Pelvic Floor Muscle Exercises

INFORMATION FOR WOMEN OF ALL AGES

Pelvic Floor Muscle Exercises
How to exercise and strengthen your pelvic floor muscles


Introduction

Many women experience pelvic floor problems at some time during their life. But did you know that problems with your pelvic floor muscles can affect your bladder, bowel and sexual function?

Your pelvic floor muscles span the base of your pelvis to keep your pelvic organs in the correct position (prevent prolapse), tightly close your bladder and bowel (stop urinary or anal incontinence), and help with sex. Your pelvic floor muscles need to be strong, but they also need to work in the right way at the right time. Even women who already do pelvic floor muscle exercises may find that they have symptoms.

Fig.1- Women pelvic anatomy

Causes

There are many possible causes of pelvic floor muscle problems. These problems may be linked to pregnancy, childbirth or the menopause and can be made worse by such things as being overweight, smoking or being constipated.

Symptoms

Symptoms may include:

• urinary leakage during activities such as coughing, laughing, sneezing or during sporting activity

• a sudden feeling that you need to rush to the toilet, or leaking on the way to the toilet

• anal incontinence which is leakage of stool (faeces) or difficulty in controlling wind

• a prolapse which may be felt as general pelvic discomfort or as ‘something coming down’

• reduced sensation and satisfaction during sex, or leakage of urine during sex

Many people think that these symptoms are all part of the normal ageing process, but they can happen to any woman at any time of her life.

Working your pelvic floor  muscles

It is important that you get the right muscles working in the right way. To do your exercises, imagine that you are trying to stop yourself from passing wind and at the same time trying to stop yourself from passing urine. You could also think of squeezing tightly inside your vagina. You should feel your muscles ‘lift and squeeze’.
Ensure that you rest for 4-5 seconds in between each squeeze. You should not feel your buttocks or legs  tightening.

There are three main ways to check if you  are contracting your pelvic floor muscles  correctly:

• use a small mirror to look at the area between your legs. The skin between your vagina and back  passage should move up and inwards away from  the mirror when you contract your pelvic floor  muscles. If you see any bulging – STOP! This could  cause more problems: for more advice you should  see a specialist physiotherapist
• feel inside your vagina with your thumb or index finger. Tighten your pelvic floor muscles. You  should feel the muscles tightening around your  thumb or finger
• if you are sexually active, you could try to squeeze your muscles during sex. Ask if your partner can  feel the squeeze
It is important to breathe normally when you are doing your exercises. You may also feel some gentle tightening in your lower abdominal muscles. This is normal.


Your pelvic floor muscle exercise programme
You need to practise short squeezes as well as long  squeezes.

Long squeezes

• Tighten your pelvic floor muscles, hold for several seconds, and then relax for several seconds. How long can you hold?
• Repeat until your muscles start to tire. How many times can you repeat your long squeezes?

Short squeezes

• Tighten your pelvic floor muscles for one second,and then relax.
• Repeat until your muscles start to tire. How manytimes can you repeat your short squeezes?

You should do your pelvic floor muscle exercises at least 3 times each day. You may find it easier to start your programme when you are sitting or lying down.
As your muscles improve, aim to do your exercises in other positions  such as standing up.

Improving your pelvic floor muscles

Most women need to aim for 10 long squeezes, up to 10 seconds each, followed by 10 short squeezes.
For some women this will be too easy, for others this may be too difficult. Start with what you feel is a comfortable length of time for you to squeeze.
Gradually increase it over the next few weeks.
Pelvic floor muscle exercises are not a ‘quick fix’. It is important that you continue with your exercises even if they do not seem to be helping.
If you practise your pelvic floor muscle exercises as above, you should notice an improvement in 3-5 months.
Further advice is available from a specialist physiotherapist.



Remembering to exercise

It is easy to forget your pelvic floor muscle exercises. Make sure your exercises are part of your daily routine - just like brushing your teeth. You should continue with your exercises for the rest of your life.
Here are some suggestions to help you to remember:

• Use coloured stickers or reminder notes around the house or at work
• Do your exercises after you have emptied your bladder. Do not practise stopping your flow of urine mid-stream.
• Use the advert break between television programmes

Preventing problems

Tighten your pelvic floor muscles before you do anything that may put them under pressure, such as lifting, coughing or sneezing.
Being overweight puts extra strain on your pelvic floor muscles. Your symptoms may improve if you lose weight. Straining to empty your bowels (constipation) may also weaken your pelvic floor muscles. If you are often constipated, you may need to seek advice.

Getting help

If you have any difficulty with the exercises described in this leaflet, or find that you are not improving you may need extra help. Chartered Physiotherapists in Women’s Health are experts in pelvic floor muscle rehabilitation.
To find your nearest specialist continence physiotherapist ask your local physiotherapy department or contact:

ACPWH Administration, Fitwise Management Ltd, Drumcross Hall, Bathgate, West Lothian EH48 4JT
T: 01506 811077 E: info@fitwise.co.uk
or visit the ACPWH website at
http://acpwh.csp.org.uk/
The ACPWH also produce other leaflets, details of which are available on the website.

CONCEPTO MULLIGAN: UNA REVISIÓN DE LA EVIDENCIA

Autor: Abraham Jorge Chinea

Ejemplo de tratamiento¹⁵

Resumen

El Concepto Mulligan (Mulligan Concept), como todo método de Terapia Manual, se basa en principios teóricos de anatomía, fisiopatología, biomecánica y neurofisiología pero dando mayor importancia a la presentación clínica y la valoración fisioterapéutica del paciente.

Las técnicas de tratamiento son denominadas “movilizaciones con movimiento” (MWM) en las extremidades y “deslizamientos apofisarios naturales sostenidos” (SNAGs) en la columna vertebral. Estas técnicas se basan en la idea de Mulligan que en una gran parte de las disfunciones neuro-musculo-esqueléticas existe una alteración en la alineación articular, lo que él denomina como un fallo posicional. Este fallo es corregido mediante la aplicación firme y mantenida de una fuerza externa, normalmente en forma de un deslizamiento (traslación o rotación), sobre un segmento corporal móvil.

Introducción

El objetivo principal de este artículo es realizar una somera introducción al Concepto Mulligan y mostrar una revisión de la mejor evidencia científica existente hasta la fecha que avale o refute su uso en el ámbito clínico.

Ejemplo de sesión de tratamiento

1. Durante la evaluación el Fisioterapeuta identificará uno o más signos comparables como los descritos por Maitland. Estos signos pueden ser una pérdida de movimiento articular, dolor asociado con el movimiento o dolor asociado con las actividades funcionales (por ejemplo, dolor lateral del codo con extensión de muñeca resistida, tensión neural adversa, etc).
2. Se aplica una movilización articular accesoria y pasiva siguiendo los principios de Kaltenborn (por ejemplo, paralela o perpendicular al plano articular). Este deslizamiento accesorio debe ser en sí mismo libre de dolor. La fuerza se aplica a través de las manos o con ayuda de una cincha.
3. El Fisioterapeuta debe controlar continuamente la reacción del paciente para asegurar que no se produce dolor. Haciendo uso de sus conocimientos sobre la artrología articular, un desarrollado sentido sobre la tensión tisular y el razonamiento clínico, el Fisioterapeuta investiga varias combinaciones de deslizamientos paralelos, perpendiculares o incluso rotaciones para encontrar el plano de tratamiento y el grado de movilización correctos.
4. Mientras el Fisioterapeuta mantiene el deslizamiento accesorio, se solicita al paciente quelleve a cabo el signo comparable. Ahora este signo comparable debería mejorar de manera significativa (por ejemplo, aumento del rango de movimiento, descenso significativo o, incluso mejor, ausencia del dolor original, etc).
5. Si no hay mejoría del signo comparable indicaría que el Fisioterapeuta no ha encontrado el punto de contacto, el plano de tratamiento, el grado o dirección de la movilización o el segmento vertebral correctos, o que la técnica no está indicada.
6. La actividad o movimiento previamente restringido o doloroso es repetido por el paciente mientras el Fisioterapeuta continúa manteniendo el deslizamiento accesorio apropiado. Se esperan mejorías progresivas con las repeticiones durante una sesión de tratamiento utilizando generalmente tres series de diez repeticiones.
7. Se puede conseguir mayor mejoría mediante la aplicación de sobrepresión pasiva al final del rango disponible. Esta sobrepresión ha de ser de nuevo libre de dolor.

Una correcta técnica de MWM o de SNAG debería convertir el signo comparable en no doloroso a la vez que mejora de manera significativa la función durante la aplicación de la técnica. Es necesario que existan mejorías mantenidas para justificar la continuidad de la intervención.

Normalmente el auto-tratamiento es posible usando los principios de la MWM con esparadrapo adhesivo y/o que el paciente lleve a cabo el componente de deslizamiento de la MWM junto con su propio esfuerzo para realizar el movimiento activo.

Se debe enseñar al paciente a realizar correctamente el componente de deslizamiento y hacer hincapié en que el dolor siempre actúa de guía.

Evidencia

A fecha de mayo de 2012 se ha realizado una búsqueda blibiográfica en Medline utilizando los siguientes términos: “mobilization with movement”, “mobilizations with movement”, “SNAG”, “SNAGs”, “MWM” y “MWMs”. Además se ha limitado la búsqueda por el tipo de publicación a estudios clínicos controlados aleatorizados, revisiones y meta-análisis para conseguir el mayor nivel de evidencia posible. La cadena de búsqueda ha sido la siguiente:

((“mobilization with movement”) OR (“mobilizations with movement”) OR (“SNAG”) OR (“SNAGS”) OR (“MWM”) OR (“MWMS”)) AND ((randomized controlled trial[Publication Type] OR meta-analysis[Publication Type] OR review[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract]) OR (review[Title/Abstract]) OR (meta-analysis[Title/Abstract])))

Se han encontrado 45 artículos de los cuales se han seleccionado los que tienen relación directa con elMulligan Concept quedando los siguientes:

Artículos que apoyan el uso de las técnicas de Mulligan

• Hoch MC, McKeon PO¹. Se podría hacer una recomendación de nivel B a favor de una intervención con MWM porque los tres estudios incluidos fueron clasificados como de nivel de evidencia 2, y las mejoras se identificaron consistentemente después de sólo una intervención con MWM, pero el tamaño del efecto fue limitado y los intervalos de confianza cercanos a cero.
• Ho CY, Sole G, Munn J².La Terapia Manual no mostró ser más efectiva que otras intervenciones conservadoras para la capsulitis adhesiva, sin embargo, el masaje y las MWM pueden ser útiles en comparación con el no tratamiento en los resultados a corto plazo para la disfunción del hombro.
• Kachingwe AF, Phillips B, Sletten E, Plunkett SW³. Este estudio sugiere que realizar movilizaciones glenohumerales y MWM en combinación con un programa de ejercicios supervisados puede resultar en un mayor descenso del dolor y una función mejorada aunque son necesarios estudios con muestras más grandes y métodos de discriminación de muestra.
• Herd CR, Meserve BB⁴. Los resultados de esta revisión apoyan el uso de la movilización con movimiento de Mulligan produciendo beneficios inmediatos, a corto y largo plazos. Además, se demostraron resultados positivos con la terapia manipulativa aplicada en la columna cervical, aunque los datos acerca de los efectos a largo plazo eran limitados. Actualmente, existe evidencia limitada que apoye una síntesis de cualquier técnica particular ya sea aplicada en el codo o en la columna cervical. En general, esta revisión identificó la necesidad de un mayor número de estudios de calidad que usen tamaños de muestra más grandes, medidas válidas de resultados funcionales y períodos de seguimiento más largos.
• Reid SA, Rivett DA, Katekar MG, Callister R⁵. El tratamiento con SNAG tuvo un efecto sostenido inmediato y estadísticamente significativo en la reducción de mareos, el dolor cervical y la discapacidad causados por la disfunción cervical.
• Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ⁶. En los sujetos con síndrome de hombro congelado, las movilizaciones en el rango final y las MWM fueron más efectivas que las movilizaciones en el rango medio a la hora de aumentar la mobilidad y la capacidad funcional. Las estrategias de movimiento en términos de ritmo escapulohumeral mejoraron después de tres semanas de MWM.
• Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Breen A⁷. Las MWMs produjeron aumentos estadísticamente significativos inmediatos, aunque pequeños, de la movilidad vertebral pero no una reducción del dolor en comparación con el placebo. Al introducir el juicio clínico en el proceso de selección de sujetos para el estudio, 19 (73%) de 26 sujetos se beneficiaron de las técnicas de MWMs en términos de rango de movimiento y/o intensidad del dolor, mientras que 9 (35%) sujetos mostraron dichos cambios con la intervención placebo.
• Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K⁸. Estos resultados proporcionan evidencia para la eficacia de la técnica de auto-SNAG en C1-C2 en el tratamiento de individuos con dolor de cabeza cervicogénico.
• Teys P, Bisset L, Vicenzino B⁹. Los resultados indican que que este tratamiento específico de Terapia Manual tiene un efecto positivo inmediato tanto en el ROM como en el dolor en sujetos con limitación dolorosa del movimiento de hombro. Es necesario un mayor estudio para evaluar la duración de dichos efectos y el mecanismo por el que esto ocurre.
• Vicenzino B, Paungmali A, Teys P¹⁰. La literatura acerca de la MWM puede ser categorizada en función del tipo de estudio, como estudios de eficacia clínica, biomecánica y las ciencias del dolor. La mayoría de la evidencia contenida en la literatura es considerada como de nivel bajo. A pesar de esto, existe una tendencia que apoya la afirmación clínica de los rápidos efectos paliativos en el dolor y la función durante e inicialmente después de la aplicación única del tratamiento y también después de un curso de tratamiento. Son necesarios más estudios controlados aleatorizados para evaluar la eficacia de la intervención del tratamiento. La explicación proporcionada de manera predominante para este efecto de alivio rápido del dolor es de naturaleza mecánica y está basada en la existencia propuesta de fallos posicionales óseos y la capacidad de la MWM para corregir estos fallos. La evidencia de los estudios en la ciencia del dolor que han intentado caracterizar el efecto hipoalgésico ha indicado que puede ser de naturaleza no opioide además de exhibir características que son complejas y están ampliamente distribuidas hacia otros sistemas, como los sistemas nerviosos motores y simpáticos. En este aspecto la literatura ni apoya ni refuta esta afirmación. Sin embargo, proporciona información valiosa sobre la dirección a seguir en futuros estudios mejor diseñados (por ejemplo, diseños controlados aleatorizados con tamaño de muestra adecuado) en los paradigmas biomecánicos y del dolor. La hipótesis biomecánica de que la MWM invierte los fallos posicionales requiere de mayor investigación.
• Vicenzino B, Branjerdporn M, Teys P, Jordan K¹¹. Este estudio preliminar demostró un efecto paliativo inicial de las técnicas de tratamiento de MWM en el rango de movimiento del deslizamiento talar posterior y en la dorsiflexión en individuos con esguince lateral recurrente de tobillo. Estos resultados sugieren que esta técnica debería ser considerada en los programas de rehabilitación después de un esguince lateral de tobillo. Este estudio proporciona justificación para una investigación de seguimiento de los efectos a largo plazo de la MWM en el esguince lateral de tobillo y se propone más trabajos sobre el test de deslizamiento talar posterior.
• Moulson A, Watson T¹². Los resultados de este estudio sugieren que las técnicas de SNAG cervical, realizadas en sujetos asintomáticos ingenuos, tienen un efecto simpático excitatorio como ha sido medidos en cambios en la conductividad y la temperatura de la piel. La importancia de este efecto simpático excitatorio en relación con potenciales mecanismos de analgesia inducidos por la manipulación se discute, y propone nuevas áreas de investigación.
• Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T¹³. Estos datos sugieren que la MWM con deslizamiento lateral no activa mecanismos asociados con la analgesia o el aumento de la fuerza en sujetos con características experimentalmente inducidas que simulan la epicondilalgia lateral.
• Collins N, Teys P, Vicenzino B¹⁴. Los resultados indican que el tratamiento con MWM para la dorsiflexión del tobillo tiene un efecto mecánico más que hipoalgésico en los esguinces de tobillo subagudos. El mecanismo por el que esto ocurre requiere de investigación si queremos entender mejor el papel de la terapia manipulativa en el tratamiento del esguince de tobillo.
• Paungmali A, O’Leary S, Souvlis T, Vicenzino B¹⁵. Este estudio mostró que un tratamiento con técnica de movilización con movimiento ejerción un efecto fisiológico similar al presentado para algunas manipulaciones vertebrales.
• Exelby L¹⁶. El artículo reflexiona sobre el posible papel que este concepto tiene que desempeñar dentro de la práctica basada en la evidencia. Una línea de investigación futura se propone a la luz de los resultados de la investigación preliminar disponible en la actualidad.
• Hearn A, Rivett DA¹⁷. La eficacia clínica de los SNAGs cervicales no pueden ser explicados puramente en base a los efectos biomecánicos resultantes en la columna cervical.
• Abbott JH¹⁸. El ROM de la rotación interna y externa del hombro aumenta significativamente después de de aplicar una MWM en el codo, en sujetos con epicondilalgia lateral unilateral. Sorprendentemente, este aumento del ROM también es aparente en la extremidad no afectada. Estos resultados sugieren que la MWM causa un descenso neurofisiológicamente mediado del tono muscular en reposo.
• Abbott JH, Patla CE, Jensen RH¹⁹. Se puede concluir que la MWM es una modalidad de intervención prometedora para el tratamiento de pacientes con epicondilalgia lateral. La fuerza de prensión libre de dolor es una medida más sensible del resultado que la fuerza máxima de prensión en los pacientes con epicondilalgia lateral. Se necesita más investigación conocer la eficacia a largo plazo de la MWM en el tratamiento de la deficiencia y la discapacidad resultantes de la epicondilalgia lateral.

Artículos que no apoyan el uso de las técnicas de Mulligan

• Moutzouri M, Billis E, Strimpakos N, Kottika P, Oldham JA²⁰. Mientras que el Zebris demostró ser un dispositivo fiable para medir el ROM de flexión lumbar, la movilización SNAG no demostró diferencias significativas en la ROM de la flexión en comparación con la movilización de farsa.

Conclusión

El mayor nivel de evidencia científica apoya el uso de las técnicas de Mulligan en multitud de patologías musculoesqueléticas destacando las siguientes:

• Epicondilalgia lateral^{4, 13, 15, 18, 19}
• Esguince lateral de tobillo^1, 11, 14
• Hombro doloroso e impingement^{2, 3, 6, 9, 18}
• Dolor de cabeza y mareos cervicogénicos^5, 8
• Dolor de espalda⁷

Se trata, por lo tanto, de una opción de tratamiento a tener en cuenta en las citadas patologías.

Bibliografía

1. Hoch MC, McKeon PO. The effectiveness of mobilization with movement at improving dorsiflexion after ankle sprain. J Sport Rehabil. 2010 May;19(2):226-32. ↑
2. Ho CY, Sole G, Munn J. The effectiveness of manual therapy in the management of musculoskeletal disorders of the shoulder: a systematic review. Man Ther. 2009 Oct;14(5):463-74. Epub 2009 May 21. ↑
3. Kachingwe AF, Phillips B, Sletten E, Plunkett SW. Comparison of manual therapy techniques with therapeutic exercise in the treatment of shoulder impingement: a randomized controlled pilot clinical trial. J Man Manip Ther. 2008;16(4):238-47. ↑
4. Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225-37. ↑
5. Reid SA, Rivett DA, Katekar MG, Callister R. Sustained natural apophyseal glides (SNAGs) are an effective treatment for cervicogenic dizziness. Man Ther. 2008 Aug;13(4):357-66. Epub 2007 Oct 22.↑
6. Yang JL, Chang CW, Chen SY, Wang SF, Lin JJ. Mobilization techniques in subjects with frozen shoulder syndrome: randomized multiple-treatment trial. Phys Ther. 2007 Oct;87(10):1307-15. Epub 2007 Aug 7. ↑
7. Konstantinou K, Foster N, Rushton A, Baxter D, Wright C, Breen A. Flexion mobilizations with movement techniques: the immediate effects on range of movement and pain in subjects with low back pain. J Manipulative Physiol Ther. 2007 Mar-Apr;30(3):178-85. ↑
8. Hall T, Chan HT, Christensen L, Odenthal B, Wells C, Robinson K. Efficacy of a C1-C2 self-sustained natural apophyseal glide (SNAG) in the management of cervicogenic headache. J Orthop Sports Phys Ther. 2007 Mar;37(3):100-7. ↑
9. Teys P, Bisset L, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on range of movement and pressure pain threshold in pain-limited shoulders. Man Ther. 2008 Feb;13(1):37-42. Epub 2006 Oct 27. ↑
10. Vicenzino B, Paungmali A, Teys P. Mulligan’s mobilization-with-movement, positional faults and pain relief: current concepts from a critical review of literature. Man Ther. 2007 May;12(2):98-108. Epub 2006 Sep 7. ↑
11. Vicenzino B, Branjerdporn M, Teys P, Jordan K. Initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. J Orthop Sports Phys Ther. 2006 Jul;36(7):464-71. ↑
12. Moulson A, Watson T. A preliminary investigation into the relationship between cervical snags and sympathetic nervous system activity in the upper limbs of an asymptomatic population. Man Ther. 2006 Aug;11(3):214-24. Epub 2006 Jul 3. ↑
13. Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Effects of a manual therapy technique in experimental lateral epicondylalgia. Man Ther. 2006 May;11(2):107-17. ↑
14. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004 May;9(2):77-82. ↑
15. Paungmali A, O’Leary S, Souvlis T, Vicenzino B. Hypoalgesic and sympathoexcitatory effects of mobilization with movement for lateral epicondylalgia. Phys Ther. 2003 Apr;83(4):374-83. ↑
16. Exelby L. The Mulligan concept: its application in the management of spinal conditions. Man Ther. 2002 May;7(2):64-70. ↑
17. Hearn A, Rivett DA. Cervical SNAGs: a biomechanical analysis. Man Ther. 2002 May;7(2):71-9. ↑
18. Abbott JH. Mobilization with movement applied to the elbow affects shoulder range of movement in subjects with lateral epicondylalgia. Man Ther. 2001 Aug;6(3):170-7. ↑
19. Abbott JH, Patla CE, Jensen RH. The initial effects of an elbow mobilization with movement technique on grip strength in subjects with lateral epicondylalgia. Man Ther. 2001 Aug;6(3):163-9. ↑
20. Moutzouri M, Billis E, Strimpakos N, Kottika P, Oldham JA. The effects of the Mulligan Sustained Natural Apophyseal Glide (SNAG) mobilisation in the lumbar flexion range of asymptomatic subjects as measured by the Zebris CMS20 3-D motion analysis system. BMC Musculoskelet Disord. 2008 Oct 1;9:131. ↑

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Bonus

El siguiente vídeo es un ejemplo de la aplicación de las técnicas de Mulligan a unos pacientes un tanto diferentes a los que estamos acostumbrados 

Orthopedic Protocols / Orthopaedic Protocols for Injury Rehabilitation

Library of Orthopedic Protocols and Guidelines

Rehabilitation and recovery from the many different muskuloskeletal injuries that occur generally follow the same phases and stages regardless of the person who experiences the injury. Therefore, protocols have been developed that have a broad application to the many types of injuries. These protocols can be used as a guideline by the person recovering from the injury and the therapist helping with rehabilitation.

As there are a huge number of different injuries that can happen to the human body, there are also a huge number of protocols that have been developed. There is a site on the web that you can visit to find hundreds of these protocols. The site is called OrthopaedicProtocols.com and it is run by well known orthopedic physical therapist / physiotherapy Terry Kane.

Orthopedic Specialists

The protocols and guidelines contained on this site were created by orthopedic specialists that are "some of the top Orthopaedic Surgeons and Physical Therapists in the world". The protocols cover a wide range of physical conditions and orthopedic surgical procedures.

Free Trial

A free trial is available and gives you access to the full library of rehabilitation protocols and guidelines. You can access the protocols at any time from any internet connected device. You are also able to download and print the protocols as often as you like. You can even email them to your patients. If you decide to sign up as a subscriber the cost works out to about $3/month. A small price to pay for instant access to hundreds of protocols.

This is a great resource and I encourage you to sign up. In addition to gaining access to the library of protocols, subscribers are also given the opportunity to promote their practice by posting your contact information in the sites Directory of clinicians and therapists.

You can read more on the website itself: OrthopaedicProtocols.com

Read more: http://physicaltherapyweb.com/articles/orthopedic-protocol.php#ixzz1uvqpR86O

What is the Alexander Technique ?

What is the Alexander Technique (AT)?

The Alexander Technique was originally developed in order to bring about the best conditions for skilled performance. It is a practical method for changing the way people use themselves in everyday activities, both in terms of patterns of movement and in terms of how people think about movement. The AT is not a therapy: it is a sophisticated method of re-education with therapeutic consequences. It does not aim to treat a particular symptom, but instead addresses a person's entire way of approaching movement in a course of practical lessons.

How does it work?

The Alexander Technique works by helping people to identify and prevent the harmful postural and movement habits that aggravate, or may be the cause of, stress, pain and under-performance. Working to its principles enables students to become aware of disadvantageous responses to stimuli, particularly with regard to physical movements and the intentions that precede them, and then to learn to complete an action without those aspects that are inefficient. These include any unnecessary stiffening or shortening in stature.

What do students learn?

Students learn how to release tension and rediscover better balance, both mentally and physically. With increased awareness they can learn how to be poised without stiffness in a way that can be commonly seen in small children, gifted athletes, dancers, etc, but in a way that is not very commonly seen in normal adults. Students learn to move gracefully and powerfully with less effort, to be alert and focused with less strain, to breathe and speak more easily and freely and to be calmer and more confident.

How is it taught?

Lessons in the Alexander Technique are usually given on a one-to-one basis. The teacher uses their hands together with verbal explanation in order to guide the pupil through everyday movements such as sitting, standing, walking, bending and lying down. Early in his teaching career F.M. Alexander, the originator of the AT, discovered that assisting a pupil to experience moving in a more refined way, relatively free from habitual interferences was, rather as "a picture is worth a thousand words", a faster and clearer way of learning a skill than almost any amount of verbal explanation. The method of hands-on work that he developed is remarkable in that the teacher does not actually do something to the pupil, but instead uses his or her hands for gentle guidance in movement. Almost anyone who has experienced the hands-on method of the AT is struck by the power and effectiveness of this way of learning.

The Alexander Technique involves no specific exercises, requires no special clothing or equipment and can be applied to any activity. No clothing is removed for lessons.

What are the benefits of the Alexander Technique?

The AT may help relieve back pain, neck pain, joint pain and stiffness, stress, tension, breathing difficulties, performance anxiety and more. It promotes improved posture, mobility, balance, agility, confidence, poise and vocal performance.

What is the evidence for the effectiveness of the Alexander Technique?

The AT has long been accepted as a powerful tool for skilled performance and it is an important part of the curriculum at the most prestigious music conservatoires and acting academies. It is less well-known by doctors as a way to help patients with relevant health conditions. This is due to a lack of major studies, a situation that is likely to change in the near future due to important recent and upcoming publications.

The results of a large, randomised, well-designed clinical trial, recently published in the British Medical Journal ⁽¹⁾ evaluating the effectiveness of the Alexander Technique compared with other health interventions for chronic low back pain, found that one year after lessons, individuals with back pain who had undertaken 24 Alexander lessons had only 3 days of pain per month compared with 21 days for similar patients who were receiving the usual standard-of-care from their family doctor, as well as reporting much less incapacity and a striking number of other 'quality of life' benefits. Even participants who had only 6 lessons had less than half the number of days of pain. No adverse effects were reported.

Smaller but well-designed studies have shown the Technique to be of benefit in Parkinson's disease ^(2-4), balance in elderly people ^(5,6), breathing disorders ⁽⁷⁾, and in a number of other conditions where the way that a person uses themselves in activity has an effect of how well they function. The evidence for the effectiveness of AT lessons across different health-related conditions has recently been evaluated and the findings published in the International Journal of Clinical Practice ⁽⁸⁾. The review found strong evidence for the effectiveness of AT lessons for people with chronic back pain and moderate evidence in helping to alleviate the disability associated with Parkinson's. Preliminary evidence was found across a diverse range of other health-related conditions. In the UK, a major clinical trial is currently investigating the effectiveness of the AT for chronic neck pain.

How many lessons do students need?

Alexander Technique teachers generally recommend that students aim to have an introductory course of about 20-30 lessons. This is the number of lessons needed by the average student in order to resolve the most common presenting symptoms, and to have a sufficient grounding in the principles in order to continue to progress without assistance. It is generally an advantage, but not essential, for students to have lessons twice or even three times weekly for the first few weeks, after which weekly lessons are usual.

Who can be helped by the Alexander Technique?

The Alexander Technique can benefit people of any age, at almost any level of physical fitness, and from all backgrounds. For the more common types of neck, back and other muscle and joint pain, the AT is likely to help where the problem is either caused or exacerbated by errors in coordination, including posture and balance. Even in conditions with systemic causes, or as a result of injury, better posture, balance and regulation of forces in movement may go some way towards alleviating symptoms.

Like all educational processes, AT lessons are essentially a partnership between teacher and student. In the case of the AT this does not require a high intellectual ability, since it is essentially practical, but it does require an interest in participating and in learning something new. Most people find a course of AT lessons an interesting and enjoyable experience ⁽¹⁾.

Finding a teacher

Most, but not all, teachers in the US are members of AmSAT, which is affiliated with most of the major international representative bodies. Membership requires the successful completion of a comprehensive three year full time training at an approved course as well as continuing education and adherence to a code of conduct. You can visit the AmSat website for more information and for a list of international affiliates.

REFERENCES:

1. Little P; Lewith G; Webley F; et al. Randomised controlled trial of Alexander Technique lessons; exercise and massage (ATEAM) for chronic and recurrent back pain. British Medical Journal 2008;337:a884.
2. Stallibrass C; Frank C; Wentworth K. Retention of skills learnt in Alexander Technique lessons: 28 people with idiopathic Parkinson's disease. Journal of Bodywork and Movement Therapies 2005;9:150-7
3. Stallibrass C; Sissons P; Chalmers C. Randomized; controlled trial of the Alexander Technique for idopathic Parkinson's disease. Clinical Rehabilitation 2002;16:695-708.
4. Stallibrass C. An evaluation of the Alexander Technique for the management of disability in Parkinson's disease - a preliminary study. Clinical Rehabilitation 1997;11: 8-12.
5. Dennis RJ. Functional reach improvement in normal older women after Alexander Technique instruction. Journals of Gerontology Series A: Biological Sciences and Medical Sciences 1999;54:M8-M11.
6. Batson G, Barker S. Feasibility of group delivery of the Alexander Technique on balance in the community-dwelling elderly: preliminary findings. Activities Adaptation and Aging 2008;32:103-119.
7. Austin JHM and Ausubel P. Enhanced respiratory muscular function in normal adults after lessons in proprioceptive musculoskeletal education without exercises. Chest 1992;102:486-90.
8. Woodman JP and Moore NR. Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a systematic review. International Journal of Clinical Practice 2012;66:98-112.

Read more: http://physicaltherapyweb.com/articles/alexander-technique-introduction.php#ixzz1uvpj1nGp

CONDITIONS, INJURIES AND DISEASES TREATED BY PHYSICAL THERAPISTS

This section of The Physical Therapy Web Space attempts to present a comprehensive list of sites which deal with diseases, injuries, and conditions which are often seen by individuals involved in the field of Physical Therapy. In addition, this page includes links to local articles on the specific conditions.

Orthopedic

• All About Arthritis . com
• Back Pain Info . com
• Back Pain: MedlinePlus
• Basic Back Biomechanics 
• Bursitis: Mayo Clinic
• Carpal Tunnel Syndrome : CTS Place
• Carpal Tunnel Syndrome Information Page : NINDS
• Collars and the Acute Whiplash Patient 
• Elbow Conditions: Elbow Pain Info . com
• Foot Conditions: Foot Pain Info . com
• Hip Replacement : Physical Therapy After...
• Intro to Osteoarthritis and the Knee 
• Lumbar Disc Quiz 
• Low Back Pain Case 
• Neck Strains / Sprains 
• Joint Conditions: Joint Pain Info . com
• Knee Conditions: Knee Pain Info . com
• Osteoarthritis Health Information : OA Health Info . com
• Osteoarthritis of the Foot 
• Osteoarthritis of the Knee: OA Knee Info . com
• RSI : Computer Related Repetitive Strain Injury Primer
• Shoulder Conditions: Shoulder Pain Info . com
• Sciatica
• Tennis Elbow Intro 
• Tennis Elbow Quiz 

Neurological

• ALS (Lou Gehrig's Disease): From Doctor's Guide to the Internet
• Alzheimer's Association
• Cerebral Palsy: NINDS
• Reflex sympathetic dystrophy (RSD) : Neurology Channel
• MS : Multiple Sclerosis Society of Canada
• Stroke: NINDS
• Trigeminal Neuralgia Association
• Guillain-Barre Syndrome

Autoimmune

• Web MD Fibromyalgia Resources
• Guillain-Barre Syndrome: NINDS
• Rheumatoid Arthritis Overview 
• Raynaud's Syndrome, Disease, Phenomenon 

Other

• Asthma : From Doctor's Guide to the Internet
• Canadian Diabetes Association
• Vestibular Rehabilitation: Mayo Clinic
• Fibromyalgia Facts for Females

Office Fitness Alongamentos no escritório

If you're like most people who have an office job, you've gotten into the habit of sitting for hours on end. If your typical workday involves a whole lot of sitting, it's time to take action. So this week's challenge is to stretch and move more during your workday.

First, let's look at why sitting for so long is such a dangerous thing. To start off, you'll experience a lower level of circulation, which can cause high levels of fatigue. That's because your muscles aren't getting the oxygen that they need. Those who sit for extended periods of time are also going to be at a higher risk for heart disease.

To counteract all this, you should consider stretching throughout the day. Stretching is a great way to get the blood flowing again, energizing your body and mind. Best of all, you don't even have to leave your office to do it.

So which stretches are best? Let's look at your line-up.

Shoulder Stretch

The first stretch to consider is the shoulder stretch. To perform this one, move one arm across the body, holding onto it with the other hand located just over the elbow.

Slowly press gently into the body as you stretch it as far across the body as possible. While doing this you should feel a slight pull in the shoulder region. Hold and then repeat to the other side.

Hamstring Stretch

The next stretch to perform is the hamstring stretch. For this one, stand in front of your desk a few feet and then place one foot directly on top of the desk. From there, lean forward, trying to keep the knee straight the entire time. Lower yourself as far down as you can go, thinking of pressing the stomach into the leg.

Hold and then switch sides and repeat.

Side Stretch

Since your back and spinal column will likely get tight and tense after sitting for so long, doing some stretches to loosen up this area is a wise move.

To perform this stretch, simply sit in a chair and then twist to one side. Keep the body as upright as possible while in this position. Using your arms placed on the chair in front and behind you, gently push the body in either direction.

Hold and then repeat to the other side.

Hip Flexor Stretch

Finally, the last stretch that you'll do for this challenge is a hip flexor stretch. The hip flexors are another group of muscles that will tend to get quite tense and tight when sitting for extended periods of time. To perform these, place one foot up on your desk(or chair) once again, but this time keep the knee bent. You should be standing closer to the desk as well, only a foot or so away.

From there, while keeping the standing knee straight, lean inwards, focusing on stretching out the top of the front thigh region (the hip flexor). Pause in this position and then switch sides and repeat.

So there you have four great stretches that you can perform as you go about your day. Of course, these are all just suggestions. The most important thing is just to move throughout the day: whether it's stretching, or walking around the office.

PCL Tears What is the posterior cruciate ligament (PCL)?

Autor: Jonathan Cluett, M.D., About.com Guide

Updated May 07, 2011

The posterior cruciate ligament, or PCL, is one of four ligaments important to the stability of the knee joint. The anterior cruciate ligament, or ACL, sits just in front of the PCL. The ACL is much better known, in part because injuries to the ACL are much more commonly diagnosed than injuries to the PCL. Interestingly, it is thought that PCL injuries account for about 20 of knee ligament injuries, however, the PCL is seldom talked about because these injuries are often left undiagnosed.

The PCL is the ligament that prevents the tibia (shin bone) from sliding too far backwards. Along with the ACL which keeps the tibia from sliding too far forward, the PCL helps to maintain the tibia in position below the femur (thigh bone).

How is the PCL injured?
The most common mechanism of injury of the PCL is the so-called "dashboard injury." This occurs when the knee is bent, and an object forcefully strikes the shin backwards. It is called a 'dashboard injury' because this can be seen in car collisions when the shin forcefully strikes the dashboard. The other common mechanism of injury is a sports injury when an athlete falls on the front of their knee. In this injury, the knee is hyperflexed (bent all the way back), with the foot held pointing downwards. These types of injuries stress the PCL, and if the force is high enough, a PCL tear will result.

What are the symptoms of a PCL injury?
The most common symptoms of a PCL tear are quite similar to the symptoms of an ACL tear. Knee pain, swelling, and decreased motion are common with both injuries. Patients may have a sensation that their knee "popped" or gave out. Problems with knee instability in the weeks and months following PCL injury are not as common as instability following an ACL tear. When patients have instability after a PCL injury they usually state that they can't "trust" their knee, or that it feels as though the knee may give out. If this complaint of instability is a problem after a PCL injury, it may be an indicator that surgery is recommended.

How is a PCL injury diagnosed?
Part of the diagnosis of a PCL tear is made by knowing how the injury happened. Knowing the story of the injury (for example, the position of the leg and the action taking place) will help in making the diagnosis. Specific maneuvers can test the function of the PCL. The most reliable is the posterior drawer test. With the knee bent, your doctor will push the tibia backwards; this stresses the PCL. If the PCL is deficient or torn, the tibia will slide too far backwards, and indicate an injury to the PCL.

X-rays and MRIs are also helpful in clarifying the diagnosis and detecting any other structures of the knee that may be injured. It is common to find other ligament injuries or cartilage damage when a PCL tear is found.

PCL tears are graded by the severity of injury, grade I through grade III. The grade is determined by the extent of laxity measured during your examination. In general, grading of the injury corresponds to the following:

• Grade I: Partial tears of the PCL.
• Grade II: Isolated, complete tear to the PCL.
• Grade III: Tear of the PCL with other associated ligament injury.

What is the treatment for a PCL tear?
Treatment of PCL tears is controversial, and, unlike treatment of an ACL tear, there is little agreement as how best to proceed. Initial treatment of the pain and swelling consists of the use of crutches, ice, and elevation. Once these symptoms have settled, physical therapy is beneficial to improve knee motion and strength. Nonoperative treatment is recommended for most grade I and grade II PCL tears.

Surgical reconstruction of the PCL is controversial, and usually only recommended for grade III PCL tears. Because of the technical difficulty of the surgery, some orthopedic surgeons do not see the benefit of PCL reconstruction. Others, however, believe PCL reconstruction can lead to improved knee stability and lower the likelihood of problems down the road.

Surgical PCL reconstruction is difficult in part because of the position of the PCL in the knee. Trying to place a new PCL graft in this position is difficult, and over time these grafts are notorious for stretching out and becoming less functional. Generally, surgical PCL reconstruction is reserved for patients who have injured several major knee ligaments, or for those who cannot do their usual activities because of persistent knee instability.

_Sources:

Cosgarea AJ, Jay PR "Posterior Cruciate Ligament Injuries: Evaluation and Management" J Am Acad Orthop Surg, Vol 9, No 5, September/October 2001, 297-307.