These simple instructions were designed to help answer common questions about your postoperative recovery as well as guide you back to your previous level of activity. Check with your physician prior to beginning this program. WHAT DO I NEED TO AVOID? It is very important that you avoid anything that will stress or strain your incision. Every day activities like lifting groceries and toileting can cause problems. They can put undue stress on your bladder repair and potentially weaken it. Try not to strain (hold your breath and bear down) while having a bowel movement and avoid constipation. If you need to cough or sneeze, you should place a pillow or your hands over your lower abdomen and support it as best you can to counteract the intra-abdominal pressure. WHAT CAN I LIFT? It is recommended that you do not lift anything over 10 pounds in the first 6 weeks after surgery. After 6 weeks, you may gradually increase the weight of objects you lift. Never lift anything you feel you cannot easily handle. Technique is important. Do your pelvic brace by contracting your pelvic floor and lower abdominal muscles together as you begin to lift heavier objects. It is extremely important to use proper body mechanics when lifting. Be sure your back is straight and your knees are bent. When you lift even a light object, keep it close to your center of gravity (near your belly button) and lift with your legs not your back. WHEN CAN I EXERCISE? Once you get home you should climb stairs only as necessary to get to your bedroom or bathroom. A gentle-walking program will gradually build up your endurance and can be initiated for short distances (around the house) in the first week. Remain at low level, gentle walking until your recheck appointment when your doctor can see if you are healed and ready for more vigorous activity. Consult with your physician about when it is OK to begin a pelvic floor exercise program. Pelvic floor muscle exercises, also known as Kegel exercises, help strengthen and support your bladder repair. If you have difficulty learning how to contract these muscles you may need extra help to relearn how to use the muscles and to start strengthening them. At this time, you should consult your therapist to instruct you in proper abdominal muscle training, lifting and postural exercises. This will ensure that the correct muscles are functioning. 1 WHEN CAN I BE SEXUALLY ACTIVE? It is not recommended that anything be placed in the vagina for 4 to 6 weeks post surgery. This includes tampons and douching. When you resume penetration or intercourse, it may be uncomfortable and you may need to use plenty of lubricant. Go slowly to allow the tissues to stretch gradually. If pain persists, massaging the scar may help. Discuss any problems with your physician. POSTURAL CONSIDERATIONS It is common to maintain a more bent or flexed posture after any kind of abdominal surgery. It is important to do some gentle exercises and to stand up straight to avoid poor posture becoming a habit. General Posture Exercise 1. Stand against a wall with your knees slightly bent. 2. Place your arms in a “hold up” position or in the shape of a goal post. 3. Perform a pelvic brace by contracting your pelvic floor and lower abdominal muscles together. 4. In this position slide your hands up toward the ceiling being careful not to let your arms come away from the wall. 5. Repeat this exercise 3-5 times at least 2-3 times a day. WHEN CAN I EXERCISE MORE VIGOROUSLY? If you participate in running or jumping sports, avoid returning to those sports until at least 12 weeks after surgery. This may be difficult to do because you feel ready to return to your previous level of exercise however your bladder may not be as ready as you are. Return gradually doing 30%-50% of what you did prior to surgery. For example, if you ran 3 miles per day before surgery, start out with no more than 1 mile. If you feel any discomfort, pain or pressure in the lower abdomen, stop exercising immediately! If you have any questions about your postoperative recovery please call your physician or therapist.

When you hear vertigo you probably think of dizziness. But did you know the term “vertigo” refers to a specific type of dizziness? Vertigo is the sensation of the room spinning around you and that’s exactly how my patients describe it when I am treating them in the Westport, Connecticut Physical Therapy clinic at Sherpa Gym. While most patients experience specific spinning with BPPV, sometimes you can just feel off balance. An extensive history of the patient’s limitations and symptoms is very important for determining what the patient is suffering from. “I rolled over in bed and all the sudden the room was spinning. It only lasted a minute or so, but now I am scared to turn my head or go to sleep.” When this happens it is indicative of a condition that’s abbreviated BPPV: Benign Paroxysmal Positional Vertigo. BPPV is caused by changes in the anatomy of your inner ear (see below). When my patient came in and told me this we did an assessment to rule in/out conditions. One of them was a direct test for BPPV (the Dix-Hallpike maneuver) to confirm, and then we performed a technique (Epley maneuver) to alleviate the symptoms. She came in later that week and hadn’t had any episodes of dizziness. Sometimes all it takes is 1 visit! The actual semicircular canals are shown above on the left. The picture on the right shows what’s inside the vestibule (labeled on the left picture). As you move your head, the fluid inside the canals lags behind and moves the hairs shown. There are calcium crystals in the vestibule which help keep the hairs in place. When these get loose they can fall into the canals, causing BPPV and dizziness. BPPV is only one of many vestibular conditions that can cause dizziness. We look at your eye movements, head movements, and balance to determine what is causing your specific dizziness. See one of our vestibular physical therapists at Zion Physical Therapy to figure out what is causing your dizziness and get back to your full function. You do not need a prescription or referral prior to your visit. Call (212) 353-8693 or email schedule@zionpt.com to schedule!

Zion Physical Therapy Can Help! Over 165,000 New Cases Read on to find out more about Post Prostate Surgery Over 165,000 New Cases Of Prostate Cancer Will Be Diagnosed In The US In 2018 According To The American Cancer Society. That’s Nearly 10,000 New Cases In New York Alone! This Makes Prostate Cancer The Second Most Prevalent Cancer In Men In The US.* Depending on the severity of the cancer, one’s doctor may recommend different treatment options for post prostate surgery. Procedures such as a radical prostatectomy, laser surgery, radiation, TURP (Transurethral Resection of the Prostate) or laparoscopic surgery are all common options. Unlike most surgeries, the most common side effects affect your sex life and your bladder. These side effects are intimate. They can feel embarrassing. They are not often talked about, but a lot of them are common. If you experience any of the following:difficulty getting or maintaining an erection pain with orgasm urinary leaking dribbling more intense urinary urgency frequent trips to the bathroom pain in your pelvic area (penis, testicles, perineum, and even lower abdomen) Zion Physical Therapy can help! These side effects are the result of weak or impaired pelvic floor muscles. The good news: You can rehab your pelvic floor muscles just like any other muscle. What are your pelvic floor muscles you ask? These are the muscles that are responsible for healthy bladder, bowel, and sexual function. These muscles can be rehabbed just like your shoulder muscles after a rotator cuff repair surgery or your back if you experience low back pain. Pelvic floor physical therapists are specially trained to strengthen both internal and external muscles so life does not revolve around wondering where the nearest bathroom is or can I have sex tonight? They’ll guide you in internal and external workouts to strengthen your pelvic floor muscles and other muscles which support your pelvic floor so you become even stronger. In addition to training your pelvic floor muscles, your physical therapist will review diet and proper hydration which can also effect symptoms, and provide a home exercise plan just like you’d get after any other injury. Feel like yourself again, realize you are not alone, and ditch the diapers! -Francesca Warner, DPT *Key Statistics for Prostate Cancer | Prostate Cancer Facts. (n.d.). Retrieved January 08, 2018, from https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html

Living in a quarantined environment due to the COVID pandemic is a challenge for us in all fronts. This can also present a challenge to look after our pelvic health, especially since that in itself within the context of normalcy is already a huge undertaking. If you’ve already been working with one of Zion PT’s skilled pelvic health therapists, please stay motivated through this time and think back on all the hard work you have put into harnessing the healing power of your own body. Below, we’ll review a few of the practices learned together in the clinic to help maintain normal length and tone in your pelvic floor during these stressful times; Diaphragmatic breathing - there’s no time like right now to keep practicing proper breathing patterns. Make sure you’re lying down in a comfortable position, propping pillows under your knees and head if necessary. Take a mental scan of your body and identify all the parts of it that hold on to tension. E.g the brow, jaw, shoulders,hands, ribcage, hips, feet. Make sure you’re slowly allowing that tension to melt away as you breathe into the diaphragm allowing your belly to rise and gently exhale. Set your timer for 5-10mins. Living in a quarantined environment due to the COVID pandemic is a challenge for us in all fronts. This can also present a challenge to look after our pelvic health, especially since that in itself within the context of normalcy is already a huge undertaking. If you’ve already been working with one of Zion PT’s skilled pelvic health therapists, please stay motivated through this time and think back on all the hard work you have put into harnessing the healing power of your own body. Below, we’ll review a few of the practices learned together in the clinic to help maintain normal length and tone in your pelvic floor during these stressful times; Diaphragmatic breathing - there’s no time like right now to keep practicing proper breathing patterns. Make sure you’re lying down in a comfortable position, propping pillows under your knees and head if necessary. Take a mental scan of your body and identify all the parts of it that hold on to tension. E.g the brow, jaw, shoulders,hands, ribcage, hips, feet. Make sure you’re slowly allowing that tension to melt away as you breathe into the diaphragm allowing your belly to rise and gently exhale. Set your timer for 5-10mins. 2. Stretching - Normalizing tone and tension in your hip muscles can help relax your pelvic floor muscles Hold the stretch steady for 30 seconds and repeat 2-3 times on each side. Some googable examples are; figure 4 piriformis stretch, supine butterfly stretch (shown below), happy baby pose and supine hamstring stretch. 3. Belly massage - for those of us with abdominal discomfort and bloating this can sometimes provide surprising relief. You can use a little lotion on your skin - or not. Make sure to be gentle in massaging your abdomen, tracing the path of the big intestine and applying a few seconds of sustained pressure to the points that feel a little denser. Breathe through it. Applying a heating pack to the abdomen for 8-10 minutes beforehand can help your body relax that extra bit, if that’s available to you. 4. Foam rolling - our other self massage tool for the home dwelling times. This one may not be as popular due to the fact that rolling out tight muscles can be a bit of an uncomfortable experience, but just think of how good it will feel when you’re done! You only need do it for 1-2 mins in total, each side. Very googable examples are; foam rolling for the glutes, foam rolling for the quadriceps, foam rolling adductors (shown below). 5. Dilators - Dilators are stretching tools for your pelvic floor, used specifically for addressing muscle tightness. Be gentle and start at the beginning. *PLEASE only complete at home if you’ve been instructed on how to use dilators by your physical therapist!!* Lie down on your side or back in a comfortable and private setting. When in doubt, start with the smallest size dilator and insert into the vagina with lubricant only as far as your body allows with comfort. Hold it there for a few mins (5-10) until your body relaxes and is comfortable. You may insert further, but only as far as your body comfortable allows- this is most definitely NOT a “no pain no gain” situation. Always listen to your body and never push further than what feels comfortable. A total of 20 mins of dilator work each day will suffice to allow for maintenance and progress. Through these times it is important to be self-sufficient in terms of setting a schedule for ourselves, to be able to properly fulfill our self-care duties. Write out a little program for yourself for the things you will do on a specific day for your pelvic floor. Eg.- Mon @6pm; 8 mins of diaphragmatic breathing, 10 mins of dilator work, figure 4 stretch and butterfly stretch. If you are a current patient, don’t give up on all the progress you made in the clinic!! Remember that ultimately our work together is meant to capitalize on your own body’s ability to heal and COVID-19 or not, that power always lies within you. As always if you need guidance with your current program, or would like to speak to one of our skilled Doctors of Physical Therapy via Telehealth or in-office visits, call (212) 353-8693 or email schedule@zionpt.com. As a somewhat random note, I included Queen Elizabeth II's address to the world because I found it comforting and inspiring. Just a little tidbit to keep the love alive. https://youtu.be/2klmuggOElE 2. Stretching - Normalizing tone and tension in your hip muscles can help relax your pelvic floor muscles Hold the stretch steady for 30 seconds and repeat 2-3 times on each side. Some googable examples are; figure 4 piriformis stretch, supine butterfly stretch (shown below), happy baby pose and supine hamstring stretch. 3. Belly massage - for those of us with abdominal discomfort and bloating this can sometimes provide surprising relief. You can use a little lotion on your skin - or not. Make sure to be gentle in massaging your abdomen, tracing the path of the big intestine and applying a few seconds of sustained pressure to the points that feel a little denser. Breathe through it. Applying a heating pack to the abdomen for 8-10 minutes beforehand can help your body relax that extra bit, if that’s available to you 4. Foam rolling - our other self massage tool for the home dwelling times. This one may not be as popular due to the fact that rolling out tight muscles can be a bit of an uncomfortable experience, but just think of how good it will feel when you’re done! You only need do it for 1-2 mins in total, each side. Very googable examples are; foam rolling for the glutes, foam rolling for the quadriceps, foam rolling adductors (shown below). 5. Dilators - Dilators are stretching tools for your pelvic floor, used specifically for addressing muscle tightness. Be gentle and start at the beginning. *PLEASE only complete at home if you’ve been instructed on how to use dilators by your physical therapist!!* Lie down on your side or back in a comfortable and private setting. When in doubt, start with the smallest size dilator and insert into the vagina with lubricant only as far as your body allows with comfort. Hold it there for a few mins (5-10) until your body relaxes and is comfortable. You may insert further, but only as far as your body comfortable allows- this is most definitely NOT a “no pain no gain” situation. Always listen to your body and never push further than what feels comfortable. A total of 20 mins of dilator work each day will suffice to allow for maintenance and progress. Through these times it is important to be self-sufficient in terms of setting a schedule for ourselves, to be able to properly fulfill our self-care duties. Write out a little program for yourself for the things you will do on a specific day for your pelvic floor. Eg.- Mon @6pm; 8 mins of diaphragmatic breathing, 10 mins of dilator work, figure 4 stretch and butterfly stretch. If you are a current patient, don’t give up on all the progress you made in the clinic!! Remember that ultimately our work together is meant to capitalize on your own body’s ability to heal and COVID-19 or not, that power always lies within you. As always if you need guidance with your current program, or would like to speak to one of our skilled Doctors of Physical Therapy via Telehealth or in-office visits, call (212) 353-8693 or email schedule@zionpt.com. As a somewhat random note, I included Queen Elizabeth II's address to the world because I found it comforting and inspiring. Just a little tidbit to keep the love alive. https://youtu.be/2klmuggOElE

Breast Cancer. We all seem to know a friend or family member who’s had it, or have had it ourselves. We also seem to be familiar with the methods associated with treating it...chemotherapy, radiation, medications, diet modification...but what about physical therapy? When you break a bone or sprain a ligament and are immobilized for a period of time you are automatically prescribed PT, why not when you are post-op breast surgery? We’ve asked the same question. Possible surgical procedures with diagnosis of BrCA: Sentinel Lymph Node Biopsy (SNLB) Axillary Lymph Node Dissection (ALND) Lumpectomy Mastectomy Reconstruction (Expanders, Silicone or Saline implants, TRAM flap, LDF flap, gracilis flap, DIEP, SIEA, GAP) Possible activity restrictions after surgical procedures: No lifting arms above 90 degrees No driving No heavy lifting > 5lbs for several weeks No lying on stomach No wearing bras No stretching anywhere from 1-6 weeks depending on procedure as per surgeon No strengthening anywhere from 2-12 weeks depending on procedure as per surgeon While these surgical procedures can be extremely helpful in addressing the cancer itself, any of these surgical procedures and the precautions that immediately follow can affect how well you can move your shoulder and arm while performing your daily activities. Activities like dressing, bathing, combing your hair, taking care of your kids and working out can be difficult from resulting pain, stiffness and weakness. Focus tends to be on the resolution of the cancer, however oftentimes the residual physical impairments are not addressed! So, what can physical therapists do to help? Manual Soft Tissue Mobilization: addresses neck, shoulder and upper back range of motion and flexibility loss secondary to soft tissue restrictions in muscle and connective tissue Joint mobilization: Restore proper joint motion to shoulders, cervical spine, rib cage and thoracic spine to normalize motion Scar work: decreases restrictions and sensitivity through gentle scar mobilization Flexibility and strengthening exercises to address shoulder range of motion loss and weakness Education regarding proper posture with activities of daily living and protection of surgical site Assess and treat lymphatic cording Recommend compression garments and provide referral to lymphedema specialist when necessary What is an Initial Evaluation and treatment session at Zion PT like? Your physical therapist will introduce themselves and take you into a private treatment room where you will discuss your past medical history, interventions thus far and any restrictions recommended by your surgeon. You therapist will then do a physical evaluation performing the following: Circumferential measurements of the upper extremities to determine presence of lymphedema Scar closure and mobility assessment Posture assessment Upper body Range of motion testing Upper body Strength testing An in depth conversation regarding individual patient goals Outline a plan of care, frequency of treatment and foster communication with your surgeon/oncologist Following the evaluation, individualized manual therapy and exercises to achieve all ROM, strength and function goals will be outlined and performed and you will be sent home with follow-up exercises and a plan of care at a frequency agreeable to both you and the PT based on your needs! We at Zion Physical Therapy are focused on optimizing quality of life for all of our patients! If you’d like to make an appointment with one of our skilled physical therapists, please call (212) 353-8693 or email schedule@zionpt.com