Cycle-controlled: nutrition and training

“A regular cycle with only moderate symptoms is an important indicator of good general health.” (Welsh Athletics)

“The complexity of the menstrual cycle is seen as a major obstacle to the inclusion of women in clinical trials.” (translated by Bruinvels G et al.)

“Female athletes train and compete under the potential influence of hormonal fluctuations during the menstrual cycle”. (translated by Ekenros L et al.)

The female cycle may be associated with discomfort for many women. Even though regularity with only minor discomfort is synonymous with good health, not every woman is pleased when she is in the bleeding phase. But with the right diet and exercise, we can help ourselves to alleviate, even improve and prevent certain conditions.

For a long time, women took a back seat when it came to conducting scientific studies. And there is still too little emphasis on thinking gender-specifically and taking a closer look at the female body. One of the reasons for this is that women seem to be too complex to be included in studies.

Today, however, we want to look at a topic that is attracting more and more attention in the media, in the field of sport and nutrition and also in science. Because the female cycle can influence our performance, our body and our mind.

Adapting your diet and training to your female cycle may seem challenging at first, but it can bring great benefits for body and mind. More specifically, cycle-oriented means that we adapt our diet and training to the hormonal conditions that change over the course of the cycle.

Physical and mental complaints such as periodic water retention, skin blemishes, exhaustion, mood and weight fluctuations as well as stomach and intestinal complaints can change over the course of the cycle. With the help of apps, we can record these symptoms as well as our menstruation in order to get to know and understand our body better. Anneke uses the Garmin app for this, which also connects to her watch during sporting activities. In her opinion, Clue or Flo are also good apps for recording your cycle and all the associated factors.

What is the most important thing we should know in advance?

Every woman is unique. Our cycle, hormone levels and the associated physical and mental conditions can vary greatly from woman to woman. It is therefore essential that you first observe your cycle and write down in detail (as mentioned above) when your menstruation and ovulation occur, how long the individual phases last and how you feel during them. The more precisely you write it down, the more targeted you can make your diet and training plan afterwards. If you are using hormonal contraception, you have no natural hormone levels, no natural menstrual bleeding (or even no bleeding at all) and usually no ovulation, so there is no point in adjusting under these circumstances.

What does nutrition and training look like in the first phase of the cycle?

The first phase begins on day 1 of bleeding. It is important that we do not count the brown discharge (so-called spotting), which can occur a few days before, as day 1. During the bleeding period, many women are often less able to perform physically due to their symptoms. A lack of iron due to blood loss reduces the supply of oxygen to the muscle, as iron is an important component of haemoglobin in red blood cells and should help with this. Light endurance training, walking, yoga and mobility are recommended. The diet should be rich in iron, vitamin A, magnesium and omega-3. Other women, on the other hand, feel more powerful and may of course adjust their training accordingly.

Follicular phase- Phase 2

As soon as you feel better and your bleeding decreases, your energy level increases. You can set new training stimuli and perform maximum strength training at high intensities. Use the increased oestrogen levels to improve your performance. Make sure you eat enough protein, good fats, fermented and sprouted products. If you want to keep your weight stable, you can reduce your carbohydrate intake.

Ovulation

Some women have similar symptoms to those at the time of menstruation. Slight or even strong pulling in the abdomen, cramps, skin blemishes, etc. You can reduce the intensity of your training and focus more on coordination and stability . This is because we seem to be more susceptible to injury during this phase. Your meals should be rich in calcium, antioxidants, vitamin D and fiber.

Luteal phase- Phase 3

During the luteal phase, progesterone increases while the other hormones decrease. Many women suffer from pre-menstrual syndrome, i.e. water retention, mood swings, fatigue and other symptoms already mentioned above at the end of this phase. A reduced training intensity with a focus on regeneration, gentle strength and endurance units can help. The diet may contain carbohydrates, dehydrating foods, vitamin B6 as well as alpha-linolenic acid (triple unsaturated fatty acids) and ligans (plant substances with an estrogen-like effect).

To summarize, it is worth trying out, but not every woman will benefit from it in the end. Start by keeping a cycle diary and create your training and nutrition plan based on the conditions you have. If you need help with this, you are very welcome to book an appointment with Anneke and/or browse the resources below. Anneke can highly recommend the information from Swiss Olympic! Also consider talking to your coach, colleagues and others about this – they can support you in optimizing your well-being and performance.

If you want to know what your hormone levels are, you can have them determined by taking a blood test. However, you should bear in mind that the values differ depending on your cycle phase.

Finally, we would like to point out that it is always best to check your training and diet with a doctor and, if necessary, with a nutritional therapist who is familiar with the subject. We can share our contacts!

Author:

Anneke Penny

References:

1 Tanja Oosthuyse; Andrew N. Bosch (2010): The Effect of the Menstrual Cycle on Exercise Metabolism. In: Sports Med 40 (3), pp. 207-227. DOI: 10.2165/11317090-000000000-00000.

2 Giuseppe Fischetto; Anik Sax (2013): The Menstrual Cycle and Sport Performance. In: New Studies in Athletics 28 (3/4), pp. 57-69. Hakimi, Osnat; Cameron, Luiz-Claudio (2017): Effect of Exercise on Ovulation: A Systematic Review. In: Sports medicine (Auckland, N.Z.) 47 (8), pp. 1555-1567. DOI: 10.1007/s40279-016-0669-8. J. Martin: Adaptative processes. Endocrinum.

3 Oleka CT. Use of the Menstrual Cycle to Enhance Female Sports Performance and Decrease Sports-Related Injury. J Pediatr Adolesc Gynecol. 2020 Apr;33(2):110-111. doi: 10.1016/j.jpag.2019.10.002. Epub 2019 Oct 31. PMID: 31678355.

4 Bruinvels G, Burden RJ, McGregor AJ, Ackerman KE, Dooley M, Richards T, Pedlar C. Sport, exercise and the menstrual cycle: where is the research? Br J Sports Med. 2017 Mar;51(6):487-488. doi: 10.1136/bjsports-2016-096279. Epub 2016 Jun 6. PMID: 27267895.

5 Ekenros L, von Rosen P, Solli GS, Sandbakk Ø, Holmberg HC, Hirschberg AL, Fridén C. Perceived impact of the menstrual cycle and hormonal contraceptives on physical exercise and performance in 1,086 athletes from 57 sports. Front Physiol. 2022 Aug 30;13:954760. doi: 10.3389/fphys.2022.954760. PMID: 36111164; PMCID: PMC9468598.

6 Sung E, Han A, Hinrichs T, Vorgerd M, Manchado C, Platen P. Effects of follicular versus luteal phase-based strength training in young women. Springerplus. 2014 Nov 11;3:668. doi: 10.1186/2193-1801-3-668. PMID: 25485203; PMCID: PMC4236309.

7 Carmichael MA, Thomson RL, Moran LJ, Wycherley TP. The Impact of Menstrual Cycle Phase on Athletes’ Performance: A Narrative Review. Int J Environ Res Public Health. 2021 Feb 9;18(4):1667. doi: 10.3390/ijerph18041667. PMID: 33572406; PMCID: PMC7916245.

8. Statham G. Understanding the effects of the menstrual cycle on training and performance in elite athletes: A preliminary study. Prog Brain Res. 2020;253:25-58. doi: 10.1016/bs.pbr.2020.05.028. Epub 2020 Jul 22. PMID: 32771127.

9. menstrual cycle: diet, exercise & psyche by phase (css.ch)

10. in harmony with your own body: what female triathletes should know about cycle-controlled training – tri-mag.de

11th PowerPoint presentation (swiss-athletics.ch)

12th cycle and competitive sports – SEMS-journal

13 The Impact of Menstrual Cycle Phase on Athletes’ Performance: A Narrative Review (nih.gov)

14. cycle-oriented training makes a difference – ÖKK (oekk.ch)

15. cycle nutrition: food for every phase – foodspring

16. training and the female cycle: what you should bear in mind (foodspring.de)

17. nutrition during your cycle – how to support your body – rundumpflanzlich

Training planning

Training principles are fundamental concepts that should be used when planning and implementing training programs . These principles help to make training more effective and efficient and to achieve optimal performance. There are different training principles that target different aspects of the training program, including intensity, volume, frequency and progression.

We also use these principles in physiotherapy and in the care of athletes, regardless of whether you have just recovered from an injury, are in the midst of a seasonal break, are pregnant or have just given birth, are celebrating your 80th birthday or are running your first marathon in two weeks’ time.

We will now explain the most important ones in this text.

The first and most important training principle is progression.

Progression refers to the gradual increase in training load over time. This means gradually increasing the training volume and intensity to challenge the body and adapt to the demands of the training. Progression that is too fast can lead to injury, while progression that is too slow is not challenging enough for the body.

Example: You no longer feel any great fatigue after 8 repetitions of a deadlift of 65 kg, it is time to increase the weight.

Results indicate that progressive overload is necessary for maximal muscle fiber recruitment and consequently increases muscle fiber hypertrophy and strength.

The second training principle is overloading.

Overload refers to the demands placed on the body in order to achieve an increase in performance. In order to achieve overload, the strain must be greater than what the body is already used to. Overload forces the body to adapt and improve its capabilities.

Example: You run at a faster average speed of 5.5km/h per minute during your next running session, instead of 5 as before.

The third training principle is specificity.

Specificity refers to the requirements of the training program, which should be specifically tailored to your goals and needs. Each sport and goal requires different types of training and movements. Therefore, it is important to tailor the training specifically to the requirements of you, your sport or your activity.

Example: As a footballer, it makes sense to train sprint units, among other things, so that you have the ability to sprint short distances better and possibly without injury during the game. Think about precise goals (SMART) when planning.

The most effective resistance training programs are those that focus on specific training goals.

The fourth training principle is variation.

Variation refers to the variety in the training program. By incorporating different training methods and exercises, you can prevent injuries, avoid boredom and promote continuous performance improvement. However, too much variation can lead to a lack of focus and hinder performance improvement.

Example: In team sports, we often work with periodization. Macro and micro cycles. The contents of these are continuously changed.

The use of periodization is not limited to elite or advanced athletes, but has been successfully used as a basis for training people from different backgrounds and fitness levels.

The fifth training principle is regeneration.

Regeneration refers to the recovery phases between training sessions. It is important to give the body enough time to recover and prepare for the next training session. A lack of regeneration can lead to overtraining, injuries and fatigue.

Example: Remember to give your body a rest. Go for walks and saunas, do light stretching and mobility units and change the type and parts of your training to give certain areas a break.

Robinson et al. found that it leads to a 7% increase in squat performance after 5 weeks of training came when 3-minute rest intervals were used, compared to only 2% with 30-second rest intervals. It is important to note that the length of rest intervals will vary depending on the goals of that particular exercise, meaning not every exercise will use the same rest interval.

The sixth training principle is continuity.

Continuity refers to the regularity of the training program. Regular and consistent implementation of the training program is crucial for continuous improvement in performance. Interruptions or longer breaks in training can lead to a drop in performance.

Example: Your muscle mass is suddenly at 35%, you were at 41% a few weeks ago, but had too few training sessions in between due to vacation and illness.

Overall, training principles are an essential part of an effective training program. Using these principles will allow you to achieve your goals more effectively while avoiding injury and overuse.

What does this mean for our physiotherapy training?

We try to successfully incorporate these principles when giving and implementing exercise programs. It is important that you give us constant feedback so that we can adapt and change the principles. If you no longer need physiotherapy sessions with us, discuss your programs with your trainers, e.g. from luxor fitness.

What is the minimum amount of exercise an adult should do?

Adults should do at least 150 minutes of moderate-intensity exercise per week

Exercise recommendations can be achieved through 30-60 minutes of moderate-intensity training (five days a week) or 20-60 minutes of intensive training (three days a week)

Both one continuous session and several shorter sessions (of at least 10 minutes) are acceptable in order to achieve the desired daily amount of exercise

It is recommended to gradually increase the duration, frequency and intensity of training in order to achieve a high level of adherence to therapy and reduce the risk of injury

What are the recommendations regarding strength training?

Adults should train each major muscle group two or three days a week, using a variety of exercises and equipment

A very light or light intensity is best suited to older people or adults who were previously sedentary and are starting to exercise

Adults can improve their strength and performance with two to four sets per exercise

For each exercise, 8-12 repetitions will improve strength and power, 10-15 repetitions will improve strength in middle-aged and older people starting out, and 15-20 repetitions will improve muscular endurance

Adults should wait at least 48 hours between strength training sessions

People who cannot meet these minimum requirements can still benefit from a certain amount of activity.

You can use the tables below to familiarize yourself with various parameters relating to endurance and strength training. Please bear in mindthat the figures may vary slightly depending on the literature. There is also more and more evidence and therefore recommendations to go to fatigue in strength training, especially when training only with your own body weight. This assumes that quality is maintained during execution. Below is a short detour on the subject.

*calculated for a 30 year old, healthy male.

You can find out your maximum heart rate (HRmax) in a test. Polar will show you how, but make sure that a medical expert is present during the test: Calculating your maximum heart rate | Polar Blog | Train Better. You can also use the calculation “220 minus your age” to determine your maximum heart rate, but this calculation is somewhat inaccurate.

Strength training forms

You can also calculate and/or test your one rep max: 1RM calculator: Maximum strength calculator for your One Rep Max (akademie-sport-gesundheit.de).

Side trip: Train to complete exhaustion?

“Training to failure” refers to a weightlifting technique in which a person lifts weights until they are no longer able to perform another repetition with proper form. This method is often used to push muscles to their limits with the aim of increasing muscle hypertrophy and strength.

While training to failure can be an effective way to challenge muscles and stimulate growth, it can also be risky if not done correctly. Lifting weights to failure can lead to excessive fatigue, increased risk of injury and longer recovery times .

In addition, training to failure is not suitable for everyone. Beginners, people with previous injuries or health problems and people who are not used to high-intensity exercise should approach training to failure gradually or avoid it altogether.

It is important to note that training to failure should not be the sole focus of your training. Including a variety of exercises and repetition ranges can help prevent plateaus and overuse injuries. In addition, adequate rest and recovery time is critical to maximizing training success and avoiding injury.

Do you have any questions for us?

90 – 100

Authors:

Oliver Penny and Anneke Klostermann

Book your appointment for physiotherapy, massage or group courses: here.

References:

1 Kasper, Korey MD. Sports Training Principles. Current Sports Medicine Reports 18(4):p 95-96, April 2019. | DOI: 10.1249/JSR.0000000000000576

2. https://www.akademie-sport-gesundheit.de/magazin/one-repetition-maximum.html

3. https://www.polar.com/blog/de/berechnung-der-maximalen-herzfrequenz/

4 Kasper, Korey MD. Sports Training Principles. Current Sports Medicine Reports 18(4):p 95-96, April 2019. | DOI: 10.1249/JSR.0000000000000576

5 KRAEMER, WILLIAM J.1; RATAMESS, NICHOLAS A.2 Fundamentals of Resistance Training: Progression and Exercise Prescription. Medicine & Science in Sports & Exercise 36(4):p 674-688, April 2004. | DOI: 10.1249/01.MSS.0000121945.36635.61

6. https://www.acsm.org/education-resources/trending-topics-resources/physical-activity-guidelines

7 Izquierdo M, Ibañez J, González-Badillo JJ, Häkkinen K, Ratamess NA, Kraemer WJ, French DN, Eslava J, Altadill A, Asiain X, Gorostiaga EM. Differential effects of strength training leading to failure versus not to failure on hormonal responses, strength, and muscle power gains. J Appl Physiol (1985). 2006 May;100(5):1647-56. doi: 10.1152/japplphysiol.01400.2005. Epub 2006 Jan 12. PMID: 16410373.

Sport and exercise during pregnancy and after birth

During pregnancy

When a woman is pregnant, it is usually safe and beneficial to continue exercising and staying active during this time. However, it is important that she follows some basic guidelines and seeks advice from a professional to ensure that she is not taking any risks to herself or her unborn child.

Question: “Won’t I harm my unborn child with sport? They say you shouldn’t go jogging anymore? Besides, I don’t want to increase the risk of a premature birth.”

It’s understandable that you’re asking yourself these questions and it’s good that you’re looking into the issue to be on the safe side. However, we can answer all your questions with a NO. Sport and exercise per se are not harmful, even during pregnancy. Providedthat there are no medical reasons against it. It is therefore important that you talk to your gynecologist about your exercise plan and, ideally, review it with a pelvic floor physiotherapist (e.g. Anneke) and adjust it week by week.

Exercise during pregnancy is important for your health and that of your child, to prevent possible pregnancy risks, to prepare you optimally for the birth process and the time afterwards and to maintain your mental strength. To date, there is no evidence that moderate exercise provokes premature birth or causes side effects for the unborn child.

The World Health Organization (WHO, 2020) updated the exercise recommendations during pregnancy. It even advises against inactivity and recommends staying as active as possible during a normal pregnancy. We offer group pregnancy fitness classes, please register here..

2.5 hours of moderate* endurance training per week, strength training 2 days a week and daily pelvic floor training are recommended for every expectant mother with an uncomplicated pregnancy. Those who were already exercising before pregnancy may continue their vigorous** training.

*Moderateheart rates are 125 – 146 beats per minute (under 29 years) and 121 – 141 (over 30 years). **Vigorousheart rates are 147 – 169 (under 29) and 142 – 162 (over 30).

But which exercises are safe? What should you avoid? And where should you focus?

Sports such as swimming, cycling, pregnancy fitness (we also offer these at Physio Restart, read more at Services), Pilates, yoga, fast walking or hiking and jogging are also permitted. You should only be careful with contact and high-risk sports where there is a risk of falling (horse riding), being hit in the stomach (boxing) or colliding, or where too high intensities can be achieved (maximum strength training). However, the latter can be done during pregnancy if you control your training well and are used to it!

CMO guideline

The pelvic floor is certainly a very important area during pregnancy that you should pay extra attention to. In addition to strengthening it, it is important that you also train relaxation, especially towards the end of your pregnancy. The table below gives you two examples of different types of training (there are other important ones too!). Try it out now! If you would like to do a pelvic floor examination, you can find out more about this here.

Activate your pelvic floor by closing both orifices as if you wanted to hold back urine and stool or pull a turnip out of the ground. It is important that you do not pull in your stomach, hold your breath or contract your buttocks. Place your hands calmly on your stomach and buttocks to control these errors. When relaxing, it is important that you do it slowly and consciously and don’t just let everything fall away. However, this alone is not pelvic floor training. It is much more varied and involves so much more.

Table 1:

1. maximum strength with relaxation:

Tense as hard as possible without compensating and consciously release. Repeat this 10 times with a pause of approx. 5 seconds. 2. relaxation:

Divide the contraction and relaxation into two phases of equal strength. To do this, first apply 50% of your strength, then another 50%, first relax only half again, and then completely. Repeat this 5 times.

Pregnant women should watch out for warning signs, such as dizziness, nausea or pain, and stop the activity immediately if these occur. It is also important that you drink enough fluids. Plan rest periods and take regular breaks, especially if you are still working and have other children at home, to minimize fatigue and maintain your energy levels.

Further information

The following video gives you another very clear overview:

Active Pregnancy Foundation – Pregnancy CMO Guidelines – YouTube

After the birth

No, you don’t have to wait 6-8 weeks after the birth before you can resume light activities. However, a certain amount of recovery immediately after the birth (early postnatal period 2 weeks) is important, use the first few days after the birth to recover, gather strength for the time ahead, get to know your baby or babies, cuddle and enjoy it. Avoid any household activities, shopping and schedule your visits well.

If you have a pelvic floor physiotherapist accompanying you during the late postpartum period (from 3 weeks onwards), he/she will discuss with you which movements are suitable. This depends on your (health) condition, your birth, your current daily routine and sleep, your available time and mood, symptoms. The training recommendations are always reassessed based on the examinations during the therapy sessions. The most important thing now is that you do the correct exercises for the abdomen and pelvic floor, which can be different for every woman, so don’t try unsorted YouTube videos or start something too early. We also offer postnatal recovery classes for later. Book your place: here.

CMO guideline

Is there anything to consider after the birth?

Yes, pay attention to the following symptoms, among others: loss of urine or bowel movements, increased urination, pulling in the lower abdomen, back pain, pressure in the pelvic floor area, pain (e.g. during urination or sexual intercourse). Don’t worry and don’t be ashamed, because many women describe these symptoms, but they should definitely be treated as early as possible and ideally prevented.

CMO guideline

Click here for the video for after the birth (in English):

Active Pregnancy Foundation – Postnatal CMO Guidelines – YouTube

Overall, it is important that you continue to stay active during pregnancy and start again soon after giving birth, but also take care of your body and your limits. A customized training plan and regular consultations with Anneke can help ensure a safe and healthy workout. We can do a lot during pregnancy, so get good advice.

Author:

Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.

References:

1 CMO guidelines UK Chief Medical Officers’ report.

2 Bø, K. et al. (2019) “Comment and questions to Mottola et al. (2018): 2018 Canadian guideline for physical activity throughout pregnancy,” Journal of Obstetrics and Gynaecology Canada, 41(10), pp. 1404-1405.

3 Davenport MH, Kathol AJ, Mottola MF, et al. Prenatal exercise is not associated with fetal mortality: a systematic review and meta-analysis. Br J Sports Med 2018.

4 Evenson KR, Barakat R, Brown WJ, et al. Guidelines for Physical Activity during Pregnancy: Comparisons From Around the World. Am J Lifestyle Med 2014;8:102-21

5 Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC expert group meeting, Lausanne. Part 4-Recommendations for future research. Br J Sports Med 2017;51:1724-6

6 Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/17 evidence summary from the IOC Expert Group Meeting, Lausanne. Part 3-exercise in the postpartum period. Br J Sports Med 2017;51:1516-25.

7 Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2-the effect of exercise on the fetus, labor and birth. Br J Sports Med 2016;50:1297-305.

Physiotherapy after knee cartilage surgery

Anneke was invited to the winter meeting of the GOTS (Gesellschaft für Orthopädisch-Traumatologische-Sportmedizin) and gave a presentation on physiotherapy treatment options following cartilage surgery. The audience consisted of specialists from various disciplines throughout Switzerland. More information about the event here: GOTS – Society for Orthopaedic-Traumatologic Sports Medicine (gots-schweiz.ch)

Cartilage

Cartilage is a form of connective tissue that is highly resistant to tearing and elastic under pressure. There are three different types of cartilage in our body: hyaline cartilage, elastic cartilage and fibrocartilage. In this article, we are referring to hyaline cartilage, which is found in our joints. It does not contain any vessels of its own, i.e. no blood vessels, lymph vessels or nerves. If it is not supplied with blood, it therefore has no healing potential of its own after an injury. Due to the lack of nerves, the pain we feel does not come from the cartilage but from neighboring, possibly inflamed tissue. Cartilage is nourished by the surrounding synovial fluid and cartilage membrane, which is formed, among other things, through adequate movement, which we supply from the outside. In a joint, the cartilage serves as a support and shock absorber between the bones and joint surfaces.

Treatment – surgery?

Cartilage can be damaged as a result of trauma, for example impact trauma (fall) or twisting, or can also develop as a result of prolonged incorrect or excessive strain. Accompanying injuries can occur, for example a rupture of the cruciate ligament or meniscus in the knee joint. The indication for surgical or conservative treatment of cartilage injuries is discussed with the treating doctor. Many factors must be taken into account: Age, concomitant injuries, location of the cartilage injury, size of the lesion, requirement profile and goals of the injured person, and many more.

Aftercare – Physiotherapy

If the cartilage injury required surgery, direct physiotherapy treatment is essential. A physiotherapist will find out which surgical method was used, which part of the joint and cartilage was affected and which restrictions are recommended by the doctor for the initial period. It can be helpful if these documents are brought to the first physiotherapy appointment.

It may be that the knee joint cannot yet be flexed to its full extent, which is why a splint limits this. You are often given sticks and are not allowed to walk fully for the first few weeks. All these measures can take 2-6 weeks, depending on the operation. We distinguish between three phases in the follow-up treatment:

  • The first phase, the protection phase, lasts from week 1-6,
  • the second, functional and active phase, weeks 6-12,
  • The final phase can last up to over a year and includes the return to sport until the previous performance level has been reached.

Phase 1

The aims of the first phase are to promote wound healing and slightly activate the muscles and joint. The operated area is often swollen and painful at the beginning. As only partial weight-bearing on sticks is permitted at the beginning, physiotherapy checks that the foot is being rolled correctly. A splint is often worn which, depending on the operation, restricts movement so as not to interfere with healing. Early mobilization of the joint, flexion and extension of the knee are very important from day 1 of the operation. The muscles can also be activated without strain and trained as the operation progresses. Less is still more in this phase, but increasing weight-bearing will soon become very important.

Phase 2

The aim of the second phase is to restore full mobility to the joint and enable full weight-bearing without sticks and braces. During the second phase, the difference in strength between the sides (left and right leg) should be as small as possible, which must be achieved through various exercises. The physiotherapist should check the exercises as often as possible, as much as necessary, and instruct constant adjustments. The focus should already be on the patient’s requirements in everyday life, at work and during sport, so that the right choice of exercises is made. It can help to record the exercises with a video so that the patient can see any possible incorrect strain, but also to be able to watch the correct execution again and again at home. Training is becoming increasingly complex and functional and should include the components of strength, coordination, balance, leg axis stability, speed and flexibility .

Phase 3

For many patients, returning to sport and their previous level of performance is the most important long-term goal of the entire rehabilitation process. Both are also possible after cartilage surgery, but can take up to 18 months, or even less than a year depending on the operation. In this case, treatment is always individualized and agreed upon in consultation with the operating doctor, trainer, nutritional therapist, sports psychologist and others. Questionnaires, strength tests and functional test batteries (e.g. the Orthelligent Pro) should help to decide whether the operated leg and the patient are ready to return to sport and later complete the therapy.

Summary and guidance

Physiotherapeutic follow-up treatment following cartilage surgery is important. It may be possible to attend a few physiotherapy sessions before the operation in order to receive important instructions on gait, mobilization and muscle activation and to keep pain and signs of inflammation at an appropriate level. The treatment should be individualized and constantly adapted as the procedure progresses.

Author:

Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.

References:

1st Anvil 2021

2.Bannuru, R.R. et al. (2019) “OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis,” Osteoarthritis and Cartilage, 27(11), pp. 1578-1589.

3.Crecelius CR, et al. (2020) Postoperative Management for Articular Cartilage Surgery in the Knee. J Knee Surg. 2021 Jan;34(1):20-29.

4.Hurley ET, et al (2019). Return-to-play and rehabilitation protocols following cartilage restoration procedures of the knee: A systematic review. Cartilage.

5.Mithoefer K, Hambly K, Della Villa S, Silvers H, Mandelbaum BR. (2009) Return to sports participation after articular cartilage repair in theknee: scientific evidence. Am J Sports Med. 2009 Nov;37 Suppl 1:167S-76S.

6.Nehrer Stefan et al. (2019) “Cartilage and osteoarthritis in sport”, GOTS expert meeting Krems (Donau) Austria

7.Stop X – rehabilitation & prevention of knee injuries (2022) Stop X – rehabilitation & prevention of knee injuries.

8.Stone, J. and Schaal, R. (2012) “Postoperative management of patients with articular cartilage repair,” Journal of Knee Surgery, 25(03), pp. 207-212.

9.Valle, C. et al. (2019) Prehabilitation and rehabilitation after cartilage regenerative surgery. Arthroscopy 32, 199-204.

10.Vogt, S. et al. (2012) “Practice in rehabilitation after cartilage therapy: An expert survey,” Archives of Orthopaedic and Trauma Surgery, 133(3), pp. 311-320.

11.Wagner, K.R. et al. (2022) “Rehabilitation, restrictions, and return to sport after cartilage procedures,” Arthroscopy, Sports Medicine, and Rehabilitation, 4(1).

Pain and cramping in the vaginal area

Sex can be exciting and pleasurable, but unfortunately it can also be a nightmare for those who suffer from dyspareunia. And the annual visit to the gynecologist is often avoided by people with vaginismus.

It is difficult to say how many girls and women are affected by one or both diagnoses, as few talk about it, let alone see a healthcare professional. Why is this the case?

What do these two terms relating to women’s health mean?

Vaginismus

… is often described as an involuntary, vaginal cramp in the pelvic floor area during penetration of the penis, insertion of a finger or tampon. The condition has been known for many, many years. More precisely, since 1547, when the term vaginismus was not yet used but the condition was described for the first time. Vaginismus was used as a term for the first time in 1862.

Unfortunately, the diagnosis is often associated with fear-avoidance behavior and high emotional stress . The girls and women refrain from visiting the gynecologist and from any sexual activity (e.g. masturbation or vaginal intercourse).

Dyspareunia

… dys means wrong/miss and pareunia is a bedfellow, it describes a painful condition during or immediately after vaginal intercourse. Most girls or women fail in 50% of attempts to have vaginal intercourse. During penetration, the muscles in the pelvic floor area tense up to such an extent that in the long term they associate any touch and advances with negative emotions.

The International Pain Classification classifies vaginismus and dyspareunia as sexual, genital dysfunctions. If both conditions are present, this is referred to as Genito-Pelvic Pain Penetration Disorder (GPSPS). It is not always easy to distinguish between these two diagnoses. In principle, the difference is that in vaginismus, the focus is not necessarily on pain and sexual intercourse, but on the cramping of the muscles.

In both situations, the success rate of conservative therapy is very high. A cause cannot always be found. Trauma (e.g. abuse as a child), previous operations, childbirth or problems in the partnership can lead to these diagnoses.

What conservative (non-surgical) treatment options are there?

It is important that, if possible, the possible medical and possibly also psychological causes are clarified in advance so that treatment can be started and successfully completed. Even if not many sufferers dare to accept one or more treatment options, there are various possibilities that can already be used without great (time) effort or cost.

It is very important that those affected can talk about it in a familiar environment and feel understood and respected in their situation.

The measures are primarily aimed at desensitization, a state of insensitivity. This includes the ability to relax the pelvic floor muscles, to reduce the tense muscle tone and thus the pain as much as possible. This can be achieved with the help of pelvic floor training, manual therapy, equipment, yoga and meditation as well as sex therapy.

Pelvic floor training includes biofeedback and electrostimulation. However, this requires that a probe (Fig. 1) can be inserted into the vagina. In order to achieve this, it is often necessary to relax the muscles to a certain extent and to learn techniques that allow the probe to be inserted (e.g. external manual techniques by the physiotherapist or progressive muscle relaxation).

Store.parsenn-products.ch

The biofeedback in the physiotherapy session can help to see the muscle tension and relaxation as a graph on the screen of the device and thus influence the ability to relax. Stimulation by electricity is also intended to support this. There are studies that prove the 100% effectiveness of biofeedback and we at Physio Restart also see great and quick results.

Dilators (Fig. 2) are devices that can also accustom the vaginal entrance to relaxation. They look like rods and are available in different sizes. The patient can use them to practise in a familiar environment (including at home).

Store Pharmacy Vagiwell® Dilators

Sometimes accompanying sex therapy with or without a partner is useful in order to restore the connection to oneself, one’s sexual organs/area and one’s partner. It can be helpful if the couple generates the woman’s sexual arousal without penetration in order to make the vaginal entrance moist, which may make it easier for the penis or finger to penetrate. These and other situations can be discussed with the therapist.

Contact a trained specialist if you have any problems. Your gynaecologist and Anneke from Physio Restart are familiar with these situations and will be happy to support you back to a fulfilling, pain-free sex life and pelvic floor health.

Author:

Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.

References:

1. https://www.womentc.com/de/Vaginismus/statistische-Pr%C3%A4valence/

2 Lahaie MA, Boyer SC, Amsel R, Khalifé S, Binik YM. Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment. Womens Health (Lond). 2010 Sep;6(5):705-19. doi: 10.2217/whe.10.46. PMID: 20887170.

3 Fordney DS. Dyspareunia and vaginismus. Clin Obstet Gynecol. 1978 Mar;21(1):205-21. doi: 10.1097/00003081-197803000-00018. PMID: 630754.

4. de Kruiff ME, ter Kuile MM, Weijenborg PT, van Lankveld JJ. Vaginismus and dyspareunia: is there a difference in clinical presentation? J Psychosom Obstet Gynaecol. 2000 Sep;21(3):149-55. doi: 10.3109/01674820009075622. PMID: 11076336.

5 Pacik PT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014 Dec;25(12):1613-20. doi: 10.1007/s00192-014-2421-y. Epub 2014 Jun 4. PMID: 24894201.

6 Pacik PT. Vaginismus: review of current concepts and treatment using botox injections, bupivacaine injections, and progressive dilation with the patient under anesthesia. Aesthetic Plast Surg. 2011 Dec;35(6):1160-4. doi: 10.1007/s00266-011-9737-5. Epub 2011 May 10. PMID: 21556985.

7. https://www.vaginismus-selbsthilfe.de/

Sports and training recommendations for pregnant athletes

A scoping review published in November in the BMJ Open Sport & Exercise Medicine Journal and authored by Anneke Klostermann and others.

In collaboration with Balgrist University Hospital and Zurich University Hospital, Anneke Klostermann researched the topic of how athletes can exercise during pregnancy.

What is already known about this topic? What can we add? And what will happen in the future?

Getting pregnant as an athlete:

More and more elite and competitive female athletes are reaching the peak of their careers during the period of optimal fertility and do not want to postpone the birth of children until they have finished their sporting careers. This is particularly the case in endurance disciplines, where training age plays a relevant role.

In addition, if possible, these athletes want to plan their pregnancy so that it does not coincide with potential career peaks (e.g. the Olympic cycle with a peak every 4 years).

Recommendations from the literature:

However, there is scant evidence and anecdotal reports of best practice recommendations to address this issue in elite female athletes. Due to the lack of direct evidence for female athletes and the gaps in knowledge regarding the safe frequency, duration and intensity of training and competition, it is possible to Recommendations can only be made individually and under close observation of the well-being of mother and child. The need for practical information on which sports and to what extent they can be continued safely and without risk to mother and child is of great importance, especially for athletes who are very uncertain about this, but also for coaches and healthcare providers.

Aim of our study:

In this scoping review, we aim to (1) identify and assess the current scientific evidence in the literature on sport and exercise recommendations for elite and competitive female athletes, (2) summarize the available evidence for the volume and intensity of physical activity for continuous exposure and acute exposure to physical activity in relation to performance, as well as for high-risk sports and their effects on pregnancy outcome parameters in female athletes, and (3) highlight existing knowledge gaps.

What can we conclude from our research?

Nevertheless, there are no known significant negative consequences of physical activity for mothers or children. Both people who adhere to training recommendations or participate in higher impact activities during pregnancy and pregnant elite and competitive athletes are encouraged to approach sporting activities with more confidence.

Read the whole article at: https://bmjopensem.bmj.com/content/bmjosem/8/4/e001395.full.pdf

Author:

Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.

References:

1 Allen SV, Hopkins WG. Age of peak competitive performance of elite athletes: a systematic review. Sports Med 2015;45:1431-41

2.Davenport MH, Nesdoly A, Ray L, et al. Pushing for change: a qualitative study of the experiences of elite athletes during pregnancy. Br J Sports Med 2022;56:452-7

3.Bo K, Artal R, Barakat R, et al. Exercise and pregnancy in recreational and elite athletes: 2016/2017 evidence summary from the IOC expert group meeting, Lausanne. Part 5. recommendations for health professionals and active women. Br J Sports Med 2018;52:1080-5

4 Solli GS, Sandbakk Øyvind. Training characteristics during pregnancy and postpartum in the world’s most successful cross country skier. Front Physiol 2018;9:595

Football prevention symposium

It was the second online symposium of the VBG (statutory accident insurance Germany) which took place on October 22nd. Physio Restart took part and summarizes the most important information we took away from the excellent speakers. VBG – Homepage

We regularly participate in online and live courses and congresses to utilize this information and ensure that we can provide our patients with evidence-based, and if not already available in the literature, good quality treatment.

Anneke is a sports physiotherapist for a local soccer team in Zurich and started as a substitute sports physiotherapist for the SFV national teams. Oliver currently coaches a floorball team and has experience in ice hockey.

What is the most common injury in football?

The ischiocrural muscle group(hamstrings), which is located on the back of our thigh, is often injured in this sport. The biceps femoris in particular is predominantly affected at 79% (BJSM). However, the mechanism of injury, prevalence and treatment are“a major, as yet unknown problem“.

The most common injury to this muscle group occurs during the lunge movement (59%), along with kicking (30%) and landing (7%).

If a player is in a stretching position with the back of the leg (extended knee) and is about to slow down or stop the movement, he or she has a 52% risk of injuring this muscle group. In a sprint during the moment of acceleration, the risk is 48%.

What kind of training should be included in soccer training?

For sure: sprints! Most of a soccer player’s training sessions should include sprints with variations: Changing direction, slowing down and stopping.

Eccentric exercises should also be included. These exercises implement “force production during active muscle lengthening” (Harris-Love et al. 2021). One example is the Nordic hamstring curl for the back of the thigh(see image below). If we want to do this exercise on the sidelines, two players should fix the legs (not just one).

Nordic Hamstring Curl (NHE)

Important: only move forward far enough to avoid a hollow back. Otherwise, feel free to drop forward onto your hands. Feet must be well fixed.

© PHYSIO RESTART

Train SMART!

Another factor is plyometrics, this type of training focuses on “repetitive rapid stretching and contracting of muscles (as by jumping and rebounding)” (Merriam-Webster).

An important factor to consider is how and when we incorporate these specific training components. Each performance of exercises should consider the individual player, especially if he or she has had an injury to the affected muscle group. Fatigue and pain should be taken into account. In addition, we must always incorporate variations with changes in: the type of exercise, repetition, duration, speed, resistance and range of motion. We must remember to perform increases if the player is performing well and is without compensation or discomfort. The same goes for regressions if the exercise is causing problems. And if the player has a game every Sunday, it makes sense to include the specific, more intensive and eccentric training in the middle of the week. To warm up before the game, it is recommended to perform isometric exercises that do not shorten or lengthen the muscle, for example:(see pictures below)

Supine bridge

Lift the pelvis only about 1 fist’s width from the floor and keep it straight, trying to prevent the left side from tilting.

© PHYSIO RESTART

Prone Leg curl

For the isometrics of this exercise, we want to hold the leg at a certain angle (we like to test different angles). There is no movement.

© PHYSIO RESTART

What other exercises are recommended for the back of the thigh?

Single leg romanian deadlift

Use little to no weight at first to learn the correct technique. The supporting leg is almost fully extended, look towards the floor, hips on one level, abdomen tensed to avoid a hollow back.

© PHYSIO RESTART

Hip extension

When doing this exercise, many people make the mistake of moving their leg too far back and falling back into a hollow back.

© PHYSIO RESTART

Romanian deadlift

To activate the back of the thighs more, we also stretch the legs in this exercise. Move the weight up and down along the legs close to the body.

© PHYSIO RESTART

Note: The Nordic Hamstrings Exercise (NHE) is a widely discussed but proven injury prevention exercise for the back of the thigh in football. We must consider the potential to even cause an injury with this exercise if performed incorrectly. As it requires a lot of muscle strength and correct execution, experts recommend replacing the NHE with a guided push-up for the time being if necessary. The knees are placed on a towel and each hand on a football, while another person stabilizes the lower legs.

What are common mistakes in rehabilitation on the part of healthcare providers?

Neglect or absence of:

  • correct diagnosis
  • Adequate time management (late diagnosis and start of treatment)
  • Tissue healing phases (too early or too late tissue loading)
  • mental readiness (no teamwork with the patient)
  • Individualization (non-specific treatment)
  • Tests to check progress (incorrect progress or no progress at all)

Physio Restart ensures that we avoid precisely these mistakes. We do this with good cooperation from other specialists.

When is the time to return to sport after a muscle injury?

Everyone is different, it always depends on the type of person, the sporting and professional strain, age, previous injuries, treatment interventions (etc.), but we can assume the following: (VGB)

  • Hardened muscle 1 – 3 days
  • Sore muscles 2 – 5 days
  • Muscle strain 3 – 5 days
  • Torn muscle fiber 10 – 14 days
  • Torn muscle bundle 6 weeks
  • Muscle tear 12 – 16 weeks
  • Muscle contusion 2 – 3 weeks

Last but not least:

We work with you, respect your thoughts and goals. We think outside the box and are ready for unexpected changes, modifications and customizations.

Author:

Anneke Klostermann and Oliver Penny

Book your appointment for physiotherapy, massage or group courses: here.

We are Physio Restart

We love a challenge and variety; we value individuality and quality; we are there for you at Physio Restart, at home, at work and on the pitch.

Picture: B. Gruhn, 2022

Physio Restart was founded as a sole proprietorship by Anneke in 2021. Since September 01. 2022, Oliver and Anneke Penny have formed the Physio Restart GmbH team.

We are pleased to be able to offer you even more professional services with this list.

Which values are at the top of our list?

Individuality.

Quality.

Scientific findings.

The joy of movement.

Cause elimination.

Holistic treatment.

Sustainability.

Collaboration with you and other specialists.

Communication skills.

Respect.

… and much more.

What do we offer you?

Sports physiotherapy.

Physiotherapy.

Manual therapy.

Dry needling.

Jaw treatments.

Pelvic floor therapy (woman).

Pregnancy and postnatal group courses.

Recovery programs.

Pregnancy care.

Fascia distortion model.

Medical training therapy (MTT).

Team support.

Training support.

Back to Sports testing.

Preventive measures.

Sports massage.

We are located at Glärnischstrasse 35, 8002 in Zurich, first floor of luxor fitness.

Author:

Oliver and Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.

Muscle cramps in sport

… and what’s the deal with the 🥒 cucumber?

Today we want to talk about muscle cramps in sport in an interview with Physio Restart . Anneke has been coaching teams with great passion for years. The topic of cramps on the pitch comes up from time to time.

Physio Restart: An anecdote that is actually used: drink the leftover juice from gherkins when muscle cramps occur as a result of sport. This reduces the duration of the cramps by a few seconds. (Miller et al. 2010) But is this the solution to the problem? No. Basically not, because firstly: the juice really doesn’t taste good, … does it? And secondly: the cause has not been solved.

Interviewer: Interesting, introductory anecdote. Anneke, what exactly are muscle cramps?

Physio Restart: Maybe you know the situation: 81st minute of the game, the score is 1:0 in your favor, but the opponent is hungry, you are exhausted and no more player changes are possible. In other words: pull through and carry on. Suddenly your left calf cramps, followed shortly afterwards by your right calf. Running on is virtually impossible.

This cramp is an involuntary or unintentional muscle spasm . (Of course you didn’t want to get this very painful cramp in the middle of the field during this game, right?)

In principle, our brain communicates with our muscles via the nerves. This requires certain electrolytes (ions), including magnesium. This is why people are quick to say that a muscle cramp occurs because there is a lack of magnesium. But in fact this is not the answer to the problem and often not the cause.

Muscle cramps can be caused by:

1. disturbances in the electrolyte balance (e.g. loss of sweat at high temperatures)

2. dehydration (not drinking enough)

3. insufficient warm-up or lack of routine stretching

4. altered neuromuscular activation/fatigue (e.g. last minutes of the game)

If we take a closer look at the literature behind it, we can quite quickly (and many years ago!) critically question the claims made in points 1 and 2.

1) Even at cool temperatures (10-12°C), almost 20% suffered from exercise-induced muscle cramps. (Maughan 1986) Marathon runners were tested.

2. despite sufficient water intake (in relation to sweat loss), almost 70% of the test subjects had cramps. (Jung et al. 2005) However, this study population was very small.

Supplement to point 1+2: Many of these claims are based on case studies, which are not good sources.

Interviewer: Too bad. So not: take magnesium, done. Okay. And point 4… Neuromusku… what? And now the whole thing again in German…

Physio Restart: Laughs.

Sorry. “Neuro” means “concerning the nerve”, “muscular” of course the “muscle”. In other words: neuromuscular = the control or communication between nerves and muscles, which, as mentioned above, trigger muscle contraction and relaxation. Experts are increasingly in agreement that this is often the problem with cramps. It is simply fatigue during intensive exercise, but not a lack of any particular ion.

Interviewer: Ok, that was actually not difficult to understand. Good, and now that I know all this… What do I do the next time I have a cramp?

Physio Restart: There’s a lot you can do for yourself and your teammates. But not just on the pitch!

Try to drink enough before the game. Before the game means at least 1 hour, as the water needs time to be absorbed and processed by the body. Apparently it takes up to 13 minutes….

Drink the right amount before and during activity. 1 liter of nutrient-rich water or an isotonic drink. Remember: not all water is nutrient-rich. It should contain sufficient potassium, calcium and magnesium, as well as many other elements . According to the FSVO, tap water here in Switzerland is of good quality. Mineral water should contain <100mg potassium, >70mg magnesium and >300mg calcium . In comparison, as a woman I need about 4000mg potassium, 500mg magnesium and 1000mg calcium . (BLV) So I also have to get it from my food.

Avoid ingesting magnesium directly before the game. Your gastrointestinal tract can cause you problems during this time.

Warm up. Warm up sufficiently and properly before the game. Maybe you have a joint warm-up routine from the physio?

Avoid tight clothing. Excessive compression, for example due to shoes that are laced too tightly, can disrupt optimal blood circulation.

If you do suffer a cramp, avoid stretching abruptly at all costs. What many people do: quickly lie on their back, raise their legs in the air, put their toes up and stretch. However, this can actually lead to strains. Instead, stand in a stepping position and stretch yourself. Otherwise, do it carefully and slowly. Ask your physio to help you massage the cramped muscle lengthwise.

Stay warm. If you are sitting on the bench as a substitute, try to keep warm. Not just by wearing clothes, but by using the Blackroll, skipping rope, jogging on the sidelines. It’s not advisable to dance around a bit just before taking the field. Laughs.

Have yourself replaced if it happens several times in quick succession. This indicates fatigue, which can subsequently lead to an injury. Neuromuscular fatigue!

Birthday party the night before? Alcohol promotes muscle cramps.

Hot and cold showers after the game and as a general preventative measure.

Interviewer: Take Home Message as always with Physio Restart? Except that I shouldn’t celebrate my 30th right before an important match or only with iso drinks……

Physio Restart: Laughs. All I can say is:

“Don’t believe everything you read and hear. Look at information with a critical eye. You can also judge this text. Nevertheless, I hope I have been able to give you a few tips: work on the cause of the problem, because prevention is the best cure, even for muscle cramps.”

Book your appointment for physiotherapy, massage or group courses: here.

References:

1.Jung A, Bishop P, Al-Nawwas A, Dale R. Influence of hydration and electrolyte supplementation on incidence and time to onset of exercise-associated muscle cramps. J Athl . 2005;40:71-75

2.Maughan R. The effect of osmolality and carbohydrate content on the rate of gastric emptying of liquids in man. J Physiol. 1995;486:523-531

3,Bye A, Kan A. Cramps following exercise. Aust Paediatr J. 1988;24:258-259

4.Schwellnus MP. Skeletal muscle cramps during exercise. Phys Sportsmed. 1999 Nov;27(12):109-15.

5.Miller, K. C., Stone, M. S., Huxel, K. C., & Edwards, J. E. (2010). Exercise-associated muscle cramps: causes, treatment, and prevention. Sports health, 2(4), 279-283.

6.Schwellnus M, Derman E, Noakes T. Aetiology of skeletal muscle “cramps” during exercise: a novel hypothesis. J Sports Sci. 1997;15:277-285

Sex and Gender Medicine: certificate of advanced studies

“Integrating sex and gender analysis into medical research and clinical practice ensures that everyone across the whole of society benefits from excellent health care. This course instructs physicians and medical researchers in how sex and gender interact in the human body across the life course. It’s a crucial part of medical education”. Prof. Londa Schiebinger

Gender-specific medicine is still a neglected topic and receives little attention in clinical practice and science. Biological sex (sex) and socio-cultural differences (gender) have a significant influence on the epidemiology, pathology and manifestation of various diseases and medical findings. But to what extent do we understand the difference between sex and gender? How often do we see a confusion between these two quite significant differences?

I was the first group to participate in this CAS, which consisted of 11 modules and taught the latest findings of this specific medicine and motivated us to promote awareness and research in this field.

  1. Cardiology
  2. Oncology and gynecology
  3. Neurology and psychiatry
  4. Musculoskeletal and rheumatic medicine
  5. Endocrinology
  6. General medicine
  7. Study design and research

I wrote my final thesis on: Sex and Gender Differences in Sleep: the Influence of the Menstrual Cycle. A very exciting topic, which I will tell you more about in another blog post: The Importance of Sleep (physio-restart.ch)

Author:

Anneke Penny

Book your appointment for physiotherapy, massage or group courses: here.