Tag Archives: acl rehab

Resistance Training Guidelines & Exercise Progression in Injury Rehabilitation

Adjusting resistance level of inverted rows (No, that’s not me – notice no bald spot!)

As rehab and fitness professionals, it is crucial that we know why we do what we do. Always be able to answer if someone asks “why?”. One of the awesome things about our profession is that, in rehabilitation and strength training, there are many successful approaches to obtaining great outcomes. Throughout my career I have seen a wide variety of rehabilitative approaches used by the physical therapists and athletic trainers I’ve worked with and known. It is very true that there is no “one way” to obtain positive results with your patients. The art of successful injury rehabilitation is not only “what” you know, but more importantly how you apply what you know (i.e you bridge the gap between knowledge and application). I also believe that, out of fear of increasing pain and setting back the healing process, many times rehab clients may not “pushed” and stressed as much as they could be in terms of developing strength and power (safely, of course, without increasing pain or dysfunction). This concern can be solved by reviewing evidence-based basic resistance training guidelines. I’m going to review an evidence-based approach that I used successfully, specifically in regards to rehabilitating athletes and persons looking to return to the healthy lifestyle they had prior to the injury. Bear in mind, however, that most of these principles are not just appropriate for “athlete” rehab. The four components I wish to discuss are:

  1. Preparing the body for reconditioning (the “dynamic warm up”)
  2. Sequence of Exercise Modes
  3. Work:Rest Ratios
  4. Resistance Training Load Prescription

Preparing the body for reconditioning (the “dynamic warm up”)

Dynamic warm up (DWU) for movement/exercise preparation actively readies the body tissues for the demands about to be placed upon them. In other words, it provides a “wake up” and “rehearsal” for the body. In doing so, you stimulate both a neuromuscular and cardiovascular response. Proper DWU raises core body temperature, increases muscle elasticity, decreases inhibition of antagonist muscles, and stimulates the nervous system. Additionally, especially in the case of athletes, there is an emotional and psychological stimulus for increased levels of activity. There is plenty of research demonstrating the use of a proper DWU:

Rationale:

  • Improves flexibility, coordination, balance, proprioception, and movement speed
  • Decreases chance of injury during training/competition
  • It serves as an excellent tool for concentrating on teaching movement/skill technique (i.e. this is where your “corrective exercises” come in)
  • On the contrary, static stretching has been shown to decrease muscle strength/force production at both slow and fast velocities, anywhere from 10 mins-24 hrs later, as well as plyometric abilities

Gradual progression example in a rehab setting*^:
Low intensity non-impact general warm up (i.e. bike/UBE) → Core/Neuromuscular activation → Joint mobility/dynamic flexibility → Dynamic movement prep → “Build Up” Agilities/Plyometrics (i.e. General linear prep → General multidirectional prep).

*Gradual progression within this from low intensity → high intensity
^ When warranted, modalities and manual therapies are performed prior to starting (as well as when isolated concerns arise during training, i.e. ankle dorsiflexion mobilizations to improve a squat pattern dysfunction)

Sequence of Exercise Modes

In order to obtain the most benefit from utilizing various modes of exercises in rehabilitation, it is important to have an idea of the recommended proper sequence based on research and rationale. If client has 1 or 2 areas (of the distinct areas listed below) of impairment or disability, it is recommended to focus on these areas first, and then supplement “accessory areas” afterwards. If taking a more global approach, a more specific progressive approach as I’ll outline has been shown to be effective in maximizing the cumulative benefits gained through each method of exercise towards the overall goal(s) of your rehabilitation. In other words, you are less likely for one preceeding exercise to have a detrimental or “limiting” affect on a following exercise. Example: you don’t run a long distance workout before performing a plyometric power workout if your goal is to improve power– your power “output” will suck.

Progression guidelines*

*NOTE:  These are after/not including the DWU.  Not all of these areas need to be addressed in every rehabilitation session. This provides a logical sequence to administer therapeutic exercises as appropriate in the event that all were performed in one session.

1) Dynamic Mobility/Warm-up (as outlined above).  For specific example, see here.

2) Agilities
– Motor learning/technique work (i.e. functional agilities such as stops, ladder footwork)
– Linear  (Assisted/BW → Resistance)
– Multi-directional (45 deg COD → 90 deg COD → 135 deg COD → 180 deg COD)
– Assisted/BW → Resistance
– Practical agilities (i.e. real-life movement and situational drills, planned à unplanned               reactions)

3) Resistance exercises/plyometrics for power

4) Resistance exercises for strength
a) Power → Non-power exercises
b) Large muscle areas → Small muscle groups
c) Multi-joint exercises → Single-joint exercises

Muscular Endurance Exercises
a) Large muscle areas → Small muscle groups
b) Multi-joint exercises → Single-joint exercises

5) Balance/Proprioception
– Static → adjust plane of movement → adjust speed of movement → add dynamic external stimulus → change terrain

6) Static Stretches

Work:Rest Ratios

Newsflash:  3 x 10 with 30 second rests, all the time/every session does not cut it. Please read that 3 x 10 times today. Your client will not gain muscle strength and functional power with this approach, setting them up for future re-injury. We need to recondition strength and power, not just muscle hypertrophy and endurance. Proper reps, set, and rest period prescription can have a huge impact on successful outcomes. It is important to remember that rest periods differ based on your training goal (i.e. strength/power vs. muscle endurance). Typically, rest periods are inversely related to load: heavy load = longer rest period. I’ve heard the argument that “I don’t want my patient just sitting around that long between sets – I have to maximize their time in the session”. Well, I agree. That’s why we prescribe “accessory” exercises to perform using different body regions/neuromuscular systems to serve as “active rest”. Superset that . An example would be using a single-leg Romanian deadlift coupled with a plank variation, or a balance/proprioception exercise between shoulder strengthening sets. Treat the body, not just the body part

Rest Period Length Based on the Training Goal
Training Goal Rest Period Length b/t Sets*
Strength 2-5 minutes
Power 2-5 minutes
Hypertrophy 30 – 90 seconds
Muscular Endurance 30 seconds or less

* Multi-joint requires longer rest than single-joint

Training Specific Energy Systems
% of Max Power Primary Energy System Stressed Typical Exercise Time Work:Rest Ratios
90-100 Phosphogen 5-10 sec 1:12 to 1:20
75-90 Fast Glycolysis 15-30 sec 1:3 to 1:5
30-75 Fast Glycolysis and Oxidative 1-3 min 1:3 to 1:4
20-35 Oxidative > 3 min 1:1 to 1:3

In terms of day-to-day rest, here are some recovery guidelines*. When performing plyometrics, lower intensity drills can be performed 3-4x/week (minimum 24 hrs recovery time; example = technique drills or jumping rope). Moderate intensity plyometric drills can be performed 2-3x/week (36-48 hrs recovery time; example = medicine ball throws or band resisted exercises).  Higher intensity, high shock drills should be performed no more often than 2x/week (72 hours recovery time; ex: high box jumps or max effort bounding). *Disclaimer – it’d be fine to do upper extremity plyos one day and lower extremity the next day – rest times are referring to a specific muscle group/body region being stressed). With regard to resistance training, training for strength should be performed on non-consecutive days for muscle group. When training for balance, proprioception, core stability, and muscular endurance, it is typically fine to perform these on a daily basis without concern for overtraining.

Resistance Training Load Prescription

In addition to proper rest periods, variation and progression of load is also key to successful outcomes. This is especially important when the client is strength training on a regular basis.  Every day should not be a “heavy stress” day (100% of the load). In order to avoid overtraining and plateaus, it is important to mix in some “medium stress” days (90 % of the load) and “light stress” days (80% or less of the load). In terms of progression of the training load, I typically follow the “2-for-2” progression rule. Let’s use this example: goal is 3 sets of 8 reps for a dumbbell bench press. I will increase resistance load when patient demonstrates the ability to perform 10 reps on the third set for 2 consecutive instances.

There is also some debate about the use of multiple sets vs single sets. Single sets may be more appropriate for untrained individuals and when performing a muscular endurance/high rep set. Multiple sets are more appropriate for intermediate/advanced persons, showing better long-term gains. Studies have also shown that multi-set without failure tends to be more effective over time vs. single set to failure.

Load and Repetition Assignments Based on Training Goal
Training Goal Load (% 1RM) Goal Repetitions
Strength 85+ < 6
Power:        Single-effort eventMultiple effort event 80-9075-85 1-23-5
Hypertrophy 67-85 6-12
Muscular Endurance < 67 > 12

Repetition Max Continuum (Baechle & Earle, 2000)

rep max continuum

One of my most common recommendations I make to athletic trainers and physical therapists is for them to take a portion of their annual CEUs through courses geared towards fitness/performance training. I’ve personally learned a ton this way, much of which I have worked in cohesively with my sports medicine/rehab background to improve my outcomes! Challenge yourself by questioning the rationale behind your approach. This is the best way to continually improve!

P.S. I apologize for the length of time between this and my last post.  Baby #3 joined the family recently, so I’ve been both sleep deprived and busy 🙂

Thanks for reading!
Ryan

RStevensATC@gmail.com

References:

  • Annaccone AR.  Balance of Power.  Adv for Dir Rehab.  21-24; Aug 2007.
  • Baechle, T.R., & Earle, R.W. (2nd ed.). Essentials of Strength and Conditioning. Champaign IL, USA: Human Kinetics. 2000.
  • Chu DA, Cordier DJ.  Plyometrics – Specific Applications in Orthopaedics.
  • Fredrick GA, Szymanski DJ.  Baseball (Part I): Dynamic Flexibility.  Strength & Cond J.  Vol 23 (1): 21-30; 2001.
  • Groner C.  Stretching…Out?  Biomechanics.  Oct 2004.
  • Howard RL.  Plyometric Concepts Reinvent Lower Extremity Rehabilitation.  Biomechanics.  Sept 2004.
  • McClellan T.  Big Jumps.  Training & Cond.  Vol 3 2007.
  • McMillian DJ, Moore JH, Hatler BS, Taylor DC.  Dynamic vs. Static-Stretching Warm-up:  The Effect on Power and Agility Performance.  J of Strength & Cond.  20(3): 492-499; 2006.
  • Myer GD, Paterno MV, Hewett TE.  Back in the Game.  Rehab Management.  Oct. 2004.
  • NSCA Certification Commision.  Essentials of Strength Training and Conditioning. 2005.
  • Pitney WA, Bunton EE.  The Integrated Dynamic Exercise Advancement System
  • Technique for Progressing Functional Closed Kinetic Chain Rehabilitation Programs.  J of Athletic Training.  Vol 29 (4): 297-300; 1994.

 

ACL rehab and return to play protocol: My approach

Anterior Cruciate Ligament (ACL) reconstruction rehabilitation: what’s your stance?  There are tons of different protocols and guidelines out there, and I recognize and respect that there are lots of successful approaches.   As part 3 of my series (in case you missed, here’s part 1 and part 2) on the ACL, I’m sharing my personal perspective and experience in rehabilitation post-surgery.  What I’m going to share is a regularly and thoroughly-reviewed approach that I’ve developed over the last 12 years, through a combination of mentors, research, and experience.  One thing I really like about it is the focus on goals and objectives in each phase, regardless of rehab exercise choice.  The reason I want to share my approach – being straight-forward: I’m extremely confident in my approach to ACL rehab, and I want to help others to have this same success.  This is based on the highly consistent positive outcomes (both short- and long-term) of the many that I’ve guided back to beyond their normal activity level as well as positive feedback from my colleagues and peers.  (Warning to the “Joes”, from here on out it may get a bit technical!)

Pre-operative “pre-hab”:  I’ve found the following to be an ideal “jumpstart” to an easier first few months post-op.  The amount of time b/t when the injury occurs and surgery can be anywhere from a few days to a few months.  Use this “pre-hab” time wisely! Exercises

used here are dictated by the pain level,  effusion amount, and injured structures involved.

  • Pre-op goals:
    • Full ROMsingle-leg-squat on box
    • Minimal swelling/effusion
    • Address any hip/lower body strength imbalances (esp. quads and hamstrings)
    • Improve proprioception and balance
    • Patient education – biomechanics, pain management, expectancies of operation/rehabilitation

Now it’s time for surgery.  Following surgery, it is imperative that the overseeing physician(s) and rehabilitative team communicate regarding which structures were damaged/repaired and any special post-surgical restrictions to ensure safe and effective post-surgical rehabilitation with minimal (if any) setbacks.

    • Special considerations:
      • When electing surgery using a hamsting (HS) tendon graft, avoid active isolated HS exercises until 2 weeks post-op, and wait 4 weeks before using open-kinetic-chain (OKC) resisted HS.
      • When electing a patellar tendon graft, main concern is monitoring and addressing signs/symptoms of patellar tendonitis if/as they arise.
      • If surgery involves a repair of meniscus, lots to consider.  Note that I said “repair”, not simply a scope and shaving.
        • Brace locked at 0 deg for first 4 weeks while walking.  Non weight-bearing (NWB) 0-2wks –> partial weight-bearing with crutches (PWB) week 3 –> Full weightbearing (FWB) starting week 4.  Unlock brace for gait after week 4.
        • Range of motion (ROM) only to 90 deg knee flexion until 4 weeks, then progress as pain-free (to avoid “pinching” repaired meniscus).
        • No isolated HS contraction when posterior horn repair (risk of pulling on repaired structure) for 8 weeks.
        • Squat/Lunge Depth:  Avoid bodyweight squatting/lunges > 60 deg knee flexion until 8 weeks; stay < 90 deg flexion until 12 weeks; avoid with rotation/twisting at knee until 16 weeks.  Also delay single-leg squats/leg press until beyond 6 weeks
      • Involved MCL repair, brace 4-6 weeks, progress ROM as pain-free.  No OKC HS for 6-8 weeks (since the medial hamstring tendons cross the ligament and “pulling” can impede healing).
      • Involved lateral-collateral ligament (LCL) repair, limit knee ROM 0-30 deg for 3-6 weeks, dependent on the extent of repair.  Often when LCL or MCL is involved and not being repaired surgically, surgeon will elect to delay ACL surgery for up to a month to give the LCL/MCL ligament a “head-start” on healing.
      • Injury involved Posterior Cruciate Ligament (PCL) tear? No OKC active isolated hamstring exercises for 4 weeks following injury.

Ok, so now surgery has happened and it’s time to rehab.  What next?  Post-op, the rehab team should provide monthly progress notes to the overseeing physician until discharged. Also, as noted in parts 1 and 2, maintain awareness of any psychological/emotional/social concerns during recovery process and offer assistance.  Refer to a counselor if needed.  The following 5 phases are discussed assuming a straight-forward ACL repair and none of the above noted modifications are needed.  Pre-protocol BONUS point:  Make sure to check out the “Load/Repetition Assignment Chart” at the end of this blog.  One of the biggest misjudgements of exercise prescription post-ACL (and in a lot of other rehabs for that matter) that I see is improper loading based on the goals of the phase.  Why is someone STILL performing 3 sets of 10 straight leg raises with an 8# cuff weight at 10 weeks post-op??  As rehab professionals, we MUST know the load/rep continuum when prescribing our exercises.  Far too many times, patients are not pushed as hard as necessary to overcome the deficits that they have in a timely (if at all) manner.  Maybe it’s a fear of producing a “setback”?  Well if the tremendous positive outcomes I have with my s/p ACL clients is any indication, some rehab pros need to respectfully get over that fear (while still using proper evaluative judgement).  Yes, you absolutely can heavily load someone’s squat and deadlift through phase 3 and 4 (if you’ve progressed them properly leading up to it)!  While we are on the topic…PROGRESS THOSE HOME PROGRAMS regularly.

Phase 1: day 1 to 2 weeks

  • Goals: Protect graft and graft fixation, decrease pain and swelling, control inflammation, active ROM 0-115 deg, regain quad NM control and patellar mobility, and patient educated on home exercise program for phase 1 and wound care.
  • Limitations: WB as tolerated with 2 crutches, brace locked in full ext for walking and sleeping, and no OKC knee extension resisted exercises
  • Orthotics:  I recommend an accommodative foot orthosis once full WB to limit subtalar joint/midfoot overpronation –> tibial rotation –> stress to graft.  Discontinue @ 3 months if desired and if gait mechanics are OK).

Some phase 1 ther-ex ideas:

  • Complimentary upper body and core workout (“6-sided”) program modified to protect ACL
  • Quad re-ed: Quad Setting w/ Russian NMS, Stick/MFR to quads, Kinesiotaping
  • Patellar mobility
  • P/A/AAROM in appropriate range based on limitations (strap, AA off end of table, AA w/ bike)
  • Stretches (Thomas, Gastroc, HS)
  • Weight ShiftsHip_Abduction wall slides
  • Mini Squats/Mini lunges
  • 4-way ankle, seated/standing heel and toe raises
  • 6-way hip (standing march, standing HS curl, Supine SLR Flx, S/L SLR Abd/add, Bent-over SLR Ext
  • Gait training w/ crutches (forward, backward, side step)

Phase 2: 2 weeks to 6 weeks

  • Goals: Regain normal gait mechanics (2 crutches –> 1 crutch –> D/C crutches as gait mechanics return), AROM full by 6 weeks, patient educated on HEP for phase 2, progressively regain strength and endurance in hips, quads, HS, and low leg with PREs as appropriate to prepare for functional activities, improve balance and proprioception, hip/ankle/patella mobility WNL and equal bilateral, and no increased knee pain or swelling during/after exercises
  • Limitations: No OKC knee ext PREs, and brace worn for ambulation (off for rehabilitation) until acceptable quad NM control and dynamic balance achieved
  • Some ther-ex ideas for phase 2:
    • Continue Phase 2 ex as needed (and only if needed!)sit to stand
    • Complimentary upper body and core workout (“6-sided”) program modified to protect ACL
    • Bike
    • Begin leg press and step up/step down progression @ 4” (Fwd, Lateral, Retro)
    • Begin squat progression (i.e. chair sits, variable load position, assisted –> unassisted)
    • OH squatBegin lunge progression (assisted –> unassisted, multidirectional)
    • Single leg and 2-leg balance exercises/weight shifts
    • Gait training w/o crutch (Fwd, bckwd, side step), progressing to resisted/variable incline gait training
    • Functional ADL training: stairs (fwd/bckwd), functional lifting patterns (i.e. deadlift)

Phase 3: 6 weeks to 12 weeks (maximum protection phase)

  • Goals: Maintain full, normal ROM, improve confidence in knee, progressively regain strength and endurance in hips/quads/HS/low leg with PREs as appropriate to prepare for functional activities (appropriate rep/load ranges), improve dynamic balance/proprioception/core stability, progress from bike to non-impact standing aerobic conditioning (elliptical, Stairmaster), aquatic jogging at 8-10 weeks <50% WB (when available and if wounds fully healed)
  • Ther-ex ideas:
    • Continue Phase 1& 2 ex (only if needed, otherwise move on)
    • Scar desensitization/patellar mobility
    • Progress bilateral and unilateral squat variations1-leg dead lift
    • Progress deadlift variations1-leg dead lift1-leg dead lift
    • Progress multidirectional lunge variations
    • Progress dynamic balance exercisesplate squat
    • Progress core/glute/lateral hip stabilizers (hip hikes, mini band walking, bridging/plank/side plank series, RNT)
    • HS strengthening (esp. eccentric): RDLs, seated HS curls, Ball/TRX curls, Russian hamstrings
    • Jogging prep -“Non-impact” jogging, elliptical, Stairmaster, bike sprints

Phase 4 : 12 weeks to 20 weeks – Before progressing, perform 3 month functional knee assessment (see Index)

    • Expectations at 12 weeks:
      • Knee AROM WNL and pain-free
      • 12” Lateral Step Down technique correct, symmetrical, and endurance within 10% of unaffected leg
      • Quads strength and endurance within 20% of unaffected
      • HS strength and endurance within 10% (may be delayed when limited by posterior horn lateral meniscus and/or MCL/LCL involvement)
      • Dynamic balance within 10% of unaffected leg
      • Girth within 5% of unaffected (mid patella, 3” superior to patella, 1/2 way b/t patella and ASIS)
      • Core stability endurance w/i 5% ant/post/right/left (Goal = 90 seconds)
  • Phase 4 Goals: Develop good dynamic hip/knee/ankle strategy, initiate progressive intensity/volume jogging program as appropriate, modified “Couch to 5K” progression (see index), initiate progressive plyometric program (as appropriate) focusing on training force absorption NM control, and initiate progressive intensity agilities (linear –> multidirectional) as appropriate.
  • Limitations: Can utilize OKC knee ext in the range of 90-30 degrees after week 12 (focus on eccentrics and utilize resistance point more proximal on tibia), and be cautious of impact training volume, avoiding recurrence of swelling/loss of motion.
  • Ther-ex ideas:  
      • Continue Phase 1-3 ex as neededplyo-squat-jumps
      • Address any “less than ideal” 12-week functional knee assessment findings
      • Force absorption/creation training: (quick drops, quick hops, jump/landing training)
      • Jogging progression (see index)
      • Continue to address any remaining LE strength deficits,
        with focus on strength and power development (8 or less rep range, appropriate loads)

Phase 5: 20 weeks and beyond: now it’s time for the 5 month “Functional Knee Assessment (see INDEX)

        • Expectations at 20 weeks:
          • No patellofemoral or soft-tissue complaints (if present, must be minimal and patient effectively able to self-manage).
          • 12” Lateral Step Down technique correct and symmetrical, and endurance equal bilateralmovement-skills
          • Normal gait (walking and running) mechanics and appropriate dynamic biomechanics (jump/landing technique, avoidance of dynamic genu valgus, postural proprioceptive control)
          • Functional Movement Screen score >15/21 with no scores of “1”
          • Dynamic balance symmetrical
          • Quads and hamstring strength and endurance within 5% of unaffected leg and HS/Quad ratio b/t 65-75%
          • Core stability endurance w/i 5% ant/post/right/left (Goal = 90 seconds)
        • Phase 5 Goals: Progressive, full return to beyond pre-injury speed/agility/power/conditioning and level of activity/sports with goal of full return to sport at 6-9 months (return to sport time-frame varies dependent on risk of sport and age/physical maturity/injury history of athlete).  Resolve any residual lower extremity weaknesses or functional deficits noted in a full functional movement assessment, and educate patient regarding maintenance home exercise program, progression of training volume (varies per sport/activity), and any possible remaining limitations.
        • Bracing:  I recommend the use of a knee brace for 1 year for contact/potential-contact sports

FInally, here’s the phase 5 return-to-sports volume progression that I use.  This will vary per sport, athlete age, and injury history.  It’s important to continue to incorporate strength, power, balance, and core training into routine weekly.  In the event that mild swelling or knee pain occurs that lingers constantly for more than 2 days, no practice/games for 3 days.  If symptoms resolve, return to play as instructed.  If symptoms do not resolve, follow-up with sports medicine team.  The athlete only moves on to next “phase” if able to tolerate current phase without swelling or knee pain occurring.  I also remind them that it is normal to feel “achy” in knee during times of increased intensity and volume more than normal, especially around patella and in area of scar.  As long as this does not cause swelling and ceases shortly following activity, there is no reason for concern.

      • Weeks 17-20 (Month 5):
        • Focus on improving multidirectional agilities in a controlled setting (no “live” drills @ practice)
        • Focus on increasing speed, power, endurance, and improving sport-specific skills
      • Weeks 21-24 (Month 6):
        • Gradual return to sports/practice participation
        • “1 on, 1 off” practice schedule:
          • This pertains to “live” drills, and not sprints/aerobic conditioning or controlled-intensity skill work.  This means that every other practice, athlete takes part in “live, game-like drills”.
          • In game-like scrimmaging, volume is limited to no more than that equal to ¼ of a full game
          • No participation in games
      • Weeks 25-28 (Month 7):
        • “2 on, 1 off” practice schedule first two weeks, then “3 on, 1 off”.
          • This pertains to “live” drills/scrimmaging at practices, and not sprints/aerobic conditioning or controlled-intensity skill work.
          • In game-like scrimmaging, volume is limited to no more than that equal to 1/2 of a full game for first 2 weeks, then ¾ of a full game next two weeks
          • No participation in games 1st two weeks, then playing no more than ½ of game next two weeks
      • Beyond week 28 (Month 8):
        • Full practice/game participation.  No restrictions.  Continue to work on balance, strength, flexibility, and conditioning in conjunction with sport-specific skills.

INDEX:  For a full description of my 3 month and 5 month post-ACL “Functional Knee Assessments”, my modified “Couch to 5K” jogging progression, and references, here’s a downloadable version of my ACL rehab and return to play protocol.

Load/Repetition Assignments Based on Training Goal

 

Training Goal

Load

(% 1RM)

Goal Reps

Strength

85+

< 6

Power:        Single-effort eventMultiple effort event

80-90

75-85

1-2

3-5

Hypertrophy

67-85

6-12

Muscular Endurance

< 67

> 12

 

Accommodation

50-75

10-15

Re-patterning/NM Re-ed

0-50

>20

Would love to hear your feedback on my protocol!  Questions, comments –> leave them below.

All the best!
RS
RStevensATC@yahoo.com