Jordan C’s Personal Experience with Zion Physical Therapy! Thank you Zion Physical Therapy and my physical therapist Staci Levine for all of your ongoing support. I am very grateful and excited for the opportunity to share my experiences. Physical Therapy changed my life. I hope my story will help someone else going through a similar situation and create more awareness and understanding around Abdomino Phrenic Dyssynergia (APD) and Pelvic Floor Dysfunction (PFD). In October 2012 when I was 16 years old, I had a very sudden onset of symptoms. I woke up one morning and my belly looked pregnant. The following days I began to experience constant major abdominal distention, and discomfort especially when eating, or even just drinking water. The bottom of my belly would be hard and round and I would get this squeezing feeling at the top of my rib cage that felt like I was being strangled from the inside. I felt this intense pressure around my ribcage and lower core. I felt bloated. It felt like a balloon of air and simultaneously heavy rocks were forever implanted in my stomach. I always felt full, like a Thanksgiving meal that would never go away. No matter how much I exercised, or how much or little I ate, the round pregnant-like distention would always be present to some degree and would get worse as the day would progress. I would have to wear XXL t-shirts to hide my round abdomen. I would feel sick for hours after meals. I was not able to eat a lot of solid foods and began to have a more liquid based diet that consisted of protein shakes, smoothies, and other soft foods. My diet was very limited and there was no food that didn’t make me feel sick, it was more a matter of finding what I could tolerate the most. For years this was a mystery and I saw many doctors and heard a variety of speculations. Doctors would tell me the distention and pain was because of slow GI motility, or possibly SIBO (small intestine bacterial overgrowth) or perhaps food sensitivities (I tried so many diets, although I ate very clean, nothing helped the bloating, distention, and top of the rib squeezing sensations). Some doctors accused me of having an eating disorder. I had doctors just dismiss my symptoms and tell me that it was all in my head.Other doctors would tell me to do more core exercises. One doctor even wanted to do a botox injection in my pyloric sphincter. Most doctors would just not know what to do and pass me along or hope my GI problems would get better over time by itself. There was also a question at one point if I could have MALS (Median Arcuate Ligament Syndrome) due to my symptoms and diagnostic imaging. I was diagnosed with slow GI motility and ultimately Gastroparesis back in 2012. At the time I was experiencing major constipation. There was a period of a few years where I would have up to six capfuls of Miralax every night as well as drinking two to three gallons of Golytely (a medication often prescribed to cleanse the colon in preparation for a colonoscopy) every four to six weeks just to avoid getting hospitalized for severe constipation. This led to me eventually being diagnosed and treated by the Mayo Clinic in 2014 for Pelvic Floor Dysfunction using biofeedback methods. PFD can commonly occur simultaneously with APD since the pelvic floor and diaphragm have a close pressure relationship and their synergy plays a large role in the core functioning optimally. The Pelvic Floor Dysfunction can present differently depending on the person but in my case, my pelvic floor was so tight that it was not releasing properly and would contract instead of relax. It’s worth noting that I was also diagnosed with Autonomic Dysfunction which was playing a huge role in my constipation and GI troubles and could perhaps be what caused the PFD and APD (but we will never exactly know for sure). Doctors figured that treating the Pelvic Floor Dysfunction would also solve the APD as well. But despite treating PFD and the constipation slowly improving, I still had no relief in the upper rib squeezing sensation, major distention, air in stomach, and pain and discomfort with eating. Another two years went by and doctors told me that it seemed like some of my GI symptoms could still be related in part to APD. They told me there was not a lot of research on APD and there was nothing much that could be done to treat it at this point. Simply put they said “it is what it is” and just continue to practice some diaphragmatic breathing. I just couldn’t believe that there was no way to help it, that just didn’t make sense to me. There had to be something we could do. Over the course of the next three and a half years I always had APD in the back of my mind and continued to bring it up to different doctors with the hope that someone would know something that could help. After a total of six and a half years of dealing with these symptoms all day, every day, I had a consultation with a GI doctor at Weill Cornell who had heard of physical therapy for APD. She referred me to Zion Physical Therapy in NYC. In April 2019 I started physical therapy with Staci Levine. She was so kind and patient, I quickly knew I could really trust her and she would be the absolute perfect person to help me! She made me feel comfortable opening up in detail about the struggles I went through and was living with. She listened with such compassion and not once did she dismiss my symptoms. I was so excited and grateful to have someone believe that I could feel better and be willing to work with me. For the next 12 months we constantly worked to release my diaphragm and pelvic floor, retrain the muscles coordination, and strengthen my core muscles. The goal was to make sure the diaphragm and pelvic floor were both releasing as effectively as possible, this way we could coordinate their functioning. With PT my pelvic floor started to release with more ease and began functioning better than ever. Treatment included abdominal/colonic massage, internal rectal muscle releases in coordination with proper relaxation of the pelvic floor, core activation exercises and core strengthening, posture education and taping to re-educate neuromuscular control. We also worked to relax my very tight upper back muscles and increase mobility in my thoracic spine. This helped loosen around my rib cage which created more freedom for my diaphragm to fully release. Staci was able to loosen my diaphragm with manual release techniques. When my diaphragm released properly, it was like a magic trick! I would go from having a round pregnant-like stomach to a flat stomach in minutes. I couldn’t believe it!!! I then immediately knew this was the missing piece to the distention and squeezing all along. This was a matter of the body not functioning cohesively. I went to PT twice a week and then was compliant with our home exercise program which consisted of: diaphragm release techniques, abdomen massages, stretches, foam rolling (for my back), and strengthening exercises on my own multiple times throughout each day. I would work to specifically focus on strengthening my lower core, obliques, and upper back. In the morning upon waking, after meals, and if I remained sedentary for too long were the main factors that increased the abdominal tightness and squeezing (in my rib cage and lower core area), so I did have to continually implement the techniques I learned in PT to manage my diaphragm throughout the day. I would spend a lot of time practicing breathing with a focus on expanding my rib cage, rather than breathing to expand my belly or shallow chest breaths. In the past doctors would often recommend the relaxation breathing technique of expanding the abdomen and filling it with air on inhale, and then feeling the abdomen retract on the exhale. Personally, this type of breathing actually made my symptoms worse because it further reinforced the pattern of my abdominals over expanding instead of contracting to compensate for the diaphragm getting stuck and pushing down on my abdominal wall. It took awhile for my diaphragm and core to learn how and get used to functioning in a “new” way. Normally the diaphragm releases, the core maintains contraction, and the pelvic floor relaxes. For those with APD and PFD the diaphragm is stuck in contraction which forces the abdominals to relax causing the distention. The pelvic floor also contracts when it is supposed to relax causing constipation. When I first started PT my stomach would often, as I call it “pop”, go back to bulging and wasn’t able to keep the proper neuromuscular pattern. Sometimes within 15 minutes of leaving PT my abdomen would return to bulging. After several months my stomach began to hold for a day before it would pop, then a couple days, in late July 2019 in held flat for a week! The diaphragm just slowly started staying and holding the correct position for longer increments of time as we continued our sessions reminding it of what it was supposed to do. There would be periods of “setbacks” where my body didn’t always respond in the way I hoped it would, but I knew it was overall slowly moving in the right direction so I felt hopeful! At just about a year into PT in March 2020, I stopped having the daily extreme pregnant looking distention all together. Staci helped me address all the ways I was compensating from living in this dysfunctional way with APD for so many years. She would put two pieces of Kinesio-tape from my ribcage down to my hip bones. The tape would act as a cue to help remind me to stand properly and try to maintain my lower core engagement (when we were able to get my diaphragm to release) rather than giving into the urge to relax my lower core muscles as they were so used to naturally doing. I would wear the tape around in my daily life often. My normal posture inclination was to lean back, standing up straight felt like I was leaning very far forward. I had to learn how to stand in proper alignment. As we were able to start getting my diaphragm to release, I had to relearn how it felt to engage my core muscles properly. Especially early in the PT process, my core muscles would tremble and shake, and feel weak because they were not used to being able to fully contract. It felt like a whole new way of existing. I had to go back to the basics and slowly build my core strength and learn how to move utilizing my newly capable core rather than compensating and using other muscles. For years my upper back and neck were chronically very tight and caused me a lot of daily pain and headaches from which we believe were partly due to the fall out of compensating for so long and having the diagram tightness. Staci works on rehabilitating my back and neck muscles so this way they are able to release, gain more mobility, and be able to handle a fuller range of motion. My headaches and constant neck pain have improved dramatically. I have always been an active person, exercise has really helped me especially since becoming chronically ill in 2012. Even though working out when feeling sick can feel very counterintuitive at times, I’ve always believed in consistent movement and the importance of keeping my body as strong as possible to give it the best chance at recovering. I am a dancer so personally, exercise was key for my APD recovery. I make a point to do some form of movement along with my PT exercises everyday otherwise I’d feel an increase in tightness in my abdomen. Dance classes along with pilates, yoga, strength training, and HIIT workouts helped me tremendously with keeping the diaphragm from tightening and retraining the core engagement. Although I learned I have to avoid crunches and upper abdominal contracting motions often seen in Pilates (when in craniocervical flexion when lying supine position). These crunching type motions irritated my diaphragm and would cause an increase in the squeezing sensations which would then at times even lead to my abdomen going back to bulging. Alongside eating very clean, I have small nutrient dense meals throughout the day (combination of solid food and soft foods) with a lot of hydration. Large meals can really irritate and cause squeezing sensations and a lot of pressure around my stomach area. Before starting PT, I used to eat just to get it over with. I am now working to practice eating more mindfully by eating slowly and chewing more fully. Mindful eating helps me better manage the pain around my rib cage that comes from eating. And here I am today! No more wearing XXL tees to hide my distention. No more excruciating pain everyday from wearing sports bras. No more planning my days around getting my daily to do list done before the distention and discomfort and back pain becomes too much to bear. My abdomen no longer gets filled with large amounts of excess air. Eating, drinking water, breathing, feels so much better. My GI motility rate is also significantly better compared to a few years ago! And I even burp now, for years I never burped. Before PT, everyday I used to dread eating food and even just drinking water and my low back was always in terrible pain from the distention. My low back pain is gone. I no longer struggle with constipation. I go to the bathroom fully everyday and I don’t use any laxatives! I am in complete awe of my progress. My daily quality of life has completely changed. I continue to go to PT twice a week and do all the work outside of the sessions everyday since the muscles still get tight and I get some bloating and air. My abdomen still gets a little more distended at times than the average person but I am able to help it by implementing my PT techniques to help the muscles to relax. Overall my stomach does stay consistent with my flat stomach ‘after picture’. Since I had APD untreated for so many years I knew I had to be patient, consistent, and dedicated to this process for the long haul. I made a promise to myself to give this rehabilitation my all. I did my best to look past the hard days and focus on the big picture and being positive and seeing the promise in every small improvement. I am committed to treating this as long as it takes. Based on my current progress I believe it will just keep getting increasingly better and I will eventually be pain free and healed as I continue my daily practices. My diet in between these before/after photos did not change at all! Exercise and dancing feels so much more free now that I can fully engage my core correctly. I look back and can now realize why there always felt like a disconnect from what my body was doing versus what I deep down knew it was capable of doing. It feels like huge missing pieces have finally clicked and I understand why so many aspects of dancing and workouts were such a struggle. I am continuing to learn how to move while maintaining core engagement and I feel stronger than ever. It's truly unbelievable the difference I feel! I couldn’t believe how much daily pain and discomfort I had lived with and normalized. After eight years I had my breakthrough! So many doctors gave up on figuring this out, but I’m so glad I never gave up when in my gut I always knew there had to be an explanation and a solution. I hope my account helps bring more understanding to the hurdles people with these types of conditions often face everyday. I went to such great lengths to hide my struggles and my stomach distention in my daily life. I forced myself to push through life, and tried my best to cope and be positive. But it was miserable everyday consistently being in physical pain and extreme discomfort. I forgot what it felt like to feel pain free. It got to the point where for years I didn't know any different than to be in discomfort. I gave it my all to try and rise above and manage but my symptoms dictated a lot of aspects of my life. It felt like a never ending nightmare. This was not something that would have gone away on its own and no doctor was specifically addressing treating APD. If it hadn’t been for me pushing and questioning all this time it’s likely I would have continued on with this for years when it was treatable all along. I am very grateful and feel so lucky that I happened to have a consultation with a GI doctor who knew I could go to PT for APD and knew where to send me. It should be noted that APD and PFD are only one aspect of my long and complicated medical journey. I am diagnosed (by the Mayo Clinic) with Dysautonomia -specifically Autoimmune Autonomic Ganglionopathy which causes a whole host of other symptoms and problems I’m currently still working through. My body has been through a lot over the years. At times I have felt discouraged and concerned about how sick and physically weak I have been. While I always wanted to be hopeful, a part of me wondered if it was realistic or even possible to truly feel better after consistently struggling for such a long period of time. My comeback with APD reminded, reassured, and helped me to realize that given the right treatment, the human body can be very resilient, capable, and strong and it is possible to make big recoveries from complex health adversities. My APD breakthrough was backed by a lot of consistent hard work, patience, optimism, and belief. It feels like a miracle and the greatest gift I could ever have hoped for. Much of my health journey over the years I have often kept private. But I want to be more vulnerable about my experiences because we all have insecurities with our bodies and I think it is important to talk about these things, it is nothing to be ashamed of. After so many years of hardship with this, I knew I would find freedom in having the courage to own my story and all its truths. APD is slowly becoming more recognized but there is still a lot to be learned about it. I want to share my story because I know there are many people like me out there with this being misdiagnosed or don’t know that there is treatment for APD. I think it is also very important that Pelvic Floor Dysfunction is talked about more freely, because it is something many people struggle with. I don’t want patients to feel alone or self conscious so that was a big reason why I decided to share my story. I first googled Abdomino Phrenic Dyssynergia back in 2014 and hardly anything came up about it. I am writing the article that I wish had popped up. Learning about someone else’s experience and perspective would have given me a direction to look into and potentially saved me many years of daily suffering. For anyone going through this, there is hope and it is not too late! I know it can feel defeating going through all this but keep searching for answers! Lastly I want to say a big thank you to Zion PT for helping me share my story. Thank you to my physical therapist Staci!!!! I am forever incredibly grateful to Staci for believing and inspiring me, and for changing my life. Written by Jordan C. If you are dealing with symptoms like this, come see one of the pelvic floor specialists at Zion Physical Therapy so we can help get you back on track to living life the way you want to! Phone: 212-353-8693 • Fax: 347-507-5510 • Office Email: frontdesk@zionpt.com

A great running friend has struggled with plantar fasciitis for years on and off. She eloquently refers to exacerbation of pain as “the Planted Fascists” drilling into her foot. This always makes me laugh thinking of angry politicians banging sharp tools into her foot- clearly not what is happening, but certainly an apt description of this pathology’s pain! If you struggle with this very frustrating, often chronic, foot ailment - here are 5 tips to calm down the ‘Foot Fascists’: Stretch your calf muscles -- All 3 (2 leafs of the gastrocnemius and the soleus) calf muscles contribute to tightness in the posterior lower leg, which then pull on the Achilles tendon which then yanks on the plantar fascia; loose calf = happy foot! Roll your foot on a ball -- the most effective tends to be a frozen golf ball, but anything small and hard to get into the firmest parts of the plantar and relieve knots; if it hurts you’re probably in the right spots! Think about how you sleep: is your foot pointed? If so, try to avoid this! It leads back to tip #1. There are socks that help you avoid doing so, some that provide compression to the medial foot/assist in correct ankle position and others that actually hook/strap so your foot remains more neutral as you sleep. Burn all your thong sandals… kidding, sort of...make sure your footwear has a good supportive arch and that your foot is secure in the shoe. Sandals that only go around your toes and slap when you walk are the worst for plantar problems, followed by very flat shoes, and of course/sadly -- high heels. Seek physical therapy! From soft tissue massage to the plantar surface, to ankle stretching, to hip mobility - PT can assist in changes throughout the kinetic chain to make foot strike and functional mechanics more agreeable for all parts of your body, including the bottom of your feet.

Recommended by an ex-professional dancer & physical therapist! Total honesty- Back in my past life when I was taking dance class twice a day 5-6 times a week and adding to that rehearsals and/or performances I wasn’t in the habit of warming-up properly. Maybe a short barre or a loose mark of the phrases to come in rehearsals or performances and in terms of class...probably hanging out in a center split while chatting with my fellow dancers/friends for 5-10 minutes before start. I had unknowingly led my body down the path of unnecessary pain, fatigue, minor-medium injuries throughout the years. It was only towards the end of my free-lance dancer career in my early thirties that I understood how healthy it was for my body to have the time and attention in the form of specific exercises that targeted my core/hips, so as to properly prepare for the awesomely complex and dynamic routines that dancing entails. After being consistent with this “before routine” my body thanked me during and after a long day of dance. I’d love to share 5 basic core/hip stabilizing exercises with you in the hopes it will help access the sometimes elusive center and turnout more readily and effectively, like it did me. Supine marches- it is important to pull your navel towards your spine and feel the lower abdominals engaging, so as to minimize rotation of the pelvis as your lift/switch legs. Carry over this sensation of activation of the lower abdominal muscles into all barre/center exercises to maintain a strong center. Bridges - your gluteal muscles also help you maintain a stable pelvis. Because dancers are usually in a turned out position, the major gluteal muscles can become a little “lazy”. Help them wake up with this exercise. 2-way Clamshells - this exercise will help you access your hip external and internal rotators. Not only are these muscles the exact one you use when standing in any turned out position they help the hip joint remain stable during any dynamic weight-bearing movement (basically all of dancing). Plank hold - full body engagement of core musculature. Pay attention to how your elbows align with your shoulders and do not sink in your upper body as much as your center. Start slow (10-15 sec holds), focus on proper form and then start adding time. At Zion PT we specialize in dance injury prevention and have helped many dancers recover from injuries and get back to doing what they love best! If you are in need of help or guidance please call (212) 353-8693 to make an appointment with one of our Dance Medicine Physical Therapists!

Refer to this chart by Zion Physical Therapy for helpful tips on your joint replacement surgery.

Do you ever feel like you never know where your body is in space? Or you end up sitting like a noodle on the couch and you didn’t even realize you got into that position? Or that your joints are always subluxing or dislocating? These are some of the common symptoms along with pain and chronic tightness that people with hypermobility syndromes combat daily. What is hypermobility and the syndromes that go with it? Hypermobility syndromes such as Ehlers-Danlos Syndrome, Marfan’s Syndrome, Hypermobility Spectrum Disorder or Joint Hypermobility Syndrome can cause instability and weakness in the joints leading to pain and other symptoms listed above. Both stability and strength training can be very beneficial for these individuals in order to increase joint stability, strength as well as reduce pain, fatigue, lack of endurance and improve overall function. Here are some tips for incorporating stability and strength training into your exercise routine! 1. When thinking about exercise you want to work on exercises that will help you improve the foundation of your body- your core, as well as the stability in your joints. The first thing that is important to work on is joint and body proprioception (proprioception is when you know where your body is in space). A good rule of thumb is that anything with a closed kinetic chain (CKC) is safe. A closed kinetic chain exercise is an exercise where you are in contact with a surface such as a wall, table or the floor. Exercises like this would include wall sits or table planks. 2. Next, think about stability. So now we’re thinking about core stability exercises and making sure to engage the deepest parts of your core! You can also use balancing on one leg or unstable surfaces to start to challenge your stability and help to improve your functional stability! 3. Once you have set the foundation with your CKC and core exercises you can begin to strengthen the muscles surrounding the joints in order to create more awareness (proprioception), stability, and strength as well as control! You can do this with body weight exercises which you will progress to weighted exercises such as squats or deadlifts as well as resistance band exercises. 4. Proper form is important within exercises but it is important to note our bodies need to be strong enough to manage many postures throughout the day so we are training our bodies to do that pain free! So while remembering proper form with exercise is important, know there is no perfect posture to maintain after exercise is done. 5. Next work on compound exercises in order to improve overall functionality and strength as well as endurance. Compound exercises can be squats and deadlifts or combining upper and lower body exercises such as a squat to overhead press or a deadlift to a row! 6. The last step is working on power, power is essential to maintaining good bone health and help us absorb and transfer strength and force well throughout our bodies. This can be done by starting with agility ladders and progressing to different jumping activities like forward hops, single leg hops, skater jumps, and finally box jumps or single leg box jumps. 7. Gradual increase in resistance and weights are important! Make sure to pace yourself, hydrate often and take breaks as needed. Building up into exercise is important in how often you exercise as well! Start with exercise once every 3 days and progress to every other or even every day with one or two rest days a week! 8. Consider calling Zion Physical Therapy at (212) 353-8693 to work with one of our very qualified physical therapists who can help you feel safe in your progressions and exercise as well as develop an individualized home exercise program for you! In conclusion, stability and strength training can be very beneficial for individuals with hypermobility syndromes to improve joint stability, reduce pain, improve strength and improve overall function. By incorporating stability exercises, resistance training, proper form, compound exercises, balance and coordination exercises, and progressing gradually, you can create a safe and effective exercise program that meets your individual needs.

Let’s be realistic. It’s awesome to have childcare available to get to your favorite fitness class, but it’s not always feasible. And we know flexibility and convenience are cornerstones of keeping up with your fitness goals. Here, I share some of my personal explorations of “making it work” with a baby at home. These exercises are what made sense for me, after two months of focused foundational exercises for the core and hips. Feel free to try them, knowing that some moves are more advanced than others. Don’t jump into it if you are having back pain, pelvic pressure, or a diastasis that has not been checked out. Or, we can work on exercises together to build an at-home workout that makes sense for you, as part of our MomStrong program. Suggested Duration: 6-18 minutes (or until baby is over it) 1 min/exercise, 1-3 times through Baby Bird-Dog Side Plank with Rotation Tickle Airplane Abs Baby Sumo Squats Straight Leg Baby Lifts Twisting Baby Lunge Contact Zion Physical Therapy to schedule an appointment online or in person at one of our four convenient locations: Phone: 212-353-8693 Office Email: frontdesk@zionpt.com Online Form: Request Appointment

During the time COVID-19 pandemic, you may be sitting more on your couch or having to figure out working from a home desk, and your neck, hips, back and wrists may be sore, tight or painful. Following are eight stretches that are easy to incorporate into your day to manage symptoms or to simply feel a little less creaky throughout your day. You can do them as often as feels good to your body, but we recommend holding each stretch for 20-30 seconds and performing them 2-3 times, 2-4 times a day. Prayer hands: palms together, pushing in Reverse prayer hands: backs of hands together, pushing in Chair pigeon: outside of leg hip height or lower, engage core, lengthen spine Cat cow desk: arch back while looking up, then tuck chin to chest, pulling shoulders forward Neck stretch holding chair: bring ear to shoulder, opposite arm holds on to seat of chair Seated spinal twist: keeping hips and legs forward, twist from the back, looking over shoulder Standing quadriceps stretch with overhead reach: grab onto foot and kick back into hand as opposite hand reaches for the ceiling Forward fold: reach for toes, alternating bending and straightening knees Happy stretching!

I run to feel good, both physically and mentally; therefore, I needed running even more during pregnancy. But running while my body was (and still is) constantly changing presents some new challenges. Here’s a guide of some helpful tips to avoid running into any problems. SAFETY FIRST Take it Slow Let’s start with the usual disclaimer: make sure you are cleared by your doctor (obstetrician/midwife/gynecologist) before beginning an exercise program. There are a number of medical and obstetric conditions that may make exercise unsafe during pregnancy. With that out of the way, the current guideline for exercise during pregnancy calls for about 30 minutes of moderate intensity exercise, most days of the week (as per the American College of Obstetricians and Gynecologists). Fortunately, running is an activity that allows you to moderate the effort you put forth. You may be a seasoned runner, aware of how hard you feel you’re working and able to regulate on your own. Or, your doctor might want you to wear a heart rate monitor and stay within a certain range. As for me and my slightly competitive nature, I needed additional external factors to slow me down. I ran with my dog so that his incessant need to stop and smell the roses would force me to take rest breaks, or I chose a running partner who was slower than my current pace (shown below at 34 weeks gestation, with my 60 year old dad). Staying out of the red zone is important because your blood volume is increasing tremendously (from 30-50% as early as 16 weeks gestation), causing your heart rate to be higher than normal even at rest. And if you’re like me, your iron stores haven’t necessarily caught up with the increased red blood cells, so your risk of anemia is increased. Add to that your difficulty breathing now that your rib cage has expanded and your diaphragm is less efficient (it’s stretched out and contracting against more resistance), and you’re likely to find yourself short of breath way earlier than usual. So, go for your run, but be prepared to slow down and incorporate intervals of walking. Don’t Overheat If you’re in warmer climates or it’s summertime in the city, be especially cautious to not overheat, which could be harmful for your developing baby. I usually like to get a tan while I run, but soon I found more comfort in taking routes that were shady instead of sunny. The thought of carrying a water bottle with the weight I had already gained seemed preposterous, so I memorized all the water fountains along the route as well. If you have retained fluid during your pregnancy, and have found that your hands or feet are swollen on the regular, keep this in mind. Dehydration will come on sooner (especially if you skipped your normal glass of water pre-run so that you could last a little longer without a bathroom break.) By my third trimester, during the heat of the summer, I kept all my runs close to home, sometimes just circling the park next to my apartment, just in case. PREVENTION Do Your Kegels It was early on in the second trimester that pressure built on the pelvic floor and the pelvis started to stretch and change, which meant leakage, first with sneezing and then with running. I had to up my kegel game immediately. I ran with a liner at first, but I caution you that you must change out of your running clothes pretty immediately after your workout, as UTI risk is higher during pregnancy. I recommend a pretty solid kegel routine as soon as you become pregnant (some apps even let you track your sets and reps), but make sure that you’re holding the kegel for 5-10 seconds at a time for improved endurance. I would try to focus on my pelvic floor contraction during the first half mile for good strengthening practice under running conditions and was able to get rid of my leakage in about one month. If you need more help on this front or aren’t sure you’re doing them correctly, check in with us. Strengthening Rules Still Apply Logically, it’s fair to say that your joints now think that you’re going out for your usual jog while wearing a weighted vest. This is not something most people do voluntarily to enhance their training, and for good reason. An increase in one pound of body weight multiples by 3-4 times that amount when you are running, and it will take its toll on your joints. So strengthening is even more important now than it was even before. Keep up your squats and lunges throughout the pregnancy to ensure support for the knees and hips as you gain weight. I chose to stick with my usual HIIT classes (high intensity interval training) with the support of some solid teachers (check out the great team below) and a number of modifications to make it a MIIT class (moderate intensity interval training). Recover Well, Stretch With Caution Recovery is more important for the same reason, mostly by means of rest and refueling. If you were an avid stretcher or just love to feel flexible, this is where you might need to hold back. With your ligaments being looser than ever, stretch with caution as it’s easier now to “over-stretch.” Keep it gentle with a minimal intensity stretch instead of moderate. I had to change my usual runner’s lunge stretch for my hip flexors to more conservative quad stretches, since it started to make me feel a little unstable (more on that later). GEAR Invest in a New Sports Bra First trimester feels a bit like all the other runs you’ve done while at peak-PMS. Mostly your boobs hurt and you feel bloated. Over the course of the pregnancy, you may need to invest in a new sports bra, the same as you will with your other bras to accommodate the change in size. Mostly, my bras made it feel hard to breathe because they were too tight against my expanding rib cage (which can widen up to 3-4 inches over the pregnancy). I ended up doubling up on some older, looser sports bras to stay supported and comfortable at the same time. Consider an SI Belt If you have a history of sacroiliac (SI) joint pain or low back pain, are feeling excessive movement in your pelvis while running, or are dealing with some SI joint, or sciatica symptoms now that you’re pregnant, consider wearing an SI belt (with extender strap) while running to decrease shear forces on your pelvis. I love the Serola belt and keep one in my office in case you want to do a trial run before you purchase. Just make sure to read the instructions to make sure you’re wearing it at just the right level. Check Your Shoes My old posterior tibialis tendonitis (an inflammation of the tendon that runs along the inside of the ankle) said hello during second trimester. Since the ligaments of your feet are also stretching, your lower leg muscles will be working overtime to stabilize your ankle as your foot hits the ground. If you notice your feet are expanding or you start to feel pain in the arches of your feet, considering switching out your neutral or minimal shoe to a stability shoe for some more extrinsic support. I threw my old orthotics into my running sneakers and it remedied the situation immediately. Couple that with a shortened stride to reduce joint loading and you should be on your way to safely running in trimester three. Suffice it to say that being a good body-listener becomes more important than ever, especially since you’re listening for two. If you’ve been cleared to exercise but just want a little more guidance, if you are struggling with feelings of heaviness or incontinence, or if you are having any pain, don’t hesitate to reach out. Zion’s physical therapists specialize in treating both prenatal clients AND orthopedic cases, so rest assured that we can put the pieces together in a way that works for you and helps you keep exercising safely throughout your pregnancy. Request an Appointment!

Here are some effective and fun activities you can do with your 2-5 year old child to strengthen the core. The core muscles are located in the front, back, and side of the trunk, as well as the muscles in the buttock region. Adjust the level of difficulty based on the child’s needs; start easy and gradually progress. Challenge within reason while having fun. Zoo Rescue! *Place a box or bucket in front of the child. This is the “zoo”. *Spread about 8 stuffed animals (or other soft toys) within reaching distance around the child in all directions (in front, to sides, and behind the child). *Choose from a position pictured below for your child to remain in while rescuing the animals. Instructions to Child: “Oh no, all of the animals have escaped from the zoo! Rescue them by bringing them back home to the zoo as quick as you can, before they run away! Rescue 1 animal at a time.” Modification: Use less stuffed animals and/or place animals & zoo closer to child. Progression: Use more stuffed animals and/or place animals & zoo farther away from child. Baby Shark *Have the child lay on their stomach and lift both arms and legs off the ground. Instructions to Child:“Let’s swim and move our arms like baby shark!” or “Lets fly like superman!”. Play the baby shark or superman song, pausing at times.“Move when the music’s on, stop when it’s off!” Modification: Lift opposite arm and leg or lift arms only. Progression: Have the child flutter their arms and legs while keeping them off the ground. Wheelbarrow Walking Wheelbarrow Walking *Start with the child laying on their belly and you hold their legs. *Lift their legs off the ground and have them walk on their hands. *Try having them walk forwards, backwards, to the left and right. Modification: Instead of walking, have them reach out and touch something (i.e. touch favorite stuffed animal), going back and forth trying it with both arms. Progression: You can move your hands down to their ankles for more of a challenge. Crab Walks *Have your child sit down with their buttocks on the ground. *Now have them raise up the buttocks so that only their hands and feet are touching the ground. *Have them walk on their hands and feet backwards and then forwards for the desired time or distance. Instructions to Child: “We are going to walk like crabs!” Modification: Your child may carry objects on their stomach while walking. You may tell your child that they are bringing supplies back to the crab house. Progression: Once your child begins to be accustomed to the movement, your child may try to walk sideways in this position. Bear Crawls *Have the child start on their hands and knees. *Now come off their knees onto just their hands and feet, not letting anything else touch the ground. *The child will move forward by crawling with the opposite hand/foot (i.e. right foot and left hand advance, followed by left foot and right hand). You can play tag and have relay races, whatever your child will have fun with. Modification: Change direction (crawl backwards, side-to-side, etc.), can create a hamstring/calf stretch by keeping hands still and walking feet up towards hands, and then letting the hands walk forward. Progression: Go outside onto soft/uneven surface, practice going up and down hills, play “red light green light” where the child has to abruptly stop and stabilize, holding that position. Concerned about your child’s core strength? Call Zion PT for an assessment of their motor skills, strength, balance, and flexibility. We’re here to help and work with your pediatrician to optimize their function! Call (212) 353-8693 or email schedule@zionpt.com to inquire about pediatric physical therapy at Zion Physical Therapy in the Upper East Side clinic!

Developmental Coordination Disorder (DCD) is a motor skill disorder that affects parts of the brain that learns and remembers motions. It is not related to intelligence. DCD affects approximately 5-6% of school-aged kids, with slightly more boys being diagnosed than girls. The exact cause is unknown. Research shows that it may be connected to low and premature birth weight. DCD results in difficulties with coordination, balance, body awareness, and movement skills like riding a bike, jumping jacks, running, jumping, skipping, kicking, throwing, catching, and playing sports. Kids tend to have a hard time imitating and learning new skills even with many repetitions and keeping up with peers their age. With inactivity, children are at higher risk of having heart disease, overweight, poor fitness, and self-esteem/social/emotional problems. While DCD continues throughout life, the good news is that PT can help kids and teens improve their coordination, balance, strength, school and daily activities by learning to use new movement strategies. Here are some exercises you can try at home to work on coordination and balance: STAND LIKE A FLAMINGO: KICK A BALL: SQUAT: JUMP OVER HURDLES/OBJECTS: WALK THE “TIGHTROPE”: FORWARD AND BACKWARDS SIDESTEPS Make An Obstacle Course: (Use cones, pillows, and boxes to step on objects, to step over, and step around) Want to learn more? Check out this website: https://www.choosept.com/guide/physical-therapy-guide-developmental-coordination-disorder Does your child have a developmental coordination disorder? Call Zion PT at (212) 353-8693 or email schedule@zionpt.com to get assessed and treated!

*WHAT: CP is caused by an injury to the brain (by infection, stroke, trauma, or loss of oxygen) that occurs before, during, or up to two years after birth. No further damage happens after the initial injury but activities such as walking, standing, reaching, sitting, crawling affected by CP can become more difficult as the child grows. *SYMPTOMS: There are different types of CP with symptoms that can appear as soon as a few months old. They include inability to hold head up, difficulty reaching, rolling, sitting, crawling, or walking, tight muscles, muscle weakness which could present as “floppy” muscles in trunk and neck, moving slower compared to other children, lack of coordination, slower than normal growth, trouble speaking, and learning disorders (with normal intelligence). *TREATMENT: Physical Therapy to improve strength, flexibility, positioning, play, self-calming, pain management, and energy conservation. A PT may also recommend braces/equipment to maximize function and health. Kids with CP are especially at risk for not getting enough physical activity, so an individualized exercise program will be designed for the child. If your child has CP, participating in sports are beneficial including swimming, basketball, cycling, bowling, volleyball, and tennis. Engaging in social events with peers is also recommended. *HOME EXERCISES: Here are some exercise ideas to get your child started in a variety of positions including standing, sitting to/from standing, and walking: Sit to stands from step stool: Standing balance at low table while playing with toys: Push cart to work on walking: Kick ball with support (if needed) to work on balance and kicking: Interested in learning more or having your child evaluated by a pediatric PT? Call Zion PT at (212) 353-8693 or email frontdesk@zionpt.com for an assessment and check out this website: https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-cerebral-palsy-2

There are many foods, fluids, and habits that can irritate the bladder. This handout has suggestions for ways you might be able to change your habits to better control your bladder and suggestions for maintaining a healthy amount of fluid intake. Although there is no particular "diet" that can cure bladder control, there are certain dietary suggestions you can use to help control the problem. There are 2 points to consider when evaluating how your habits and diet may affect your bladder; 1. Foods and Fluids that that can irritate the bladder Some foods and beverages are thought to contribute to bladder leakage and irritability. However their effect on the bladder is not completely understood and you may want to see if eliminating one or all of these items improves your bladder control. If you are unable to give them up completely, it is recommended that you use the following items in moderation: Foods with acidic properties: Alcoholic beverages Tomato based products Vinegar Coffee (regular and decaf) Tea (regular and decaf) Curry Spicy foods Caffeinated beverages Carbonated beverages Cola Milk Food colorings and flavorings Artificial sweeteners Chocolate Substitutions for Bladder Irritants Although water is always the best beverage choice, grape and apple juice are thirst quenchers and are not as irritating to the bladder. Low acid fruits: pears, apricots, papaya, watermelon For coffee drinkers: KAVA® Postum® Pero® Kaffree Roma® For tea drinkers: Non-citrus herbal Sun brewed tea 2. Drinking enough and the right kinds of fluids Many people with bladder control issues decrease their intake of liquids in hope that they will need to urinate less frequently or have less urinary leakage. You should not restrict fluids to control your bladder. While a decrease in liquid intake does result in a decrease in the volume of urine, the smaller amount of urine may be more highly concentrated. Highly concentrated, dark yellow urine is irritating to the bladder surface and may actually cause you to go to the bathroom more frequently. It also encourages the growth of bacteria, which may lead to infections resulting in incontinence. © Herman and Wallace | Pelvic Rehabilitation Institute