The Marfan Foundation 33 rd Annual Conference; Atlanta, GA.; The Marriott Buckhead August 4, 2017

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1 The Marfan Foundation 33 rd Annual Conference; Atlanta, GA.; The Marriott Buckhead August 4, 2017 By: Dr. Michael P. Healy, PT, DPT, DOMTP, IOMT, CPT, CSN, GFI, MBA

2 A Manual Physical Therapy & Therapeutic Exercise Approach: to Marfan Syndrome Ehlers-Danlos Syndrome

3 Michael P. Healy, PT, DPT, DOMTP, IOMT, CPT, CSN, TPI Certified (GFI), MBA: Owner, President and CEO of Healy Physical Therapy & Sports Medicine, Inc. 31 years of practicing manual physical therapy. Trained by world renowned Osteopaths and Physical Therapists. Two Office Locations: 927B Warren, Avenue, East Providence, RI (401) and fax (401) Diamond Hill Road, Cumberland, RI (401) and fax (401)

4 Education (CV): BS in Physical Therapy UNE 1986 MBA Bryant University 1997 CPT and CSN 2003 TPI Certified Golf Fitness Instructor (GFI) 2007 DOMTP Osteopathic College of Ontario 2008 DPT Simmons College 2012 Integrated Osteopathic Manual Therapist Certification

5 Disclosure and Disclaimer I have nothing to disclose. I have no actual or potential conflict of interest in relation to this presentation. Discussions in this presentation are for general information purposes only. 5

6 Pictures of Patients in this Presentation 6

Understand why the combination of manual therapy and therapeutic exercise lead

7 Goals of this presentation Understand why proper posture and body mechanics are important in positive patient outcomes. Understand why the combination of manual therapy and therapeutic exercise lead to better patient outcomes vs therapeutic exercise or manual therapy alone. What should you look for in a Physical Therapist?

Connective Tissue Disorders Collagen is the most abundant protein in the human body Collagen provides the structural strength of human tissues It is the

8 Connective Tissue Disorders Collagen is the most abundant protein in the human body Collagen provides the structural strength of human tissues It is the glue that wholes us together When muscles, ligaments, organs and bones are built with defective collagen it will cause systemic weakness and instability.

9 What Does Marfan & Ehlers-Danlos Syndromes Affect? 1,2 Heart Blood Vessels Bones Spine Eyes Ligaments Muscles Joints Lungs Skin Nervous System Stomach GI System

contract Muscles On tension Attempting to co-stabilize

10 Muscle and Ligament Functions Typical/Normal EDS/Hypermobility/Marfan Muscles Off tension Actively contract Muscles On tension Attempting to co-stabilize Ligaments On tension Support stabilize Ligaments Off tension No stability 10

11 Goal of Manual Therapy To restore maximal pain-free movement of the musculoskeletal system in a postural balance

12 EDS/Marfan/Hypermobility: Results Muscles On tension = pain, muscle tightness, spasms, trigger points and weakness. Ligaments Off tension = joint pain, instability, subluxations and/or dislocations. 12

13 Manual Physical Therapy GOAL Reverse the process muscles off tension ligaments on tension Once structures are balanced Therapeutic strengthening, stabilization, toning, cardiovascular and proprioceptive exercises begin. Specific stretches for muscle tightness, muscle spasms and trigger points begin once spinal segment or joint are stabilized. 13

14 Analogy Typical House EDS House This slide is used with permission of Patricia Meegan

17 Good Posture vs. Bad Posture

18 Cane & Weight Demonstration 18

19 Poor Sitting Posture

20 Postural Re-Education Exercise Do not perform with patients with shoulder instability

26 Corrected Sitting Posture

27 Poor Computer Posture

29 29

30 Seated Postural Self Correction Exercise

31 Corrected Seated Computer Posture

32 Computer Postures Poor Sitting Posture Correct Sitting Posture

33 33

34 Review of literature Patient doing nothing Therapeutic exercise alone Manual therapy alone Combination of manual therapy and therapeutic exercise

35 Physical Therapy Deficits Joint laxity and instability Muscle weakness from underuse Muscle weakness from muscle spasms Lack of proprioceptive Input Poor cardiovascular endurance Poor muscle endurance

36 The Best Treatment Program Should Consist of Manual therapy Therapeutic core stabilization exercises Therapeutic joint stabilization exercises Proprioception exercises Cardiovascular exercises Muscular endurance exercises

37 Structural Manual Therapy Muscle Energy Technique (MET) Myofascial Release (MFR) Jones Strain/Counterstrain (JSCS) Cranial Therapy Craniosacral Therapy (CST) Visceral Manipulation/Mobilization (VM) Manual Lymph Drainage

38 Manual Physical Therapy or Osteopathic Treatment Session 38

39 MFR to Rib Cage and Thoracic Paraspinals

41 MFR to the Pelvic Floor

43 SIJ Decompression

45 Thoracic Inlet Release

47 Hyoid Release

49 Suboccipital Release

51 Classic Claw Grip - Frontal Release

53 Frontal Release

55 Parietal Release

57 Sphenoid Release

59 Frontal Nasal Suture Release

60 End CST with CV4

61 MET for O/A

62 Alternate MET and Self Correction for O/A Dysfunction: SRRL

63 MET for FRSL L-5

65 MET for Upslip

67 MET for Left on Left Sacral Torsion

69 Postural Comparison Pre Treatment Post Treatment

70 Comparison Pre Treatment Post Treatment

73 Comparison Pre Treatment Post Treatment

76 Therapeutic Exercises:

100

101

102

103

104

105

106 Cervical Isometrics with Rigid Cervical Brace

107 Frontal View Cervical Isometric with Rigid Cervical Brace

108 Cervical Isometric with Eye Motion

109 Cervical Isometrics without Rigid Cervical Brace

110 Core Stabilization Exercises Bridging Initial visits After treatment progressions

111 Straight Leg Raise Initial visits After treatment progressions

112 Shoulder Stabilization Exercises ABD. to 90 degrees without weights ABD. to 90 degrees with 1lbs. Weight

113 Biceps Curls

114 Theratube Scapular Stabilization Exercises Lat. Pull Downs Lower Traps.

115 Physio-Ball Modified Sit Up

116 High Level Balancing & Proprioceptive Exercises

117 BOSU Mini Squats

118 BOSU Single Leg Stance with Hip Flexion to 90 Degrees

119 Cardiovascular/Muscle Endurance Recumbent Bike Stationary Bike

120 Self Corrections 1 st Rib Sacroiliac Joint

121 Finding the Right Physical Therapist (PT) PT with a working knowledge of Marfan, EDS, CCI, CM and/or Connective Tissue Disorders or he/she is willing to learn more about them. PT willing to work with you and your team of medical care providers. PT with good manual therapy skills combined with a good working knowledge of therapeutic exercise and appropriate progression with individuals with connective tissue disorders or willing to learn.

122 Finding the Right PT Continued PT needs to work one-on-one with their patient in a hands on approach. PT must understand that your progression in rehab is going to be slower and different than their typical patient population. You need to find a PT Clinic that will treat you in a private quiet treatment room especially during manual therapy sessions and not out in open noisy gym.

123 NO CERVICAL MANIPULATIONS.. Could Cause: TIA CVA Dissection Horner s Syndrome Paralysis Quadriplegia DEATH

124 References: 1. The National Marfan Foundation, A Guide To Marfan Syndrome and Related Disorders, elines.

GOLF EXERCISE PROGRAMME

GOLF EXERCISE PROGRAMME WEEK 1 PHASE 1 SESSION 1 Golf Subjective Assessment form to be completed. Initial Assessment as per the Golf Gapscreen. Exercise Programe - Core stability exercises, TVA and Multifidus