how can physical therapy help my eds/hsd …...how can physical therapy help my eds/hsd symptoms?...
TRANSCRIPT
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How Can Physical Therapy Help My EDS/HSD
Symptoms?Leslie Russek, PT, DPT, PhD, OCS
Clarkson University, Physical Therapy Dept.Canton-Potsdam Hospital, Physical Therapy Dept.
A Checklist of potential physical therapy interventions For EDS/HSD is available on my web page:
https://webspace.clarkson.edu/~Lrussek/hsd.html
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Objectives1. List complaints PT may be able to address2. Outline a process for PT to evaluate you and
determine a plan of care3. Describe treatment approaches PT may use4. Describe the role of PT in long-term
management of EDS/HSD5. Explain how your PT should empower YOU to
manage your EDS/HSD signs and symptoms
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Why Physical Therapy?
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• PTs are experts in the movement system• Some approaches are are best provided by PT:
o Exercise, neuromuscular re-education, body mechanics, posture, ergonomics, manual therapy, modalities, braces, assistive devices…
• Most PTs are skilled in:o Pain management, pain neuroscience educationo Application of behavioral approaches to functional
activities: e.g. pacing, sleep hygiene…• You may develop a strong therapeutic relationship
with your PT, discuss problems & solutions• Some PTs have advanced training: e.g., women’s
health, visceral mobilization, etc.
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Pain Management1. Assessment of pain type, source, perpetuation2. Education about prevention and management3. Exercise to improve quality of movement,
endurance, enhance natural pain-decreasing neural pathways
4. Manual therapy for alignment, tissue healing5. Taping/bracing/orthotics for alignment & quality
of movement6. Modalities for pain and inflammation
(Engelbert, 2017, Chopra, 2017)6
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Pain Assessment• Use a biopsychosocial
approach• Look for contributing
factors as well as signs, symptoms, & involved tissues
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CENTRAL SENSITIZATION: Central nervous system becomes hyper-responsive; widespread allodynia
Inflammation ➔ nociception and SENSITIZATION
DEEP SOMATIC NOCICEPTION: muscle/trigger points, ligament, tendon, bursae, fascia: referred pain, other symptoms; dull cramping or aching, poorly localized.
DEEP VISCERAL NOCICEPTION:Many ‘silent nociceptors’.
Types of Pain
NEUROGENIC INFLAMMATION
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Biopsychosocial Pain Assessment• Identify causal, aggravating & perpetuating factorso Stressors affecting sensitive, stressed, or injured tissues
• (Nociception, inflammation)o Referred pain from musculoskeletal or visceral tissues
• (Nociception, inflammation, activation of silent nociceptors)
o Sensitive nerves, neurogenic inflammation, neuroplasticity• (Neuropathic pain, peripheral and central sensitization,
inflammation, neurogenic inflammation)
o Emotional, psychological and environmental factors• (Central sensitization, neurogenic inflammation)
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Physical Stresses to Tissues1. Is there an imbalance between lax joints and tight
muscles? 2. Does poor posture, alignment or gravity stress
joints/muscles? 3. Are body mechanics stretching or stressing
joints/muscles?4. Is poor proprioception or motor control leading to
instability? 5. What is causing muscle trigger points?
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Referred Pain
• Visceral and deep musculoskeletal tissues can refer pain
• Pain referral can irritate tissues at the referral site through neurogenic inflammation
• This can cause nociception and tissue damage at the referral site.
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Visceral Referral Patterns
Trigger Point Referral Patterns
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Referred Pain: Headaches
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• Many headaches are caused by musculoskeletal problems in the neck or head
• Trigger points• Joint problems in the
neck• Temporomandibular
disorders(picture from Travell & Simons)
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Neurological Changes
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Neuroplasticity• Changes in brain structure or
connections due to painPeripheral & central sensitization: • Increased reactivity of neurons in
peripheral or central nervous system
• Occurs due to inflammation, psychological factors (e.g. stress or anxiety), being sedentary
Neurogenic inflammation• Sensory nerves can fire backwards
and release inflammatory chemicals at their peripheral receptors.
• Can cause nociception and tissue damage in those tissues
Picture: http://www.nationalpain.com/central-sensitization/
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Psychosocial Aspects of Pain
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The pain experience is affected by:• Physiologic response to actual
or potential tissue damage• Previous pain experience• Beliefs/attitudes about pain• Coping style• Emotions• Family, social, and cultural
background• Interaction between sensory
input and brain processing
http://www.painxchange.com.au/images/BiopsychosocialPain.png
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Pain Management: Education
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• Factors contributing to/perpetuating tissue stress• Preventing and managing nerve sensitivity
o Pain neuroscience education & “Explain Pain”
• Addressing psychosocial factors aggravating pain• Self-management using exercise, TENS, heat, ice,
topical rubs, relaxation, mindfulness meditation, etc.• Use of braces, splints, orthotics, assistive technology,
environmental modification
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Pain Management: Exercise
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• To address contributing factors: posture, muscle tightness/weakness, trigger points, coordination problems, non-muscle tissue weakness.
• Neuromuscular re-education for motor control training, muscle recruitment, balance, relaxation.
• Aerobic exercise to restore normal pain inhibitory pathways and improve endurance.
• Neuromuscular re-education and exercise to address kinesiophobia (fear of movement) (Kernan, 2007)
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Pain Management: Exercise“Exercise-induced analgesia”• Regular exercise activates nerve pathways from the brain,
stopping nerves from transmitting nociceptive information • Improves descending pain control• Decreases hypersensitivity of nerves• This process does not work properly in people who
are deconditioned/sedentary • A single bout of exercise may increase pain• Regular exercise restores proper function of exercise-induced
analgesiaLima LV, Abner TSS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena. J Physiol. 2017;595(13):4141-4150.
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Not All Exercises Are Appropriate
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• For exercise to be helpful and not harmful, it must be:o The correct exercise (for you, now)o Done correctly (proper motor control)
o At the correct dose (intensity, time/reps)o Not overstressing other joints or muscles
• There is no protocol appropriate for everyone with EDS/HSD
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Doing Exercises Correctly
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• External feedback seems to improve accuracy, learning and retention compared to internal feedback. (Lauber, 2014; Lohse, 2014)
• Using laser targets, biofeedback, etc.
• See Jan Dommerholt’s presentation
www.optp.com/SenMoCOR-System
www.optp.com/STABILIZER-Pressure-Biofeedback?kw=stabilizerwww.amazon.com
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Pain Management: Manual Therapy
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• Goals:o Decrease spasm, trigger points, adhesions
o Restore proper tissue alignment and mobility
o Calm peripheral or central nervous systemo Decrease pain
• Options: massage, trigger point release, soft tissue mobilization, myofascial release, joint mobilizations, instrument-assisted, dry needling
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Pain Management: Taping
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Kinesio/Rock taping
• Improve tissue alignment, position sense, stability, fluid movement in tissues
McConnell taping• Improve tissue
alignment, stability, proprioception
http://www.ktss.us/what
https://americanpostureinstitute.com/the-ultimate-guide-to-posture-taping/
http://www.beantownphysio.com/pt-tip/archive/mcconnell-taping.html
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Pain Management: Modalities
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• Options: Heat, ice, TENS (conventional or acupuncture-like), ultrasound/phonophoresis, laser, iontophoresis, shock-wave therapy, etc.
• Can be helpful to temporarily decrease pain or inflammation, or improve tissue mobility
• Benefit is not maintained unless tissues are used during the period of benefit, through active interventions such as exercise or function
• Regular home use of heat, ice, TENS may decrease pain enough to improve function and exercise tolerance
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Pain Management Patient Resources
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• 5-minute video about chronic pain neuroscience: https://www.youtube.com/watch?v=RWMKucuejIs
• UC Davis pamphlet: search “U.C. Davis pain self-management plan” has multiple modules that let you pick what area might be most helpful for you now.
• American Chronic Pain Association: https://www.theacpa.org
• On-line pain self-management: https://www.liveplanbe.ca has questionnaires to customize information and suggestions for issues that you face
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Joint Instability• Potential causes:
o Joint laxityo Traumao Muscle weakness, poor motor controlo Poor position sense or body awarenesso Excessive stress from tight muscleso Excessive stress from habits, postures or
activities◦ (but stresses may be really mild)
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Cartoon from: https://darrengoossens.wordpress.com/category/comic/page/8/
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Joint Instability: Education• Address contributing factors: posture, body
mechanics, ergonomics, joint protection• Use of braces, splints, taping, assistive
technology, environmental modification.o Generally recommended for acute flares, return to
function, controversial for long-term use(Engelbert, 2017)
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Joint Instability: Neuromuscular Re-ed
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• Improve body awareness (Engelbert, 2017)
o Intrinsic feedback: proprioception, body awareness, tactile feedback (compressive clothing or taping)
o External/augmented feedback: laser, pressure biofeedback, wobble boards, virtual reality, Wii
◦ External focus seems to result in better retention and transfer of motor skills than internal focus
o (Lauber, 2014; Lohse, 2014)
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Decreased Function: Manage Pain• Assessment of pain type, source, contributing
factors• Education about:
o Musculoskeletal, neurological, and psychosocial contributing factors
o Self-management of paino Orthotics, braces, environmental modifications
• Exercise to address contributing factors, motor control/coordination, aerobic conditioning
• Manual therapy, taping, modalities29
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Decreased Function: Fear of Movement
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• People with EDS/HSD may be afraid of movement (kinesiophobia) due to fear of pain, injury or instability
• Decreased activity leads to decreased muscle tone, aerobic capacity, and strength, making pain and injury more likely
• Fear of movement is also linked to fatigue, perhaps through decreased activity and deconditioning. (Celletti, 2013)
• Fear of movement is a common reason people with EDS/HSD do not exercise. (Simmonds, 2017)
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Decreased Function: Fear of Movement
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• PT should address this fear through gradually progressed activity and exerciseo Best if integrated with a behavioral approach
• PT should not aggravate this fear by increasing pain (Perrot, 2018)
• Good communication and partnership with a PT knowledgeable about EDS/HSD can help patients exercise more successfully (Simmonds, 2017)
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Developmental Delay in Children• Education about contributing factors • Neuromuscular re-education (as for joint
instability)• Therapeutic exercise for functional stability,
especially in mid-range (but not excluding end range)
• Orthotics, braces, environmental adaptations(Engelbert, 2017)
33http://www.otforkids.co.uk/conditions/developmental-delay.php
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome
(POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Fatigue and Sleep Dysfunction• Assess reasons for fatigue
o Sleep disturbance due to: ◦ Pain, anxiety, poor sleep hygiene, apnea
o Deconditioning, sedentary lifestyleo Trying to do too much, not pacing, boom/bust cycleso Stress, not being able to relax and rechargeo Autonomic disorder such as POTS or orthostatic
tachycardiao Psychological factors such as depression, grief, etc.o Dieto Medicationso Other medical conditions: MCAD, fibromyalgia, etc.
o (Hakim, 2017)35
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Fatigue: Managing Poor Quality Sleep
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• Pain interfering with sleepo Positioning for decreased paino General pain management
• Sleep hygiene
• Physiological quieting, relaxation training• Regular exercise• Good information at https://sleep.org
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Fatigue: Education
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• Pacing• Body mechanics• Assistive technology and environmental
modifications
• Excellent fatigue self-management booklet at: https://www.ncl.ac.uk/medicalsciences/research/centres/fatigue/ “CRESTA Fatigue Clinic -Managing Your Energy”
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Fatigue: Managing POTS
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• Education about: Hakim, 2017o Common triggerso Fluids, salt, compression stockingso Postural changes, muscle activationo Exercise positioning and progressiono Pacingo Adapting tasks
• Exercise: o Progression from horizontal to verticalo Graded exercise therapy
• See WWW.POTSUK.ORG for excellent info
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Fatigue: Graded Exercise Therapy
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• Many people try to do too much too fast: “Start low, go slow”• Stabilize your daily routine• Start easy, e.g., muscle stretches or relaxation exercises• Select an activity/exercise you enjoy and will do consistently
o Set a baseline that you can do 5d/wk, even on bad dayso Rest after exercise, sitting, not lying down, <30 minutes
• Increase time gradually – no more than 20%/wk• Increase intensity once you can do 30 min/day• Plan for setbacks• Source: “Graded Exercise Therapy: A self-help guide for
those with chronic fatigue syndrome/myalgicencephalomyelitis.”
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Incontinence• Education about voiding, fluid management,
urge inhibition, nocturia control• Pelvic floor muscle retraining, including
biofeedback
• Manual therapy to low back/pelvis/hip• TENS protocol for incontinence
(Neville, 2016)
• May need an women’s/men’s health specialist
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Vaginal Pain• Education about self-management• Pelvic floor muscle retraining, including
biofeedback• Electrical stimulation
• Dilators(Morin, 2017)
• May need a women’s health specialist
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Complaints PT may be able to address• Pain: localized or widespread, including headaches• Joint instability, subluxations or dislocations• Functional limitations: gross or fine motor• Developmental delay and clumsiness• Fatigue, sleep disturbance• Postural Orthostatic Tachycardia Syndrome (POTS)• Incontinence, vaginal or pelvic pain• (Anxiety and depression)• (Gastrointestinal problems, gastroparesis)• (Immune issues)
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Anxiety• Education about EDS/HSD• Assessment for POTS, education about POTS
self-management• Neuromuscular re-education & exerciseo To decrease fear of movement (Kernan, 2007)
o To calm the nervous system• Exercise: stretching muscles, relaxation, aerobico Encourage Tai Chi, qigung, Pilates, (yoga), etc.
• Manual therapy, massage (Pederson, 2018)
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Gastroparesis/Constipation• Education about
gastroparesis in EDS/HSD• Aerobic exercise• Trigger point management
through self-care or manual therapy?
• Abdominal propulsive massage?
Harrington & Haskvitz, Phys Ther. 2006;86:1511-19)
• Visceral mobilization (additional training needed)
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Inflammation• Education about inflammation, neurogenic
inflammation, role of stress• Education about Mast Cell Activation Disorder• Exercise (regular aerobic exercise stimulates
immune function; Abd El-Kader, 2018)• Modalities to decrease localized inflammation
during flares: ice, non-thermal ultrasound, phonophoresis, iontophoresis
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Summary
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• Physical Therapy can address a range of concerns that are common in EDS/HSD
• There are a variety of treatment approacheso Education emphasizing self-managemento Exercise, neuromuscular re-educationo Orthotics/bracing/adaptive equipmento Manual therapyo Modalities
• Exercises must be the correct ones for you, done correctly, in the correct dosage
• Some approaches require specialized training
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Your PT should empower
YOU to manage your
EDS/HSD signs and symptoms
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References
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