Presentation on theme: "Tara Jo Manal, PT, MPT, OCS, SCS University of Delaware"— Presentation transcript:
1 Non-Operative Management of Lumbar Stress Fractures in Dancers and Figure Skaters Tara Jo Manal, PT, MPT, OCS, SCSUniversity of DelawareDepartment of Physical TherapyGood afternoon. My name is Airelle Hunter. I am a physical therapist at the university of Delaware and I am here today to discuss…
2 PurposeTo discuss alternative ways of successful non-operative management of figure skaters and dancers with stress fracturesMy purpose is to
3 Clinical InstabilityLoss of the ability of the spine under physiologic loads to maintain its pattern of displacement so that there is no initial or additional neurological deficit, no major deformity, and no incapacitating painWhite and Panjabi
4 Clinical Instability Anatomic Considerations Biomechanical Factors Clinical ConsiderationsTreatment ConsiderationsRecommended Evaluation systemRecommenced managementRecorded cases of patient post-polio with cervical paralysis and no instability if bones and ligaments remain intact
5 Stabilization of the Spine Passive systemActive systemNeural control
15 Spondylolithesis Grading Grade 1: 25% Grade 2: 25% to 49% Grade 3: 50% to 74% Grade 4: 75% to 99% Grade 5: 100%*
16 Spondylolisthesis 5 Types Dysplastic- Congenital abnormalities of arch of L5Rare and likely to progressMore often with neurologic compromiseSurgery- Laminectomy and fusion
17 Spondylolisthesis Isthmic- Pars interarticularis Most common in children and adolescentsLytic type- fatigue fractures of pars (stress fracture, has familial link)Elongated intact parsAcute fracturePain, tight hamstrings and neurologic changes are due to spinal instability
18 Spondylolisthesis Isthmic-Treatment Observation Stress Reaction Low incidence of progressionGrade 2 or less- non-op managementProgressive neurologic deficit may need surgeryGrade 3- 8% relief non opStress ReactionBrace or immobilize for symptom controlUntil symptoms resolve
19 Spondylolisthesis Degenerative- Long standing instability Most common cause of adult spondyloTraumatic- Other Fracture (ie articular process)Pathologic Type- Bone disease
20 Treatment Typically nonoperative (esp. children) Rest from aggravating symptomsImmobilizationSurgicalFailure of conservative managementProgression of the subluxationSpondylo >50% in skeletally immatureCan see continued slip after posterior lateral fusion
21 Old Spondylolysis Can create pseudo joint and fill with scar tissue Can be going through active fracture/repair and active fracture again
22 Active System- Muscular Control of the Spine Extensors – MultifidiSpan only a few jointsProduce extensor torque/resistanceOnly small amounts of rotation or SBContribute to correction or support
23 Muscular Control of the Spine Abdominal MusclesRectusMajor trunk flexorActive with sit-up and curl-upsLittle to no evidence to support upper/lower differentiation
24 Muscular Control of the Spine Abdominal Wall- Ext/Int ObliqueTorso Rotation and Lateral flexion
25 Muscular Control of the Spine Abdominal Wall-Transverse abdominisBeltlike support and generation of intra-abdominal pressureDelayed onset during ballistic movements in patient’s with LBP
26 Muscular Control of the Spine PsoasPrimarily hip flexorCompressive force to spine during contractionQuestionable contribution to spine stabilityIf so, under high hip flexor forces
27 Muscular Control of the Spine Quadratus LumborumHighly involved with spine stabilizationActive in flexion, extension and SBDuring Lifting, increased oblique activity followed increases in QL
28 Muscular Control of the Spine Deep Rotators-Function primarily as force transducersPosition SensorsElectrically silent with large rotations (involving Abs)Extensor GroupGenerate large extensor momentsGenerate posterior shearAffect one or two segments
29 Co-activation of the Muscular Spine 90N force (20lbs) creates buckling without muscular forcesCo-contraction increases support against buckling
30 Muscular Stability Continuous contraction ~10% MVIC of abdominals No single muscle is critical one
31 Lumbar Extensor Musculature Erector spinae musculature are responsible for extensor forceMultifidus muscles are segmental extensors responsible for stabilization of lumbar motion segmentsFritz et al 2000We all know that the erector spinae musculature are the largest contributors to extensor force in the lumbar spine and Fritz et all in 2000 showed that the multifidus muscles help with the segmental extension that is responsible for stabilization of the lumbar motion segments.
32 Muscle Strength and Low Back Pain In firefighters, muscle strength of the low back was a good indicator for the development of low back painCady et al 1979In manual material workers there was a positive correlation between strength and frequency of low back painChaffin 1974This leads into similar findings by Cady et al in 1979 and Chaffin in 1974 which showed that lack of muscle strength in the low back had correlation with low back pain.
33 Performing Arts and Low Back Pain Lumbar extensor strength is needed to achieve many positions and to successfully land jumps and leapsAs we start to discuss performing artists such as figure skaters and dancers, we realize that lumbar extensor strength is greatly needed to achieve many positions and to successfully complete the high level of jumps and leaps that they need to land as well as to sustain the many postures it takes to be competitive.
34 Case #1 13 y/o female dancer Low back pain for 4 weeks that came on with an ArabesquePain onset: whenever dancing especially with extension activitiesNo pain at restX-rays: noneWE are going to discuss two cases today with the first one being that of a young 13 year old female dancer who dances in point, ballet, and modern dance. She came to see us last year, complaining of low back pain with extension activities that came on with an arabesque scale about 4 weeks previous to her initial evaluation. At this time she was not resting and was continuing to dance at 100% due to numerous upcoming shows and recitals.
35 Case #1 Evaluation (-) SI testing Cibulka et alForward Flexion: ↑’d pain thru mid range↓’d Right Sidebending vs. Left↓’d Left Rotation vs. RightRight Max Closing: (+) Pain on the RightRight L5-S1: Hypomobile and PainfulOn initial evaluation: Read slideSo at this time her pain and symptoms were pointing towards a closing restriction on the right.
36 Case #1 Evaluation Palpation: (+) muscle spasm and pain Right Paraspinals L2-L5Right QuadratusAlso has hip pain and right lateral thigh and buttock pain with prolonged dancing(-) SLRShe also showed significant muscle spasms in her right paraspinals and quadratus. Not only was back pain one of her symptoms but she also complained of hip, lateral thigh and buttock pain that came on with prolonged dancing. Her straight leg test for any neural tension signs was negative.
37 Case #1 Early TreatmentManipulation: Left Rotation in Sidelying: ↓’d pain at L5/S1 with Right Max ClosingGrade II/III Mobilizations to L5-S1TENS to Right L5/S1She was treated on the first day for the right closing restriction. A manipulation was performed in right side lying with left rotation which produced an audible pop. Retesting in right max closing was much less painful at the L5/S1 area. Grade II and III mobilizations were also performed to try and decrease pain and inflammation as well as TENS and ice were applied after treatment.
38 Case #1: Treatment #2 60% improvement 1 week later No ROM restriction pattern notedGrade II/III joint mobilizations and Soft Tissue Techniques to Quadratus and ParaspinalsProgress to pain free activity onlyAt treatment 2 which was one week after her initial evaluation, she felt 60% improved and showed no signs of a ROM restriction. Treatment at this time consisted of the same Grade II/III mobilizations and continued soft tissue techniques to the spasming areas. She was allowed at this time to return to activity as long as it was pain free. She had kept all of her ROM gained in her previous treatment and just now needed to be calmed down since most likely the arabesque and repeated extension caused a dysfunction in her facet joint. At this point we’re seeing immediate responses, she is still dancing, we think we’re golden.
39 Case #1: Treatment #3 1 week and 3 days from Evaluation Danced full out the night before: Pain 4x worse and as bad as the IENo ROM Restriction Pattern notedGrade II/III joint Mobilizations for Pain and Soft Tissue Techniques and given TENS unitHer third treatment was one week and 3 days after her initial evaluation. She danced full out the night before and came to the clinic reporting 4x more pain than at her previous visit and thought she had regressed back to the same pain as at her initial evaluation. Upon reassessment of her lumbar spine, she was still without ROM restrictions. Treatment was the same as the previous visit being predominately pain control and she was given a Home Tens unit for pain relief.
40 3 Weeks after IE Some improvement noted over the next 3 Treatments By the 7th treatment, still dancing full out but pain is lasting longer periods of time with night pain and increasing leg symptomsPain also is moving from the right to leftWith variable symptoms including legs concern about current diagnosisSpoke with PCP: Requested Bone Scan but MD ordered X-ray and MRIAfter the irritable third treatment, she did continue to show signs of improvement during the next three visits with soft tissue and joint mobilizations. She was continuing to dance full out but at the 7th treatment which was 3 weeks after the initial evaluation, she was complaining of pain that was longer lasting and waking her up at night. She was also getting leg symptoms and night pain as well as the pain was shifting from the right to the left sides of her back. With such variable symptoms as these, and increasing leg symptoms, we were beginning to think that the original diagnosis was too simplistic. Our next hypothesis with no improvement and no motion restrictions is a stress fracture. We then spoke with her primary care physician about our concerns and asked for a bone scan since this would be the best way to determine acuteness or chronicity if it was a stress fracture. Her PCP refused saying it was too much radiation and ordered a x-ray and MRI.
41 Test Results MRI: (+) for Bilateral Pars Fracture @ L5 Unable to determine if chronic or acute without Bone ScanReferral to Sports Med Spine Specialist: Hold on PTContinue Home TENS UnitCASH Brace: reminder to stay out of extensionHer MRI results were positive for a bilateral pars fracture at L5. When we asked the MD if chronic or acute, she reported chronic but we really didn’t have a bone scan to show us those results. At this time the PCP agreed to send the patient to a sports medicine spine specialist. We held on PT for almost a month while the patient had further testing and follow up by the specialist and she continued to use the TENS unit at home and was given a CASH brace as a reminder to stay out of extension.Spieth & BhattacharjeeMarshfield Clinic, Dep. Of Radiology
42 Test Results Bone Scan: Ordered TLSO Reinstate PT (+) Bilateral L5 Stress Fracture at Pedicle/Post. Arch with Bone Marrow Edema at Pedicle L>R. This is consistent with L5 Spondylolysis BilaterallyOrdered TLSOReinstate PTThe spine specialist ordered a bone scan which revealed a bilateral L5 stress fracture at the pedicle/posterior arch with bone marrow edema at the pedicle on the L>R. This was consistent with a L5 spondylolysis bilaterally. The physician ordered a thoracic lumbar sacral orthosis and reinstated PT. The time frame is now a month and a half after the initial evaluation.
43 Treatment Isometric Abdominal Squeezes in brace Practice Ballet in brace in the open positionIncrease core strengthening3x/week for 6wksWhen she returned to PT, we implemented a treatment program consisting of a progressive core strengthening program that started with abdominal isometrics and progressed through a stabilization program. At this time, she was allowed to practice ballet in her brace in the open position as long as she was pain free. She mostly completed barre work but no pointe.
44 HypothesisNow that patient is in a TLSO brace, strength gains will be slow as well as brace and fracture will make correct exercise performance difficultElectrical stimulation used to assist patient in rapid strengthening and be a successful adjunct to her strengthening programWith the recent changes we now hypothesize that since the patient has been diagnosed with a stress fracture and has been placed in the TLSO brace, core strengthening with correct technique may be difficult. We also thought that implementation of NMES to her lumbar paraspinals would assist with more rapid return of strength in conjunction with a core stabilization program which I believe Lee will talk more about in the next segment.
45 Intervention for Strength Problem:How to increase or prevent loss of strength in the Paraspinals (while immobilized), without increasing stress to the L5 region?Concern: how much force will L5 receive with High Intensity Electrical Stimulation?Consultation with the PhysicianDecision: Let pain be the guideIf her LBP complaint is recreated, discontinue use or decrease intensityWe didn’t think that abdominal exercises while braced would be enough to help keep her strong so that she could return to dancing as soon as she was released so we discussed the need to preventing loss of or gaining strength without increasing stress to the compromised structure. We therefore considered the benefit of electrical stimulation for strengthening.We were concerned about the force that L5 would receive with the high intensity electrical stimulation so we consulted with the physician and we all agreed to let pain be the guide and if her LBP was recreated, we would first turn it down and if no improvement, we would discontinue the treatment for that visit.
46 Electrical Stimulation for Strength Snyder-Mackler et al., 1995Conclusion: For Quadriceps Weakness, High-Level E-stim with Volitional Exercise is more successful than Exercise aloneFitzgerald et. al., 2003In 1995, Dr. Snyder-Mackler et al looked assessing the effectiveness of common regimens of electrical stimulation as an adjunct to ongoing intensive rehabilitation in the early postoperative phase after reconstruction of the anterior cruciate ligamentShe concluded that the use of high intensity NMES combined with volitional exercise is more successful than exercise alone.
47 Electrical Stimulation for LB Strengthening The application of this same type of Electrical Stimulation to the LB may help increase strength and recovery of Low Back Musculature following injuryKahanovitz et al., 1987McQuain et al., 1993Therefore, we believed theoretically that the application…There has been some limited evidence by Kahanovitz and McQuain et al, suggesting that NMES can work in the lumbar spine, however these studies had some limitations. Mainly, the intensity of electrical stimulation was set to the maximal level that was considered comfortably tolerable, and the stimulation units were portable battery powered stimulators that the patients were trained to set for themselves.Once again, our hope was to minimize the morbidity of the immobilizer and be able to get her back on the ice quickly.Therefore, our plan, was to attempt to follow the protocols utilized in the quadriceps literature.
48 Parameters of Electrical Stimulation 2500 HzVariable wave formtriangle, sine, square75 bursts/second2 second ramp12 seconds on time50 second rest time10-15 contractionsOnce we were set to start NMES, we followed the parameters we use for quadriceps strengthening, which are:
49 Patient Positioning: Isometric Prone over pillowsPelvis strapped to the table in Posterior Pelvic TiltAssess movement to active lumbar extension and tighten as necessaryThe patient is positioned prone over 2 pillows with the pelvis strapped isometrically with a belt and the patient is in a posterior pelvic tilt so that once the NMES started, there is no contraction that leads to end ranges of flexion or extension
50 Current IntensityIn quadriceps 50% maximal volitional isometric contractionLook for visible contractionMaximal tolerable contraction by the patientA single channel is placed on the right and left side of the spineWe do not have the ability to assess Maximal Volitional Isometric Contraction and then grade the stimulation to a minimum of 50% as we do in the quads, therefore, we look for a visible and tolerable contraction by the patient which is hopefully tetanic in nature. There is a single channel place of each side of the spine.Around 2.5 months into this treatment progression, the spine specialist ordered a follow up CT scan to assess the healing of the L5 pars fracture.
51 Progression CT scan : low grade spondylolisthesis, chronic stage MD does not expect more slippageAllowed to swim without brace: (~2 months)Allowed to dance while in TLSO with no back or hip extensionSoft brace prescription and allowed to dance into extension: (~3.5 months)Dancing with no brace: (~4.5 months)The CT scan showed a minimal degree of spondylolisthesis of 1-2 mm in the chronic stage of the spectrum of this disease. Her physician at this time was not concerned of more slippage therefore, she was allowed to start swimming brace free and dance more while in the brace but still without hip or back extension. Keeping her braced for 2 months was a conservative measure but the doctor felt it was necessary since CT showed acute marrow edema and she wanted to return to a very advanced level of dancing. At 3.5 months, she was prescribed a soft brace and was allowed to dance into extension. One month later she was cleared to dance at 100%. Although held out of dancing for almost 5 months, she returned to dance at 100% in 1-2 weeks after being released back to sport.
52 Outcome Full dancing in all classes at 6 months No pain with any activityOswestry: 0%Fairbanks, et al, 1980At 6 months, she was discharged from physical therapy and was dancing in all of her classes. Speaking with her now, 10 months after injury, she reports no pain with any activity including any type of dance. Her oswestry is 0% and she even reached her goal of being accepted to the 6 week Boston Ballet summer company program, which she was unable to do the year before because of injury.Photo by: Tessa Develope
53 Case #2 12 year old Figure Skater History of back pain which began after a fall 2 weeks earlierFor 3 months, treatment centered around pain management in order to complete the seasonEnded season as Junior National FinalistRanked in top 10 in the NationIn our second case, we had a figure skater who was referred to our clinic by the Athletic Trainer at The University of Delaware Ice Arena.She was a 12 year old female, who complained of persistent low back pain for 2 weeks after falling on the ice. At this time she was in the midst of her competition season and she was doing incredibly well as you can see, she was ranked in the top 10 in the nation. In conjunction with her physician, it was agreed to manage her pain with anything possible until her season ended in 3months. Not competing, was not an option. Upon completion of the season, the physician would initiate further diagnostic testing.Treatment during this time period included mobilization, manipulation, lumbar stabilization, TENS, ice, and various soft tissue release techniques.
54 Case #2 EvaluationBone Scan positive for stress reaction bilateral pars interarticularis of L5Oswestry - 18%Pain level after Nationals 8-9/102 weeks later 4/10Once her season ended, the physician ordered a MRI and bone scan. The bone scan was positive for a stress reaction at the bilateral pars interarticularis of L5.Upon completion of the dx tests, she returned to our clinic, and was given the Oswestry Low Back Disability Questionnaire which revealed 18% dysfunction with ADL’s.Her pain upon completion of the Nationals Competition was excessive compared to her response after other competitions that season. Her pain significantly decreased by 50% with just 2 weeks of rest, however, she was still at a higher level than she had been for the past 3 months.
55 Case #2 Evaluation Lumbar ROM Hip ER 60° R and 66° L Decreased L Sidebending below L3Decreased R Rotation below L3Extension Apex at L3/L4No Extension below L4Closing Restriction Below L3Hip ER 60° R and 66° LBilateral Hip IR and ER 4/5On physical exam, her ROM during gross screening was normal to excessive in all directions. However, more in-depth assessment demonstrated that all her motion was occurring above L3. She had : read slideWe also decided to look at the movement of joints above and below which showed asymmetrical hip ROM and weak hip internal and external rotation.
56 Case #2- HypothesisThis patient will benefit from intervention aimed at decreasing stress in L5 areaThis will include:Increasing hip ROM and strengthIncreasing joint mobility in low lumbar spineIncreasing strength in paraspinal musculature
57 Case #2 HypothesisMedical Strategy: TLSO brace and rest off the ice for 1 monthPhysical Therapy Strategy:Increase Hip ROM and strengthIncreasing joint mobility in lower lumbar spineIncreasing strength in paraspinal musculatureTo resolve her back pain we hypothesized that interventions aimed at decreasing stress in the L5 region would allow the inflammatory process to settle down.This was in agreement with the physician, who chose to place her in a TLSO brace and rest off the ice for one month.Our strategy included resolving the restrictions in hip Rom and lumbar mobility as well as increasing the strength of her paraspinal musculature.
58 Intervention for Strength Problem:How to increase or prevent loss of strength in the paraspinals (while immobilized), without increasing stress to the L5 region?TrainingVolitional vs. ElectricalPrevious attempts to increase strength volitionally caused her pain and she demonstrated no improvement. Therefore, we considered the benefit of electrical stimulation for strengthening.
59 Case #2 - Intervention High Intensity Electrical stimulation 11 Attempts3 aborts due to painAll at the end of the weekVolitional stabilization exercisesOur treatment intervention included NMES to her paraspinals with MD approval and a volitional core stabilization program.This young lady attempted 11 treatments of NMES but we had to stop on three occasions due to pain, which all happed to be at the end of a week, which we attributed to being fatigued since she had already had two other treatments that week and was sitting in class all day. And in respect to the last case, this patient was highly more irritable coming into PT having knowingly skated at more than 100% for some time with the diagnosis.One of the things you will notice is that this picture shows extension of the lumbar spine while the stimulation is on. The stimulation is actually lifting her chest off the table. The patient in this picture happens to be the patient this case is about, and she barely weighed 70 pounds. This amount of extension is just in the beginning of her available arc of motion. We made a conscious decision not to strap her chest down, due to our lack of knowledge of the forces that would be generated through the lumbar spine. She was not getting pain in this position.In most patients we have used this on, the trunk is too heavy to rise off the table.
60 Exercises Lumbar Stabilization Progression Level I- V Maintenance Schneider et.alLevel I- VMaintenanceWhen adding the stabilization exercises, we followed an exercise progression by Schneider, Schmitt and Manal. It is program with five different levels of stabilization exercises and after reaching the highest criteria, you can continue with the maintenance phase. Our patient started with level I and progressed to level three before discharge.
61 Case #2 - Outcome Return to Skating Oswestry 0% at 11 treatments stroking and spins9 treatmentssingle jumpsfalling without painOswestry 0% at 11 treatmentsAfter 7 treatments she returned to stroking and spins and after 9 sessions, she returned to single jumps and falling without pain. Her Oswestry pain questionnaire was 0% after 11 treatments.
62 CASE #3 14 y/o female ice skater Low back pain for 3-4 weeks Pain onset during 80 minute lessonPain level of 8-9/10 during skatingPain level of 7/10 in AMPain exacerbated with twisting and bending
63 Case #3 - Early Intervention 1 week rest from skating (symptoms reduced)Return of pain intensity after 2-3 days of skating2 week rest from skatingNo pain with ADL’s
64 Case #3- PT Evaluation Limitation in lumbar L sidebending Limitation in lumbar R rotationRecreation of pain with maximal stress of left lumbar spineOpening (flexion and right side-bending)Closing (extension and left rotation)Decreased muscle mass of L lumbar paraspinals
65 Case #3- EvaluationExtension strategy for return from right sidebendingHypermobile joint play L1, L2 and L5Hypomobile joint play L3-L4Painful unilateral joint play left L2-L5
66 Case # 3 - HypothesisAn injury occurred in practice irritating the Left lumbar facets L2/L3 and L4/ L5These joints are painful in end rangesMuscular imbalance of the paraspinals and stiffness of the L3/L4 segment only contribute to increased stresses at the irritated site
67 Case #3- Treatment Plan Joint Mobilizations to hypomobile joints Electrical Stimulation for paraspinal muscleSpinal stabilization exercises (pelvic neutral)Pelvic Tilts, supine bridgingProne quadruped arm and leg liftsSide planksProne back extension
68 Case #3- ProgressAfter 4 treatments- Pain-free with ADL’s not currently skatingComplaints of muscle fatigue following treatments
69 Case #3- Return to Skating After 6 treatments- Return to skating with pain onset 5-6/10 after 15 minutesNext AM pain improved and skated 40 minutes with increasing pain4 weeks off skating for continued strengthening and diagnostic testing
70 Case # 3 - Diagnostic Testing Diagnosis of spondyloislthesisx-ray (minimal)given brace for skatingNew physicianHold on braceMRI and Bone Scan negativeProgressive return to skating
71 Case #3 - Strengthening Progression One legged bridgingProne extension on a ball10# medicine ball catches with rotation
72 Case #3- Skating Progression Return to skating at 16th treatmentStroking and spins only2- 40 minute sessions with only tightness in low backNext day minutes sessions pain-free17th Treatment40 minutes ice dance20 minutes freestyle (stopped when pain began)
73 Case #3- Skating Progression Progressing with choreography and spinsAfter 19th treatment- began jumpingProgressed jumps over next 4 treatmentsdouble axlefew triplesReturned to full program and practice at discharge of 24 treatmentTransfer exercise to training room
74 Case #3- Oswestry Scores At eval with ADL’s 8%At eval with skating activity 17%At discharge with ADL’s 0% with skating activity 11%Follow up 2 months later 0% with skating
75 Discussion Assist in the maintenance of strength training Successfully optimized their strength through with NMES to the paraspinals, and an intensive core stabilization programMinimize what they may loose with inactivityReturn to sport at a faster rateMuschik et al, 1996WE know that par interariculars fractures exist in athletes who perform hyperextension activities but Muschik et al shows that there is no relation between their sports activity and progression of the disease process. We also don’t know if these patients potentially had the stress fracture before radiographic testing with that this could be an acute exacerbation of a chronic problem since many of them do not show healing.So what do we do for a high level athlete while they have to be immobilized and are not allowed to participate in their sport?This case series shows how we can assist in the maintenance of strength training which would have otherwise been lost with immobilization techniques. We have successfully optimized their strength through this time frame with NMES to the paraspinals, and an intensive core stabilization program in order to minimize what they may loose with inactivity.These techniques have allowed them to return to sport at a faster rate once they are finally cleared to go back.
76 DiscussionElectrical stimulation has been successfully added to programs of lumbar stabilization with figure skatersThere were no negative effects to the high intensity stimulation treatmentsfusionstress response
77 DiscussionElectrical stimulation may show promise in assisting patients in recovering following lumbar injury especially when returning to demanding activitiesElectrical stimulation may be beneficial for patients who are unable to perform other exercise programs due to pain
78 Further ResearchResearch must be done to determine the effectiveness of the addition of electrical stimulation to a rehabilitation program for low back painWork aimed at determining the forces generated in the lumbar spine during these contractions will help therapists determine who can best benefit from this intervention
79 Thank You! Kimmie Meissner, U of D Thank you for listening. I also want to the thank my colleagues at the University of Delaware for their support and as you can see, I just want to put a little plug in there for our local figure skater, Kimmie Meissner. May she have the best of luck in the Olympics.Kimmie Meissner, U of D