Objectives 10/5/2012 “What Does this Have to do With My Patients?”

10/5/2012
Objectives
“What Does this Have to do With
My Patients?”
Age Specific Review –
Young Adult
• Considerations for test/measures and
screening questions during evaluation
• Develop, design and implement an entry
level treatment plan
• Recognize when to refer to a pelvis floor
specialist or other health care professional
Nicole L. Dugan, PT, DPT, MSOD, CLT-LANA
Young Adult
• 18 – 40 years
• Female Athletes
• Pregnancy
Types of Referrals
• Female Athlete:
– Musculoskeletal injury
• ACL, Patella Femoral
– Stress Fracture
• Lower extremity
– Post – operative
Female Athlete
• Female Athlete Triad
– Eating Disorder – low energy stores
– Bone Loss – osteopenia
– Menstrual disturbances – amenorrhea
• Anemia
• Incontinence
Female Athlete Triad
• 170 female High School Athletes
– 8 sports, 6 schools in Southern California
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Eating Disorder – 18.2%
Low bone mineral density – 21.8%
Menstrual irregularity - 23.5%
All 3 - 1.2%
Nichols 2006
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Stress Urinary Incontinence
Physical Therapy Evaluation
• 41.5% of 106 female athletes
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– Regardless of type of sport
– Lower body weight
– Lower BMI
– 4-8 hours per week
– Mostly stress UI(62%)
– Occurred during sport and urgency
– Athletes considered it normal
Knowledge of signs and symptoms
Carefully listening to patient
Thorough history including menstruation
Review of sport exercise schedule
Refer to appropriate health care providers
Consult with coach/ trainer
Be Aware of red flags and vulnerabilities
Jacome 2011
Types of Referrals
Musculoskeletal Changes
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• Pregnancy
– Musculoskeletal changes
– Cardiovascular changes
– Balance deficits
Pelvic Floor Laxity
Increased joint mobility
Increased tissue laxity
Change in center of gravity
Increased lumbar lordosis and thoracic kyphosis
Possible increased muscle mass and strength
Abdominal muscle trauma
Pelvic Floor muscle drops 2.5 cm
Posture
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Center of gravity - moves anterior and superior
Feet – increase pronation
Knees - increase hyperextension
Pelvis – increase anterior pelvic tilt
Lumbar spine – increase lordosis
Thoracic spine – increase kyphosis
Scapular - Abduction, Protraction, internal rotation
Cervical spine – increased lordosis
Head – exaggerated forward head
Gait – wider base of support
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10/5/2012
Cardiovascular Changes
• Increased stroke volume 15-20%
• Increased cardiac output ~40%
• Increased resting heartrate ~15
bpm
• Decreased blood pressure
• Increased venous distensability
• Increased venous pressure in
lower extremity
Musculoskeletal Pathology
During and After Pregnancy
• Back Pain:
– Low back pain and lower extremity radiculopathy resulting
from poor posture, discogenic disease, mechanical
dysfunction or sciatica
• Sacroiliac Joint/ PPP/ Pubic Symphysis Pain:
– Low back or buttocks pain resulting from sacroiliac joint
dysfunction, joint laxity or poor posture
Gutke A. Spine 2006, Gutke A. J Rehabil Med 2008,
Stuge Spine 2004, Mens Phys Ther 2000, Wu Eur Spine J 2004
Musculoskeletal Pathology During
and After Pregnancy
• Lower Extremity Joint Pain:
– related to poor body mechanics, muscular imbalance,
arthritis, increased joint forces or ligamentous laxity
• Plantarfascitis:
– Foot and ankle pain resulting from ligamentous laxity,
long hours standing or walking, foot and ankle
weakness
• Tired Legs/Varicose veins:
– Fatigue associated with lower extremity edema
Musculoskeletal Pathology During
and After Pregnancy
• Muscle Tendonitis or Strain:
– Muscular pain from overuse, poor body
mechanics, repetitive motion, or acute muscle
injury
• Balance Dysfunction:
– Balance disorder secondary to vestibular
system dysfunction, altered center of gravity,
weakness or proprioceptive dysfunction
Musculoskeletal Pathology During
and After Pregnancy
• Cervical Spine Pain:
– Neck pain or headaches resulting from strain,
discogenic disease mechanical dysfunction or
poor posture
• Nerve Compression:
– Upper extremity pain secondary to nerve
compression symptoms. Thoracic outlet
syndrome (TOS), and carpal tunnel syndrome
due to altered posture, body mechanics or
repetitive motion, or static postures
Musculoskeletal Pathology
During and After Pregnancy
• Urinary & Fecal Incontinence:
– Stress, urge or mixed incontinence from pelvic floor
weakness, episiotomy or incoordination
– Evaluate for nerve damage
• Pelvic Floor Pain:
– Pain resulting from
hypertonus dysfunction
of the pelvic floor muscles
or pelvic pressure
• Dyspareunia
– usually from hypertonus dysfunction
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10/5/2012
Postural Supine Hypotension
Evaluating the Pregnant Patient
• Cautions/ Precautions
– Positioning
• Musculoskeletal Evaluation
– Joint mobility
• Modalities
• Other Referrals
Goals for the Obstetric Client
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Promote improved posture
Promote correct body mechanics
Promote cardiovascular fitness
Prevent musculoskeletal pathology
Improve control and strength
of abdominal/ pelvic floor musculature
• Increase strength/endurance of
lower extremities to handle weight gain
• Increase strength/endurance of
upper extremities to prepare for infant care
Stabilization for PPP
• 81 subjects = 40 SSEG, 41 control
• Both groups:
– Body Awareness, ergonomics, mobilization, stretching
– 30-60 min, 3 days/wk, 18-20 wks
– Specific stabilization –
• Local (trans ab & multifidi)  global muscles (gluts, lats,
obliques)
• After intervention and 1 year post partum
• Specific stabilizing group
– Lower pain intensity = 3 points on VAS
– Lower disability = 10% on Oswestry
– Higher QOL by SF-36
Stuge 2004
Exercise Benefits
ACOG Guidelines
In the absence of either obstetric
or medical complications,
pregnant women can continue to exercise
and derive related benefits
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Cardiovascular fitness
Minimize weight gain & fat retention
Improve/ maintain overall fitness
Endurance for labor & delivery
Reduce potential poor posture
- ACOG 2002
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Exercise Benefits
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Injury prevention
Psychological
Reduce gestational diabetes
Decrease in risk of venous stasis,
DVT, varicosities, edema and leg
cramps
• Reduced bone density loss
Contraindications to Exercise
• Relative (MD clearance required)
– Multiple gestation
– Anemia
– Overheating
– Diastasis recti
– Uterine contractions
– Cardiac or lung disease
– Pregnancy induced HTN
– Extreme over/ underweight
Exercise Guidelines
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MD clearance
Weightbearing
Warm up and cool down
Use proper support
Adequate hydration & nutrition
Upper limits
– maternal HR below 140 bpm
– fetal HR below ~180bpm
• Gradual resumption of activity postpartum
with MD clearance (6wks)
Contraindications to Exercise
• ABSOLUTE!!!!
– Incompetent cervix
– Vaginal bleeding
– Placenta previa
– Premature Rupture of
Membranes (PROM)
– History of 3 or more
miscarriages
– Pre-eclampsia
– Poor fetal growth
Exercise Warning Signs
• Terminate Exercise if:
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Lightheaded/dizziness
Excessive shortness of breath
Chest pain or discomfort
Irregular pulse
Increased uterine contractions
(Braxton-Hicks)
Vaginal bleeding/ other vaginal discharge
Unsteadiness, loss of balance
Other Pains
Phlebitis, calf pain
Fall in fetal heartrate
Baby not kicking for 30 min after exercise
Exercises to Avoid
• Any exercise that requires right
sidelying or prolonged supine (>5min)
after 1st trimester
• Bilateral straight leg raise
– 2 Diastasis recti risk
• Exercises that require high level
balance or single leg stance/ forces
• High-risk sports with an increased
potential for injury, specifically falling
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Questions?
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