Tibial Internal rotation is often limited with conditions like patellofemoral syndrome - what I call "knee pain" ? - and a functional mobilization, or in weight bearing with the rotation force applied during the painful activity, like a lunge, squat, or step up/down often makes it pain free. In this case, simultaneous tibial IR and distal femoral lateral glide was applied which abolished lateral knee pain and also improved ankle dorsiflexion. As a bonus, the patient can make sure the knee tracks over the 2nd metatarsal in closed chain. A high dosage of this mobilization performed hourly for a few days should help restore pain free function and get the patient ready for loading/strengthening.
Functional Mobilization for Lateral Knee Pain
MMT: The Eclectic Approach to UQ and LQ Assessment and Treatment is now fully online! 11.5 hours and 26 modules!
Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!
Learn more online!
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!
Keeping it Eclectic...
This article was originally posted on themanualtherapist.com
from https://www.themanualtherapist.com/2018/11/functional-mobilizaion-for-lateral-knee.html
0 Comments
DRAM/DRA is the acronym for diastasis of the rectus abdominus muscle, which is a separation between the left and right halves of the rectus abdominus through widening for the central ligament known as the linea alba (LA). This increase in inter-rectus distance (IRD) has been shown to be present in 27%-100% of women during the second and third trimester of pregnancy and up to 68% of women in the post-partum period (Hilde, Tennfjord, Sperstad & Engh., 2017). Currently, there are only a small amount of research trials investigating this condition. There is no evidence that confirms that there are any risk factors for developing a DRAM (Gluppe, et al., 2018). “Natural resolution and greatest recovery of DRAM occurs between 1 day and 8 weeks after delivery, after which time recovery plateaus” (Benjamin, van de Water & Peiris., 2014, p.1).
It is suggested that increasing the distance between the rectus abdominus muscle through a DRAM may lead to reduced lower back and pelvic stability and be related to the development of urinary incontinence, pelvic organ prolapse and pelvic floor muscle (PFM) weakness. For this reason, research trials have aimed to explore the impact of pelvic floor and abdominal muscle training on the recovery of DRAM, but conclusive evidence is yet to be found showing a direct correlation between DRAM severity and back pain and/or PFM dysfunction. Despite this, physiotherapists continue to offer pelvic floor muscle training and abdominal muscle strengthening exercises as a treatment for patients. I, am one of those. After reading the available research, it appears that while there is no reported risk in providing patients with these exercises, it cannot be conclusively know that performing them will lead to a faster recovery. There is also no evidence suggesting that one exercise program is superior to another.
Questions raised
WHAT IS THE IDEAL ASSESSMENT OF A DRAM?
>2.7cm at the level of the umbilicus is considered pathological (Benjamin, et al., 2014). Smaller levels of widening are considered physiological.
Finger palpation
Categorising DRAM (Gluppe et al., 2018)
Ultrasound measurement
Benjamin et al (2014) pose a valid question that all clinicians should consider: are we using assessment to diagnose the presence of a DRAM or to monitor change in DRAM width over time?
Clinicians need to be clear about their goals for assessment. Most Physical Therapists continue to use finger palpation in assessment and this is suitable to detect the presence/absence of a DRAM. For monitoring change over time, U/S, MRI or callipers are more suitable assessment tools.
ARE THERE EXERCISES THAT HELP?
Benjamin et al (2014) completed a systematic review to determine the effectiveness of non-surgical interventions for DRAM. Their aims were to understand if exercises could reduce/prevent a DRAM in the ante-natal period? And, if they could reduce DRAM and health-related negative effects of a DRAM in the post-natal period.
The systematic review located 8 studies of various design and ranging levels of study quality. The interventions included abdominal muscle strengthening and provision of an abdominal corset/tubigrip.
It has previously been suggested that exercise during pregnancy can reduce the presence of DRAM development by 35% as well as DRAM width (Chiarello et al., 2005), however after further evaluation, the quality of this trial was low. The conclusion of this SR was that non-specific exercise may or may not help to prevent DRAM or reduce DRAM in the post-natal period.
Since this systematic review in 2014, four additional RCTs have been published looking into this topic. A recent RCT published in the Physical Therapy Journal in April 2018 (Gluppe et al., 2018) looked at the impact of a 16 week training program in addition to daily HEP on the recovery of DRAM. The program involved one supervised class each week and daily PFM as a HEP.
In this particular study, at the 6 week post-partum period, ~55% of each group were diagnosed with a DRAM. The exercises included in this trial were: draw in on all fours (quadruped), draw in while lying prone, forearm kneeling plank, kneeling side plank, oblique sit up and straight sit up. In each of these six position there were three sets of 8-12 contractions of abdominal muscle activations.
Pelvic floor muscles were trained in 5 different positions. In each position there were 8-12 attempts of a maximum contraction for 6-8 second holds. For the last 4-5 contractions in each position 4-5 fast contractions were added on to the end of each long hold. This can be referred to as long holds and quick flicks. The pelvic floor muscle HEP consisted of 3 sets of 8-12 contractions of maximum holds each day. Further detail of the training program protocol can be found in a separate paper by Bø et al (2017).
DO EXERCISES HAVE AN EFFECT ON DRAM RECOVERY?
The results of this study found that no significant difference in DRAM measurement was found in the test group at 6 months and 12 months post-partum. However, after looking more closely at the study design 2 elements stood out to me.
The presence of a DRAM has not been shown with convincing evidence to result in an increased prevalence of pelvic floor muscle weakness in post-partum women. “No significant differences in PFM function were found between women with or without diastasis at 6 weeks, 6 months, and 12 months postpartum.” (Hilde, Tennfjord, Sperstad & Engh., 2017, p. 718) Therefore, if it is not clearly linked to pelvic organ prolapse, urinary incontinence or pelvic floor muscle dysfunction, should we routinely assess for this problem? Personally I believe that women benefit from an assessment and education of what a DRAM is and provision of safe modification of daily movements. For example, how to get out of deep chairs or out of bed while pregnant so that they do not strain their stomach or lower back.
ARE SIT UPS SAFE?
This is a common question pertaining to the presence of a DRAM during pregnancy and after, because the way in which an abdominal contraction impacts the linea alba is of debate. In 2016, Lee & Hodges conducted a study to explore the impact that contracting the rectus abdominus muscles during a sit up with/without pre-activation of the transversus abdominus muscle (TrA) has on the inter-rectus distance and therefore tensioning through the linea alba.
Although prescription of exercises to narrow the IRD would seem a logical objective of rehabilitation for cosmetic purposes, this may not be the best way to support the abdominal contents. What this study found is that:
Although pre-activation of the TrA does not reduce the IRD as much, it provides more support to the abdominal contents and this would be visualised by reduced bulging during the sit up movement. So should we be telling women to avoid sit ups post-partum? Perhaps not? I believe that is very important however to educate and teach them about safe technique for performing a sit-up with pre-activation of the TrA to support their abdomen.
OTHER HELPFUL TOOLS
External supports may mimic muscle function and therefore feel supportive. We can use simple supports like tubigrip to more structured abdominal support bands and recovery shorts. Anecdotally, my patients have always loved the support from SRC recovery shorts but I am sure there are many other similar products available. None of them have been evaluated in high quality research trials but again, there is little to no harm that can occur from trying them to improve comfort levels in the post-partum period.
Take away messages:
*** side note: I was very fortunate to study under Deenika at the Angliss Hospital and everything I know and practice comes from my training during my Women’s health rotations there. This hospital provides excellent pre/post natal exercise and education classes and have a strong focus on the identification of those at risk for developing PND and offering support and treatment for them.
twitter @siansmale
instagram @siansmale_SF
REFERENCES:
Benjamin, D. R., Van de Water, A. T. M., & Peiris, C. L. (2014). Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy, 100(1), 1-8.
Bø, K., Hilde, G., Tennfjord, M. K., Sperstad, J. B., & Engh, M. E. (2017). Pelvic floor muscle function, pelvic floor dysfunction and diastasis recti abdominis: prospective cohort study. Neurourology and urodynamics, 36(3), 716-721.
Chiarello, C. M., Falzone, L. A., McCaslin, K. E., Patel, M. N., & Ulery, K. R. (2005). The effects of an exercise program on diastasis recti abdominis in pregnant women. Journal of Women’s Health Physical Therapy, 29(1), 11-16.
Gluppe, S. L., Hilde, G., Tennfjord, M. K., Engh, M. E., & Bø, K. (2018). Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Physical therapy, 98(4), 260-268.
Keeler, J., Albrecht, M., Eberhardt, L., Horn, L., Donnelly, C., & Lowe, D. (2012). Diastasis recti abdominis: a survey of women's health specialists for current physical therapy clinical practice for postpartum women. Journal of women’s health physical therapy, 36(3), 131-142.
Lee, D., & Hodges, P. W. (2016). Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. Journal of orthopaedic & sports physical therapy, 46(7), 580-589.
van de Water, A. T., & Benjamin, D. R. (2014). Measure DRAM with a purpose: diagnose or evaluate. Archives of gynecology and obstetrics, 289(1), 3-4.
Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!
Learn more online!
Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!
Keeping it Eclectic...
This article was originally posted on themanualtherapist.com
from https://www.themanualtherapist.com/2018/11/pregnancy-related-diastasis-of-rectus.html
Even cash-based therapists can't escape all of Medicare's confusing compliance rules.
from https://www.webpt.com/blog/post/5-medicare-compliance-issues-for-cash-based-pts-0
Even cash-based therapists can't escape all of Medicare's confusing compliance rules.
from https://www.webpt.com/blog/post/5-medicare-compliance-issues-for-cash-based-pts While documentation may not be the most-liked aspect of your job as a rehab therapist, it surely is a crucial one—for you and your patients. from https://www.webpt.com/resources/download/defensible-documentation-toolkit
Here's everything you need to know about defensible documentation for PTs, OTs, and SLPs.
from https://www.webpt.com/blog/post/what-defensible-documentation Hey everyone, my HUGE Black Friday sale is back! Starting now through Cyber Monday, you can save 25% off all my acclaimed online products including my Inner Circle, online Knee and Shoulder courses, rehab protocols, IASTM course, and Functional Stability Training! The post My Huge Black Friday Sale is Back appeared first on Mike Reinold. from https://mikereinold.com/black-friday-2018/ Catch up on all my latest content and articles to read from around the web. This week's Stuff You Should Read comes from Sian Smale, Ryan DeBell, and Darin Jerome. The post Windlass Mechanism, Shoulders HAVE to Move Differently, and 5 Programming Tips appeared first on Mike Reinold. from https://mikereinold.com/windlass-mechanism-shoulders-have-to-move-differently-and-5-programming-tips/ On this episode of the #AskMikeReinold show we talk about the benefits of post-professional residencies and fellowships for physical therapists, as well as some things you should consider before applying. The post Should Physical Therapists Do a Post-Professional Residency or Fellowship? appeared first on Mike Reinold. from https://mikereinold.com/should-physical-therapists-do-a-post-professional-residency-or-fellowship/ Sponsored Content: This video contains paid product placement. Thank you to Massage Therapy Concepts for sponsoring this video and providing Doctor Jo with a free Cordless Handheld Massager to use. If you purchase this product from these links/ads, Doctor Jo will receive a commission. Delayed Onset Muscle Soreness (DOMS) is when you have gradually increasing soreness in the muscles that occurs 24-48 hours after activity. DOMS is completely normal, and it’s how we build stronger muscles. There are some things you can do to help makes sure the muscles heal properly and don’t cause problems later. One great way to relieve sore muscles is using massage with vibration. The folks at Massage Therapy Concepts sent me their Cordless Handheld Massager. It has 7 different attachments to make it very versatile, and its long handle makes it easy to reach those hard-to-reach spots on your shoulders and back. Once you use the massage to relax the muscles, you always want to stretch afterwards to help lengthen the muscles. Also, drinking plenty of water and getting plenty rest after your workouts will help decrease DOMS. from https://www.askdoctorjo.com/relieve-sore-muscles |
ABOUT USWe provide a unique multidisciplinary approach using the latest technical advancements in rehabilitation to treat patients with pain and physical limitations caused by injuries. For nearly 25 years, we have helped thousands recover from pain and injuries with our one of a kind combination of personalized, hands-on techniques and technical expertise. For nearly 25 years, we have helped thousands recover from pain and injuries with our one of a kind combination of personalized, hands-on techniques and technical expertise. ArchivesNo Archives Categories |