Modern Manual Therapy Blog

Most clinicians not only have inadequate training for concussions, but also have difficulty with true empathy. Dr. Molly Parker on instagram is an amazing resource.


Palpation studies show the assessment of trigger point to be unreliable. If your treatment, whether smashing, needling etc, is based upon palpation, the least we can have is reliability. (study here)

This is an informative 5 post series on instagram from @physicaltherapyresearch. If you're viewing on desktop, make sure to click the little arrow on the side to see all the pics/videos for the entire post before moving on!
๐Ÿ“š๐Ÿ”ฌ SERIES(0/5) Elite Athlete Rotator Cuff Injury Management โ„น️ Injuries to the rotator cuff are a common across all sports and levels of competition. โ„น️ A spectrum of severity exists, ranging from contusions and tendinopathies to tears and can be classified as either partial-thickness of full-thickness disruptions. โ„น️ Injuries to the rotator cuff can be treated either conservatively or surgically, and in the elite athlete, there are many factors for the treating clinician to consider, including: Sport Level of contact Positional demands Time of year Post-season and financial implications. โ„น️ Weiss et al. (2018) examined in-season management of rotator cuff injuries in elite athletes. . ๐Ÿ’ช๐Ÿผ๐Ÿ’ช๐Ÿผ RELEVENT ANATOMY: Supraspinatus: Abduction Infraspinatus and Teres minor: External rotators Subscapularis: Internal rotation ๐Ÿ’ช๐Ÿผ A disruption or injury can affect glenohumeral joint stability and disrupt normal shoulder kinematics. . ๐Ÿ“๐Ÿ“ CLASSIFICATION: Classification of a rotator cuff tear is important to guide treatment and to allow comparison between outcome studies. . ๐Ÿ“ A tear may be classified based on size of the lesion, the number of tendons involved, and signal abnormality in the tendon on MRI. . ๐Ÿ“ [A] Rotator cuff contusion: Acute MOI Increased signal intensity in the tendon and overlying bursa, but no tear. Associated bone marrow edema Fluid collection in the subacromial/sub-deltoid region, suggestive of an acute bleed . ๐Ÿ“ Tendinopathy: Abnormal signal intensity on MRI. Thickening of the tendon. Common in repetitive overhead athletes. ๐Ÿ“ [B] Tendonosis can also develop in football players from years of heavy weight lifting exercises. . ๐Ÿ“ Partial thickness tears may develop in tendons with underlying tendinosis ๐Ÿ“ A full thickness tear in a young athlete is less common, but often seen with pre-existing tendonosis (acute on chronic presentation). . ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 1. Clinical Presentation 2. Early Rehabilitation 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlet
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๐Ÿ“š๐Ÿ”ฌ SERIES(1/5):Clinical Presentation Elite Athlete Rotator Cuff Injury Management ๐Ÿ”๐Ÿ” CLINICAL PRESENTATION: Can vary by type of injury and mechanism of onset. ๐Ÿ” Examination of the athlete should include: History including, arm position during MOI Thorough palpation. Cervical spine and elbow ruled out. Active & passive ROM Strength of shoulder & scapular musculature. Glenohumeral stability. ๐Ÿ” Athletes will often demonstrate a painful arc of active motion. . ๐Ÿ” Overhead athletes with rotator cuff pathology may present with GIRD; (excessive passive external rotation and limited internal rotation at 90 degrees of glenohumeral abduction (>20ยบ vs. normal side) ๐Ÿ–ฅ๐Ÿ–ฅ Imaging includes: Plain radiographs - rule out bony injury & assess for pre-existing degenerative changes . ๐Ÿ–ฅ MRI scan - gold standard to assess integrity of the rotator cuff tendon, musculature, labrum and articular cartilage. . ๐Ÿ–ฅ Diagnostic ultrasound - Dynamic assessment of rotator cuff injury ๐Ÿ–ฅ Particularly in the setting of elite athletes, it is beneficial to have a designated musculoskeletal radiologist who is experienced with athlete-specific pathology to partner with for such studies. . ๐Ÿ™Œ๐Ÿผ๐Ÿ™Œ๐Ÿผ REHABILITATION: Conservative management should include a comprehensive program. . ๐Ÿ™Œ๐Ÿผ A recent review by Edwards et al. (2016), provided an evidence-based 4-phase exercise protocol for the conservative management of rotator cuff injury. ๐Ÿ™Œ๐Ÿผ Including: 1. Range of motion 2. Flexibility 3. Strengthening 4. Advanced strengthening/proprioception. . ๐Ÿ™Œ๐Ÿผ Focused on: Eliminating initial pain Improving mobility Addressing stability, strength, power, and neuromuscular control Correcting identifiable issues along the kinematic chain. . ๐Ÿ™Œ๐Ÿผ Programs should be progressive and sport-specific for RTP preparation. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 2. Early Rehabilitation 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCES: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med. . ๐Ÿ“š Edwards et al. 2016. Exercise rehabilitation in the non-operative management of rotator cuff t
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๐Ÿ“š๐Ÿ”ฌ SERIES(2/5): Early Rehabilitation Elite Athlete Rotator Cuff Injury Management โ„น️ Early rehabilitation should focus on the reduction of: Pain. Inflammation. Swelling. Restoring normal ROM. โ„น️ This can be accomplished using both local physical modalities in addition to manual therapies. โ„น️ The athlete should also avoid activities which reproduce symptoms. . ๐Ÿ™Œ๐Ÿผ๐Ÿ™Œ๐Ÿผ Manual therapies such as joint mobilization and passive ROM can help restore normal joint kinematics and improve shoulder ROM ๐Ÿ™Œ๐Ÿผ Grade I and grade II glenohumeral joint mobilization techniques can be performed to reduce pain, decrease muscle guarding and improve ROM. ๐Ÿ’ช๐Ÿผ Also, Codman’s pendulum exercise is safe and can reduce stiffness and improve ROM. ๐Ÿ’ช๐Ÿผ ROM exercises can be progressed to active-assisted, followed by active-unassisted exercises. . ๐Ÿ’ช๐Ÿผ Internal rotation limitations in overhead athletes, are commonly related to chronic tightness of the posterior rotator cuff and shoulder musculature caused by poor position of the scapula, or the posterior joint capsule. ๐Ÿค™๐Ÿผ [A] The modified sleeper stretch can effectively increase shoulder internal rotation. . ๐Ÿค™๐Ÿผ [B] the modified cross-body stretch can effectively increase horizontal adduction ๐Ÿค™๐Ÿผ Stretching the pectoralis minor may also help improve scapular mechanics and overall shoulder function. . ๐ŸŠ๐Ÿผ‍♂️ Aquatic therapy early in the rehabilitation process can help restore active ROM, normal shoulder kinematics, and prepare the shoulder for progression to land-based activities. . ⚡️ Neuromuscular electrical stimulation can assist with neuromuscular re-education and reducing muscle inhibition. ⚡️ Isometric exercises are also a safe and effective way early in the rehabilitation process to promote muscle activation. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 3. Intermediate Phase 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med.
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๐Ÿ“š๐Ÿ”ฌ SERIES(3/5): Intermediate Phase Elite Athlete Rotator Cuff Injury Management โ„น️ A progressive strengthening program focused on scapular musculature and the rotator cuff should be included. โ„น️ Neuromuscular control focused on proximal stability should be focused on prior to addressing distal segment mobility. โ„น️ Human and sports-related movement occurs in orchestrated interactions between many joints in multiple planes. โ„น️ Scapulothoracic articulation serves an essential bridge between the core musculature and lower extremity to transfer kinetic energy up the chain. โ„น️ Abnormal scapular kinematics can be caused by pain associated with injury, soft tissue tightness, strength imbalances, and deficiencies in muscle activity. โ„น️ Targeting serratus anterior and middle and lower trapezius, while minimizing upper trapezius activation, can enhance scapulohumeral rhythm and glenohumeral position in space, thus allowing better function of the rotator cuff during shoulder activities. ๐Ÿ’ช๐Ÿผ A progressive scapular strengthening program should include both: [A] Open kinetic chain activities; Ex. Wall Ball Bounces ๐Ÿ’ช๐Ÿผ [B] Closed kinetic chain activities; Ex. Roller + Ext Rot ๐Ÿ’ช๐Ÿผ The ‘Push-up plus” has also been shown to generate high muscle activation of the serratus anterior. ๐Ÿ’ช๐Ÿผ [C] Studies have demonstrated that sidelying external rotation produces high EMG activity in both the infraspinatus and teres minor. . ๐Ÿ’ช๐Ÿผ The “Thrower’s 10” program is a progressive isotonic strengthening program based on EMG data, addressing rotator cuff strength and scapular stabilization. . ๐Ÿ’ช๐Ÿผ Blood flow restriction (BFR) training is a newer technique that can be used as an adjunct to traditional resistance training during this stage. ๐Ÿ’ช๐Ÿผ Hypertrophy and strength similar to that of higher load resistance training have been seen with BFR. ๐Ÿ’ช๐Ÿผ However, further research is needed to determine the overall efficacy for athletes with rotator cuff injury. . ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 4. Advanced/Late Stage Rehabilitation 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. C
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๐Ÿ“š๐Ÿ”ฌ SERIES(4/5): Advanced/Late Stage Rehabilitation Elite Athlete Rotator Cuff Injury Management โ„น️ Advanced strength & endurance training, dynamic stabilization, and sport-specific activities should be considered. โ„น️ Including sport- and position-specific drills. โ„น️ Careful collaboration between medical, rehab, and strength & conditioning staff is required to progress the athlete back into full weight training activities. ๐Ÿ’ช๐Ÿผ Strength training should address: Upper body pulling exercises. Upper body pressing exercises. Core stability exercises. ๐Ÿ’ช๐Ÿผ [A] Upper extremity plyometric exercises can be introduced and can improve proprioception, kinesthesia, and muscular endurance for the rotator cuff. . ๐Ÿ’ช๐Ÿผ Plyometric exercises involve three distinct phases: 1. Eccentric pre-stretch 2. Amortization phase 3. Concentric contraction. . ๐Ÿ’ช๐Ÿผ The amortization phase, defined as the time between the eccentric and concentric phases, should be as short as possible to allow for adequate energy transfer. . ๐Ÿ’ช๐Ÿผ Upper extremity plyometric exercises usually include throws, which are progressed from two-handed to one-handed drills, and performed in a variety of conditions (tall knee, half kneel, unstable surface). . ๐Ÿ’ช๐Ÿผ [B] Rhythmic stabilization exercises can be progressed to more complex exercises to include unstable surfaces and performance on a physioball to improve overall neuromuscular control. . ๐Ÿ’ช๐Ÿผ For the overhead thrower, a throwing program can be initiated and should include a graded training, carefully monitoring quantity of throws, distance, intensity, and types of throws. ↗️↗️↗️ Don’t miss anything! Turn on Post Notifications ✅✅ Next Up: 5. Future Directions and Conclusions ๐Ÿ“š๐Ÿ“š๐Ÿ“š SOURCE: Weiss et al. 2018. Management of Rotator Cuff Injuries in the Elite Athlete. Cur Rev Musc Med.
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๐Ÿ“š๐Ÿ”ฌ SERIES FINALE(5/5): Make sure swipe for @rehabscience great video of ๐Ÿ’ฅ๐‘๐จ๐ญ๐š๐ญ๐จ๐ซ ๐‚๐ฎ๐Ÿ๐Ÿ ๐€๐ง๐š๐ญ๐จ๐ฆ๐ฒ๐Ÿ’ฅ ✅✅✅ RTP, Future Directions, Conclusions ๐Ÿƒ๐Ÿฝ‍♂️ Return-to-Competition: RTP decisions should be made collaboratively with the team physician, rehabilitation staff, and the athlete. . ๐Ÿƒ๐Ÿฝ‍♂️ Physical exam findings should be consistent with pre-injury levels of pain, ROM, stability, strength, and overall function. . ๐Ÿƒ๐Ÿฝ‍♂️ The athlete should demonstrate adequate: Power. Muscular endurance. Sport-specific demands. ๐Ÿƒ๐Ÿฝ‍♂️ RTP should be step-wise and the athlete should be carefully monitored to avoid a repeat injury. . ➡️➡️ FUTURE DIRECTIONS: Current options for biologic augmentation include: PRP injection Cell-based therapy. . ➡️ However, there is currently limited data to suggest that PRP is effective in treatment of tendinopathy or tendon healing. . ➡️ Cell-based approaches (“stem cells”) also appear to have great potential for improvement of tendon healing. . ➡️ Promising approaches in the area of stem cell research include: ➡️ Potential use of induced pluripotent stem cells (iPSC’s) Stimulating the endogenous stem cells (“intrinsic stem cell niche”) that are known to be present in many tissues, including tendon. . ➡️ Ongoing research can provides further insight into the development of novel pharmacologic agents and other approaches to improve tendon healing. . ❗️❗️ CONCLSIONS: Rotator cuff injuries remain a common cause of pain and dysfunction for the elite athlete and can result in time loss from participation. . ❗️ Many of these injuries can be managed conservatively in-season with anti-inflammatories, injection, and a comprehensive rehabilitation program. . ❗️ Non-Responders to conservative management may be managed surgically, during off-season or immediately based on current level of dysfunction and ability to meet sport-specific demands. . ❗️ Newer treatments such as blood flow restriction therapy, and biologics are supported by some early data but require more level I studies. ❗️ An early and accurate diagnosis followed by individualized rehab will allow the greatest opportunity to RTP both expediently and safely. . ๐Ÿ“š๐Ÿ“š๐Ÿ“š
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The Talking Tendons podcast was first found on tendinopathyrehab.com

In this week's podcast, I delve into the minefield that is isometric exercise. Is it the best thing since sliced bread? Does everyone respond? What are the key questions we need to understand?

 On another note, I am excited to announce the UPDATE of my Mastering Lower Limb Tendinopathy course. It will be launched this December and will include all the new evidence out and lots of new clinical info! 
 Hope you enjoy!
Peter

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Keeping it Eclectic...



Erson shares a quick story about another unintended success when directions weren’t followed as expected for some rib taping.
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Keeping it Eclectic...


Today, I talk about an important question my brother asked me the other day:
“Is physical therapy school really that expensive?”


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
  1. What is the ideal assessment?
  2. What is the ideal exercise program?
  3. What is the ideal frequency for completing the exercise program?

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
  • “Assessment with finger breadth has been found to have an intra- and inter-observer ICC value of 0.7 and 0.5, respectively.” (Hilde, Tennfjord, Sperstad & Engh., 2017, p. 717)
  • Cut off of ≥ 2 fingers width 4.5cm above, at the level of, and 4.5cm below the umbilicus (Benjamin, van de Water & Peiris., 2014; Gluppe, et al., 2018).
  • The position is in supine with knees bent and feet flat. Some authors have arms across chest. (I learnt with hands below lower back.)
  • The movement performed by the patient during assessment is a small sit up only until the level of the shoulder blades.
Categorising DRAM (Gluppe et al., 2018)
  • Normal < 2 fingers
  • Mild DRAM 2-3 fingers
  • Moderate DRAM 3-4 fingers
  • Severe DRAM >4 fingers
Ultrasound measurement
  • Test-retest reliability ICC of 0.83-0.95 above the umbilicus and 0.5-0.85 below the umbilicus. (Benjamin et al., 2014).
  • The reliability is highly dependent on the operator.
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?
  • As a diagnostic tool, palpation and ultrasound can be used. i.e is a DRAM present or not?
  • As a monitoring tool, palpation is not recommended as an accurate tool and instead U/S, MRI and callipers are preferred.
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 Bรธ 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.
  1. The first, is that these participants only included vaginal deliveries. With caesarian section being an exclusion criteria (and this is common for all articles I read) there is little know about the recovery of a DRAM in this population.
  2. The second, was that they measures DRAM severity in 4 categories (normal, mild, moderate, severe) and then grouped all DRAMS ≥ 2 fingers into the same group. This means that little is known about the effectiveness of an exercise program on DRAM recovery based on the initial severity.
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:
  • People diagnosed with a DRAM with have a wider IRD at rest than those without (makes sense) and that this IRD will be widest at the level of the umbilicus (Lee & Hodges., 2016, p. 583).
  • During an automatic sit-up (without pre-activation of the TrA), the IRD will narrow and the linea alba will slacken. This may result in bulging of the abdominal contents.
  • During a sit-up with pre-activation of the TrA, the IRD will not reduce as much but the LA will tighten. This is due to the horizontal orientation of TrA muscle fibers. This pattern was observed in both DRAM and control group participants.
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:
  • Be careful with promising results that exercise can speed up recovery beyond the natural healing time frames.
  • Be realistic with patients that exercises may or may not help. In saying that, exercises have minimal risk and there is no harm in trying.
  • If a DRAM is present, educate patients about safe biomechanics and movement patterns to prevent unnecessary stress on the abdomen.
*** 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.

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a traveling Physiotherapist for the Olympic Winter Institute of Australia, a volunteer faculty member teaching on the Doctorate of Physical Therapy program, and is working as a Physical Therapist at UCSF.

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.
Bรธ, 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., & Bรธ, 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...