Sports Exerc. 2010;42(3):413-21.

SantosMJ, McIntire K, Foecking J, Liu W. The effects of ankle bracing on motion of the knee and the hip joint during trunk rotation tasks. Clin Biomech. 2004;19(9):964-71.

Venesky K, Docherty CL, Dapena J, Schrader J. J Prophylactic ankle braces and knee varus-valgus and internal-external rotation torque. Athl Train. 2006;41(3):239-44.

Verhagen EA, Van der Beek AJ, Bouter LM, Bahr RM, Van Mechelen W. A one season prospective cohort study of volleyball injuries. Br J Sports Med. 2004;38(4):477-81.

What Kind of Massage Should I Get?

As Physical Therapists, we utilize various forms of massage for rehabilitation purposes, however sometimes a full session of massage is helpful to prevent injuries or help recouperate from an injury.  Finding the right massage can be an intimidating task.  Is deep tissue massage better than soft tissue massage? Is massage about no pain no gain?  These are some of the many questions one may encounter prior to scheduling an appointment.   Essentially, what classifies a good massage is truly variable from person to person.  It is appropriate to feel pain at 6-7/10 on ones personal pain scale for therapeutic effects.  Anything over 7/10 pain will be counterproductive as you may resist the massage.  Furthermore, one Massage Therapist may be just as trained and competent as the next, but the comfort level you feel between one over another could make the difference in regards to your body’s reaction to their touch.  Just like there are many ways different restaurants prepare the same meal, there is one that makes it just the way you like it.  Please note that it may take awhile for you to find the right Massage Therapist.  Test a few out.  It’s a comfort thing.  So, below is a list of popular massage techniques that you may find helpful. 

 Swedish Massage

This is the basic massage that focuses on relaxation.  Long strokes are used to ease the body targeting the superficial muscles.  This type of massage can vary in pressure, so it is important to discuss the type of pressure with your massage therapist before and during the massage to get what you really want.

 Deep Tissue Massage

Most confuse strong pressure Swedish Massage and Deep Tissue Massage.  Deep Tissue may use some of the same strokes as Swedish, but this type of massage is intended to reach deeper soft tissue slowly.  It’s slow because if too much pressure is applied too fast the muscles have an automatic response to protect themselves, and tenses up, which defeats the purpose because now the deeper structures cannot be reached.  A mild discomfort might occur with this type of technique, but nothing too painful.  Again, muscles will fight back to protect.

Cross Friction is also utilized here.  Muscle fibers travel in a specific direction, and so the therapist/practitioner will move perpendicular to the muscle fibers.  This allows for scar tissue to be broken up due to the chaotic remodeling of micro-damage to soft tissues caused by repetitive overuse.  This type of massage technique is usually a focused treatment of a specific body part and not necessarily a full body experience.

 Sports Massage

This is not just for athletes.  A Sports Massage session is not likely to have wind chimes and soft music with flickering candles, but can.  A good Sports Massage is a mixture of techniques to increase flexibility, to ease tight muscles, to prep muscles to do work (you’ll often see runners beating their legs with their fists), to reduce swelling that have recently been working, to relieve “knots” or contractures, address cramping, and helps reorganize soft tissue.

Trigger Point Therapy

A trigger point is a specific “knot” of the body that produces referred pain around or near the site.  Janet Travell, MD has pioneered treatment for myofascial pain. She has mapped out the specific trigger points and its referred pain pattern.  This type of therapy takes a knowledgeable Massage Therapist, as there are hundreds of trigger points and referred pain patterns.  Pressure is applied to the “knot” or attachment sites of the “knotted” muscle to release the tight muscle band. 

This is a very brief introduction to what can be encountered.  There are a whole host of other types of massage techniques out there that are not so mainstream such as: Rolfing, Shiatsu, Reiki, Lymphatic Drainage, Acupressure, etc.  Explore and enjoy the experience and find which technique benefits you the most.  Do not hesitate to call or do the research and inquire upon the qualifications of your massage therapist.  It’s a good idea to find a Massage Therapist who can assess your needs before and during a session so that any number of techniques can be used. 

Check out this website to learn more about the different types of massage:

Stay light on your feet with the AlterG

Are you training for your first marathon?  Are you dealing with shin splints, sore knees, or recovering from a sprained ankle?  Do you want to start a running or walking program but afraid you are too overweight or injury prone?  The AlterG Anti-Gravity Treadmill may be the answer to those nagging concerns!

What is the AlterG Anti-Gravity Treadmill?

AlterG’s unique unloading treadmill provides the opportunity to initiate or continue a walking or running program painfree.  Unloading is achieved by using air in a pressure-controlled chamber to gently lift the user. Precise calibration of 100-20% of the user’s body weight is achieved in 1% increments to ensure comfort and monitor progress.

Why unload? 

Whether you are a weekend warrior or a competitive athlete, recovering from an injury or trying to prevent an injury, the AlterG’s Anti-Gravity Treadmill can provide many benefits to address your needs including:

  • Protecting healing tissues
  • Weight control and reduction
  • Aerobic conditioning
  • Sport specific conditioning
  • Neurological retraining

Now that you know what the AlterG provides, you can finally try it out for yourself!  The AlterG Anti-Gravity Treadmill is the newest addition to the CPMC Sports Wellness Programs!

Young Pitchers and Injury Prevention

Baseball season is here and teams are ramping up their practices and training time to prepare for the upcoming season. I’m not just talking about the professionals either. Kids need to start training for their little league season and get in shape to prevent injuries during the season.

Overuse injuries during youth sports are on the rise and about 20-40% of youth baseball players suffer from elbow pain alone. Sometimes this is caused by training errors and sometimes it is caused by things we can’t change like biology, but we should try and train most effectively to prevent injuries as best we can.

Competition is a driving force behind wanting to learn new pitches. Kids want to learn new pitches so they can strike out more players at younger ages. A 12 year old boy has his parent take him to a Giants’ game and he sees Lincecum’s nasty curveball. He wants to learn how to throw one and 3 weeks later, he develops elbow pain and is not able to pitch for the rest of the season because it was too much for him.  When this happens it is imperative that the young athlete rest and begin rehabbing.

However, injury can be prevented with proper throwing progression with various pitch types.  Below are some published guidelines for when it is okay to begin to throw certain pitches and how many pitches should be thrown at various ages.

Age Begin throwing a… Total Pitches per game Total Pitches per week Total Pitches per Season Total Pitches per Year
8-10 Fastball 50 75 1000 2000
11-12 Change-up 75 100 1000 3000
13-14 Curve ball 75 100 1000 3000
15-16 Slider, Forkball, Split finger, Knuckleball 90 3000
17-18 Screwball 105

Here are some guidelines on safe return to sport after rehab from a throwing injury.  Here are more guidelines for safe progression in other positions and age groups in throwing sports.  When in doubt contact a medical professional to be evaluated for risk factors affecting pitch mechanics.

Play Ball!

Little league elbow. Benjamin HJ, Briner WW Jr. Clin J Sport Med. 2005 Jan;15(1):37-40.

Knee Pain: Tendinitis or Tendinosis?

Whether you are a serious competitive athlete, weekend warrior or participate in sports recreationally, chances are you’ve experienced some sort of knee pain. Annually, knee pain results in over 1 million trips to the ER and nearly twice that in visits to primary care providers. Patellar tendon overuse injuries are a common culprit in many of these cases, particularly for individuals who run, play high-impact sports (basketball, volleyball, tennis) or have physically demanding jobs.

Common diagnoses you might hear from your physician include: Patellar Tendinopathy, Patellar Tendonitis and Tendinosis affecting the front of the knee joint.

So what is the difference between them?

  • Tendinopathy is an umbrella term that means a disease of the tendon, and can refer to either tendinitis or tendinosis.
  • Tendonitis is an acute injury, involving an active inflammatory process. If treated properly, symptoms can improve and heal within 3-6 weeks.
  • Tendinosis refers to a chronically overused tendon with microtrauma and physical degenerative changes to the tendon. Symptoms may last up to 6 months.

What is the best course of action to treat these injuries?

 Early diagnosis by a medical professional is important, as treatment may vary depending on your activity level and specific diagnosis. Don’t allow weeks to pass thinking that it will “get better on its own”, particularly if the pain is getting worse or not improving.

  • Depending in the severity or acuity of the injury, activity level should be modified to avoid additional injury to tissues. “Playing through the pain” will only delay healing and return to activity.
  • Early application of ice to a painful knee can be very beneficial in reducing pain levels and controlling any inflammation that may be present

What is the role of Physical Therapy?

Physical therapy is important in reducing pain and permitting a safe return to normal activities.  Individuals experiencing knee pain may resort to compensatory movement patterns with walking, stairs and other daily tasks.  This creates muscle imbalances and heightens the risk for further injury to the affected knee and to other joints above and below the knee as well. Physical therapy will help to identify and correct these improper movement patterns in order to reduce pain and facilitate a safe resumption of daily activities and return to sport.

Additionally, your physical therapist will help you determine what activities and/or exercises are safe to promote healing and prevent reoccurrence.

General guidelines for treatment of patellar tendonitis/tendinosis

Acute tendonitis

–       Inflammation control is essential to decrease pain and to progress with activities.

–       Strengthening of surrounding muscles

–       Relative rest from use of affected area


–       Gradual progression of eccentric strengthening (muscle lengthening) in pain free ranges

–       Strengthening of supporting and stabilizing muscles

–       Dynamic and static stretching

Examples of exercises to maintain proper muscle function and control while protecting your knee include:

Quad setting

Heel slides

SLR 4 way

Make sure all exercises are done in pain free ranges. If you experience pain, stop or reduce the intensity of the exercise.  Check out the video below for demonstration of how to perform the exercises above.

Check out CPMC Sports Wellness for more information on injury prevention and fitness tips.


–        Chronic Tendiopathy . Marsha Rutland et al. North American Journal of Sports Physical Therapy, Vol 5, N3, September 2010, pg 166-178

–        Comparing the effects of eccentric training with eccentric training and static stretching exercises in treatment of patellar tendinopathy. A controlled Clinical Trial. Stasinopoulos Dimitrios, et al.  Clinical Rehabil DOI: 10.1177/0269215511411114. downloaded from at Samuel Merrit Univ 2011

–        Risk Factors for Patellar Tendinopathy in Basketball and Volleyball players: a cross sectional study. H. Van der Worp, M. van Ark, J. Zwerver, I. van den Akker-Scheek. Scand J. Med Sci Sport 2011 1-8

Safe and Timely Return to Sport for Adolescents

“If you can walk you can run. No one is ever hurt. Hurt is in your mind.” Any guess as to whom this quote belongs to?  None other than the great former Green Bay Packers coach, Vince Lombardi.  Examples of this mentality in sports history are many: Michael Jordan battling the flu in the 1997 NBA Finals; Curt Schilling’s bloody sock in Game 6 of the 2004 AL Championship series; and gymnast Kerri Strug sticking her vault landing on a severely sprained ankle at the 1996 Olympics.  Unfortunately, because of the adulation bestowed upon such performances, playing with pain is a behavior that a lot of young athletes may feel inclined to emulate.

Young athletes should not be encouraged to “play through the pain” because mismanaged injuries can have long term consequences including the development of chronic musculoskeletal dysfunction, impaired sports performance and shortening of athletic careers.  Emphasis instead should be on constructing positive sports experiences and preventing injury.  That being said, pain and injury are common in sport and it’s important to understand how to manage them appropriately.

So how do we know when our young athlete is ready to return to their sport? First, it’s important to determine if the athlete is “hurt” or “injured”. “Hurt” can involve exhaustion, contusions, abrasions, and blisters whereas “injured” may involve fractures, muscle strains, joint sprains, concussions, and overuse injuries. Athletes experiencing the former can usually return to participation with no or very brief downtime, while the latter will require substantially more time away from sport and medical management with rehabilitation. Also important to understand is an athlete’s typical reaction to pain and that some individuals tolerate “hurt” better than others.

A second question to ask is “Where is the athlete within the season?” Injuries occurring during the off-season, pre-season or beginning of the regular season should be rehabilitated to facilitate the athlete returning at full capacity for the end of the season and/or playoffs rather than rushing to get back on the playing field before fully recovered. Injuries occurring during the heart of the competitive season or playoffs may need to stop playing if continued participation is contributing to increased pain.

If your young athlete is experiencing any of the following symptoms, you should consult with a doctor for examination: 1) pain persisting more than 2 weeks despite relative rest, 2) pain getting worse, 3) swelling, 4) impaired or painful range of motion, and 5) a noticeable limp with walking.

Here are some key points to remember when determining when to return a young athlete back to their sport following an injury:

  • Understand the individual athlete’s situation and goals
  • Determine the severity of the injury
  • Evaluate the risks of return to play
  • Discuss the risks and benefits with the athlete and parent
  • Give the athlete another outlet for physical and mental energy, such as physical therapy or practice modification.

Here at CPMC, we have a great team of physical therapists along with an array of wellness programs that can help your athlete return to his/her beloved sport. Contact us at for more information!

Strength Training for Throwing Athletes – Part 2

Are you an injured or at risk throwing athlete?  Welcome back for the second half our our blog on how to prevent a throwing related injury.

See an explanation of The Throwers 10 and the first 3 exercises on our last blog.

This week we will present the second half of our series focusing on upper body strengthening to help prevent injuries and improve performance for all you throwing athletes.  Check out the video below for demonstration of the following exercises.

4: Scaption with Internal Rotation – great to strengthen one of the 4 rotator cuff muscles, but it is now recommended that you perform this exercise with your thumb up (external rotation) to prevent unnecessary stress to the muscle.

5: Prone Horizontal Abduction – a great exercise to work on stabilization of the scapula.

6: Lower trap press ups  – one of the only exercises that targets the lower part of the shoulder blade and is crucial to developing a stable shoulder.

7: Prone rowing – keep your shoulder down and back, be cautious not to hike your shoulder blade up towards your ear.

8: Pushups – Great as an advanced exercises but I would add a “plus” to this exercise as this has been shown to increase activation of the lower and outside part of the shoulder girdle.

9: Biceps curls and Triceps press

10: Wrist Flexion, Ext, Supination and Prontation

If you have further questions you should seek further consultation from a qualified professional.  Check back every two weeks for more blogs written by your CPMC Sports Wellness Physical Therapists.  In the next couple of months we will discuss popular health and fitness related topics including:  PRP, Bikram Yoga and CrossFit.