Central Park Fitness Test
This is a picture of my 85 year old Mother and I on a recent family vacation to New York City.
My Mom has kept herself fit and active. She has traveled with us on many vacations. I have taken her to the top of mountains in Banf and across rock formations in Moab. She is an elderly person who is enjoying a long and big life. On this New York City vacation, we walked from the south end of Central Park, up into Harlem for a well-deserved lunch of beer and Italian cuisine. She traversed six floors in the Empire State Building stairwell. Every day required multiple trips up and down subway stairs.
I hope and pray I have inherited every single amino acid of the genes that code for this vitality.
Michael S. O’Hara, PT, OCS, CSCS
Sarcopenia And The Media
Older individuals have the most to gain from strength training. Six weeks of dedicated strength training will normalize balance, rejuvenate posture, revive the metabolism, and eliminate long-standing pain. I often tell physical therapy patients that strength training is the “fountain of youth”. Unfortunately, it is difficult to convince older individuals that they need to become dedicated to a routine of consistent resistance training. I recently got some help from Jane Brody in the New York Times, *Preventing Muscle Loss Among the Elderly.
Drs. Evans and Rosenburg are Tufts University researchers interested in the physical attributes that keep humans healthy and vigorous over an entire life span. They have determined that the top four biomarkers are:
- Muscle Mass. What percentage of your body is made of muscle?
- Strength. Can you use that muscle to push, pull, lift and carry?
- Basal Metabolic Rate. The number of calories your body expends at rest.
- Bodyfat Percentage. What percentage of your body is composed of fat?
They named these top four biomarkers, the decisive tetrad. They are the prerequisites to maintaining healthy numbers in all of the other essential biomarkers.
- Aerobic Capacity
- Blood Sugar Tolerance
- Cholesterol / HDL ratio
- Blood Pressure
- Bone Density
- Internal Body Temperature Regulation
Drs. Evans and Rosenburg coined the term age related sarcopenia in their 1991 book Biomarkers. It refers to the gradual loss of muscle mass that occurs as we age. The keys to aging well; staying durable- no injuries, and maintaining control of all health parameters is maintaining or improving muscle mass / strength and eating properly. An ongoing program of strength training and nutritional discipline are the foremost components of fitness and health.
I was happy to see that Jane recommended her elderly compatriots consume more protein. Not enormous amounts of protein- just some protein. Many fitness clients fail to make optimal gains because they have the protein intake of a bunny rabbit. Adequate training recovery requires the building blocks of muscle in order to produce results. A bagel for breakfast, a kale sandwich at lunch, a yogurt snack and a diner of soup, bread and ice cream does not supply the nutrients necessary for recovery.
So, take the time to read the amazing Jane Brody and then get those dumbbells out of the basement.
*Brody, Jane. Preventing Muscle Loss Among the Elderly, September 1, 2018, New York Times. View article
Michael O’Hara, PT, OCS, CSCS
Calculating Nutritional Needs
If you are hoping to see serious changes in your weight and body composition, then nutrition is going to play a huge role. There are many parts to a solid nutrition plan. For the purposes of weight gain/loss, we must look at overall energy intake. A chronic surplus of calories consumed leads to weight gain, while a chronic deficit leads to weight loss. But most people want to do more than to lose or gain weight. Most individuals want to gain or maintain lean body mass (muscle, bone, organs, tendons/ligaments, water) while decreasing body fat. For this, we need to focus on protein. Nutrition needs to be based on performance goals, the types of activities you enjoy doing, your lifestyle, and your food preferences. Adherence to a program is huge, so it’s important to pick a nutritional approach that fits within your lifestyle.
Calories: We must first start with calculating caloric needs. First, determine a good target body weight (TBW). This should be based on a healthy/realistic body composition range. For men, this is typically 10-20% body fat, for women it tends to be 18-30%. A good trainer can help you determine this number/range. Once you have your TBW, we must determine your activity multiplier. It is important to be brutally honest here, odds are you are 1 lower than you think. The multipliers are:
Very Inactive & Older: Multiplier is 8. This is for anybody who never does anything physical day to day. They have a long commute, office job, and engage in little unplanned movement from day to day. They are also over the age of 55.
Very Inactive: Multiplier is 9. Same as above but for individuals under the age of 55.
Inactive: Multiplier is 10. This for anyone who while mostly sedentary during the day, does get up and walk around or move several times per day. This can also apply to someone who doesn’t move much during the day, but has a standing desk.
Moderately Active: Multiplier is 11. This individual is never sitting for more than 90 minutes straight and moves around several times per day. They also engage in leisurely activities a few times each week such as walking or casual bike riding.
Active: Multiplier is 12. This individual sits no more than 60 minutes at a time during the day, and engages in leisurely activity 5-7 days per week.
Very Active: Multiplier is 13. This is for individuals who have a very physically demanding job such as construction, landscaping, assembly line work, etc.
Hard Gainer: Multiplier is 14. This is reserved only for those individuals who are trying to gain wait, have a very low body fat percentage (below the norms listed), and has never been able to gain wait.
The final thing we must determine is how many moderate to intense training hours we are going to perform each week. Again, be realistic. Don’t count warm up time, and if you think you are going to train 3-4 hours per week, use the low number for weight loss and the high number for weight gain. Here is what the equation looks like:
(TBW x (activity multiplier + training hours))=estimated caloric needs
Here are two examples to help you work through this:
200lb male, with a target body weight of 185lbs who is inactive, and trains 3 hours/week.
(185 x (10+3))=2405 calories/day
150lb female, with a target body weight of 140lbs who is very active and trains 2 hours/week. (140 x (13+2))= 2100 calories/day.
Protein: Now that calories have been determined, we must determine protein intake. Calories will dictate weight gain/loss. Protein will help preserve or increase lean body mass. Protein intake should be set at 0.72 up to 1g per pound of target body weight (TBW). So, for our 2 examples listed earlier, we would have the following:
200lb male with a TBW of 185lbs. 0.72 x 185= 133.2g
The low end would be 133 grams of protein, and we could go up to 185 grams reasonably.
150lb female with TBW of 140lbs. 0.72 x 140= 100.8g
This puts our low end at 101 grams of protein with the upper reasonable range of 140g.
There are 4 calories in 1 gram of protein. This will come into play when we set our carbohydrate intake later. Our male would be targeting 133-185g of protein per day which equates to 532-740 calories coming from protein. For our female, we have targets of 101-140g of protein each day with 404-560 calories coming from protein:
Fat: Fat is essential for optimal hormonal health and should be consumed from a variety of sources. There is no good or bad fat (outside of trans fats), we should simply seek a variety of fat sources. Fats (just like carbohydrates) have a huge healthy range you can pick from based on food preference and tolerance. Fat should make up 20% of your calories at a minimum, but can go as high as 1g per pound of target body weight (TBW). Using our previous examples:
200lb male, with a TBW of 185lbs. Calories projected at 2405/day. 0.2 x 2405=481 calories coming from fat. There are 9 calories in each gram of fat. So, we take 481/9=53 grams of fat each day for the lowest possible number. The upper end would be 185g or 1665 calories from fat. Our fat range could be 53g (481 calories) up to 185g (1665 calories).
150lb female, with TBW of 140lbs. Calories projected at 2100/day. 0.2 x 2100=420 calories from fat. 420/9=47 g of fat. Her low end would be 47g (420 calories from fat) up to 140g (1260 calories from fat).
Carbohydrates: While carbohydrates are not technically essential in our diet, your brain prefers them for fuel, and intense exercise tends to be best fueled through their inclusion. However, for the recreational gym goer who trains 2-4 days per week, the amount of carbohydrate intake probably has minimal bearing on progress. Food preference, as well as how your body tolerates different levels should be your main determinant in setting levels here. To determine carbohydrate levels, we simply take your remaining calories (after setting protein and fat intakes) and a lot them to carbohydrate intake. There are 4 calories in 1 gram of carbohydrate. So again, using our previous examples, we would have the following:
200lb male with TBW of 185lbs. 2405 calories per day, sets protein at 0.72/lb of TBW. This equals 133g of Protein (532 calories). This guy loves fat so he sets his fat at 1g per pound of TBW. This would be 185g of fat (1665 calories). So 2405-(532+1665)=208 remaining calories. 208/4=52 grams of carbohydrate. Same guy may also choose to up protein to 1g/lb of TBW. This would give us 185g protein (740 calories). Let’s say he loves pasta, bread, etc. So, he sets his fat to the minimum of 53 grams (481 calories). In this example we have 2405-(740+481)=1184 calories from carbohydrates. 1184/4=296 grams of carbohydrate per day. There is an endless combination of macronutrients here.
Conclusion: There are many approaches that can be used when determining nutritional needs. The most important variable is adherence. Can you stick to this approach long term? Data suggests that both very low carbohydrate diets (under 100g) and very low fat diets (under 15% of total calories) are difficult to maintain beyond 6 months. Do the foods you eat make you feel energized, taste good, and satisfy you? These are all things that should be considered. We want to emphasize whole foods, while not avoiding any food group entirely unless you have a proven medical condition. These equations are to be used to help you set baseline numbers. For weight loss, we should target 0.5% up to 1.5% body weight lost each week. For weight gain, we should target 0.25% up to 1% body weight gain each month. If your rates fall below or above those respective rates, we simply need to increase/decrease caloric intake accordingly. For help setting your numbers schedule your nutrition consultation by reaching out at firstname.lastname@example.org or calling 810-750-0351. Nutrition coaching is available for those that require more education and/or accountability.
-Jeff Tirrell, CSCS, CFSC, Pn1
Location, Location, Location
Overcoming The Diameter Dilemma
The location of bodyfat is far more important than the amount of bodyfat. Visceral fat, the kind stored in and around the belly, is the hormonal driver of metabolic syndrome; the precursor to diabetes, elevated blood lipids, high blood pressure, and coronary artery disease. To optimize health, you need to monitor the diameter of your waistline. The number you need to know is your waist to height ratio. You want your waist to be less than half your height. If your waist size is greater than one half your height, then reducing your waist diameter should be the primary goal of your fitness program. The New York Times has an excellent *article by Jane Brody on the perils of too much belly fat.
After the age of 25, the average American gains a pound of fat and loses a ½ pound of muscle every year. If no action in taken to reverse this trend, the average American will have gained 25-30 pounds of fat and shed 12-15 pounds of muscle by the time they reach 55 years of age. This 55 year old will stand on the scale 12 to 18 pounds heavier but the true alteration in body composition is far more dramatic. The tape measure reveals a much more dramatic transformation.
One of the adverse effects of calorie restriction diets is the loss of muscle that accompanies a reduction of bodyfat. Muscle is the metabolic engine, injury preventative armor and longevity enhancing elixir of human biology. The recent research reveals that a program of strength training produces optimal fat loss with significantly less muscle wasting. Your choice of exercise activity can have a profound impact on your physical performance and health.
Michael S. O’Hara, PT, OCS, CSCS
*The Dangers of Belly Fat, Jane Brody, New York Times, June 11, 2018. Here’s the link: https://www.nytimes.com/2018/06/11/well/live/belly-fat-health-visceral-fat-waist-cancer.html
Happy Brain Exercises
Daily Neurodevelopmental Brain Boosters
Exercise improves brain neurochemistry, neural connections, and even the number of brain neurons. I have two suggestions on the best exercise activities to improve brain health. They both have roots in human neurodevelopment and can be employed by nearly everyone. Build better brain health with a walk and a crawl.
Morning walks work magic. Many top leaders talk about how much better they think and analyze when they start the day with exercise. If you are the decision maker for your family or company, please take a morning walk.
Cadence Counts. If you are moving at 60 steps a minute, you are not walking, you are strolling. A compilation of many studies has found that 100 steps per minute as the sweet spot for walkers under the age of sixty. The data for older walkers has yet to be fully evaluated, but it appears the cadence should not slow much below 100.
Tune in. Ditch the earbuds. Tame the dopamine damage of “connectivity” and leave the phone at home. Be alone with your thoughts for the duration of your walk. Gandhi, St. Augustine, Thomas Jefferson tell us that difficult problems are resolved with contemplative walks.
Get off the pavement. The human species evolved walking through undeveloped environments. Take your walk to a quitter and more tranquil setting. More trees, less noise, and serene surroundings provide a calmer event. I personally believe that uneven and inclined pathways do a better job at stimulating neurodevelopmental pathways.
Get comfortable with a long walk. Thirty minutes a day is great, but once a week go for a sixty-minute walk. Stretch out the distance you can travel. Load up a backpack with water and try a two hour ruck walk. There is no greater brain regenerating activity than a long October nature walk in Michigan.
“Walking is the best possible exercise. Habituate yourself to walk very far.”
It does not matter if you are an Ashtanga Yoga devotee, hard style kettlebell lifter, Crossfit firebreather, PureBarre, or Pilates disciple, there is one exercise that everyone in the fitness world has performed. For many months we all diligently worked on becoming better at this exercise and it rewarded us with crucial neural connections. The bad news is that most of us have stopped using this exercise. The good news is that we can still use the crawl pattern and reboot the brain connections that allowed us to stand and walk.
More of your brain is devoted to movement than any other activity. Despite what you have read, muscles never work in isolation. Our muscles are arranged in an interconnected, spiral, and diagonal fashion. The “core muscles” are neurologically wired to connect your left hip with the right shoulder and the right hip with the left shoulder. They are designed to stabilize your middle so you can transfer force from the hips to the shoulders. Crawling is all about that critical, spiral-diagonal connection.
Try adding two crawl training sessions a week to your fitness program. Crawls are one of those exercises that produce the “What the heck?” effect. Other activities of daily living suddenly become easier. Joints move better, posture improves, and long standing soreness resolves. Just ask any baby.
Michael S. O’Hara, PT, OCS, CSCS
Please Watch the TED Talk by Dr. Wendy Suzuki
The incredible impact exercise has on your neural and hormonal systems are the biggest reasons to stay consistent with a program of fitness. More of your brain’s real estate is devoted to movement than math, reading, or texting. Exercise is unmatched at creating the essential neurochemicals that help us make good decisions and maintain emotional wellness. For more information on the impact a program of exercise has on brain health watch the *TED talk given by Dr. Wendy Suzuki.
Dr. Suzuki is a neuroscientist researcher at NYU. In her talk, she discusses how exercise helps build up the areas of our brain responsible for memory and cognition. She discusses how consistent physical training replenishes brain chemistry, improves mood, and helps us think clearly. If, after you watch the TED talk you want more information, read her book, Healthy Brain, Happy Life.
We are learning that neurochemicals have a profound impact on family and work place interactions. Leadership guru Simon Sinek talks about how endorphins, dopamine, serotonin, and oxytocin all play a role in workplace and family happiness. If you are a decision maker or leader for your family or teammates, you owe them a devotion to the brain enhancing powers of exercise.
Consistent exercise builds more neural connections, immunizes us from depression, and greatly reduces pain. Physical therapy patients and fitness clients frequently say the most beneficial aspects of a renewed devotion to exercise is the improvement in their mood. Hundreds of studies have demonstrated the positive effects exercise has on brain chemistry. All of the happiness promoting and pain suppressing molecules are boosted with exercise. Levels of endorphins, serotonin and BDNF- Miracle Gro for your neurons, all increase with exercise. Some of the most revealing research on pain science demonstrates that “pain circuitry” is repaired with exercise.
To build the biggest and baddest hippocampus in the gym, look to the next email. Take the time and watch the TED talk by Dr. Suzuki.
*TED, The Brain-Changing Benefits of Exercise. Dr. Wendy Suzuki.
Michael S. O’Hara, PT, OCS, CSCS
View the Ted talk: https://www.ted.com/talks/wendy_suzuki_the_brain_changing_benefits_of_exercise
Bad Man Break
Men Need To Be More Aware Of Bone Density
Allen was getting out of his fishing boat when he twisted his left leg and fractured two bones in his ankle. Six weeks after ankle surgery, he landed in our clinic with considerable pain and a very limited lifestyle. Allen reported lower back pain that he attributed to his limping and use of the boot on his left leg. On recommendation from his physical therapist, Allen had further medical assessment of his lower back pain. An x- ray of his lumbar spine revealed two lumbar vertebrae fractures.
On a recent vacation, Mike went on a horseback ride with his grandchildren. During the ride, he developed pain in his upper back that “took his breath away”. A visit to the emergency room with what he thought was a cardiac issue revealed a three-level compression fracture in his thoracic spine. Further assessment showed significant osteoporosis in his hips, pelvis, and lumbar regions. Allen started on some bone rebuilding medications and physical therapy. It took over four months to fully recover from this injury.
Randy was working on his garden and fell onto the lawn. He had right hip pain and was unable to stand. His wife called the ambulance and he was diagnosed with a hip fracture. Four days after the surgery to repair his hip, he suffered an embolism and at the age of seventy-one, he passed away.
All three of these older guys had testing that revealed a significant loss of bone density. Unfortunately, the tests occurred after and not before injury onset. We are getting better at keeping men alive longer–less smoking and better medications. As men get older, the need to monitor bone density becomes a crucial aspect of healthy aging. Men need fewer commercials for the latest in testosterone replacement and ED medication and more awareness of how brittle their bones can become.
The general public views osteoporosis as a “women’s health issue”, but management of osteoporosis is just as important for men. Although men are less likely than women to sustain an osteoporosis related fracture, they are much more likely to become permanently disabled or die from the fracture. Since 2008, the rate of osteoporosis related hip fracture in the American male population is going up at an alarming rate.
Osteoporosis is a silent disease. Most people do not realize they have a problem until something breaks and they are in the middle of a medical crisis. Even after a fracture, many physical therapy patients are reluctant to follow up with a bone density screening. Being proactive is the only method of managing osteoporosis.
We know that individuals that participate in consistent resistance training exercises are more likely to have better bone density. Just like muscle, bone is a living thing that grows stronger in response to the force that is placed upon it. The best bone building exercise activities produce a stimulus through your skeleton. Bone building exercises are easy to understand, but they do require more effort than swallowing a pill or having an injection. Everyone can perform some form of bone reinforcing exercise. Proper exercise prescription and consistent progression can work wonders. See the trainers and physical therapists at Fenton Fitness.
Jane Brody of the New York Times wrote a helpful *article on bone density testing. It covers the latest medical guidelines for testing and the when and why of testing for both men and women.
Michael S. O’Hara, P.T., OCS, CSCS
*New York Times, July 16, 2018, Jane Brody, When to Get Your Bone Density (View Article:here)
Play It All
How To Keep Your Child On The Field And Out Of The PT Clinic
Taylor was recently referred to physical therapy with a painful shoulder and a right hand that frequently went numb. For the last five years, she had been a year round participant in softball. At the age of fifteen, she was missing out on softball and a good night sleep secondary to the pain and limited function in her right arm.
Andy played soccer, and at the age of thirteen, he developed knee pain that prevented him from changing directions and sprinting. Andy practiced or played soccer four days a week for 50 of the 52 weeks in a year. It took four years of year round soccer to create the knee damage that required surgery and an twelve week rehab.
Many of the young athletes we treat in physical therapy are the victims of over exposure to the same training stimulus for far too long a period of time. Gymnastics, dancing, baseball, soccer, and softball are worthwhile endeavors, but a developing body needs a break in order to stay healthy. This becomes even more important as the athlete becomes stronger or more skilled.
Take a moment and read the *article by Jane Brody in the May 7th, 2018 edition of the New York Times. Jane interviews several Orthopedic Surgeons that are treating younger patients with injuries that usually occur ten or fifteen years later in an athlete’s career. The research they present is clear; year round single sports participation is not the best way to excel in athletics or remain healthy.
The recent popularity of the club system has children playing the same sport year round. In the clinic, we are treating more young athletes with old person overuse injuries. Participation in a variety of athletic activities is infinitely more beneficial and safer than single sports specialization. It is no coincidence that most successful collegiate and professional athletes are the product of multi-sport participation.
*New York Times, Jane Brody, May 7, 2018, How to Avoid Burnout in Youth Sports. View article: https://www.nytimes.com/2018/05/07/well/how-to-avoid-burnout-in-youth-sports.html
Michael S. O’Hara, PT, OCS, CSCS
100 Steps Per Minute
Step Cadence and Fitness
Exercise researchers have been studying gait cadence for years. A cadence of 80 steps a minute is a stroll. 100 steps a minute is considered a brisk walk. At 130-140 steps a minute, you move into jog or slow run. Recent high tech evaluations of gait cadence has been able to predict the onset of dementia in older people. For many people, walking is their primary form of exercise. Gretchen Reynolds has written an excellent *article on the walking cadence that produces optimal health benefits.
A compilation of many studies has found that 100 steps per minute is the sweet spot for walkers under the age of sixty. The data for older walkers has yet to be fully evaluated, but it appears a slightly slower cadence is a good goal.
I like evaluations of performance. Evaluations tell you if you are getting better or getting worse. The human body is in a constant state of adaptation and never stays the same. Keep track of your cadence by counting your steps for twenty seconds and then multiplying by four. Use that information to track your fitness level. Ideally it should get easier to walk, at faster pace over a greater period of time.
15 x 4 = 60 Pokey Joe.
20 x 4 = 80 Still too slow.
25 x 4 = 100 Good job.
Michael S. O’Hara, PT, OCS, CSCS
*Walk Briskly for Your Health. About 100 Steps a Minute, Gretchen Reynolds, New York Times, June 27, 2018
You Have A Social Media Disease
There Is No App for Thumb Pain
Your thumb is made up of an intricate system of tendons that enable very precise movement. The joints of a thumb are fairly small and yet we are able to produce an amazing amount of force with this single digit. In this age of all things digital, the modern American thumb has been subjected to greater workloads. Problems with thumb pain, numbness, and limited function are becoming more common complaints in physical therapy. I have some suggestions on how to manage pain and limit the damage and embarrassment of excessive social media thumb exposures.
Thumb Tendon Troubles
Dr. De Quervain was the first to clinically described thumb tendonopathy, and we call thumb tedonosis De Quervain Syndrome. The test for De Quervain Syndrome was created by a clinician with an equally odd name and it is called the Finkelstein test. Place your thumb in the palm of your hand. Make a fist with the finger around the thumb. Hold the wrist in neutral and then deviate the wrist toward the pinkie finger. If you feel pain it is a positive Finkelstein test.
Resolution of thumb tendonopathy pain happens quickly when you give in to the symptoms of pain and modify your activities. Rest the thumb tendons by using your fingers instead of your thumb on that smart phone. Avoid fitness activities that put stress on the thumb. Lifting in front of the body with the palms facing inward is often the lift that new mothers perform and develop painful thumb tendons. Early on in the pain onset, icing is often helpful. In physical therapy, we are successful with soft tissue mobilization, ultrasound, and manual therapy. A gauntlet type thumb splint you wear at night is an unattractive but provides aviable position of rest for severely aggravated thumb tendons.
The Numb Thumb
Irritation of the median nerve in the carpal tunnel of the wrist will create thumb, second, and third finger numbness and pain. An injury of the recurrent median nerve in the front of the palm will produce numbness in the thumb and limited strength during thumb opposition–thumb to pinkie finger. Patients with neural irritation often develop numbness, weakness, and then pain. The pain often wakes them from sleep and disrupts hand function.
Once again, you will resolve a numb thumb with rest. Once neural irritation gets fired up, it takes longer to resolve than an aggravated tendon. Giving in to the numbness and resting the hands will produce better results if you start early. Two weeks of avoiding the aggravating hand activity produces good results. Night splints for the wrist and thumb are often helpful. A carpal tunnel release is a common surgical alternative that takes pressure off the median nerve.
Gumbie Thumb Beware
Every joint has a certain degree of stability and certain degree of mobility. Our spine, knees, hips, shoulders, and elbows must move enough to produce motion but not so much that they fall apart. The amount of movement in our joints is largely an inherited characteristic–you can blame Mom and Dad. The person at the extreme end of the scale (“double jointed”) needs to take certain precautions with their thumbs.
The Beighton Score is a popular screening technique for joint hypermobility. It has been around for thirty years and is used in research all around the world. The scoring is based on eight passive range of motion assessments and one active range of motion assessment. One point is assigned for each of the following.
A pinkie finger that can be passively bent backward more than 90 degrees.
A thumb that can be pulled down to the front of the forearm.
Elbows that passively hyperextend to 10 degrees.
Knees that passively hyperextend to 10 degrees.
The subject can place the palms on the floor during a straight leg, forward bend.
Researchers disagree on the score that should be a threshold for concern about systemic joint hypermobility. I have found that fitness clients and physical therapy patients that score a 5/9 or higher require modification of their training programs. It is not uncommon to encounter physical therapy patients that have a Beighton Score of 9/9. Hypermobile individuals need to take more precautions when they perform repetitive tasks such as texting on a smart phone.
Kimberly Salt wrote an excellent article on social media induced thumb pain in the May 19, 2018 issue of the New York Times. Take a minute and read, Me and My Numb Thumb: A Tale of Tech, Texts and Tendons.
Michael S. O’Hara, PT, OCS, CSCS