STAGES OF TREATMENT

The information contained within these articles is purely informational in nature. In no event shall Bridge Physiotherapy or any individual or company involved with Bridge Physiotherapy be liable for special, indirect, incidental, or consequential damages of any nature, including, but not limited to personal injury, loss of anticipated profits, or claims from third parties.

Always consult your doctor before making any changes in your diet and before performing any of the exercises presented in these articles.

For further information on your readiness to participate in an activity program go to:
http://www.csep.ca/cmfiles/publications/parq/par-q.pdf or http://www.csep.ca/CMFiles/publications/parq/PARQplusSept2011version_ALL.pdf

The main reason people seek out treatment is because they are in pain. When the pain is gone most believe their need for treatment is over.

Unfortunately, this is very seldom the case. You have healed stiffer and weaker than before your injury, and often with poorer balance and proprioception (more on this later). If you do not address these issues then you will be at increased risk for re-injury.

There are three basic stages to your treatment program:

• Stage 1: Pain control
• Stage 2: Recovery of movement
• Stage 3: Physical conditioning -Work/Sport conditioning

These stages are not mutually exclusive. They serve as a guide for goal setting during your treatment. They overlap one another, and you may move backwards and forwards through the three stages depending on the nature of your injury, your general health status, among other reasons.

 

PRINCES PRINCIPLE

 

PROTECTION:
Protect the painful structures from further injury or aggravation. This may range from protective taping and bracing to lumbar and night rolls. It also involves temporary avoidance of the aggravating activities or positions. You must learn to recognize what they are. If it is not possible or practical to avoid these activities then you must be prepared for an increase in your symptoms. However, this increase in your symptoms should only be temporary and does not necessarily mean you have caused any further damage.

REMEMBER: HURT DOES NOT NECESSARILY EQUAL HARM.

 

REST:
This does not mean stop all activities, but rather to modify your activities to avoid the ones that cause significant pain, muscle spasm, and/or swelling.

An example would be if weight bearing activities, such as walking flare your pain, try changing to a non-weight bearing activity, such as swimming or cycling. This principle of activity modification is very important because it allows you to stay active, while avoiding aggravation of your pain.

Every structure in the musculoskeletal system has a “RESTING POSITION”. When people are experiencing Back Pain the three main positions they tend to rest in are:

Sitting: The human spine is not designed to sit in a chair. It almost does not matter what is hurting in your back; sitting is going to aggravate it. If you cannot avoid sitting then use of a lumbar roll, will help to maintain the normal curve in your low back

Standing: The human spine is a piece of machinery. It is intended to move, and so does not like staying in one place for long periods of time. Often, people with back pain will notice their pain is aggravated if they try to stand still for long periods (e.g. while at a social function or if your job requires you to be on your feet a lot). If you cannot avoid these situations, try to adjust your position on a regular basis. This can be accomplished by:

• shifting your weight from side to side
• introducing frequent, small amounts of walking/movement
• simply by putting one foot up on a stool or footrest and changing positions frequently

Lying: The purpose of going to bed at night is to rest the body. If the position you are sleeping in is correct three rules should hold true. The first rule of thumb is that your pain should never get worse when you first lie down. The second rule is that you should not be woken up during the night because of your pain is getting worse. This is not the same as waking up because you need to go to the washroom and notice that you are still in pain. The third and most important rule is that when you wake up in the morning (before you get out of bed) you should always be in less pain than when you went to bed. If not, then the position you are sleeping in is not the right one for you and needs to be modified (see sleep hygiene article for details on modification of sleeping postures).

The resting positions for other parts of the body are obviously different and are covered elsewhere

 

ICE/HEAT:
Ice or cold pack use minimizes bleeding and swelling by reducing blood flow to the injured area. Pain is decreased due to the numbing effect of the cold. The most convenient method of icing is to use a gel pack that you keep in your freezer .You can use also use crushed ice.

Do not apply the cold pack/ice directly to the skin as over time, frostbite may occur. Typically, we recommend wrapping the cold pack in a towel.Apply the cold pack to the sore area for 10- 15 minutes, repeating every two to three hours.

As a general rule of thumb, if you find repeated applications of cold either do not ease or relieve your discomfort, or in fact seem to be making your pain worse, try applying heat to the sore area. Heat applied to tight and spasmed muscles can often help them to relax, which can ease your pain. Apply the hot pack to the sore area for 15-20 minutes, repeating every two to three hours.

Again, be careful not to apply heat packs directly to the skin as they can burn you. A common mistake individuals often make is to lie down in bed on an electric heating pad. If you fall asleep it is quite easy to wake up later with a burn!

 

NSAID:
“NSAID’s” stands for Non-Steroidal Anti-Inflammatory Drugs. This can be in the form of prescription or “Over the counter” medication and can be effective in decreasing inflammation and pain, thus speeding the healing process. All medication should be taken under a physician’s supervision and, as with any medication your doctor gives you or recommends, follow the instructions on the prescription.

 

COMPRESSION/ELEVATION
Many times when we injure ourselves, such as when we sprain an ankle, there will be a lot of bruising and swelling. Wrapping the injury with a tensor bandage and elevating the injured body part will help reduce this response; thus speeding up our recovery.

 

EDUCATION
To fully recover, your active participation in your treatment program is essential. This is difficult to do if you do not know what is wrong with you or what to expect in the future. Make sure you understand the nature of your problem. If you are not sure what your pain control techniques are, check with your therapist.

 

SUPPORT
During stage one; your clinician will also apply treatment techniques to assist you in resolving your pain as quickly as possible. These techniques may include exercise, massage, manipulation, and/or modalities such as Laser, Traction, TENS, IFC, or Ultrasound.

 

MUSCLE RELAXATION – BASIC PRINCIPLES

 

Have ever had your doctor, therapist, or chiropractor test your reflexes? We take a small rubber hammer and rapidly apply a force to a tendon to stretch the muscle attached to it. What does the muscle do? It jumps back or contracts. However, if you do just the opposite; apply a deep pressure slowly to the muscle; it will have just the opposite effect. The muscle will actually release or relax. This is the idea behind therapeutic massage and trigger point release treatments.

While it is nice to get a massage on a regular basis, it is also convenient to learn how to do some type of release technique on yourself. Very rarely can we predict those occasions when we are really in need of releasing muscle tension that has gotten out of control. This is especially true when we are away on holidays and do not have access to the therapist that we know and trust.

The two most commonly used self-treatment techniques are the foam roller and the small release ball. One is not better than the other; it really comes down to a matter of personal preference and/or what you have easy access to. Do you have a friend that has a foam roller? Try it out and see if you like it before you buy it. Also, talk to your health care practitioner to find out what they like and where you can purchase the item.

Foam rollers come in several different sizes and shapes. The most common is the 36 inch long, 6 inch round roller. You can get them shorter or longer, or even in a half round version. The release balls come in a three different sizes, typically 5-6-7 inches in diameter. The larger ball is softer and a little more user friendly for people who are in discomfort. The smaller ball gets into tighter spaces and put more pressure on the spots. This is more applicable for the more advanced individual such as the sports enthusiast.

 

Basic Principles:

1. To produce the effects of a massage you use your own body weight by lying, sitting, or leaning on the foam.
2. Find the tender point and hold the position for 30-60 seconds, or until the muscle release. You may also want to roll up or down the length of the muscle to accentuate the massage effect.
3. Avoid rolling over joints, tendons, or boney structures
4. Make sure you pay attention to your posture. Apply your Spine Sparing Strategies when positioning yourself.
5. Work both sides of the body as equally as possible. You may notice that different muscles are tight/tender on opposite side of the body.
6. If you cannot breathe in a slow relaxed manner, you are pushing it too hard.

 

 

Muscle Relaxation
Foam Roller Techniques

 

Sub-Occipitals: Place the foam roller at the base of your skull; roll your head slowly from one side to the other. If you have trouble with tension headaches or are recovering from a whiplash injury you will often find this area very tender, even radiating into the eyeball area on the same side.

 

Latissimus Dorsi: While laying on your back, angle the roll slightly under one of you arm pits. You may need to move your arm position around to find these tender spots. For the muscles in the upper part of the body and neck area it is easier for most people to use a release ball or a smaller foam roller to get into the tight areas.

 

Upper Fibers of Trapezius: Slide the ball or roller onto the top of the shoulder area. Let the ball/roller support the weight of your head.
SCM/Scalenes: Slightly change your position above to place gentle pressure on the outside of your neck.

 

Pectorals: Roll over so you are facing down towards the floor. Place one hand down at your side. Angle the roller or ball across the front of your chest on this side, and try to breathe slowly and regularly into the pressure.

 

Erector Spinae: Place the foam roller between your shoulder blades, hands behind the head, elbows close together. Lift your hips up in the air and roll up and down the spine. An alternate way of doing this is to place the roller lengthwise between your shoulder blades and roll from side to side.
Quadratus Lumborum: Place the roller off to one side, between the pelvis and the ribs. Be careful not to bang against the ribs in this area because they are very tender.

 

Glut Roll: Sit on the roller with both legs extended in front of you. Support yourself with both hands on the floor. Make sure you maintain a neutral spine position. Slowly shift your weight more onto one side and find the tight/tender areas in the buttock area. You have three different glut muscles so don’t be surprised if you find more than one tender spot.

 

Piriformis: This one is a more difficult progression of the glut roll. From the glut roll position, cross your ankle (on the side you are rolling) over the opposite knee and roll to find the tender spot.

 

TFL: This is a small muscle that runs from the bony point at the front of your pelvis to the front of your hip.

 

Hamstrings: Slide the roller off the gluts and down the back of the legs.As you advance you can cross one leg over the other to increase the pressure on one side.

 

Calves: To start keep the weight on both calves. Remember to turn your toes in or out to find all your tender spots. As you advance you can cross one leg over the other to increase the pressure on one calf.

 

Quadriceps: Roll over so that you are facing down towards the floor, with your weight supported on your elbows. Roll from the top to the bottom of your leg. Do Not roll over your knee cap.

 

Groin: Bring your affected leg up towards your shoulder, making sure to roll the entire length of the muscle. This is a really helpful treatment to treat or prevent groin injuries in hockey and soccer.

 

Shin: Kneeling on the foam roller.

 

STRETCHING – BASIC PRINCIPLES

 

There is good evidence that a comprehensive daily stretching program can significantly increase function and decrease pain. Your stretching program should be structured in such a way as to minimize changes in body position to perform them. It should also be comprehensive enough to ensure all major structures are stretched.

It is not necessary to be completely pain free before starting an active stretching program. Remember: Hurt does not always equal harm. As you transition from Stage 1 to Stage 2 pay attention to how your body responds to the introduction of new movements and activities. None of your exercises should be painful to do; at the same time the stretch has to be strong enough to be effective.

Bob’s 10 minute Rule: Every one of your stretches should stretch – none of them should hurt. The stretching sensation should subside completely within 10 minutes. If it does not you are pushing to hard. Ease up just a little bit! If you perform your stretching routine regularly throughout the day things should feel the same each time you do them. If things get a little sorer as you repeat the routine, then reduce the stretching program by about 50% for a day or two (and consult with your therapist).

General Principles:

Warm up: Warm muscles are looser, more comfortable, and easier to stretch out than cold ones. If you have been sedentary for any length of time then it is a good idea to warm or loosen up before you stretch. Taking a brisk 5 minute walk, ride on a stationary bike, or elliptical is all it takes.

Perform all stretches slowly and gently: The more rapidly the stretches are done the more they fight the movement, thus increasing the likelihood of straining the tissues. Start with a short stretching interval and gradually increase the time the stretch is maintained as your body adjusts to the new activity. The most effective stretches are those that are performed slowly and for a long period of time. Gradually increase your stretches to 10-30 seconds of longer.

Pain free: Do each stretch carefully, avoiding the tendency to rush or push too far. Move slowly and only try to increase the range as your flexibility increases. Any time you stretch the muscle too far, your body responds by sending a signal to the muscles to contract to prevent from being injured. Therefore, when you stretch too far, you tighten the very muscles you are trying to stretch!

Repeat: each exercise 2-3 times before moving on to the next stretch. Remember to perform an equal number of repetitions on each side; this keeps your muscles in balance.

Do not be discouraged: If you find the exercises somewhat demanding at first or that your flexibility is not improving as rapidly as you had hoped. Your body will yield gradually and it will become progressively easier to achieve the same degree of stretch.

Maintenance: When you have normal movement and the emphasis is on maintaining what you have. The stretches are still performed in the same manner; however, they only need to be completed 2-3 times per week.

 

CARDIOVASCULAR TRAINING – AEROBIC

 

One of the major limiting factors in the ability to perform work/exercise is the capacity of the cardiovascular system to deliver oxygen to the working tissues.
Aerobic activities are those that work the large muscle groups in a rhythmic fashion and keep you breathing hard for 20-30 minutes. Aerobic exercises include but are not limited to brisk walking, jogging, cycling, swimming, and skating. The important thing is to find an activity that one enjoys and will perform regularly.

At rest, approximately 15% of cardiac output goes to the skeletal muscles. This can increase to as much as 80% during high intensity exercise.

Aerobic exercises are occasionally referred to as anxiolytic, that is, anxiety reducing. This is because they create many positive chemical changes in our body (i.e. the Runner’s high). They burn off the chemicals created by the fight or flight response that remain unused, as well as stimulate the production of the body’s own morphine-like substances. These substances, called endorphins, are responsible for creating the “runner’s high”, the euphoric feeling associated with aerobic exercise.
The most reliable way for you to monitor the intensity of your aerobic exercise program is to learn how to monitor your heart rate. To measure your heart rate, place the first two fingers over the pulse at your neck or wrist. Alternatively, personal heart rate monitors can be purchased for as little as $50-60.

There are three kinds of heart rate you should be aware of before beginning an exercise program:
1. Your maximum heart rate (MHR) is the theoretical maximum rate at which your heart should beat. It is typically calculated by subtracting your age from 220.
2. Your resting heart rate (RHR) is the rate at which your heart beats before you get out of bed. Record your resting heart rate on at least three separate occasions and record it.
3. Your target heart rate (THR) is the range in which you should keep your heart rate while exercising.

Remember, your RHR is measured before you get out of bed, so have a watch with a second hand nearby. Alternatively, you can measure your heart rate after you have been sitting quietly for 5 minutes.

An aerobic program usually has three components to it. The first five to ten minutes are a warm up period in which the heart rate remains below the THR. The middle period, which will last approximately 20 minutes, is performed in the THR. Finally, the last five minutes is a cool down period, again below the THR.
It is unrealistic to expect to progress from a sedentary lifestyle to a regular exercise program in one leap. An aerobic program should start at a low intensity and for a short duration. Gradually but systematically increasing the time and intensity for a period of weeks (pacing), will minimize any discouraging increases in pain level, and lead to a greater likelihood that you will be able to stick with it.

Target Heart Rate Zone:

Depending on your fitness level, you need to work at 60-80% of your maximum capacity to give your cardiovascular system a meaningful workout. The easiest way to calculate your exercise intensity is to subtract your age from 220 and multiplying it by .60, .70 or .80. If you are just starting out it is better to start at the lower level of 60% and gradually increase your workload. For example; if you are 40 years of age your Target Heart rate is 220-40=180x.60=108 beats/minute.

Quick Guide: Heart Beats per minute

	60%	70%	80%
20-25 years	120 BPM	140 BPM	160 BPM
26-30 years	114 BPM	133 BPM	152 BPM
31-35 years	111 BPM	130 BPM	148 BPM
36-40 years	108 BPM	126 BPM	144 BPM
41-50 years	102 BPM	119 BPM	136 BPM
51-60 years	96 BPM	112 BPM	128 BPM
61-70 years	90 BPM	105 BPM	120 BPM

 

 

For a more accurate method of calculating your target heart rate, use the Karvonen method:
220 – Age = Maximum heart rate
Maximum heart rate – resting heart rate = heart rate reserve
Heart rate reserve x training % + resting heart rate = target heart rate
Example: 60 year old with a RHR of 60 who wishes to train at 70%
220 – 60 = 160
160 – 60 = 100
(100 x 0.7) + 60 = 130 BPM

A very good explanation of how and why can be found at:

http://www.briancalkins.com/HeartRate.htm

 

BALANCE AND PROPRIOCEPTION

 

Human balance is maintained through a very complex process. In order to maintain their balance a person must continually acquire information about the body’s position and trajectory in space. This is accomplished through the sensory system. Next, the body must determine in advance an effective and timely response (central processing). Third, the body must carry out that response via the effector (musculoskeletal) system. This subconscious awareness of where our body is, and our ability to move safely and effectively is not limited to just “Balancing”. It affects every movement and activity we perform.

Think of it this way: With your eyes closed – touch your finger to the tip of your nose. You were able to do this because three things worked together; 1) the sensors in your finger accurately told your brain where it was (sensory system), 2) your brain was able to tell your muscles what to do (central processing), and 3) your muscles were able to carry out the instructions(musculoskeletal system).

When we have an injury: at least one and possibly all three no longer work properly. Even if the injury heals completely and you are pain free, your balance and proprioception does not come back automatically. It must be retrained! This is why so many people who have sprained their ankle on one occasion, continue to do so more and more easily as time goes by.

Proper proprioceptive responses are essential in the prevention of loss of balance injuries, especially in the aging population. Approximately 1/3 of elderly individuals fall each year, with about 1 in 20 resulting in a serious injury. In the United States of America approximately 250,000 people fall and fracture their hip each year. It has been shown that, in healthy people as old as 90, training can reduce their tendency to fall by 50%.Another study has shown that daily proprioceptive training performed on a wobble board can reduce the incidence of ACL rupture by 19%.

Deficits in balance and proprioception can be determined through a large variety of both static and/or dynamic balance tests. The most common tests performed by physical therapists are 1) static balance tests such as the ability to stand on one leg and 2) dynamic tests such standing on a balance board. The difficulty with most of these tests is that they are subjective and do not differentiate between balance deficits due to sensory and motor deficits. For the most part, treatment in a private rehabilitation facility is geared to a patient population with a compromised musculoskeletal system and an intact neurological system. When a joint is injured there is a decrease in the mechanoreceptor function and proprioceptive feedback to the brain. This inhibits properly coordinated muscular effort and results in an altered perception of the body-space relation.

Balance can be improved dramatically by stimulating the soles of your feet. Perform the exercises in bare feet. Stand on a rough textured surface such as Berber carpeting. Another handy trick is to learn the short foot position. The analogy for understanding the short foot position is to imagine what it is like to palm a basketball and then imagine palming the floor with your foot. That is to say, you are gripping the floor with the ball of your foot without squeezing your toes.

Before starting any balance routines, warm-up for a few minutes and then perform a light stretching program. In the beginning, focus on developing smooth controlled movements rather than lots of repetitions. Perform the exercises when you are not fatigued. Balance activities require that the nervous system be well rested. Be sure to carry out the activities with the knees slightly flexed (In an athletic action position). The difficulty can be increased later on by adding weights to the hands, closing the eyes etc.

Test yourself: Place your hands on your hips. Stand on one leg, while placing the opposite foot on the stance leg. Stop timing yourself if you have to take your hands off your hips or the foot off the opposite leg. You can repeat the test up to three times, and give yourself the best of the three scores.

 

 

 

L	Stork Test	R
	>50 Seconds: Excellent
	40-50 Seconds: Above Average
	25-39 Seconds: Average
	10-24 Seconds: Below Average

 

 

Standing Proprioception Balance Exercises

1. Stand in a doorway with both feet together, eyes open, and arms outstretched for balance. Hold on to or lightly touch the door frame only as much as necessary to maintain good technique. You should feel stable and confident before progressing to single leg stance.In the single leg stance, lift the opposite leg up from the floor as if you were going up the stairs. You can lift this leg up as high as you feel comfortable doing so.
2. Progress to standing in a doorway with both feet together, eyes closed, and arms outstretched. Progress to single leg stance.
3. Marching in place – shift your weight to one side and slowly lift the opposite leg up to 90 degrees. Slowly shift the weight back and forth from right to left.
4. Lunges: Place one foot approximately 18 inches in front of the other; shift your weight back and forth from one foot to the other – maintaining your balance the whole time. Switch feet to do an equal number of repetitions in each direction. This exercise can also be performed side to side.
5. Hurdle walk; step over objects and then pause in the one-legged balance. Then repeat for the next step.

Each exercise is performed for up to 50 seconds,or until you are beginning to experience fatigue or discomfort. Repeat each exercise one to three times. When you are able to complete the exercise pain free and with appropriate proficiency for 50 seconds, progress to or add the next exercise.

 

PHYSICAL CONDITIONING – MUSCLE STRENGTHENING

 

The human body is a mechanical device that designed to move and be used. Without movement and activity the body will become progressively more deconditioned. In addition movement is essentially to the healing process.

When we are injured and unable to remain active, we will typically lose 1-3% of our muscle strength per day in the injured area. This means that in a 4-6 week time frame you can lose as much as 30 to 40% of your strength. There is good evidence that a daily strengthening program can help prevent this deconditioning, increase your function, and decrease pain perception. The program should be designed to target all the major muscle groups, while at the same time minimizing changes in body position to perform them.

Your Danger Alarm System is hardwired to react to injury/pain in a fairly specific pattern. The general pattern of reaction is fairly consistent in all people, such as the fetal position we go into when in pain. This occurs at a subconscious level, in other words you have no direct control of it.
How this general patterning is actually expressed in any individual is a function of their specific strengths and weaknesses, physical variables, previous sports and leisure activities, and other adaptations. The general pattern of reaction results in:

1. Changes in joint mechanics
2. Changes in the range of motion of the joints, both hypo (stiff) and hyper (loose) mobility
3. Changes in proprioception (our subconscious awareness of where our body is in space) input (garbage in).
4. Impaired reciprocal inhibition.
5. Altered programming of movement patterns (garbage out)

If a postural muscle such as Ileopsoas (hip flexor) becomes shortened from overuse, not only will it limit the range of motion of its antagonist (opposite) muscle, the gluteus maximus, but it will also neurologically inhibit (make it weak) its action as well. Other muscles, such as the piriformis become over active (spasm) to help compensate.

As a result of this change in activity, over time we develop significant muscular imbalances and poor postural habits. Even if the pain or injury is resolved, this new way of functioning has become hard wired into our nervous system (New muscle memory), and so becomes self perpetuating. In the long term these changes in muscle function and patterning actually increases the stress to the injured area. This can often result in a vicious downward spiral, in which less and less stress is required to provoke pain, and it requires longer and longer periods of time to recover, independent of your injury.

 

Principles of Strength Training

Develop conscious awareness of your posture, especially the neutral position of the injured body part, and how it moves. After any injury lose our proprioception – our subconscious awareness of where our body is in space. This deficit does not return automatically when the injury has healed.

Learn to isolate and retrain the weak and inhibited muscles. Focus on developing muscular endurance rather than muscle strength. As an example: perform the exercises 10 times and hold for 10 seconds.

You must develop good balance and proprioceptive sense. Proprioception is the term used to describe the body’s ability to know where it is in space without looking. Nerves travel from the joints and surrounding soft tissues back to the brain. These nerves carry electrical signals which give feedback to the brain as to the body’s position in space. Based on this feedback information, the brain then decides how it needs to move the body part in question to either properly adapt to the current environment or perform the required/desired movement.

Make the skills transferable and build whole body strength and stability. Up until this stage the majority of the exercises are performed lying down, or in an isolated manner. This does not necessarily mean you can apply these skills in the real world (when you are standing, moving etc.). This also means integrating exercises involving the upper and lower extremities as well as your core into your exercise program. As much as possible these should be functional activities i.e. they should mimic the activities that we perform on a regular basis, whether this is for home, work, or play. It is important to use appropriate spine sparing strategies while doing this.

Build Strength. You can be the most coordinated person in the world and technically have terrific muscle endurance joint and stability. However, if you are a “98 pound weakling” you are still going to have problems.

 

1. Do not be alarmed if you experience some minor muscle fatigue or soreness when you first start the exercises. This should subside within a day or two, and is a normal reaction to the increased activity level. Extreme muscle soreness the next day however probably indicates you did too much. The following recommendations are suggested:
   • The exercise should never be painful to perform
   • You should not need to lie down to rest, or take any analgesic medications following/because of the exercises
   • You should feel sufficiently recovered the next day to perform the exercise routine all over again. It is not necessary to perform a strengthening program on a daily basis. You should just feel good enough that you can!
2. Before beginning your strengthening program, it is best if you have prepared the muscles by warming up, followed by releasing techniques such as using a foam roller.
3. Perform the exercises on a regular basis. Muscles tend to ignore of resist any exercise program that is not performed on a regular basis.
4. A complete exercise program can be designed so that it does not require any sophisticated training equipment. However, obtaining some light hand held weights or equivalent resistance device, such as a rubber band, will help you obtain maximum benefit.
5. Evaluate your current baseline for each exercise.
6. Progress your program according to the pacing and shaping guidelines Set SMART Goals!
7. Keep an exercise flow sheet so that you can objectively chart your progress. Work with a friend to keep you motivated. Remember, quality is more important than quantity.