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Clinical Guide to Positional Release Therapy The use of PRT for the treatment of somatic dysfunction provides both opportunities and challenges when working with diverse patient populations. Although every patient is unique, I have found over the course of my clinical experience that some groups r...

Clinical Guide to Positional Release Therapy The use of PRT for the treatment of somatic dysfunction provides both opportunities and challenges when working with diverse patient populations. Although every patient is unique, I have found over the course of my clinical experience that some groups require special considerations during the evaluation and treatment process. These include youth and elderly patients, patients recovering from mastectomies, competitive athletes, pregnant women, and clients with disease and disability. This book provides the nuts and bolts of how to apply PRT to a variety of tissues and injury conditions, although the life, work, and sport demands of clients often dictate how they are evaluated, how PRT is applied, and how they are managed throughout the recovery process. For example, women who are carrying a child at some point are not able to lie prone, and an elderly patient who has progressive knee osteoarthritis is unable to tolerate joint compression or rotation. Situations such as these require the therapist to alter the evaluation and treatment approach to ensure the safety of the patient and the effectiveness of the therapeutic interventions. Youth and Elderly Patients Besides the obvious characteristics of young and elderly patients, both groups are unique in their receptiveness to PRT. I have noted that clients in both groups who are treated with PRT appear to heal at a faster rate than middle-aged patients do. Considering the metabolism of the young, it is not surprising that they bounce back quickly when treated with PRT, but this does not explain the return to pain-free activity experienced by the elderly. Two plausible explanations are age-related differences in cellular signaling and lower levels of physical and psychological stress. Altered Cellular Senescence Signaling It is well documented that human tissue declines in efficiency with age. Campisi and colleagues (2011) laid out a convincing hypothesis for the reason our tissues and their respective cellular responses to stress decline with age; they attribute it primarily to alterations in cellular senescence signaling. “Cellular senescence generally refers to the essentially irreversible loss of proliferative ability that 30 occurs when cells experience potentially oncogenic stimuli” (Campisi et al. 2011, 3). Essentially, when proliferative cells are damaged or stressed, they are at risk of mutating and initiating tumorigenesis, or tumor growth. According to Campisi and colleagues (2011, 3), stressed or damaged cells can cause an “increase in mRNA levels and secretion of numerous cytokines, chemokines, growth factors and proteases,” which they termed senescenceassociated secretory phenotype (SASP). Cytokines and chemokines (e.g., IL-1b) and growth factors such as transforming growth factor (TGF-b), vascular endothelial growth factor (VEGF), and IL-8, among other inflammatory mediators, enable the healing process to progress (Gouin and Kiecolt-Glaser 2011). However, the continued presence of these inflammatory mediators may or may not be advantageous to healing. For example, in cataract patients younger than 40 years of age, Dawes, Duncan, and Wormstone (2013) found higher levels of TGF-b than in older patients as well as reduced cellular signaling activity in aged patients despite high levels of ligand availability. The authors postulated that the decrease in growth factors and higher senescence levels found in their older patients may be the result of their shortened telomeres and impaired healing ability. Telomeres are DNA sequences that cap the ends of chromosomes, enabling cells to divide; however, as the cells divide, the telomeres become shorter resulting in cell aging. The enzyme telomerase is more abundant in young people than in older people, which keeps the cells from breaking down to a great degree (Blackburn 1991). The breakdown of cells, however, may release SASP to repair the stressed or damaged cells, which may activate senescent cells to limit fibrosis during repair (Campisi et al. 2011). Senescent cells are eliminated by the immune system, but they are found in greater number in aged tissues, which may be from a decline in functionality of the immune system and increased oxidative stress as a result of the inefficiency of the mitochondria (Campisi et al. 2011). Decreased Physical and Psychological Stress Research suggests that cellular signaling is more robust early in life, enabling the healing process to advance with little complication. As we age, however, our cellular signaling systems, intended T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. Special Populations to rid our bodies of damaged cells, become less efficient, leading to delayed healing and an array of diseases and illnesses such as cancer (Campisi et al. 2011). Therefore, an increase in cellular signaling along with the preservation of telomeres may explain, in part, why young people treated with PRT heal more quickly than older people do. However, the more expedient return to homeostasis in older people is likely due to the lower levels of physical and psychological stress at this stage of life, which may limit cellular stress. We can also assume, then, that recovery from somatic dysfunction during midlife may be hampered by increased psychological and physiological stress from work and life demands. In their examination of the impact of stress on wound healing, Gouin and Kiecolt-Glaser (2011) presented compelling research that affirms the negative impact of psychological and physiological stress on healing. The authors pointed out that psychological stress activates the hypothalamicpituitary-adrenal and sympathetic-adrenalmedullary axes, resulting in the increased production of glucocorticoids and catecholamines, which have been shown to retard wound healing in both humans and animals. The researchers also reported on studies that demonstrated improved healing in people who perceived greater support from their partners and were surrounded by a supportive social network. Conversely, women who discussed marital strife demonstrated lower levels of proinflammatory cytokines (IL-1b, IL-6, TNF-a). McPartland and Simons (2006) also pointed out that psychological and physical stress can impair the ability of acetylcholinesterase (AChE) to deactivate acetylcholine (ACh). “Intrasynaptic ACh must be deactivated; otherwise, it will continue to activate nicotinic ACh receptors (nACRs) in the muscle cell membrane” (McPartland and Simon 2006, 6). Excess ACh has been strongly linked to the development and persistence of myofascial trigger points (Gerwin, Dommerholt, and Shah 2004). Although the young and old have plenty to be stressed out about, I propose that a diminished level of psychological and physical stress coupled with less exposure to repetitive movements and postures at work result in less of a demand on the somatic system in these populations, enabling them to capitalize on the application of PRT unlike other age groups. Even though the young and elderly populations may attune better to PRT, special precautions should be exercised when applying PRT to the elderly. Treating Elderly Patients With Low Bone Mass and Osteoarthritis The elderly may be particularly prone to the development of somatic dysfunction as a result of aging telomeres, decreased cellular signaling efficiency, and the presence of osteoporosis and osteoarthritis. Based on data from the 2005-2008 National Health and Nutrition Examination Survey, 49% of all adults over the age of 50 have low bone mass—a precursor to osteoporosis, which 9% of the sample possessed (Looker et al. 2012). Values were assessed at either the femoral neck or lumbar spine, which are common areas of osteoarthritis in the aged population (Murphy and Helmich 2012). The prevalence of low bone mass was found to be 39% at the femoral neck and 27% at the lumbar spine. However, the prevalence for osteoporosis at these sites was flipped: 4% at the lumbar spine and 3% at the neck of the femur. Therefore, nearly 50% of people over the age of 50 have low bone mass, and roughly 10% are osteoporotic. Bearing these statistics in mind, PRT is an excellent modality to use with this population because of its gentle, nonforceful nature. However, the amount of force used during joint compression, rotation, and distraction should be based on patient comfort and joint feel. If low bone mass is suspected, a bone mineral density test will help to ascertain the integrity of the bone, particularly when working with the hip, pelvis, and spine. The potential presence of osteoarthritis (OA) also calls for special considerations in the application of PRT. Based on available epidemiological data, Murphy and Helmich (2012) estimated that approximately 27 million U.S. adults have clinical OA, which accounts for more than 10% of the U.S. population. Although OA can emerge in the young and throughout life, the incidence rises with age (Murphy and Helmich 2012). Nguyen and colleagues (2011) reported that OA is the most common cause of knee pain in people over the age of 50 and the primary reason for knee replacement. Although aging may increase the risk for knee OA (Murphy and Helmich 2012), obesity is also a strong risk factor (Nguyen et al. 2011). Guillemin and colleagues (2011) found similar results in a population-based survey of a multiregional sample in France. The authors found that the incidence of OA increased with age, and that OA was more prevalent among those with obesity. An additional modifiable risk factor for OA is excessive mechanical stress on the job, such T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. 31 Clinical Guide to Positional Release Therapy as that experienced in agriculture, construction, cleaning, and retail occupations. Zidron and colleagues (2005) found a high prevalence of somatic dysfunction among 103 Kenyan elders, which was associated with caregiving intensity, being female, and being engaged in manual labor such as farming. Although there are no studies yet linking somatic dysfunction to OA in a U.S. population, somatic dysfunction is often present among patients with OA. Osteoarthritis typically is caused by microtrauma to the joint over time, which results in inflammation and pain. The inflammation and pain can cause thickening of the joint capsule and the formation of osteophytes, which can disturb the normal function of the joint and produce dysfunctional movement patterns. Murphy and Helmick (2013) reported that the three most commonly found activities with functional limitations among arthritic patients were bending, stooping, and walking. Although young patients can develop OA, advanced OA is more typical in the aged population and results in more deeply rooted joint structure and function alternations, somatic dysfunction, and functional movement impairment (Cooper et. al 2013). When applying PRT to older people with osteoporosis, osteoarthritis, or both, therapists must be cognizant of how patient positioning and the application of force during positioning may affect them (see figure 3.1). Therapists should take the following into consideration when using PRT with OA patients, particularly the elderly: CLINICIAN THERAPEUTIC INTERVENTIONS Osteoarthritis • To avoid evoking pain and irritation, exercise caution when moving the joint through the range of motion and when applying joint compression and rotation. Osteoarthritic joints often present with diminished osteoand arthrokinematic movement, and pain is often elicited when attempting to move beyond the available range of motion. • Consider requesting a radiograph to ascertain the severity of the OA. • Address modifiable risk factors with the patient such as weight loss and occupational and ADL (activities of daily living) modifications. • Ascertain whether an underlying condition exists that may be causing increased joint loading such as a significant leg length discrepancy or a prolonged pronation phase during gait. • Educate the patient on the use of nonimpact exercises that will help to stabilize and nourish the joints. • Provide the patient with educational and stress management resources. A popular resource is the Arthritis Program of the U.S. Centers for Disease Control and Prevention. Treating Young Patients With Osteopathic Lesions Figure 3.1 patient. 32 PRT pes anserine treatment for an OA The therapist must be attentive when applying force during PRT to the young to avoid disturbing epiphyseal growth. However, the most important thing to remember when working with children is to address osteopathic lesions immediately before they cause central sensitization and functional movement impairments that may manifest late into life and during sport participation. As early as 1958, Bates and Grunwaldt reported that myofascial pain with trigger areas was a “common clinical entity in childhood” (p. 208). The authors reported on myofascial pain and “trigger areas” in children as young as three years of age and presented a variety of chronic myofascial pain conditions, such as headache, that were treated T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. Special Populations successfully with ethyl chloride spray and procaine hydrochloride injection. In a recent pilot study, researchers investigated the impact of trigger point–specific physiotherapy on tension-type headaches in nine female children ages 5 to 15 (von Stülpnagel et al. 2009). The physiotherapy was applied to the shoulders, neck, and head twice a week over the course of a month and consisted of active and passive stretches, deep-stroking massage, trigger point pressure release, and heat and electrical stimulation. The authors determined improvement through participant self-reported journaling of headache intensity and frequency throughout the treatment phase of the study as well as changes in pain based on the visual analog scale (VAS). Self-reported symptoms reduced by 67.7%; and symptoms reported using the VAS, by 74.3%. The authors attributed the reduction in headache symptoms to interrupting the nociceptive input to the caudal trigeminal nucleus, thereby mitigating the central sensitization caused from myofascial trigger points (MTrPs). Little is known to date about the prevalence of MTrPs and tender points in children, what treatments are most effective for this population, and how the pathophysiology and treatment of MTrPs may differ between children and adults. Additionally, investigations into the long-term consequences of osteopathic lesions in children are lacking. However, based on the clinical implications of chronic active and latent trigger points on the persistence of somatic tissue disorders and function in adults, the early treatment of osteopathic lesions in children warrants significant attention by researchers and clinicians. Therapists should take the following into consideration when using PRT with young patients with osteopathic lesions: CLINICIAN THERAPEUTIC INTERVENTIONS Osteopathic Lesions in the Young • Examine children who complain of persistent pain for the presence of osteopathic lesions. • To avoid central sensitization development in children that may persist late into adulthood, treat osteopathic lesions quickly. • Reduce the use of compressive or traction forces at the joints, and use these forces cautiously to avoid disturbing epiphyseal growth. • Consider ordering a radiograph to ascertain the presence of epiphyseal growth disturbance in the presence of an associated injury mechanism. • Ensure that a parent or legal guardian is present during treatment, particularly when working in sensitive areas. • When young patients do not respond readily (within two or three sessions) to PRT, investigate other causative or underlying factors that may account for the persistence of their somatic dysfunction. • Educate young patients and their caregivers about other therapeutic measures to optimize their treatment and healing. Mastectomy Patients Cancer is the leading cause of death in developed countries and ranks second in developing countries (Mathers, Fat, and Boerma 2008). Approximately 12.7 million cases of cancer occur each year globally, of which 7.6 million result in death. In 2008 the most frequently diagnosed cancer in women was breast cancer (1.38 million cases worldwide); it accounted for 14% (458,400) of cancer deaths (Jemal et al. 2011). In 2000 Andrews, Cofield, and O’Driscoll reported that 1 in 10 American women were affected by breast cancer in their lifetimes. In 2014 the American Cancer Society estimated that one in eight American women (12.4%) are afflicted with invasive breast cancer, equating to 232,670 new cases annually. Of these cases, 62,570 will be new cases of carcinoma situ, an early form of breast cancer; however, 40,000 of the cases overall will result in death. Breast cancer rates are two to five times higher in developed countries such as the United States and the United Kingdom, which has been attributed primarily to early detection and the reduction in the use of combined postmenopausal hormone therapy (Jemal et al. 2011). Fortunately, improvements in the medical management of the disease have resulted in a five-year survival rate of 89% (Ebaugh, Spinelli, and Schmitz 2011). According to Jemal and colleagues (2011), risk factors for developing breast cancer in women are a long menstrual history (1.2–1.3 RR), nulliparity (1.3–1.4 RR), the recent use of postmenopausal hormone therapy (1.3–2.0 RR), late age at first birth (1.1–1.4 RR), alcohol consumption (1.2–1.4 RR), and obesity (1.3–1.6 RR). However, the greatest relative risk (5–30 RR) factor for breast T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. 33 Clinical Guide to Positional Release Therapy cancer has been observed in women who possess a genetic germ-line mutation on chromosome 17q, known as BRCA1, which confers a 39 to 62% lifetime risk (Easton, Ford, and Bishop 1995). The strongest preventive breast cancer recommendation from the National Comprehensive Cancer Network (NCCN) is for women to maintain an acceptable body mass index (BMI) and to remain active throughout life. When preventive measures fail, surgical and radiation interventions are often pursued to address the disease. The classical treatment for breast cancer based on 2014 NCCN guidelines includes two options: breast conservation therapy consisting of a lumpectomy followed by radiation therapy, or a more aggressive approach such as mastectomy with or without radiation. Regardless of the option chosen, complications often result (Andrews et al. 2000) and can persist for several years or more if left unchecked (Ebaugh et al. 2011). Complications that often result from classical treatment are shoulder and chest wall pain, subcutaneous fibrosis, decreased shoulder range of motion, lymphedema, impaired scapulothoracic function, axillary web syndrome, shoulder girdle weakness and altered alignment (Fourie and Robb 2009), and shoulder girdle somatic dysfunction (Ebaugh et al. 2011). One reason a mastectomy patient may complain of shoulder pain and dysfunction is that the somatic dysfunction that ensues from surgery may cause rotator cuff disease (Ebaugh et al. 2011). Shoulder girdle somatic dysfunction, whether driven by active or latent osteopathic lesions, impairs range of motion, strength, and scapulothoracic rhythm (Lucas et al. 2004), which may inhibit the rotator cuff’s ability to stabilize the humeral head in the glenoid fossa. This can result in the impingement of the supraspinatus tendon at the subacromial arch (Ebaugh et al. 2011). Although early detection and survival rates have improved over time, no therapeutic interventions have been found to be superior in addressing the associated surgical complications of mastectomy (Ebaugh et al. 2011; Todd et al. 2008). In our clinical practice, we have found PRT to be an extremely effective tool to address postmastectomy pain, shoulder girdle weakness and range of motion deficits, and resultant shoulder and chest wall somatic dysfunction. Most patients report pain-free ADLs within six weeks. The application of PRT to this population opens the door for effective rehabilitation to occur because it frees hypertonic tissues, thereby 34 taking pressure off lymphatic and vascular tissues. This may improve perfusion-engendering tissue homeostasis, increase strength, and restore shoulder girdle function and range of motion. Most important, PRT dramatically reduces pain at rest and with ADLs, allowing postmastectomy patients to resume normal life and sport activities without physical impairment. Therapists should take the following into consideration when using PRT with mastectomy patients: CLINICIAN THERAPEUTIC INTERVENTIONS Postmastectomy • Perform an evaluation to determine the magnitude of shoulder girdle dysfunction. • Examine the affected tissues for the presence of axillary web syndrome, which may need additional therapeutic and surgical interventions to resolve. • Perform PRT first; then treat recalcitrant tissues with therapeutic ultrasound or another deep heating modality to facilitate collagen reorganization under range of motion restoration procedures. • Use myofascial release and massage postPRT treatment to increase blood flow, relax tissues, and further fascial unwinding. • Educate the patient about chronic pain control methods such as meditation, visual imagery, ADLs, and palliative modalities. • Initiate a progressive therapeutic program to address deficits found in the initial evaluation. • Teach the patient how to self-release affected tissues. Patient Self-Treatment Interventions • Perform self-release daily. • Perform a daily self-massage for five to eight minutes on affected tissues. • Stretch affected tissues daily or after physical activity. • Apply palliative modalities to control pain and spasm. • Meditate or perform relaxation pain control techniques daily to reduce chronic pain. Treatment Points and Sequencing 1. Sternum 2. Xiphoid T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. Special Populations 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Pectoralis minor Pectoralis major Serratus anterior Intercostals Trapezius (upper) Subclavius Infraspinatus Teres minor Rhomboids Levator scapulae at the shoulder Competitive Athletes Critical to treating competitive athletes is addressing injuries and resultant osteopathic lesions as quickly as possible. If the clinician can treat the injury or painful tissue lesion(s), be it a myofascial trigger point (MTrP) or tender point (TP), the potential for these osteopathic lesions and their root injuries to cause alterations in nervous system function may be mitigated. Mense (2003) proposed that if muscle pain is not treated in a timely manner, the prolonged stimulation of inhibitory interneurons may cause dorsal horn neuroplastic changes that can lead to functional reorganization of the spinal dorsal horn. This can cause nociceptive neurons to become dysfunctional and hyperactive, leading to the development of chronic pain. Mense noted that clinicians should “abolish the muscle pain as early and effectively as possible to prevent the central nervous system alterations. If a patient already has developed alterations in the nociceptive system, treatment will be difficult and long-lasting because alterations need time to disappear” (2003, 423). Therefore, evaluating acute and subacute patients for MTrPs and TPs at the time of injury and throughout the recovery process is critical to prevent central sensitization (see figure 3.2). As pointed out previously, an evaluation may reveal both painful active and nonpainful latent trigger points. Both should be treated, because nonpainful latent trigger points have been shown to negatively affect muscle activation and the movement of the shoulder girdle as well as the distal musculature in the arm; conversely, treating them has been shown to normalize muscle activation patterns (Lucas, Polus, and Rich 2004). Unfortunately, regardless of whether an injury is acute or chronic, most competitive athletes have both active and latent osteopathic lesions because Figure 3.2 On-field PRT hamstring procedure performed on a track and field athlete. of the nature of athletic activity, which requires a significant amount of repetitive eccentric work, muscular action over sustained periods leading to fatigue, and the need to react to unforeseen forces (e.g., getting stiff-armed in American football). Repetitive eccentric muscular contractions have been shown to disrupt the cytoskeleton of the muscle fiber, disturb its cellular processes, increase its size because of the contracture, and produce shortening leading to the production of painful taut bands of tissue (Fridén and Lieber 1998). Itoh, Okada, and Kawakita (2004) found active MTrPs in the forearm among 15 healthy subjects after a bout of eccentric exercise of the extensor digitorum. The hyperirritable taut bands that developed in the elbow of subjects demonstrated increased tenderness, altered electrical activity assessed through EMG analysis, and referred pain into the distal extremity. The demand of eccentric work experienced during training and competition coupled with a lack of sleep from a hectic schedule, academic and competitive stress (Gouin and Kiecolt-Glaser 2011; Salinis and Webbe 2012), an underlying nutritional deficiency such as in the female athlete triad T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics. 35 Clinical Guide to Positional Release Therapy (Gerwin 2005; De Souza et al. 2014), or previous injury (Sytema et al. 2010) may play a role in the development and persistence of osteopathic lesions in the competitive athlete. Moreover, Simons (2004) suggested that complaints of regional pain or pain of sudden onset as a result of sustained or sudden muscle overload or repetitive activity may help determine the presence of clinically relevant myofascial trigger points. Therefore, when working with competitive athletes, the following considerations should be taken into account: CLINICIAN THERAPEUTIC INTERVENTIONS Injured Athletes • Use PRT to treat acute injury immediately or as soon as possible. • Consider additional triggers that may propagate the development and persistence of osteopathic lesions (e.g., nutritional deficiency, hormonal disturbance, lack of sleep, stress, muscular fatigue, previous injury). • Consider prescreening athletes for active and latent MTrPs and TPs prior to the start of the season or at its completion to develop a preventive PRT and therapeutic treatment regimen. • Keep in mind that because PRT may produce marked soreness, particularly among chronic pain patients, treatment prior to a game or practice could negatively affect performance. For patients with chronic pain, apply PRT on an off day or after practice to ascertain their post-PRT soreness response. If there is no soreness response, then using PRT prior to or during competitive periods should not be problematic. Pregnant Patients Most women experience low back and pelvic pain at some time during pregnancy and postpartum. Pennick and Liddle (2013) reported that more than two thirds of pregnant women experience back pain, and one fifth experience pelvic pain. The severity of lumbopelvic pain has been reported to increase throughout pregnancy, limiting activities of daily living, sleep, and work (Lillios and Young 2012; Pennick and Liddle 2013). There is no clear consensus about why women develop low back and pelvic girdle pain during pregnancy, but it is believed to be due to anatomical and physiolog36 ical changes that occur during pregnancy such as increased ligamentous laxity, weight gain, and altered pelvic biomechanics (Ritchie 2003). Ritchie (2003) proposed that as a woman progresses through term, the gravid uterus promotes the pelvis to rotate forward, which increases lumbar lordosis, thereby placing an increased mechanical strain on the low back. The shift of the pelvis forward places a call on the sacroiliac ligament to resist its forward rotation. However, as the ligaments become more lax as the hormone relaxin is released, they lose their ability to resist the forward shift, resulting in more low back strain (Ritchie 2003). The hormone relaxin also causes widening of the pubic symphysis at approximately the 10 to 12th week of pregnancy, which may produce inflammation and tenderness (Ritchie 2003). As a result of increased fluid production and retention during pregnancy, women may also experience transient carpal tunnel syndrome and de Quervain syndrome (Khorsan et al. 2009). However, when the clinician is faced with a pregnant woman who complains of hip pain, other differential diagnoses should be considered such as a rupture of the pubic symphysis, osteitis pubis, osteonecrosis and transient osteoporosis of the hip, and lumbar disc pathology (Ritchie 2003). Although low back and pelvic girdle pain are prevalent during pregnancy, no therapeutic intervention to date has demonstrated a superior effect on pregnancy-related low back and pelvic pain and disability (Pennick and Liddle 2013). The authors of several systematic studies (Boissonnault, Klestinski, and Pearcy 2012; Ee et al. 2008; Lillios and Young 2012; Pennick and Liddle 2013) have examined the efficacy of therapeutic interventions for the treatment of pregnancyrelated low back and pelvic girdle pain. The primary interventions examined have been traditional physical therapy, aquatic exercise, osteopathic manipulative therapy (OMT), acupuncture, and physical and manual therapy combined. Although no therapeutic intervention was found to be more effective than any other for relieving pregnancyrelated low back and pelvic pain, evidence suggests that when exercise and acupuncture are tailored to the stage of pregnancy, lumbopelvic pain is reduced (Ee et al. 2008; Pennick and Liddle 2013). However, a low level of evidence exists for using exercise alone to reduce low back and pelvic pain during pregnancy or postpartum (Lillios and Young 2012; Nilsson-Wikmar et al. 2005; Pennick and Liddle 2013). Lillios and Young (2012) and T. Speicher, Clinical Guide to Positional Release Therapy, Champaign, IL: Human Kinetics, 2016). For use only in Positional Release Therapy Course 1–Sport Medics.