Author Archives: dave

Office Chair Yoga

In an ever-changing world full of daily demands and personal struggles, we all try to maintain as much balance and harmony as we possibly can.  At times, this notion is difficult to achieve for individuals who are trying to balance work, family and other obligations.  In this busy world, it is important to make time for ourselves to nurture our harmony.  One of the easiest ways to achieve this is through yoga.  Yoga is a form of exercise that unites breath, mind, body and spirit.  Typically, yoga is thought to be done only on a mat or in a standing position; but that is not the case.  Although yoga has been around for thousands of years, it’s become increasingly popular and has taken on many variations.  Yoga can offer many benefits such as relieving stress, increasing productivity and strengthening our minds.  Whether you work in a confined office space or have physical limitations that keep you from doing a traditional class, seated yoga incorporates the same breathing and a gentler style of poses to help you achieve the same benefits.

Benefits of Seated Yoga:

  1. Reduced stress and improved mental clarity
  2. Improved strength
  3. Improved flexibility
  4. Pain management

Doing a seated yoga routine, like the one given here, is a great way to incorporate stretching into your day. Stretch breaks are essential for people whose jobs require them to sit at a desk all day.  Please remember to consult a doctor before beginning any new exercise program.  When participating in yoga of any kind, it is very important to relax your mind and focus on your breathing to ensure the best results possible.  During each of these sequences, you will slowly breathe in through your nose and out through your mouth, allowing your body and mind to relax.  Another important part of each sequence involves tightening your abdominal muscles (pulling your belly button in towards your spine) while doing each exercise to strengthen your core muscles.  To execute each pose in the above picture, follow along with the steps outlined below:

  1. Sit up tall in your chair both feet on the floor clasp your hands together. While breathing in through your nose and out through your mouth, draw your arms upward hold for a few seconds.  Relax, repeat three times.  This pose is also great to do in between or at the end of the sequence to reset the mind and body.
  2. Rotate your body first to the right grasping the back of the chair with your right hand then place your left hand on your right knee slowly going into a stretch. Repeat sequence on left side, repeat each side three times.
  3. First, bend your right leg over the left allowing your knee to relax downward you can place your hand on the right knee to extend the stretch as well. Repeat on the left side.  Repeat each side three times.  Remember to sit up straight!
  4. This pose is a bit more difficult for some. If you are unable to do the full stretch at first only go as far as you are able then as you progress you will see the improvement in your flexibility over time.  Start by putting your right arm up as though you are waving at someone, bring your left arm down.  Slowly begin moving each arm towards the middle of your back until you are grasping the fingers together, hold for 3 seconds.  Repeat this on the left side and each side three times.
  5. This triceps exercise requires a stationary chair that does not move or has locked wheels. Start by placing your hands on either side of the chair face down. Slowly begin by pushing your body upward and down, keeping your arms locked the entire time. Relax and repeat three times.

Recognizing the Signs of a Concussion

A concussion is a mild traumatic brain injury. Concussions can be caused by a bump, blow, or jolt to the head or body that causes the brain to move inside the skull. In the United States, between 1.6 to 3.8 million sports-related and recreational concussions occur annually. High risk sports include soccer, football, lacrosse, field or ice hockey, and cheerleading. Concussions also can occur from non-sport activities such as riding a bike, a fall, or a motor vehicle accident. No matter the cause, concussions should be treated properly.

In high school comparable sports, females have a higher concussion rate than males. Female athletes have also been shown to experience more post-concussive symptoms and have a greater recovery time as compared with males.

Signs of a Concussion

Concussion symptoms usually appear within minutes of the injury, but some symptoms may take several hours to occur. Anyone with a suspected injury, especially from a sports-related impact, should be examined for a concussion or a spine injury. You do not need to have lost consciousness to have a concussion.

If you suspect your child has suffered a concussion, they may exhibit the following symptoms:

  • Headache or a feeling of pressure in the head.
  • Nausea or vomiting.
  • Balance problems, dizziness, or double or blurry vision.
  • Sensitivity to light or noise.
  • A sluggish, hazy, foggy, or groggy feeling.
  • Confusion or problems with concentration or memory.

You also may notice, or they may express, that they are “just not feeling right” or are “feeling down.”

What to Do If You Suspect a Concussion

  • Cease play or immediately remove the athlete from play.
  • Get examined as soon as possible by a licensed health care provider. This can include an athletic trainer, physical therapist, or physician.
  • Rest for 24-48 hours, and then begin a gradual return to activity that starts with a walking program. Gradually work your way up to walking 30 minutes per day. Note: When starting a concussion recovery program, walking is generally safe even if you experience a slight increase in symptoms. Completing an early supervised exercise program has been shown to improve recovery.
  • Limit screen time during the first 48 hours. You may resume screen time after 48 hours as long as symptoms do not increase significantly.
  • Return to school after 2 to 3 days. Studies support a return to school in this time frame with accommodations if needed.
  • Get good nighttime sleep. This is important for recovery, and you may need more nighttime sleep in the early days after a concussion. Try to avoid daytime napping to keep a normal sleep-wake cycle.
  • Stay close to an adult after a suspected concussion. A child or athlete should not be left alone after the injury.
  • Monitor symptoms closely. If they worsen, seek an evaluation in the emergency room to determine if a more serious brain injury exists.

Sometimes concussion symptoms persist for longer than 7 to 10 days. If so, a physical therapist can assess symptoms and treat lingering issues by guiding you through a safe and personalized recovery program.

Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement.

Article courtesy of APTA.

Fibromyalgia – What to Do When the Fibro Ignites

As we head into the dog days of summer, the weather is heating up. For the nearly 5 million people in the United States with Fibromyalgia, they might experience a different kind of heat – the burning pain that typically comes along with this diagnosis.

What is Fibromyalgia?
Fibromyalgia is a chronic condition that can cause a wide range of symptoms throughout the body. It’s usually diagnosed between the ages of 30 and 50, and 80% to 90% of the people affected are women.

The most common symptoms are:
Chronic pain all over the body fatigue memory problems sleep disturbances depression or anxiety.

HOW DOES PHYSICAL THERAPY HELP?
Because of the wide range of symptoms, fibromyalgia can be a debilitating condition. It is not uncommon for people to begin avoiding activities altogether because of pain and fatigue. This begins a cycle of deconditioning that not only impacts the person’s overall health, but also makes the symptoms of fibromyalgia worse. The cause of fibromyalgia is currently unknown and there is no cure, so physical therapy treatments are designed to reduce and manage the symptoms. This requires a multi-pronged approach. Common treatments include:

EDUCATION
The first step in treating fibromyalgia is often helping people understand what’s going on, and what they can do about it. Research has shown that people who are knowledgeable about their condition have better outcomes, more confidence, and cope better.

DECREASE PAIN AND IMPROVE RANGE OF MOTION
Physical therapists are movement experts with a lot of tools and techniques to help with the pain and stiffness caused by fibromyalgia. A PT might use gentle manual therapy or massage, prescribe specific stretches, or a simple yoga routine. They might also use modalities like electrical stimulation, biofeedback or in states where it is allowed, dry needling.

EXERCISE
Once patients understand the condition and are able to move a little better with less pain, exercise often enters the treatment picture. Research has shown that low to moderate intensity aerobic exercise like walking, biking, or swimming is important in managing fibromyalgia symptoms. It can help with pain, fatigue, sleep disturbances, depression, and more. Physical therapists and patients work together to find the right type of exercise and the right intensity to best manage fibromyalgia. They often have to start slow, and make adjustments along the way.

Each physical therapy session is tailored to the needs of the patient and will vary depending on the severity of their symptoms. Despite there still being no cure for fibromyalgia, physical therapists can help with pain management, strength, mobility, fatigue and function to help patients find relief from their symptoms.

References:

Research (peer-reviewed)
Exercises for Fibro – https://pubmed.ncbi.nlm.nih.gov/32455853/
Manual therapy for fibro – ​​https://pubmed.ncbi.nlm.nih.gov/32604939/
Aquatic PT for fibro – https://pubmed.ncbi.nlm.nih.gov/23818412/
Effectiveness of exercise with fatigue, etc for fibro – https://pubmed.ncbi.nlm.nih.gov/32721388/
Aerobic exercise for fibro – https://pubmed.ncbi.nlm.nih.gov/28636204/
Articles and Content
https://www.choosept.com/guide/physical-therapy-guide-fibromyalgia
https://www.everydayhealth.com/fibromyalgia/aquatic-therapies/
Physical Therapists are poised to treat and manage Pain (AOPT) https://www.orthopt.org/uploads/content_files/files/Pain_Manual_Draft_FINAL_6.25.2021%281%29.pdf

Improve Function and Mobility with Neurorehabilitation & Therapy

You can expect our neurorehabilitation and neurological therapy to include the evaluation and treatment of movement problems caused by disease or injury to the nervous system. Our Physical and Occupational Therapists can provide these services to patients of all ages with the goal of improving function and overall ability to participate in personal roles and activities important to them. Click here to learn more about the different ways our Therapists can help.

Getting the Most Out of Your Workouts

Exercise is one of the best things you can do for your health. It can reduce your risk of chronic diseases like diabetes or cancer. It reduces your risk of stroke, dementia, osteoporosis, and obesity. Exercise also helps with your mood, sleep, and overall quality of life.

Despite all of these benefits, most Americans don’t get enough. According to the Department of Health, 80% of Americans don’t meet the recommendations for physical activity. This is impacting our health. About half of American adults have a preventable chronic disease. The good news is that exercise has a positive impact on seven of the ten most common ones. That leads to the question:

Are you getting enough activity?

Here are the current guidelines:

  • Preschool-aged children (ages 3 – 5) at least 3 hours of physical activity daily
  • Children and adolescents (ages 6 – 17) at least 60 minutes of activity a day
  • Adults 150 minutes of moderate-intensity aerobic activity weekly, and muscle-strengthening activities on at least 2 days
  • Older adults (ages 65 and older) Same as the adults above with additional components added such as balance training

If you’re falling short on physical activity, you may not think of your PT as someone who can help, but you should!

Physical therapists have extensive training in anatomy, physiology, and movement science. They can get anybody moving! Here are some great times to choose a PT to help with your fitness:

  • You’re recovering from an injury or surgery.
  • You have pain or limitations that affect your movement.
  • You have a chronic condition that affects your fitness, like arthritis.
  • You need help improving your balance or preventing falls.
  • You want a personalized program that addresses specific weaknesses or imbalances.

Your PT can work with your physicians and medical team to ensure your workouts are safe. As you progress, they can also work with professionals like strength coaches or personal trainers to take your fitness to the next level.

With your PT’s guidance, you can address limitations, prevent injuries, and design a personalized program that keeps you motivated and moving towards a healthier you.

References

1)      Building motivation and sustainability into the prescription and recommendations for physical activity and exercise therapy: The evidence, Physiotherapy Theory and Practice, 25:5-6, 424-441,

  1. DOI: 10.1080/09593980902835344

2)      The physical therapist’s role in physical activity promotion. British Journal of Sports Medicine 2009;43:99-101.

  1. https://bjsm.bmj.com/content/43/2/99.citation-tools

3)      Improving Adherence to Exercise: Do People With Knee Osteoarthritis and Physical Therapists Agree on the Behavioral Approaches Likely to Succeed?.

  1. Arthritis Care Res, 70: 388-397. https://doi.org/10.1002/acr.23297

4)      Periodization and physical therapy: Bridging the gap between training and rehabilitation

  1. https://www.sciencedirect.com/science/article/abs/pii/S1466853X1500067X

Articles/Content:

1)      Physical Activity Improves Your Health and Quality of Life

  1. https://www.choosept.com/video/physical-activity-improves-health-quality-life

2)      Home Exercise From a Physical Therapist

  1. https://www.choosept.com/video/home-exercises-floor-mat

3)      Tips to Avoid Overtraining

  1. https://www.choosept.com/health-tips/tips-avoid-overtraining-injuries

Is PT for Me?

 

Physical Therapy (PT) can be used to treat the whole body. Did you know that physical therapy can help with chronic back pain, headaches and even controlling diabetes? PT is an excellent option for people with pain or recovering from an injury, accident or surgery. Physical therapy can be used to get you back to enjoying the activities that you love.

Here is an overview of some ways that PT can help you:

1. Prehab Rehabilitation Pre-surgery rehabilitation, or “prehab,” can help kick start your recovery process with the help of expert Phoenix Physical Therapists. Prehab therapy is designed to strengthen the body before surgery. The stronger you are before surgery, the easier it will be to meet your goals. Some patients have great success controlling pain and improving mobility with prehab PT.

2. Prevent Injury Physical therapy can be used as a form of preventative care. Learn proper techniques for stretching, running, and more to prevent injuries and even improve your athletic performance.

3. Improve Strength, Mobility and Balance Physical Therapists understand movement in the human body. They can provide you with useful stretches, exercises, and proper posture techniques to prevent everything from neck pain, carpal tunnel, knee pain and more. You can use physical therapy to improve your overall body mechanics for everyday activities and exercise.

4. Manage Aging Physical therapy can have many benefits for seniors. It can be used to address pain, osteoarthritis, balance, and fall prevention while also helping seniors maintain their independence. A Physical Therapist will assess all the contributing factors and develop exercises to address specific issues.

5. Treatment for a Disease or Condition Physical Therapy can be used to treat a variety of diseases and conditions. Many Physical Therapists complete advanced training to specialize in treating patients with specific conditions. Patients can benefit from physical therapy for pelvic floor pain and dysfunction, type 2 diabetes, headaches, and neurological conditions such as Parkinson’s disease and multiple sclerosis. Physical therapy can also be extremely helpful in recovering from illnesses like COVID-19. A customized program is created for each patient to address their specific condition, pain and goals.

6. Work-Related Injuries and Recovery Your employer or doctor may refer you for physical therapy for a variety of reasons. Employers often partner with a physical therapy practice for workers’ compensation related injuries as well as pre-employment screening, work conditioning and hardening and functional capacity evaluations. Physical therapy can help you return to work safely and efficiently.

Physical Therapy Helps Children Move with Confidence

Physical therapy isn’t just for adults recovering from injuries. Pediatric PTs use fun, play-based programs to get kids moving and help them reach their goals.

How Pediatric Physical Therapy Works

Pediatric PT sessions are all about play! Therapists use games, activities, and exercises tailored to a child’s specific needs and interests. This might involve:

  • Building Strength and Coordination: PTs can help children improve their balance, agility, and muscle control with fun activities such as walking like animals, going through obstacle courses, or playing games. The skills learned in these activities are essential for everything from moving through the world to keeping up with friends.
  • Addressing Developmental Delays: Physical therapy can be a game-changer for children who are experiencing delays in reaching milestones. PTs can help identify what’s holding them back, then help them develop the skills they need to progress towards the next milestones.
  • Recovering from Injuries: Just like adults, young athletes can get hurt. PTs help kids heal and regain strength and flexibility so they can return to their favorite activities safely.
  • Managing Chronic Conditions: Children with conditions like cerebral palsy or muscular dystrophy can benefit from physical therapy to manage their symptoms and improve their overall function and well-being.

Benefits Beyond Movement

Physical therapists play an important role in promoting physical activity and general health. But the benefits of physical activity go beyond that. By improving movement and coordination, PTs also help children with:

  • Self-Confidence: As kids gain strength and independence, they start to meet their goals. This helps with confidence, impacting all areas of their lives.
  • Pain Management: PTs can teach children techniques to manage pain and discomfort, improving their overall quality of life.
  • Socialization: Children use gross motor skills to play and participate in games with peers. Better gross motor skills help children develop social skills and build friendships.

If you think your child might benefit from physical therapy, talk to your pediatrician, or give your PT a call. They will assess your child’s needs and create a personalized plan to help them reach their goals!

10 Exercises To Do In the Pool

Aquatic exercise refers to exercises performed in water using various water depths. It is a physical activity that offers many benefits. Buoyancy, which is a water property, also benefits the person exercising by supporting a portion of their body weight.

Being immersed in water can allow a person to perform exercises that may be difficult to do on land. The buoyancy of water can make it easier to move and improve your flexibility. Water also provides resistance to movements, which helps to strengthen muscles. In addition, by supporting much of a person’s body weight, buoyancy reduces the load placed on joints. This can allow a person to exercise sooner after an injury or surgery than would be safe or possible on land.

Strengthening and flexibility exercises are important for managing and recovering from many conditions. Regular physical activity can benefit your physical, mental, and social health. It also can help you prevent or improve many chronic conditions, such as heart disease, diabetes, obesity, depression, and weakness associated with cancer treatment.

Pool exercises can improve your:

  • Agility (ability to move quickly and easily).
  • Balance.
  • Cardiovascular fitness.
  • Flexibility.
  • Strength and endurance.
  • Walking.

Many conditions can benefit from and improve with pool exercise. These include, but are not limited to:

Pool exercises also are helpful for children with developmental disorders such as cerebral palsy, spinal muscular atrophy, and autism. Also, older adults can reduce their risk of falls when exercising in a pool compared with exercising on land.

Preparing for the Pool

Before starting a pool exercise program, check with your physical therapist or primary care provider to ensure the exercises are right for you. Then, follow these tips for the best possible experience:

  • Water shoes will help provide traction on the pool floor and protect your toes from being scratched.
  • In general, exercise in water that is waist or chest high. If you have a specific condition, ask a physical therapist for the best water level for your condition.
  • Choose a water temperature that is best for your condition. Exercising in cooler water may allow a person to exercise more without fatiguing. Exercising in warmer water may be good for reducing pain.
  • Use a Styrofoam noodle or floatation belt/vest to keep you afloat in deeper water.
  • Slower movements in the water will provide less resistance than faster movements.
  • Use webbed water gloves, Styrofoam weights, inflated balls, or kickboards to increase resistance.
  • Never push your body through pain during any exercise.
  • Although you will not notice it, you still sweat with pool exercises; it is important to drink plenty of water.

10 Excellent Exercises for the Pool

    1. Water walking or jogging (forward, backward, and sideways). Start by walking forward in chest- or waist-high water. Walk 10-20 steps forward and then the same distance backward. Increase speed to make it more difficult. Also, increase the intensity of your effort by jogging gently in place. Switch between jogging for 30 seconds and walking in place for 30 seconds for five minutes. You can hold a kickboard vertically in the water while walking to increase resistance. Sideways walking: As a progression, try walking sideways by crossing your right foot in front of your left, bringing your left foot back to start, then cross your right foot behind your left foot. Continue with this pattern for 20 steps in one direction, then 20 steps in the other.
    2. Forward and side lunges. Stand near a pool wall for support, if needed, and take a big lunge step in a forward direction. Do not let the knee in front of you advance past your toes. Return to the starting position and repeat with the other leg. For a side lunge, face the pool wall and take a giant step to the side. Keep your toes facing forward. Repeat on the other side. Try three sets of 10 lunge steps. For variation, do your lunges forward or sideways across the pool instead of staying in place.
    3. One leg stand/balance. Stand on one leg while raising the other knee to hip level. Place a pool noodle under the raised leg so it forms a “U” with your foot in the center of the U. Hold as long as you can up to 30 seconds, then switch legs. Try one to two sets of five on each leg. If you have trouble with balance, try this exercise while holding onto the side of the pool or without using a noodle.
    4. Sidestepping. Face the pool wall. While keeping an upright posture, take sideways steps with your body and toes facing the wall. Take 10-20 steps in one direction and then return. Repeat twice in each direction.
    5. Hip kickers. Stand with the pool wall to one side of your body for support. Move one leg forward with your knee straight, like you are kicking. Return to start. Then move the same leg to the side and return to the start position. Then move that same leg behind you. Lastly, move your leg in a circle (as if drawing a circle on the pool floor). Repeat three sets of 10, then switch the kicking leg.
    6. Pool planks. Hold the noodle parallel to the pool floor with both hands (shoulder-width apart). Keep your toes on the pool floor as you straighten your elbows and lean forward to submerge the noodle in front of you, so you end up in a plank position. Your body should be straight and diagonal to the pool floor. Hold from 15 to 60 seconds (as long as comfortable). Repeat three to five times.
    7. Deepwater bicycle. In deeper water, loop one or two noodles around the back of your body and rest your arms on top of the noodle for support. Move your legs as if you are riding a bicycle. Continue for three to five minutes.
    8. Arm raises. Stand in water deep enough to submerge your shoulders. Using arm paddles or webbed gloves for added resistance, hold your arms at your sides and bend your elbows to 90 degrees. Keeping your elbows bent and your shoulders down, raise your arms outward toward the water surface, then bring them back to your sides. Repeat for three sets of 10. You can perform arm raises while standing on one leg to challenge your balance during exercise.
    9. Pushups. While standing in the water at arm’s length from the pool edge, place your hands shoulder-width apart on the pool edge. Keeping your feet on the pool floor and your body straight, lower your chest toward the pool edge. Then press your weight through your hands to raise your body back up to the starting position. Repeat for three sets of 10.

For more challenge: While standing close to the poolside, place arms shoulder-width apart on the pool edge. Press your weight through your hands to raise your body up and halfway out of the water (keep your elbows slightly bent). Hold for three seconds, then slowly lower your body back into the pool.

  1. Standing knee lift. Stand with your back against the pool wall and both feet on the floor. Lift one knee like you are marching in place. While your knee is even with your hip, straighten your knee so your leg is parallel to the pool floor. Continue to bend and straighten your knee 10 times, then repeat on the other leg. Complete three sets of 10 on each leg. For more challenge: Try this exercise without standing against the pool wall.

If you have limited mobility or a chronic condition that makes it hard for you to do these pool exercises on your own, a physical therapist can help.

Physical therapists are movement experts who use the best available evidence to design treatment plans for each person’s needs and goals. They improve quality of life through hands-on care, patient education, and prescribed movement. Ask your doctor how physical therapy can help you or contact a physical therapist directly* for an evaluation. Click here to find a location near you.

Article courtesy of ChoosePT.

4 Things To Expect After Shoulder Replacement Surgery

Shoulder replacement (also known as shoulder arthroplasty) is a major surgery in which all or part of the shoulder joint is replaced. This surgery is only done when other conservative treatments no longer provide pain relief or when severe pain limits your ability to use your shoulder. Shoulder replacement surgery can address pain and improve the use of your shoulder, but the recovery time is often significant and requires some work to get the full benefit of the surgery.

If you or someone you know needs shoulder replacement surgery, knowing what to expect can help you have a better outcome.

Here are four things to know:

1. Managing pain after surgery.

You can expect some pain after shoulder replacement or any major surgery. Your pain should decrease as you heal. Most people report barely noticeable to mild pain after they have fully recovered from shoulder replacement surgery through targeted physical therapy. Many people report a great improvement from the pain that they experienced before surgery.

Work with your physical therapist to learn positions and exercises that reduce pain and help you heal. Work with your surgeon and pharmacist to understand how to safely use pain medications after surgery. If your surgeon prescribes opioid medications after surgery, it is important to have a plan to decrease their use in a timely manner.

Research shows that taking prescribed opioids before surgery leads to worse pain management after surgery. Consider weaning off these medicines prior to surgery with the supervision of your health care team. This can help with your pain management after surgery.

2. An initial need for help and assistance.

You can expect to be in a sling for a few weeks. You will not be able to use your arm for anything except prescribed exercises. Your PT will teach you specific exercises to promote healing.

Consider having ready-to-eat meals that are easy to prepare. You may want to set up things at home that you need regularly at an easy-to-reach level. Button-up shirts are easiest to wear while you cannot lift your arm.

Let your friends or family know that you are having major surgery, so they can support you while you recover.

3. Difficulty sleeping.

Initially, sleep may be difficult after surgery but can improve with good habits. Good sleep habits, also known as sleep hygiene, include:

  • Avoiding large meals and caffeine before bedtime.
  • Limiting or avoiding alcohol.
  • Avoiding nicotine.
  • Removing electronic devices from the bedroom.
  • Having a regular set bedtime.

Finding a well-supported position also will be important. Talk with your physical therapist about positions to keep your shoulder protected while you sleep.

4. Improved mobility and function.

Physical therapy is a critical part of recovery after shoulder replacement surgery. Before surgery, a physical therapist can help you improve your shoulder and upper back movement to keep your shoulder as strong and mobile as possible until the time of surgery.

After surgery, a hospital physical therapist will educate you about what precautions to take when you go home and what movements to avoid during the initial healing phase. They also will teach you how to get in and out of bed while protecting your shoulder.

After discharge, continuing physical therapy is very important to ensure your safe recovery. Your physical therapist will work with you to progress your exercises at the right times in the healing process. They will help you get back your range of motion, improve your strength and function, and eventually help you get back to your everyday activities, job, or sport.

Be sure to tell your physical therapist your goals, so both of you can focus on what is important to you.

Physical therapists are movement experts who improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. Find a location near you.

Article courtesy of APTA.