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THE LOCAL RESPONSE OF SKIN BLOOD FLOW
      TO DYNAMIC EXERCISE OF AN
              EXTREMITY
                        This study was done at:

                    The Creighton Diabetes Center
                        601 North 30th Street
                       Omaha, Nebraska 68131
                                   by
   Dr. Marc Rendell*, Henry Wang, Brian K Milliken, Kristine L. Bailey
                using the electronic muscle stimulator
                                  the
                         NEURO CARE 1000

  KEY WORDS: LASER DOPPLER, MICROVASCULAR BLOOD FLOW,
  ELECTROCUTANEOUS NERVE STIMULATION, ARTERIOVENOUS
                     ANASTOMOSES

    *To whom page proofs and reprint requests should be addressed




             2121 South 125th East Ave. Suite 107
                   Tulsa, OK, 74129 USA
                        (918) 439-9060
                      New Tradition Clinic
                              ABSTRACT
Large changes in skin blood flow occur with exercise. Most studies have dealt with
changes in cutaneous flow at sites distant from vigorous exercise. Thus, hemodynamic
effects and changes in core body temperature are the dominant influences on
measurements obtained. It has been technically difficult to determine skin blood flow at
sites near vigorous muscular activity. We have developed a technique to carry out
dynamic exercise of an extremity while maintaining the site of blood flow measurement
motionless. Therefore, we are able to obtain valid readings using Laser Doppler
technology, free from motion artifact.

Using this technique we measured skin blood flow on the paw on the Wistar-Kyoto rat
during dynamic limb exercise induced by electrocutaneous stimulation. We contrasted
results on the planter surface of the paw, which has a high density of arteriovenous
anastomoses (AVA), with measurements on the dorsal surface, which has a nutritive
(NUTR) perfusion (NUTR). At basal skin temperature, the average maximal flow reached
at the planter paw surface was 46 + 4 mVmin 100 gm compared to 33 + 2rnl/min/100 gm
at the paw dorsum. With application of heat, there was no change in the mean maximal
flow attained during exercise at the paw dorsum. At the planter paw surface, there was a
small increase to 68 + 10 ml/min/100 am. Expressed as a percentage of increase,
exercise induced an increment over preexercise baseline of 992 + 100% at the planter
paw surface at basal temperature, but only 30 + 3% at 44 C. In contrast, there was a
sixfold increase in mean maximal flow at the paw dorsum with exercise both at basal
temperature and at 44 C. At the dorsal surface, the increase was mediated by an
equivalent increase in microvascular volume and red blood cell velocity. In contrast, at
the planter surface, the increase was chiefly one of red blood cell velocity. Distant
exercise raises skin blood flow through increased heart action and reflex vasodilation due
to core body thermogenesis. In contrast, local exercise appears to act by a direct physical
action.




                 2121 South 125th East Ave. Suite 107
                       Tulsa, OK, 74129 USA
                            (918) 439-9060
                       New Tradition Clinic
                         INTRODUCTION
The cutaneous microcirculation plays a major role in maintaining thermal homeostasis.
Therefore, skin temperature is an important regulatory influence on cutaneous blood flow.
Using laser Doppler techniques, we have previously investigated thermal effects on skin
blood flow. Local heating of the skin elicits substantial increases in flow, overcoming
many other regulatory influences. For example, postural effects, such as the
venoarteriolar reflex, are eliminated by local heating to 44 C(1). However, the effects of
heating on skin blood flow are not uniform. Although most of the skin surface is perfused
primarily by small nutritive (NUTR) capillaries, areas such as the tips of the fingers and
toes have a high density of large diameter arteriovenous anastomoses (AVA). We have
shown that the effect of local heating is greater at AVA areas than at NUTR sites, and
that the mechanism of response is different(2). At NUTR sites, the thermally induces
increase in blood flow is mediated by a large rise in microvascular volume (VOL),
denoting an increase in the number of perfused capillaries, and an equivalent rise in red
blood cell velocity (VEL). In contrast, AVA sites respond to heat with a much smaller
increase in VOL, the increased flow resulting primarily from a very large rise in VEL.

We were interested in exploring stimulatory effects on skin blood flow other than heat
using our techniques. Large changes in cutaneous flow occur with exercises. However, it
is technically difficult to measure cutaneous blood flow during local exercise. There are
large changes in muscle flow during exerciser These changes make the calculation of
skin blood flow as distinct from muscle blood flow very problematic using measurement
techniques such as microspheres, Xenon washout and thermal dilution. Conversely, laser
Doppler technology does measure cutaneous flow directly, but is invalidated by
movement of the probe. As a result of these technical constraints, most studies have
dealt with the cutaneous response to exercise occurring distant to the measurement site,
for example forearm blood flow changes resulting from vigorous lower extremity
exercise(5-7) Furthermore, the evaluation of blood flow changes during very vigorous
distant exercise is confounded by systemic hemodynamic effects, most notably increase
in heart rate, and by calorigenic effects of the exercise(8,9). Using isometric exercise, it
has been possible to avoid such confounding factors and directly measure cutaneous
blood flow in the region of exercise. However, the increases which occur during isometric
exercise are much smaller than during dynamic activity(10).

We were interested in exploring the effect of local exercise on skin blood flow,
independent of systemic hemodynamic changes and free from motion artifacts.
Therefore, we have devised a technique to measure skin blood flow on the paw of the
actively exercising limb of the Wistar- Kyoto rat while keeping the measurement site
immobile. In our previous work, it has been demonstrated that rat serves as a useful
comparative model for skin blood flow studies. In the rat, hair covered areas, such as the
back and dorsal surface of the paw, have only a small response to heating, with
equivalent increases in VOL and VELDT, similar to NUTR skin sites in man. In contrast,
the hairless planter surface of the paw demonstrates flow properties similar to those of
the AVA areas in man, with a substantial thermal response resulting chiefly from an
increase in VEL. The effects of local heating on blood flow response are greater than
those of core heating of the body(11) Changes in blood viscosity affect blood flow
primarily at AVA sites12 . Furthermore, the diabetic rat shows decreases in skin blood
flow at NUTR sites which are similar to those in diabetic man(13-15) . Thus, we felt
confident that results of exercise testing using our new technique would be applicable to
man. We proceeded to compare skin blood flow at the dorsal with that at the planter
surface of the rat paw during dynamic exercise, contrasting thermal with exercise induced
effects at these two sites.

                  2121 South 125th East Ave. Suite 107
                        Tulsa, OK, 74129 USA
                             (918) 439-9060
                        New Tradition Clinic
              MATERIALS AND METHODS
Laser Doppler Measurements: The techniques have been extensively described in our
prior work. We use a Vasamedic Model BPM2 laser Doppler device (Vasamedics Inc., St.
Paul, Minnesota, USA)(16). The instrument has a low power solid state laser diode as a
coherent light source. A fiber optic line delivers light to a probe affixed to the tissue with
an adhesive ring. As light enters the tissue, photons are scattered in a random fashion by
moving erythrocytes and stationary tissue cells. Photons that interact with moving
erythrocytes are Doppler (frequency) shifted and scattered. Photons that interact with
stationary tissue cells are scattered but not Doppler shifted. Two separate fiber heads
next to the output probe pick up a portion of the scattered photons and return them to the
instrument through a fiber optic line. A photodetector converts the photons to a DC
electrical signal related to the level of scatter from stationary tissue. An additional small
AC signal is generated by Doppler shifted photons. The AC:DC ratio is converted to the
average number of Doppler shifts per photon(17). That number is proportional to the
blood volume. A signal processing algorithm converts a time domain autocorrelation to a
frequency domain which gives a mean frequency proportional to blood velocity. Blood
flow is the product of linearized volume and velocity. This flow parameter, in units of Hz,
has been tested by comparison with values obtained using a diversity of other techniques
in a wide variety of human and animal tissues. The alternative procedures have included
video microscopy(18), thermal(19-20) and H2 clearance(21-23), xenon washouts(24-25),
as well as microsphere depositions(21,26,27) and plethysmography(20-28). There are
good correlations between the laser Doppler technique and these alternative methods,
given that each method measures microcirculation at different levels of surface
penetration(29). For example, the tissue volume sampled by microspheres extends much
more deeply than that of the laser Doppler. The laser Doppler technique measures skin
blood flow to a depth of 1-2 mm, deep enough to measure flow in nutritive capillary loops
and in the subpapillary arteriovenous plexi(30). A calibration factor of 6 ml X 100 gm-
1/.min-1 X 100 Hz has been derived on the basis of theoretical calculations to convert the
laser Doppler flow parameter to conventional blood flow units(17). In all tissues sampled,
using different comparison techniques, values fall with 15% of this derived calibration
factor(19,23,26,28). Thus, this calibration verification allows us to express blood flow
directly in ml/rnin/gm as opposed to units of Hz, or in arbitrary units.

The BPM2 unit contains a temperature control module which is used to set the local skin
temperature control. The ends of the laser Doppler fiber optic probes are inserted into a
19 mm diameter thermal head attached to the module. The controller accurately controls
the temperature within plus or minus 0.5ø C of setpoint. The probe is placed on the skin
site taking care to avoid placing the fiber optic ends directly over a superficial vein or hair
follicle.




                  2121 South 125th East Ave. Suite 107
                        Tulsa, OK, 74129 USA
                             (918) 439-9060
                       New Tradition Clinic
Testing took place in a room controlled at an ambient temperature of 24ø C. Rectal
temperature was measured with an Omron thermometer (Vernon Hills, III., USA). We
determined systolic blood pressure using a tail cuff and a Narco Physiograph. Hair
covered areas were shaved the day before measurement to avoid transient traumatic
hyperemia. At measurement, the animals were lightly anesthetized with 20-30 mg/kg
ketamine. We have verified that light ketamine anesthesia does not affect skin blood flow.
Dynamic Exercise: The rat, anesthetized with 0.3 to 0.5 cc of ketamine, was placed on a
thin Plexiglas sheet which rested on ball bearings free to roll on an enclosed plate (Fig. 1
below). The rat paw was strapped
with Velcro to a small wood
platform attached to the frame.
The strap was secure enough to
hold the paw to the platform but
not so tight as to affect blood flow.
The laser Doppler head was
affixed to either the dorsal or
planter surface of the paw with an
adhesive ring. Additional tape was
used to secure the Doppler head
to the platform. The muscles of the
upper leg were electrically
stimulated using a NEURO CARE
1000 transcutaneous nerve
stimulator generously provided by
EMS / Northwest, Inc. (Hermiston,
Oregon). The device emits a
biphasic pyramidal stimulus at a
frequency of 47 Hz. The stimulus
is delivered via pulse train, on for
1.5 seconds and off for 1.8
seconds. Two TENS electrodes
were placed on the surface of the
upper leg. After a pre exercise
baseline period of 5 to 10 minutes, we began exercising the limb by delivery of an initial
low level stimulus which was rapidly incremented to 1.5 mAmps. The rat's limb
responded by a rhythmic extension followed by relaxation to the rest position. With each
extension, there was movement of the Plexiglas sheet carrying the rat body away from
the platform. The Plexiglas rolled back toward the platform with the subsequent
relaxation. During this muscular activity, the rat paw usually remained motionless.
Occasionally there was movement of the digits of the paw. However, the laser Doppler
head, located more proximally on the limb, did not move. Periodically, during exercise,
we measured blood pressure using a tail cuff. We were also able to measure the force
exerted on the paw using a strain gauge. Obviously, this required removing the rat from
the frictionless bed in order to obtain an accurate reading.

Values for flow, microvascular volume, and red blood cell velocity were acquired at 0.05
second intervals using PROCOMM, a data acquisition program, and stored to hard disk
on an IBM 386 PC. Data manipulation and analyses was then carried out using Microsoft
EXCEL. Statistical Analysis: Comparisons were made using weighted analysis of
variance techniques. Data values are presented as mean + SEM. Non-parametric
statistics (Kruskal-Wallis and Mann- Whitney tests) were used to compare ratios.




                  2121 South 125th East Ave. Suite 107
                        Tulsa, OK, 74129 USA
                             (918) 439-9060
                      New Tradition Clinic
                               RESULTS
At maximal exercise, the rat limb movement generated considerable force, averaging 82
+ 10g. This force was approximately one quarter of the 350 gm weight of the rat. Despite
this substantial force generation, there was no significant blood pressure change during
exercise. Blood pressure averaged 168 + 7 mm Hg during exercise, and 166 + 7 mm Hg
after exercise. The pulse rate preexercise rate of 359 + 4 beats per minute did not
change during exercise (357 + 5 bpm), but dropped slightly post exercise to 346 + 4 bpm.
There was no change in core body temperature. With each extension of the rat limb,
there was a substantial increase in blood flow. With relaxation, blood flow dropped back
toward baseline levels. The peaks were not of uniform height and were greater at the
planter than at the dorsal surface of the paw. (Fig 2a, b). The




maximal peak values attained at the planter surface were 250 ml/min/100 gm versus 175
ml/min/100 gm at the dorsal surface. Blood flow during the active exercise period was
somewhat variable. At times there were higher peaks, at other times lower peaks, with no
evident pattern. There was no systematic increase or decrease in flow, irrespective of
duration of exercise. We prolonged the active exercise period to as long as 45 minutes
with no obvious change. Control experiments with no electrical stimulation showed a
constant baseline level flow over these prolonged periods. We interrupted stimulation for
30 seconds every five minutes during the course of exercise. During these 30 second
rest periods, skin blood flow dropped to baseline (Figs II, b).

                 2121 South 125th East Ave. Suite 107
                       Tulsa, OK, 74129 USA
                            (918) 439-9060
                              New Tradition Clinic
       We decided to standardize to a five minute initial preexercise period, followed by a 10
       minute exercise duration containing one 30 second rest period, and then a five minute
       post exercise period. We computed mean blood flow during the preexercise period, the
       two periods of active exercise, and the post-exercised period for six rats. We also
       measured flow during the exercise period on the contralateral, non-exercised paw (Fig
       III). There was only a small increase in skin blood flow on the contralateral paw.




                                                                                  In order to
determine the effect of thermal stimulation on exercise induced flow, we carried out the
measurement during exercise with the probe heated to 44ø C (Fig IV). At basal skin temperature,
the mean flow during exercise at the planter paw surface was 46 + 4 ml/min/100 gm compared to
33 + 2 ml/min/100 gm at the paw dorsum. With application of heat, there was no change in the
mean flow attained during exercise at the paw dorsum. At the planter paw surface




                         2121 South 125th East Ave. Suite 107
                               Tulsa, OK, 74129 USA
                                    (918) 439-9060
                              New Tradition Clinic




there was an increase in mean exercise induced flow to 68 + 10 ml/min/100 am. However, the
pre-exercise mean flow at 44ø C was 56 + 10 ml/min/lOO am. Expressed as a percentage of
increase, exercise induced an increment over pre exercise baseline of 992 + 100% at the planter
paw surface at basal temperature, but only 30 + 3% at 44ø C. In contrast, there was a sixfold
increase in mean flow at the paw dorsum with exercise both at basal temperature and at 44ø C
(Fig V). Thus, the flow attained during exercise at the paw dorsum could not be further increased
by thermal stimulation. At the planter paw surface, a small increment in flow was obtained with
local heating of the skin.




                         2121 South 125th East Ave. Suite 107
                               Tulsa, OK, 74129 USA
                                    (918) 439-9060
                       New Tradition Clinic
                             DISCUSSION
The model we have developed permits the measurement of skin blood flow in a region of
active exercise. By immobilizing the paw while allowing the entire body of the rat to move,
we eliminate the motion artifact which would otherwise render laser Doppler
measurements invalid. Although the level of exercise is not so great as to stimulate
hemodynamic changes in blood pressure and heart rate, the activity is sufficient to
generate flow comparable to that achieved with maximal local heat. Although both the
dorsal and planter surfaces of the paw showed increases in skin blood flow with exercise,
the mechanism of increase was different at the two sites. At the dorsal surface, the
increase was mediated by an equivalent increase in microvascular volume and red blood
cell velocity. In contrast, at the planter surfaces the increase was chiefly one of red blood
cell velocity. Furthermore, the blood flow response to heat was much greater at the
planter paw surface than at the dorsal surface. Exercise was much more effective than
thermal stimulation at raising skin blood flow at the dorsal surface.

Distant exercise raises skin blood flow through increased heart action and reflex
vasodilation due to core body thermogenesis. In contrast, local exercise appears to act
by a direct physical action. There are peaks in blood flow during muscle contraction
which are followed by falls to baseline during relaxation. Thus, there appears to be a
direct pumping action of blood through cutaneous capillary networks. Distant exercise
often induces an initial phase of reflex cutaneous vasoconstriction(3,4). We observed no
such effect with vigorous local exercise. The differences seen in the mechanisms of
increase in skin blood flow between the dorsal and planter surfaces confirm that the
measurements are not influenced by motion artifact. Apparently, exercise promotes
vasodilation in the NURTR capillary beds of the paw dorsum whereas the AVA vessels of
the planter surface tend to dilate but, rather, to passively allow blood to pass through at
greater velocity.

In the model we have presented, our measurements are performed at the most distal
point on the exercising limb. It would be of interest to measure skin blood flow at sites
closer to the point of muscular contraction. We were not able to do this because of
motion artifact. However, this limitation was due to the size of the thermal probe head in
relation to the rat limb. It is possible to eliminate motion artifact at or near the site of
active contraction by appropriate placement of the electrodes and laser Doppler probe
head on a larger limb. In preliminary studies, we have carried out measurements on
human volunteers. This is possible because the NEURO CARE electrocutaneous nerve
stimulator does not cause discomfort, even at maximal level of discharge, Future studies
will determine whether the mechanisms of local exercise demonstrated in the rat also
exist in man.




                  2121 South 125th East Ave. Suite 107
                        Tulsa, OK, 74129 USA
                             (918) 439-9060
                      New Tradition Clinic


                   LEGEND TO FIGURES
FIGURE 1: LASER DOPLER MEASUREMENT ON RAT PAW DURING DYNAMIC
EXERCISE.

FIGURE 2: MEASUREMENT OF BLOOD FLOW DURING PROLONGED EXERCISE:
This is an example of skin blood flow measurement for one rat on the dorsal surface (a)
and the planter surface (b) of the paw. After a five minute baseline period,
electrocutaneous stimulation was started and rapidly incremented to maximal level. Every
five minutes, stimulation was stopped for thirty seconds. After thirty minutes, exercise
was ended. Flow was also measured for a control period of equivalent length with no
electrical stimulation. The dotted lines in panel (a) and panel (b) represent the control
values for this period.

FIGURE 3: SKIN BLOOD FLOW DURING THIRTY SECOND REST PERIOD: The effect
of abrupt cessation of stimulation is illustrated above for the dorsal (a) and planter (b)
surfaces of the paw.

FIGURE 4: EFFECT OF EXERCISE ON SKIN BLOOD FLOW ON CONTRALATERAL
NON-EXERCISING PAW: Mean flow values during the five minute pre-exercise baseline
(PRE), the 20 minute active exercise period (EXER), and the five minute post-exercise
period (POST) are given for the exercising paw (black bars) and the contralateral resing
paw (white bars). *: p<0.01 compared to pre-exercise.

FIGURE 5: EFFECT OF EXERCISE COMBINED WITH LOCAL THERMAL
STIMULATION: Flow, microvascular volume, and red blood cell velocity were measured
at basal skin temperature (BASAL) and with the probe head heated to 44ø C. * p < 0.01
compared to preexercise period. : p< 0.05 compared to basal temperature.

FIGURE 6: RATIOS OF BLOOD FLOW, MICROVASCULAR VOLUME AND RED
BLOOD CELL VELOCITY TO RESTING LEVELS. The increments in blood flow,
microvascular volume, and red blood cell velocity are represented as ratios to the values
during the preexercise baseline period. ø: p<0.01 compared to preexercise period. 1
p<0.05 compared to basal temperature.




                 2121 South 125th East Ave. Suite 107
                       Tulsa, OK, 74129 USA
                            (918) 439-9060
                       New Tradition Clinic
                           REFERENCES
1. RENDELL, M.S., GIITTER, M., BAMISEDUN, O., DAVENPORT, K., AND SCHULTZ,
R. (1992) The laser Doppler analysis of posturally induced changes in skin blood flow at
elevated temperatures. Clin. Physiol. 12, 241-252.

2. RENDELL, M.S., KELLY, S.T., BAMISEDUN, O., LUU, T., FINNEY, D.A., AND
KNOX, S. (1993) The effect of increasing temperature on skin blood flow and red cell
deformability. Clin. Physiol. 13, 235-245.

3. JOHNSON, J.M. (1992) Exercise and the cutaneous circulation. Exerc. Sport. Sci.
Rev. 20, 59-97.

4. LAUGHLIN, M.H. (1987) Skeletal muscle blood flow capacity; role of muscle pump in
exercise hyperemia. Am. J. Physiol. 253, H993-H1004.

5. TAYLOR, J.A., JOYNER, M.J., CHASE, P.B., AND SEALS, D.R. (1989) Differential
control of forearm and calf vascular resistance during one leg exercise. J. Appl. Physiol.
67, 1791-1800.

6. KENNEY, W.L., TANKERSLEY, C.G., NEWSWANGR, D.L., AND PUHL, S.M. (1991)
Alpha adrenergic blockade does not alter control of skin blood flow during exercise.
Amer. J. Physiol 29, H855-H861.

7. KELLOGG, D.L., JR, JOHNSON, J.M., KENNEY, W.L., PERGOLA, P.E., AND
KOSIBA, W.A. (1993). Mechanisms of skin blood flow during prolonged exercise in
humans. Amer. J. Physiol. 265, H562-H568.

8. TANKERSLEY, C. G., SMOLANDER, J., KENNEY, W.L., AND FORTNEY, S.M.
(1991) Sweating and skin blood flow during exercise: Effects of age and maximal oxygen
uptake. J. Appl. Physiol. 71, 236-242.

9. TANKERSLEY, C.G., ZAPPE, D.H., MEISTER, T.G., AND KENNEY, W.L. (1992)
Hypohydration affects forearm vascular conductance independent of heart rate during
exercise. J. Appl. Physiol. 73, 1232-1237.

10. TAYLOR, W.F., JOHNSON, J.M., KOSIBA, W.A., AND KWAN, C.M. (1989)
Cutaneous vascular responses to isometric handgrip exercise. ~ Appl. Physiol. 66, 1586-
1592.

11. RENDELL, M.S., MCINTYRE, S.F., TERANDO, J.V., KELLY, S.T., AND FINNEY,
D.A, (1993) Skin blood flow in the Wistar-Kyoto rat and the Spontaneously Hypertensive
Rat. Comp. Biochem. and Physiol. 106A, 349-354.

12. RENDELL, M.S., MCINTYRE, S.F., TERANDO, J.V., KELLY, S.T., FINNEY, D.A.A,
MILLIKEN, B.K., KINGSLEY, D.W., AND SATTERLEE, M. The effect of polycythemia
on skin blood flow in hypertensive rats. Comp. Biochem. Physiol. (In Press).

13. RENDELL, M., BERGMAN, T., O'DONNELL, G., ET AL. (1989) Microvascular blood
flow, volume, and velocity measured by laser Doppler techniques in insulin dependent
diatbetes. Diabetes 38, 819-824.

14. RENDELL, M., AND BAMISEDUN, O. (1992) Diabetic cutaneous microangiopathe.
Amer. J. Med. 93, 61 1-618.

                  2121 South 125th East Ave. Suite 107
                        Tulsa, OK, 74129 USA
                             (918) 439-9060
                     New Tradition Clinic

15. RENDELL, M. S., KELLY, S. T., FINNEY, D., LUU, T., KAHLER, K, MCINTYRE,
S.F., AND TERANDO, J.F. (1993c) Decreased skin blood flow early in the course of
streptozotocin-induced diabetes mellitus in the rat. Diabetologia 36, 907-9 1 1.

16. BORGOS, J.A. (1990) TSI's LDV Blood Flowmeter. In: Shepherd AP and Oberg PA
(eds). Laser-Doppler Blood Flowetry, Norwe.., Massachusetts: Kluwer Academic
Publishers, 73- 92.

17. BONNER, R. AND NOSSAL, R. (1981). Model for laser Doppler measurements of
blood flow in tissue. Appl. Optics. 20, 2097-2107.

18. TYML, K., AND ELLIS, C.G. (1985) Evaluation of a laser Doppler flowmeter by video
microscopy. IEEE/Seventh Annual Conference of the Engineering in Medicine and
Biology Society 528-531.

19. NITZAN, M., FAIRS, S.L.E., AND ROBERTS, V.C. (1988) Simultaneous




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Description: Lying down, arms and legs slightly apart, palms turned to the ceiling, eyes closed, breathe deeply three times, concentrate on each breath completely empty flat body. Then from the toes to the head, tighten and then relax the muscles a little bit, carefully to feel every step. For the shoulder and head muscles, use the rotation instead of tightened. This is a developing body flexibility and effective practice, with a strong relaxation of, but also to ease the tension.