Tuesday Tune-up: Non-weightbearing Gluteus Medius Conditioning superset

Really want to get your hips strong for walking, hiking, running and any sports that require you to be on one leg? These exercises are for you! Injured and limited in your running abilities? Do these to be ready to hit the ground running? Want to fatigue less easily and be less likely to get injured while running? This superset of gluteus medium non-weightbearing endurance and motor control exercises will get you well on your way. Bonus it will also work on your back stability, strength, conditioning, control, and endurance! Yes!

Be aware, this is not a beginner exercise, but helpful for those looking to take their health to the next level of endurance and more thorough strength. Reach out to Artisan PT for a remote wellness consultation via video or schedule a wellness or physical therapy visit at our Los Angeles office to see what exercises are best for you, at this moment of time.

We are currently doing Tuesday Tune-ups on our Instagram feed and IGTV. Follow us at @artisanphysical to make sure you don’t miss out. As appropriate, we will do our best to also upload to our Artisan Physical Therapy YouTube channel as well. Make sure to subscribe to our YouTube channel to get notifications about new videos on how to live your healthiest life. Don’t miss out.

That’s our goal at Artisan PT: to partner with you to optimize your health for a lifetime.

Thank for reading and watching,

Elle

(owner, doctor of physical therapy, fellow in orthopedic manual PT)

(PS: These hip abduction/abductor exercises are helpful for preventing pain and improving tolerance to running, walking, hiking, skateboarding, soccer, ultimate frisbee, basketball, volleyball, triathlon, mountain biking, yoga, dancing, and anything else you spend time on one leg!)

Sleep Hygiene? Part 2 of 2

Not sleeping well is a detriment to healthy living and healing. Now that you have considered the concept of sleep hygiene from Part 1 of this 2-Part series, consider the following list of habits to develop in order to improve your quality of sleep, allowing you body to heal, recover, and reenergize:

1. Exercise daily - but not too close too bedtime. It varies, but exercising too late at night can disrupt sleep, if performed 1-2 hours before trying to sleep.

2. Limit screen use (TV and social media) before bed - Neither allows you to focus and declutter your mind nor control the imagery and messages you let in. Being on the screen is also often about productivity and on social media easily brings us to envy and comparison, both of which do not promote rest. The blue light from the screen is not good for you. You can have your phone dim and switch to orange or black/white light later in the evening to assist you in this regard.

3. Prepare things for the next day ahead of time, so that your mind does not need to focus on them - e.g. set a reminder in your calendar so you remember to email that person and don't have to worry about keeping it in your mind. As you do this, move more slowly, so your body gets the cue to slow down.

4. Meditate or contemplate 10-20 minutes - in contemplation you have an affirming mantra/phrase that you keep repeating bringing your mind towards as it wanders.

5. Limit talking - decreasing your motor output will help you slow down and unwind both physically and mentally.

6. Read with low light:

   • Something engaging, but not upsetting

   • Consider something about positive human potential

   • Try not to read something so light that your mind doesn't have to focus

7. Stop being productive - don't work or study right up until sleeping, instead create a buffer zone. 

8. Practice being in the present moment - pay attention to your body, your breath, enjoy physical being with your family/partner/roommate. This is a perfect time for cuddles and getting cozy with pillows and blankets!

9. Breathe - work on slow breaths from your abdomen to ensure your diaphragm is properly facilitating your breathing and thus promoting the parasympathetic system to be active (which is your "rest and digest" system).

10. Turn lights low as you prepare for sleep and then fully dark to optimize deeper sleep states

11. Rest in bed before attempting to sleep

12. Sleep in a cool room. Too much heat can be disruptive to sleep.

13. Create quiet environment: Use ear plugs or head phones to limit outside distractions & silence your phone

14. Listen to calming, quiet music; podcasts, talks, or books that are quiet as well as affirming and positive about the human potential. Use a timer to have this turn off after 15, 30, 45, or 60 minutes, depending how long it typically takes you to drift into a dream state. I bookmark my starting point in books so that I can easily come back to where I started from - some days it takes a whole 30 minutes for me to fall asleep, sometimes I am no longer listening within 5 minutes!

15. Journal to process thoughts and concerns from the day to limit them from looping in your mind

Do you have other things you practice and find helpful? Comment below.

Oh! FYI - You shouldn't have pain with waking up from sleep. This may indicate you need help from a physical therapist, but it may also mean that you need to sleep with different pillows or mattress to obtain more healthy and restful sleep.

Happy sleeping!

Elle

PT Better Than Surgery for Shoulder Impingement and Subacromial Pain

New guidelines for management of shoulder impingement are strongly in favor of physical therapy and away from surgery! These recent guidelines were posted in the BMJ (British Medical Journal) and you can read more here. This is exciting news supporting conservative treatment that physical therapy provides versus more invasive techniques such as surgery.

As the research was examined, the findings revealed: decompression surgery resulted in no significant differences from other approaches—including PLACEBO surgery! The lack of difference was long-term, remaining at 6-month, 2-year, and 5-year follow ups.

Shoulder impingement occurs when structure that pass through your shoulder get pinched between the humerus and acromion that compose part of your shoulder joint. This can lead to irritation, pain, and wear and tear to structures such as the bursa (bursitis), supraspinatus (rotator cuff strain, tears, tendonitis, and tendinopathy), biceps (long head of biceps strain, tears, tendonitis, and tendinopathy).

The following helpful schematic visuals presents the findings for how to management shoulder pain from rotator cuff disease/dysfunction (RCD) and subacrominal pain syndrome (SAPS).

The fact that physical therapy is the ideal way to treat these pain syndromes is not surprising given that the shoulder joint is a complex joint comprising of 4 separate joints and myriad muscles that must coordinate well. Tightness, weakness, poor endurance, control, or posture at any of these points including at the shoulder blade (scapula) can lead to narrowing at the subacromial space and thus impingement. Reversing these problems can then increase the space and reduce the strain, pain, and irritation.

Bottom line?

Having shoulder pain? Come to PT before a surgeon! Please note that these findings are for overuse and non-traumatic shoulder injuries present for more than 3 months.

Thanks for following along as we journey to: Get to the Source, and TOGETHER, get moving.

Liz

Finding the Perfect Pillow

Neck pain is a real problem for many people. Unfortunately for many people, their pillow is a main contributing factor. Also unfortunate is the fact that pillows are confusing. In desperation, many people will pay ridiculous amounts for a “perfect” pillow that promises to miraculously reduce their neck pain, improve sleep, and allow them to move their neck better throughout the day. All you need to do is spend $80-$200. However, many of the designs behind these pillows are flawed.

What should you look for in a pillow? You want a pillow that helps to keep your neck in neutral position. What is neutral position? Neutral position is a position that reduces the stress on your joints, muscles, ligaments, and tendons. Each joint has this ideal position. For your neck this means that when you lie on your pillow you shouldn't feel like your head is dropping down, or rotating, or getting forced up.

Find Neutral Position

This woman pictured has too much pillow & is straining her neck as she sleeps. The midline of your head should be straight with the midline of your torso to reduce stress on your body and prevent neck pain or arm numbness/pins & needles.

I suggest getting an inexpensive, soft, yet supportive pillow. Soft, yet supportive, is tricky. You want soft, but sufficiently full so that it gives support. Get a pillow too fully packed and it's no longer soft and adaptable to your head and your body position. Get a pillow that's too flat and it will not be appropriate for lying on your side. To get your neck and corresponding joints into their neutral position, you need the pillow to be just right, so do not be surprised if it takes time to find the right pillow for the size and weight of your head and the proportion of your body. For example, when lying on your side, you need the pillow to be the right size to take up the space between your head and the bed, created by your shoulder and torso. Too big relative to your body and your head will get pushed up, compressing the top side of your neck and pulling the lower side. Too small and your head will dip down, similarly causing strain to your neck but in the opposite pattern of too big a pillow.

I have a little trick for how to take any garden variety pillow from your favorite inexpensive store and make a winner, comfortable, soft, yet supportive pillow and look forward to sharing that with you in a future post and possibly even in video format. In the meantime, please save your money and don't buy that expensive pillow promising to save the world, starting with curing your neck pain and insomnia.

Questions? Comments? I'd love to hear them.

Liz

Awesome, Effective Advanced Shoulder Stability Exercise

Looking for an excellent, if not awesome, way to strengthen your shoulder.? We've got an exercise for you including a video demo! Here is one of Liz's favorite exercises that she is incorporating into her March daily fitness challenge - which is alternating between the hip and shoulder stability and strength.

The shoulder joint is a "ball and socket" joint. It has a lot of freedom to move in a variety of directions, which is means it needs stability and strength in multiple directions. This exercise is a constant isometric force into external rotation pushing out with the wrists which strengthens and challenges two of the rotator cuff muscles, in particular, the teres minor and the infraspinatus. As you push constantly out through the band you will simultaneously raise your arms overhead which works additional shoulder muscles including shoulder blade (scapular) muscles responsible for upwardly rotating it. These muscles include the serratus anterior and the lower trapezius, which when weak can lead to shoulder impingement, bursitis, and rotator cuff tears and injury. 

This is not an exercise to perform when your shoulder is very weak. For that you want to exercises that place less demand on your shoulder. If you missed it, a video we created for that is this:

Mixing things up with "easy" and "hard" exercises is good for a healthy shoulder. I've been doing exercises from each of these videos as I seek to have an even stronger and healthier shoulder than I already have.

Have you started a daily fitness challenge? If so, what are you trying?

Not started yet, but thinking about it? What are you considering? Even the considering, is a step forward and progress! The planning stages count for fitness and health.

Stay tuned for next month's daily fitness challenge which will be headstands and handstands! April is almost here. Would you like to join me? At this time, May is scheduled to be ankle and foot stability, so reach out with any questions or suggestions for that if that provokes some interest from you. This is particularly meaningful for those of you with "weak" ankles, foot and ankle pain, history of ankle sprains or foot/ankle fractures (broken bones). 

Let's Get to the Source, and TOGETHER, Let's Get Moving

Liz

8 Minute Abs

Last month I did a daily physical challenge of running every day - with the goal of being healthy. Success! This month the physical challenge is "8 min abs". I've spent everyday of November (one day to go) targeting abdominal strength, endurance and control for 8 minutes. Now this isn't about aesthetic or beach body abs. Being able to do crunches and sit-ups are important but have been over-emphasized in the fitness industry for years. Having healthy appearing abdominal muscles - a 6 pack - doesn't mean you are in fact healthy. More specifically, it doesn't mean you are preventing injury. Abdominal strength and stability in combination with low back and hip strength and control make up what we physical therapists call "lumbopelvic stability" or "lumbopelvic control." This is something we emphasize in helping and rehabilitating persons with low back pain, sciatica, SI joint (sacro-iliac joint) pain, lumbar radiculopathy, herniated discs, DJD (degenerative disc disease), arthritis in the joints of the back, and stenosis. The back is connected to the pelvis, which is connected to the hips/thigh/femur. I often sing  to my patients and clients about the wisdom of the children's song: "the back bone's connected to the hip bone. the hip bone's connected to the thigh bone" (They love it, as you can imagine).

So me spending on this focused time on this region wasn't just sit-ups and crunches. In fact, it was much more perform leg and arm motions without letting my back move. I spent 8 minutes each day this month emphasizing a variety of challenges to lumbopelvic stability to promote and preserve a healthy back. I brainstormed a list of exercises and invited a friend to join me with this month's challenge. My list is long and varied. I challenged my abdominal muscles - all of them (rectus abdominus, internal and external obliques, and very importantly the transverse abdominus). I rotated through 48 different exercises these 30 days! There's no reason to get bored. And as we strongly recommend here at Artisan PT - variety is good and very healthy for us. 

Want an example of how to train the transverse abdominus? The transverse abdominus is the most important abdominal muscle to prevent back injury and recover from a back injury or back pain. Learn more in our video on a starter transverse abdominus exercise. PS - Side effects of this exercise include flatter stomachs! PPS - I won't be posting pre- and post- 8 min ab challenge photos, but will be enjoying the results.

Watch should the next challenge be? December is right around the corner!

Let's Get to the Source, and TOGETHER, Let's Get Moving!

Liz

3 Simple Strengthening Exercises to Prevent Climbing Shoulder Injuries

Today we have a guest post from a friend and fellow colleague on preventing shoulder climbing injuries. Dr. Jared Vagy - The Climbing Doctor - out of Los Angeles, California works with high level climbers and teaches at USC. The following is an excerpt from his blog post. 

"It is the end of the day. You are tired and beat, but you decide to give it one last go on your project. You get to the crux move and give it everything you’ve got. Suddenly you feel a sharp pain in your shoulder. You know that you likely injured your shoulder. What happened and what could you have done to prevent this?

The tendons in the shoulder slide through a very narrow passageway and attach to the shoulder bone. Impingement occurs when the space between the bones in this passageway is reduced. This can occur from repetitively moving the shoulder into a stressful or suboptimal position. When this occurs, the bones in the shoulder pinch down on the tendons and cause shoulder impingement. You should be aware of the dangerous movements that can lead to shoulder impingement. These movements include hanging on your arms during rest stances, climbing with a hunched posture and strenuous overhead reaching."

Bent over T's, Y's, and L's:

Dirtbag tip - use items you have around: cans, bottles to provide the weight.

These should not cause any shoulder pain! 

Climb INJURY-FREE

Dr. Vagy just released another book! 

You can find it on Amazon now.

Thanks, Dr. Vagy for the helpful content.

Any questions? Comment below. 

Why Does My Foot Hurt in the Morning?

"Why does my arch hurt?" 

"I get a sharp pain in my heel every morning I get out of bed.

"When I've been on my feet too long, the bottom of my foot hurts so bad."

Do you say these things? You may have plantar fasciitis.

The plantar fascia is a ligament that helps support the arch of your foot and gets stretched when you put weight on it and every step you take.

"Itis" is Latin for inflammation, so plantar fasciitis is a diagnosis of inflammation of the plantar fascia. Inflammation takes place when you have an injury and the body is trying to heal. Research is showing that most cases of plantar fasciitis is not an "itis" but is instead an "-osis" which reflects degeneration. This is why rolling on a frozen bottle might not make your symptoms go away.

At Artisan Physical Therapy, your PT will try to figure out a few distinct things in your evaluation - what tissue is injured or irritated and then the why it is injured/irritated/painful. Often both need to be treated the sore tissue needs to be calmed down and then that factors that led to the injury need to be changed and/or alleviated otherwise it will be perpetually irritated.

Common factors that lead to plantar fasciitis or fasciosis include:

• Insufficient arch support - going barefoot, wearing flip flops, or shoes without arch support or very flexible soles
• Tight ankles and calve muscles
• Weak hip (gluteal muscles)
• Excessive body weight
• Increasing activity too quickly (deciding to train for a marathon or get in shape drastically from prior level of activity)
• Weak foot muscles or inappropriate muscle use/activation

Just because you have arch or heel pain, it doesn't mean you have plantar fasciitis. It could be a tendinitis or tendinopathy of a foot or ankle muscle or an issue in the joints of your foot. A quality physical therapy exam will clarify this for you.  As mentioned above knowing which tissue is irritated allows for specific, targeted treatment to get rid of your pain and get you back to pain free walking, running and whatever else you love and need to do.

Think you might have plantar fasciitis? Take the first step towards health and get a PT evaluation to get quality manual therapy to temporarily decrease the pain in your foot and learn exercises to keep it away by learning how to reduce the stress to the plantar fascia and learn what activities to avoid a do instead to allow it to begin healing today.

Let's Get to the Source - and TOGETHER - Let's Get Moving!

Preventing Rock Climbing Hand & Tendon Injuries: Part 2 - Techniques For Open Grip Strengthening

People are often injured by trying to progress too quickly and this is very prevalent in rock climbing. People fall hard for the sport and enjoy the challenge of pushing their limits, but lack the knowledge needed to stay healthy, prevent injury, and thus climb for a lifetime and not have to take months and month off due to tendon or pulley injuries in their hands or forearms.

In this video you'll learn the how-to principles of hand strengthening to cross train to improve open grip strength and reduce hand pulley and tendon injuries for rock climbers. Climb better, climb harder, climb longer. Climb for a lifetime.

For a personalized assessment, contact us at our Portland office.

If you have injured this area, make sure to give sufficient rest and see your local PT who specializes in manual therapy & treating climbers to learn how to get back to your prior level and incorporate this open hand strengthening to improve your grip and reduce compensatory strategies that overload your pulleys. Also find out how shoulder weakness, for example, can influence which grip you choose. 

This is Part 2 of a 2 Part series, with the possibility of a Part 3 adapted to interest, questions, and feedback from the first 2 Parts. Watch Part 1 to learn why hand strengthening matters to prevent injury and the important of incorporating into your climbing routine. Questions? Should we do a Part 3?

Let's Get to the Source, and TOGETHER, Let's Get Moving!

Car accident blues

Were you in a auto accident? Rear-ended? T-boned? Don't relinquish control of your health!

One of the biggest mistakes we see people make after automobile accidents is not taking responsibility for their health. Waiting on payment from insurance and settlements before receiving professional medical care to rehabilitate from whip lash, pulled, strained, and sore, achy muscles, joints, and ligaments is common and results in prolonged injuries, negative outcomes, side effects, and chronic pain.

The best thing to do is to receive professional care as soon as possible, and what better, than a physical therapist? Physical therapists are EXPERTS in musculoskeletal movement dysfunction and rehabilitation.

Make sure to rest, limit extremes of body range of motion and speed, let your body recover, and take steps to reduce inflammation in your body. Don't put off take care of your health. It is your livelihood. It is your life. First get the quality, personal, and focused care you need to deal with your motor vehicle accident (MVA).

At Artisan Physical Therapy, you don't get generic treatments such as lying on hot packs, getting electrical stimulation, and ultrasound. Instead you get quality and focused manual therapy specifically suited to your needs to reduce swelling, inflammation, pain, stiffness and tightness so that you can get back to doing what you love and when you want to do it. We give you things to put you in control of how you feel - education on the specifics of what to do and what not to do in your daily activities and active body movements and therapeutic exercises.

It's not uncommon that people through care with Artisan Physical Therapy can learn more than they even knew about their bodies and live healthier lives than they did even BEFORE their car accident.

A Physical Therapist's Back Pain Confessional

Dang it, even therapist's have injuries, so let's talk about it. In our latest video, Dr. Liz Bottrell shares her personal experience with an acute occurrence of low back pain (aka - lumbar spine pain). Learn what happened and what she's doing about it and what you can do when you experience unexpected pain that lingers.

Back pain can come on suddenly and unexpectedly as it did for our physical therapist, limiting the ability to sit and lift and do normal daily activities. Learn how to recover as quickly and as optimally as possible. Note - you may have to change your behavior!

What is Manual Therapy & Why is it so Effective for Pain?

Liz Bottrell, PT, DPT, FAAOMPT, manual physical therapist and owner of Artisan Physical Therapy in the Echo Park neighborhood of Los Angeles, CA explains what manual therapy is.

Manual therapy, or "hands on," evaluation and treatment improves motion, mobility, decreases stiffness, tightness and pain, as well as improving circulation and speeding healing. The healing hands lead to areas of injury and work them out. It is a place where science and art meet.

Do you want to get better as soon as possible? Do you want to see an expert? Have you not seen the results that you hoped for with prior physical therapy. Maybe your therapist wasn't highly skilled in manual therapy. Liz is a fellow of the American Academy of Orthopedic Manual Physical Therapist (FAAOMPT) - her specialized manual therapy training and skills set her apart from other physical therapists.

See a manual therapy specialist and experience the difference in your day to day - the ease of movement, the reduced pain and stiffness, and improved muscle activation (read strength, coordination, and balance). All of this helps you sleep, walk, run, stand, reach overhead, and so on more easily and with less pain.

Combine quality and focused physical therapy with your needed exercises and necessary modifications and get ready for amazing results beyond what you though possible!

A Simple & Effective Exercise to Minimize Headaches

A new video from Liz went live earlier this week! Do you have headaches or know someone with headaches who would like to reduce their frequency or intensity and even eliminate them entirely?

In this video Dr. Elizabeth (Liz) Bottrell, PT, DPT, FAAOMPT, manual physical therapist and movement specialist, demonstrates a simple but effective exercise to reduce the frequency and intensity of headaches.

Many people have cervicogenic headaches - headaches arising from tight muscles and joints in the neck or poor posture - but think they are migraines or other types of headaches. This basic, easy exercise will stretch your neck muscles and reduce referred pain to your head. It is also effective for neck pain after a car accident or whiplash.

Try this exercise, 3 sets of 10, without pain or just to the point of pain.

If you have more questions about what other exercises to do for your condition or would like hands-on, manual therapy to improve joint range of motion, reduce pain, improve circulation, enhance muscle flexibility, and increase ease of movement and maintaining good posture, contact Artisan Physical Therapy to schedule an appointment for your physical therapy evaluation and treatment session.

Let's get to the source, and TOGETHER, let's get moving!

2 Simple Exercises for a Healthy Rotator Cuff

Want to have healthy shoulders and rotator cuff? Want to prevent injury when swimming, doing yoga, while weightlifting or crossfit? Want to rockclimb better? Want to play tennis and volleyball for years? Then take a couple minutes and learn a few strengthening exercises for the rotator cuff using an exercise band. The exercises are simple and easy to do wherever you are! No fancy or expensive equipment needed!

Have lingering shoulder pain, a prior rotator cuff tear, aching or weakness? Try these as some basic strengthening.

The rotator cuff is extremely important for basically all arm movement and certainly all shoulder motions. Make sure your rotator cuff is strong and has a lot of endurance to prevent injury!

For recommendations specific to your situation and body, contact Liz in Los Angeles or your neighborhood physical therapist. We are the movement specialist.

Let's get to the source, and TOGETHER, get moving!

Until next time,

Liz

5 Best Neck Posture Exercises

Have you noticed a prominence or lump developing in your upper back and wondered what it was, and if you can do anything about it?

A friend of mine last week asked a question. What is this lump on the back of my neck? When I heard the word "lump," I was not hopeful that this was something a physical therapist could help with. A quick examination revealed that his spine was changing shape over time and he was developing a bony prominence where his neck and upper back meet. Why? This often takes place from repeated stress on the area over time. The forward slouched sitting posture so many of us find ourselves throughout the day while we are doing activities such as studying, working on the computer, driving, and reading.

Think about the elderly person with the stooped posture and rounded upper back. This didn't happen over night but was from poor sustained postures that resulted in progressive stiffness and weakness that eventually prevented them from sitting and standing with a straight back and neck. I like to say the body adapts to what we do to it and the spine is like wet cement that is hardening - what position do you want it to stiffen into?

(Disclaimer: Some people with stooped postures (aka excessive kyphosis) have pathological conditions in their spines that lead to these deformities, not simply due to impaired posture).

What can be done about it? My friend wanted answers! He might not be able to change his "lump" that is already there due to bony changes that have already occurred but maybe we can help it from increasing by working on some posture exercises to improve the flexibility of the thoracic and cervical spine and improve the strength of the muscles that hold these positions. Fortunately for him, His condition isn't painful yet. Doing some simple posture exercises can prevent painful conditions from forming in his neck and shoulders and even reduce headaches.

Subscribe to the blog and get access to the to 5 Best Neck Posture Exercises delivered to your inbox! Who doesn't love free professional advice?

Comment below for any questions you have for a physical therapist and Liz may answer your question in a future blog post!

Exercise recommendations for Minimizing IT (iliotibial) Band Tightness

Did you watch the first video in my 2-part series about IT (iliotibial) band tightness and have been waiting ever since for video 2? Well, wait no longer, for that moment has finally arrived! In part 1, I explained the anatomy of the IT Band and how it can become tight and problematic. It is often muscle imbalances that lead to this or sometimes just shear volume of activity and training.

In this video, I detail some of the practical, basic stretching and strengthening exercises that I recommend for people's whose IT Band and tensor fasciae latae (TFL) are tight, particularly due to the TFL/ITB serving as an "overachiever" muscle in the hip.

Enjoy the video.  Contact me with any questions and/or suggestions for future video topics.

Let's get to the source, and together, get moving!

Liz

Iliotibial (IT) Band Tightness/Syndrome - Anatomy, the Why, & the What

Iliotibial band or IT band tightness effects a large segment of the population and can manifest itself in many negative ways. It can get tight in the sedentary (aka non-active) population but is a common problem with runners, bikers, and cross fit participants or those regularly lifting weights.

Liz created a 2-part video series to help you understand the issue and what to do about IT band tightness and IT band syndrome. In this first segment, Liz talks about what the IT band is and why it becomes problematic. Then discusses some general ways to manage or prevent it. The follow-up to this video will go through specific stretching and strengthening exercises that are beneficial for minimizing IT band tightness.

Subscribe to the blog and the Artisan Physical Therapy YouTube channel to benefit from free advice and education from a movement specialist including part 2 of the IT band tightness series to get the exercise recommendations and demonstration.

Together, Let's Get Moving!

Liz