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 • • • • Eating Disorder – 18.2% Low bone mineral density – 21.8% Menstrual irregularity - 23.5% All 3 - 1.2% Nichols 2006 1 10/5/2012 Stress Urinary Incontinence Physical Therapy Evaluation • 41.5% of 106 female athletes • • • • • • • – 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 • • • • • • • • 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 • • • • • • • • • • 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 2 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 3 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 • • • • • 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 • • • • • Cardiovascular fitness Minimize weight gain & fat retention Improve/ maintain overall fitness Endurance for labor & delivery Reduce potential poor posture - ACOG 2002 4 10/5/2012 Exercise Benefits • • • • 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 • • • • • • 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: – – – – – – – – – – – 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 5 10/5/2012 Questions? 6