the acl: clinical update in conventional and integrative … · clinical update in conventional and...

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The ACL:Clinical Update in Conventional and Integrative Rehabilitation

For Professional Yoga Therapist candidates: This CE corresponds to Module 10, Part 3, Hour 1

Program Matriculation:Recommended Module Progression

• Distance Modules: Prior to taking this

course, complete Modules 1-7.

• Onsite Module: Complete and practice

final sequences in Module 8 and 14.

©2014. Ginger Garner.

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Course Outline – Hour 1

• ACL Injury Epidemiology

• Biomechanics Update

• Prevention Update

• Management Update

• Case Study


Integrated Clinical Guidelines

• Conventional + Integrative Medicine

• WHO ICF

• Medical Therapeutic

Yoga Biopsychosocial Model

© 2014 Ginger Garner.

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Problem:

You have to inform your patient that she has an increased risk for ACL reinjurydue to certain variables which could make it more difficult for her to be an active part of the soccer team…

Think about how you will answer her questions.


Is this very common?

In order to answer her question, you must know:

• The rate of ACL injuries and subsequent ACL reconstructions are on the rise in the US.

• Reported rate variable: US varies from 60,000 to 175,000 (Lyman et al 2009).

• Females suffer 4-6 fold higher risk of ACL injury as compared to males who play the same sport (Barber-Westin et al 2009, Myer et al 2004, Hewett et al 2001, Hewett et al 2007, Arendt and Dick 1995, Malone et al 1993).

• Research trends - Gender specific toward the female athletic population.


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How would reinjury happen?In order to answer her question, you must know:

Common mechanisms of injury include:

Competitive sports.

Running and cutting.

Recreational activities (typically soccer).

Any activity involving.

Sudden stop or deceleration maneuver of the tibia with a

concomitant rotation of cutting motion medially or laterally over a stationary tibia or planted foot (Alentorn-Geli et al 2009).

Landing from jumping or making a lateral pivot while running (Hewett et

al 2001, Hewett et al 2007, Alentorn-Geli et al 2009).

Typically non-contact.

Running and cutting over artificial turf, thick grass, sand, or dry turf can

increase injury potential (Alentorn-Geli 2009).


What others factors contribute to ACL injury?

• Altered neuromuscular control of the hip and knee during dynamic landing and postural stability deficits (Paterno et

al 2010).

• Rates of osteoarthritis after ACLR

are high, with almost 50% of patients developing mild to moderate osteoarthritis six years after surgery (Keays et al 2010).

• Predicting factors for OA include:

• Meniscectomy

• Chondral damage

• Patellar tendon grafting.


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How can you be sure the problem is in my knee?


Patients with ACL injury or complication might experience the following:

• Audible pop

• Feeling of internal popping

• Knee giving way

• Sudden instability or buckling of the knee after a sudden

stop or jump

• Change in direction

• Blow to the knee

• Knee pain

• Knee swelling/hemarthrosis or bleeding in the joint

• Limited ROM

•Johnson et al 2007, Walz et al 2010, Calfee et al 2008, Levin et al 2005, Jobe et al 1994


How can you be sure I am “high risk?”


• Largely gender related (Myer et al 2004).

• Females at higher risk for injury.

• Attributed to high knee abduction moment (KAM) during landing and pivoting movements.

• Important to predict KAM in athletes.


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How can you predict KAM?

• In order to answer her question you must know that risk factors for KAM include:

• Decreased knee flexion ROM

• Increased body mass

• Increased tibia length

• Decreased hamstring strength (compared to quads)

• Muscular fatigue

• Altered neuromuscular control

• Decreased core strength

• Diminished proprioception

(Myer et al 2004, Myer et al 2010, Ford et al. 2003, 2006, Malinzak et al 2001, Hewett et al 2004, 2006b; Chappell et al 2002, McLean et al 2004a, Kernozek et al 2005, Zeller et al 2003, Pappas et al 2007, Boden et al 2000, Uhorchak et al 2003, Hewett et al 2005, Padua et al 2009).


Risk Factors and Characteristics

• Female athletes who demonstrate higher KAM and higher risk for ACL injury also are found to have:

• Decreased hip, trunk, and knee flexion ROM.

• High dynamic knee valgus.

• Increased ankle dorsiflexion.

• Increased hip internal rotation.

• Increased tibial external rotation with or without foot pronation.

• Myer et al 2010, Myer et al 2010b, Alentorn-Geli 2009


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Polling Question #1

Despite identifiable high risk populations, ACL injury has preventable

factors

Crucial Factors Include:

• Identify deficiency(s).

• Prevent meniscus injury.

• Intervene early to avoid chondral damage.

• Consider hamstring tendon grafting if an ACL reconstruction is required.

• Restore quadriceps-to-

hamstring strength ratio/balance.

Additional factors include:

• Genetic predisposition.

• Joint laxity.

• Small and narrow intercondylarnotch width.

• Environmental factors.

• Hormonal influences (i.e. pre-ovulatory phase of menstrual cycle).

Barber-Westin 2009, Alentorn-Geli 2009

Keays et al 2010


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What would happen if I kept playing?

In order to answer her question, you must know that continued use of her knee could result in:

• Articular cartilage damage

• Meniscus damage (usually medial in 70% of injuries – Shea et al 2003)

• Medial collateral ligament damage

• Fracture


Objectives

1. Identify at risk populations for ACL injury through learning 5 objective measures to screen athletes.

2. Describe how predisposing factors increase injury risk in order to identify 5 MTY methods for use in rehabilitation or injury prevention.

3. Summarize indications and contraindications for use of medical yoga in ACL rehabilitation and/or injury prevention.

4. Utilize 5 training methods for use in ACL rehabilitation and/or injury prevention.


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Garner G. Medical Therapeutic Yoga prospectus for publication. Handspring Pub. Ltd. Scotland, UK. 2015

BPS: Self-Management Strategies

Change Stress

Response

Experiential

learning &

practice

Intuitive

Bio-energetic

methodsOR

©2014 Ginger Garner. All rights reserved.

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Integrated Rehab

The MTY Model allows for &/or establishes:• Inter-rater and intra-rater reliability through

standardization of biomechanical alignment of postures/breath.

• Rationale for documented approach.

• Improving patient outcomes and consumer safety.

• Culturally relevant context for postures.

• Educational competencies for yoga used as therapy or medicine.

• Lesson plans for wellness (prevention) programs and pathophysiology.

• Therapists to supervise and design medical therapeutic yoga programs for integrative medicine facilities.

• Stabilization (and safety) rather than mobilization (proximal to distal) i.e. Spine then extremities, Shoulder then elbow.

PYTS graduate, international lecturer, and Canadian physio, Shelly Prosko PT, PYT

A&P

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Stages of Injury

Acute

• Inability to walk after the injury

• Inability to work without significant pain or giving way.

Chronic

• Instability of the knee due to ACL deficiency

• Knee pain

• Giving way

• Edema


Indications for ACL Injury Risk Reduction

Training which can reduce ACL injury risk should include:

• Neuromuscular retraining for control and position during sport and exercise.

• Lowering center of gravity.

• Pre-position the body and lower extremity prior to initial ground contact.

• Developing appropriate muscular strength and proprioceptive motor

control.

• Develop multi-component programs.

Barber-Westin 2009, Alentorn-Geli 2009a

© 2012 Ginger Garner. Living Well, Inc. excerpt from PYT Texts ©2001-2012. All rights reserved.

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NM & Pain Mng. Indications

• Addressing all points of BPS model

• Dynamic balance and strength

• Plyometrics (advanced) in yoga postures

• Specific core and trunk control work (Alentorn-Geli 2009b)

• Proprioceptive activities combined with decision-making

• Dynamic neuromuscular training during postural performance (Myer et al

2004)

• Joint stabilization requisites (Modules 1-

7/PYT Volume 1 text)


Yoga Posture Rx

• Balance agonist/antagonist

• Stabilization of the knee joint through targeting balance in

the quadriceps femoris.

• Standing poses – i.e. warrior

series, tree, mountain, triangle

series

• Seated poses - i.e. staff, head to

knee, sage

• Squatting poses – i.e. chair, wall assisted poses


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Contraindications

• Absence of low level force loads for training dynamic stability in the knee joint.

• Performing asana quickly in absence of proper NM patterning and movement strategy.

• Returning to activity before adequate

healing and strengthening.

• Premature weightbearing before physician has released patient (after repair of medial meniscus, for example).

• Yoga postures (e.g.)

• Not addressing entire pentagon of wellness.


Polling Question #2

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Biopsychosocial Model:A Pentagon of Wellness

PHYSICAL

Anti-Inflammatory Lifestyle

Role of Nutrition & Exercise

Focus on Stability

ENERGETIC

Breath; Gut-Brain-Body Axis

PSYCHO-EMOTIONAL-SOCIAL

Meditation; Mindful Living

INTELLECTUAL

Patient Education

SPRITIUAL

Mind/body Homeostasis

Introspective Analysis

Empowering patients to take responsibility for their health depends on focused, biopsychosocial assessment.


WHO ICF ModelCase Study

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.

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Case Study: Warm-Up

Female University Level Soccer Athlete

• Warm-Up (@5:30 AM – 7:30 AM)

• Rope Jumping or bike ride to facility.

• Dynamic Neuromuscular Stabilization and Proprioception

• Slow, metered LE AROM.

• PNF Patterns

• Box Training (see figure 4.2 grid) (cont. next slide)

Figure 4.2 Plyometric Box Markings


Case Study: Stability & Plyometrics

• Medial/Lateral Stability Exercises

• Block hops graduating to cone hops (graduated heights and increased duration).

• Yoga postures and transitions from postures.

• Lower Extremity Plyometrics with and without decision making

• Box Training

• Graduated box heights from 2 inches to 8 inches demarcated with T pattern in figure 4.2.


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Case Study: Core, Balance, Flexibility, & Constitution

• Core and Trunk Control Exercises

• Supine yoga postures

• Balance Training

• Static and Dynamic Standing Postures

• Flexibility

• PNF Lower Extremity (LE) patterns integrated with yoga postures

• Lower quarter/LE yoga postures

• Emphasis was given to athlete’s constitution (type A or pitta) psycho-emotional status during each session. Some recommendations:

• Cross-training with pet (for stress relief)

• Deep abdominal breathing

• Mental imagery for academic and improved sport performance


Changing the Stress Response


Ewen 2006

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Other Program Considerations

Restoratives

• Restful postures

• Improve joint and/or psycho-emotional or physical flexibility

• Combined with breath techniques and/or hand

postures for increased efficacy

• Passive, supported positions

• Includes meditation , guided relaxation, or yoga nidra (yogic

sleep)

Program Impact

Results

• No recurrence of reinjury over next 24

months

• No recurrence of patellar tendonitis or related pain

• Demonstrated improved strength, flexibility, proprioceptive awareness, and field performance

• The athlete received the MVP award that year


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The Foot & Ankle:Clinical Update in Conventional and Integrative Rehabilitation

For Professional Yoga Therapist candidates: This CE corresponds to Module 10, Part 3, Hour 2

Course Outline – Hour 2

• Injury Epidemiology

• Biomechanics Update

• Prevention Update

• Management Update

• Case Study


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You have to inform your patient, a triathlete, that

she won’t be able to compete in the upcoming

races this season because she has developed……

• Think about how you will answer her questions

Problem

Are AT injuries common?


• Achilles tendon disorders are one of the most

common overuse injuries reported in literature

(Clement et al 1984, Kvist 1991, Maffulli et al

2003, Magnussen et al 2009).

• Achilles tendinopathy is replacing its previous term, Achilles tendonitis

• Secondary to finding use of the term tendonitis or tendinosis may be misleading

• Secondary to the frequent lack of

inflammation found in studies (Astrom and Rausing 1995, Maffulli et al 2004, Movin et al 1997)


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Are AT problems serious?

The injured Achilles tendon suffers from* (2):

Tendinosis is:

Non-inflammatory?

Fatty tissue infiltrate, graying, & softening of the tendon which leads to:** (3)

• Osteophyte formation on the calcaneus plus***

• Morphologic changes (4)

• Biomechanical changes**** (2)

• *Sorosky et al 2004, Kader et al 2002; **Khan et al 1999; Dressler et al 2002, Ippolito et al 1980, Amiel et al 1991, Buckwalter et al 1993, Kannus and Jozsa 1991; Woo et al 1991, Kannus and Jozsa 1991


Are foot problems common?

In order to answer his/her question you must know: • Most common cause of heel pain

seen in outpatient clinics is plantar fasciitis (Singh et al 1997).

• Most prevalent among active working adults aged 25-65 years old (Crawford et al 2000, Riddle and Schappert2004).• Studies differ on which gender experiences PF most often.

• Over-pronation probably causes a maximum of about 10% of all running injuries (Walther et al. 1989; Nigg2001).• Specific anatomical abnormalities are not predictably related to specific running injuries (Wen et al. 1997; Razeghi and Batt 2000; Nigg 2001).


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What is typically the problem in the foot?

Plantar Fasciitis/Fasciosis(PF)

• Fasciitis evolution toward plantar fasciosis(PF)

• Factors

• Age-related histopathologicalfindings

• Degenerative vs. Inflammatory

Lemont et al 2003


Is microtrauma serious?The Repetitive Stress Continuum and how it impacts the foot

Microtrauma (caused by repetitive or prolonged weightbearing activities) contributes to

inhibition of the normal repair process which causes

collagen degeneration and subsequent structural changes such as

thickening of the heel pad and perifascialedema Amis et al 1988, Rome et al 2002, Narvaez and Narvaez 2000, Wearing et al 2004

The thickening is associated with loss of shock absorption, pain and plastic deformation of the heel pad Lemont et al 2003, Crawford et al 2000


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Polling Question #3

Levels of TendinopathyPathology

Classification systems of tendinopathy developed by Nirschl et al. (2003).

• Pathologic stages:

• Stage I: temporary irritation (chemical inflammation?)

• Stage II: permanent tendinosis - less than 50% tendon cross-section

• Stage III: permanent tendinosis - greater than 50% tendon cross-

section

• Stage IV: partial or total rupture of tendon


Current opinions on tendinopathy

Kaux Jean-Francois, Le Goff Caroline, Forthomme Benedicte, Crielaard Jean-Michel, Croisier Jean-Louis The Journal of Sports Science and Medicine

2 () 2011, 01 июня 2011

http://bmsi.ru/authors/2f20c5d5-18ef-4cd3-9a5f-0440278c0035

http://bmsi.ru/authors/a344089f-e282-49a3-bb36-422b20db87d2

http://bmsi.ru/authors/d5aa15c0-f0e1-44b2-ba20-9e0413913155

http://bmsi.ru/authors/db4c9dc9-4f78-4c57-9dfc-a232192119e7

http://bmsi.ru/source/b11e0998-756e-44e0-ac7c-41c923e2006e

http://bmsi.ru/issue/f5609168-fb66-4563-a0a2-f3e71b34a738

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Pain Stages


Kaux Jean-Francois, Le Goff Caroline, Forthomme Benedicte, Crielaard Jean-Michel, Croisier

Jean-Louis The Journal of Sports Science and Medicine2 () 2011, 01 июня 2011

Phases of pain:

• Phase I: mild pain after exercise activity, <24 hours

• Phase II: pain after exercise activity, >48 hours, resolves with warm-

• Phase III: pain with exercise activity, does not alter activity

• Phase IV: pain with exercise activity that alters activity

• Phase V: pain caused by heavy activities of daily living

• Phase VI: intermittent pain at rest that does not disturb sleep; pain caused by light activities of daily living

• Phase VII: constant rest pain and pain that disturb sleep


Tendinopathy Morphology

Source: http://bmsi.ru/doc/c3c00ec9-

45b4-4f64-8b58-5feaa368ef6a©2014. Ginger Garner.







http://bmsi.ru/doc/c3c00ec9-45b4-4f64-8b58-5feaa368ef6a

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Polling Question #4

How can you be sure the problem is my foot/ankle

Ankle or foot pain S&S can include:

• Pain with periods of inactivity followed by immediate weight bearing.

• AM pain (Crawford et al 2000, Riddle and Schappert 2004).

• Audible or internal feeling of popping or tearing with first step(s) in AM or after period of inactivity

• Stiffness in AM, before, during, or after activity

• Pain localized to the heel or radiating through entire foot involving &/or

• Achilles tendon

• Gastrocnemius complex

• Pain going barefoot, wearing dress shoes or other shoes without support

• Loss of functional mobility in ankle

• Edema©2014. Ginger Garner.

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How did my AT injury happen?

• Risk factors/acquired general factors for AT pain include:

• Over age 35*

• An abnormally or poorly positioned bone or joint that stresses soft tissue

• Repetitive stress over uneven terrain or poorenvironment

• Infection

• Poor shoe wear; impingement

• Fault sport or activity mechanics; excessive/repetitive loading

• Other comorbidities – high CRP level, nutritional status, obesity

•*Fahlstrom et al 2002, Krolo et al 2007, Dressler et al 2002, Ippolito et al 1980, Amiel et al 1991, Buckwalter et al 1993, Kannus and Jozsa 1991



Kaux Jean-Francois, Le Goff Caroline, Forthomme Benedicte, Crielaard Jean-Michel, Croisier

Jean-Louis The Journal of Sports Science and Medicine2 () 2011, 01 июня 2011

How did my foot injury happen?

Risk factors have been attributed to:

Lower quarter mal-alignment

• Excessive pronation in the foot?

• Limited ankle dorsiflexion?

• Underlying muscle weakness or

inflexibility?

• PFPS or ITBS

• Obesity

• Age

• Kinesiophobia (Lentz et al 2010; Kangas et al 2011)

• Occupational hazards

• Prolonged weightbearing

• Inappropriate shoe wear

• Rapid increases in activity level

©2014. Ginger Garner. Kangas et al 2011, Werner et al 2010, Singh et al 1997, Irving et al 2007, Riddle et al 2003, Frey and Zamora 2007, Hill and Cutting 1989, Rano et al 2001, Amis et al 1988







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Polling Question #5

Despite identifiable high risk populations, At

issues are considerably preventable. AT

problems can fall into two broad categories:

1. Intrinsic Risk Factors

2. Extrinsic Risk Factors

Activities related to AT injury include*:

• Walking & running• Cross-country

• Track and Field

• Cycling

• Construction work

*Mazzone and McCue 2002


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Injury Prevention

Intrinsic Factors• Abnormal ROM• Ankle dorsiflexion• Subtalar joint ROM• Decreased ankle plantar

flexion strength• Compensatory LQ anomalies (6)• Abnormal tendon structue• Comorbidigies

• Obesity• Hypertension• Hyperlipidemia• Diabetes• Personal factors (WHO)

Carcia et al 2010

Extrinsic Factors• Training errors• Environmental factors (WHO)• Fatigue• Surface condition where activity takes place• Faulty equipment

In order to prevent Achilles tendon injury it is critical that you identify:

What would happen if I kept playing?

• Chronic Plantar Fasciosis/degeneration

• Tendinopathy (tendonitis

and –osis)

• Paratendonitis

• Retrocalcaneobursitis

• Rupture


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Objectives

UnderstandExplainEvaluateIdentifyApply

Upon completion of this webinar, you will help patients reduce, manage, and prevent future Achilles tendon injury by doing the following:

1. Describe the morphologic, bony, and biomechanical changes of the Achilles tendon and plantar fascia to identify phases on pain and injury.

2. List the 2 categories of predisposing risk factors for Achilles tendinosis in order to understand 12 factors for injury prevention.

3. Discuss current evidence based conventional therapeutic methods for foot and ankle injury and how clinical efficacy can be enhanced through integrated care

4. Critically analyze a case study format using MTY methodology from acute to chronic phases of AT and foot management

5. Summarize guidelines, indications, modifications, and contraindications for integrated management of the foot and ankle.

6. Discuss the relationship between age, histological analysis, and risk factors for foot injury in order to more effectively manage the most common cause of heel pain.


Anatomy of the Achilles Tendon

Achilles Tendon Anatomy includes:

• Gastroc-soleus complex

• Achilles Tendon

• Bursa

• Achilles tendon insertion


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Anatomy & Physiology-Pronation


Anatomy & Physiology - Supination


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Windlass

Mechanism

PF is like – windlass

mechanism

• “Crank”

Gait Assessment

• Phases of Gait Cycle

• Stance phase – 62%

• Look at weight loading – heel contact to termination of contralateral stance phase (12%)

• Single leg stance (38%)

• Weight unloading (12%)

• Swing Phase – initial, mid-swing, terminal

• Toe-off

• Spatial foot-floor contact variables

• Temporal foot-floor contact variables (stance and swing phasees)

• Obligatory motion

• Compensation for lack of dorsiflexion


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Prerequisites for Intervention: Directional-Based Impairment

Kangas et al 2011; ©2014. Ginger Garner.

Functional Analysis Using Yoga


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Biopsychosocial Model:A Pentagon of Wellness

PHYSICAL

Anti-Inflammatory Lifestyle

Role of Nutrition & Exercise

Focus on Stability

ENERGETIC

Breath; Gut-Brain-Body Axis

PSYCHO-EMOTIONAL-SOCIAL

Meditation; Mindful Living

INTELLECTUAL

Patient Education

SPRITIUAL

Mind/body Homeostasis

Introspective Analysis

Empowering patients to take responsibility for their health depends on focused, biopsychosocial assessment.


Acute Phase Injury Management

Acute Phase

• RICE

• Gentle lengthening of AT in dorsiflexion/Maintenance of flexibility

• Restoratives

• Breathwork

• Orthotics or heel lift

• Night splints?

• Iontophoresis with dexamethasone

• Low level laser therapy

• Manual therapy


Alfredson et al 1998, Falhstrom et al 2003, Knobloch et al 2007, Mafi et al 2001, Ohberg et al

2004, Roos et al 2004, Shalabi et al 2004

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Subacute Phase

Subacute Phase

• Correction of LQ functional impairments

• Eccentric loading strengthening during yoga posture prescription

• Decreases pain

• Improves function

• Decreases tendon thickness

• Increases strength

• Proprioceptive training

• Taping Alfredson et al 1998, Falhstrom et al 2003, Knobloch et al 2007, Mafi et al 2001, Ohberg et al

2004, Roos et al 2004, Shalabi et al 2004


Extra Tools

Manual Therapies

• Marma massage points

• Gulpha (AT)

• Kurchcha shirah (med./lat. Malleolus)

• Self stretch of toes, plantar fascia

• http://www.gingergarner.com/?s=marma+point+massage

• Trigger point needing/IMT/Dry needling

Regional Interdependence issues


http://www.gingergarner.com/?s=marma+point+massage

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Regional Interdependence

Using the following postures, you can globally evaluate and source underlying problems which contribute to foot pain and dysfunction:

Lower quarter screen in yoga postures

• Unilateral Stance (mountain)

• Bilateral Stance (tree)

• Walking (mtn.)

• Alternate weight bearing position

(Downward facing dog prep)

Assess related joints and neuromuscular function

• PFPS

• ITBS©2014. Ginger Garner.


Shoe Engineering

Melvyn P. Cheskin/Fairchild PublicationsFigure 3: The results of extensive testing yielded these requirements

for running shoes.

• “Rocker” test• “Pencil” test

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Guidelines

Safe Prescription of Postures depends on:

1. Introducing planar movements one degree of freedom at a time while correcting lower quarter malalignment

2. Teaching Downdog prep. (pre-posture) beforedownward facing dog or any standing posture

3. Slow performance speed

4. Motor control & awareness in lower quarter

5. Address MFR or NV involvement

6. TATD breath©2014. Ginger Garner.

Contraindications

A patient is unable to perform pre-asana/postures with safety and self-correction because of the following:

• Lack of motor control and awareness

• Performing asana quickly and without proper biomechanical alignment.

• Not introducing low level force loads for dynamic stability during asana

• Returning to activity before adequate healing and strengthening

AVOID Yoga postures that:

•Involve heel raises or stress the GS complex in the acute phase such as:

• Crescent pose

• Warrior I

• Bounding transitions

• Weight bearing postures which put the AT under a loaded stretch


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WHO ICF Model/BPSCase Study

World Health Organization (WHO) (2002). International Classification of Functioning, Disability and Health. Geneva, Switzerland.

Graduated Acute Program (0-6 wk)

Deep Abdominal Breathing; Shoulder Lock; TATD Breath

• Rest progressing to active rest

• Spinal Neutral/Postural alignment

• Dynamic Neuromuscular Re-education in postures

• Flexibility surrounding musculature in NWB and WB

• Stress management

• Pain management/Breathwork

• Centering

• Seated Meditation


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Acute ProgressionNWB Sequence Supported staff; Legs up wall, Reclined hand to big toe

Sub-Acute Program• WB Sequence: Mountain, Tree, Downward Dog Prep, Transitional lunge, DD for

gastroc and soleus with modifications


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Sub-Acute Progression• Top left to right: Modified FSB, Modified Warrior I

• Bottom left to right: Chair to standing Warrior II


Advanced Sub-Acute Progression

Left to right: Supported squat with blankets; Chair; Hand to big toe modified; Eag

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Program Impact

Post-Test Results/8-12 week follow up

• Post-test AROM – full, pain-free dorsiflexion

• PAS 0/10 with full activity

• MMT – 5/5, painfree

• Able to return to full ADL’s and activity without pain

• Golf game objectively improved by several strokes


Now it’s your turn….


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Want More?Applying yoga in rehab:

• Promotes complete

healing through caring

patient connection

• Expand programming,

cash & insurance

based; grow referral

base

• Prevent practitioner

burnout


ResourcesShifting your practice paradigm touse yoga as medicine:

• Learning Lab for this module –Module 8 & 14 –www.professionalyogatherapy.org

• Self-Massage for Lower Quarter, including foot: http://gingergarner.com/Marma%20Massage%20Lower%20body.pdf

• Lower Extremity Review. Read Biomechanical Precepts Define 21st Century Yoga. LEW March 2011 Vol. 3/No. 3. http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga


http://www.professionalyogatherapy.org/

http://gingergarner.com/Marma Massage Lower body.pdf

http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga

http://www.lowerextremityreview.com/article/biomechanical-precepts-define-21st-century-yoga

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