Category Archive Fitness

Control Blood Sugar – Super Food Items That May Help

Control Blood Sugar/When your blood sugar levels are higher than normal, carbohydrates such as cereals, pasta, fruits, milk, dessert and bread are usually responsible. When one is diabetic, a meal plan is very important because it guides you on what kind of foods to eat. It should be good enough to fit in your eating habits and also your schedule. A good meal plan should include:

  • Glycemic index
  • Carb counting
  • Plate method

Foods with low glycemic index values are better choices for stabilizing blood sugar than foods with high glycemic index values. The glycemic index basically depends on the physiological ability of dietary carbohydrates to lower or increase the level of blood sugar in reference to the type of food consumed by the diabetic patient. Relatively high glycemic index foods have ratings above 50, and often between 75-100.

The purpose of a good meal plan is to help keep your weight on track, improve your cholesterol level, blood sugars and also blood pressure. According to past research & health educators from the American Diabetes Association (ADA), a healthy diet along with a healthy lifestyle of exercising to maintain a healthy weight can help to reduce diabetes type 2.

Here is a list of 45 foods that can help you to maintain/reduce your blood sugar

1. Beans

These are rich in fibres & help you feel full for longer periods. Beans, including black beans, do contain carbohydrates, but they also contain a significant amount of dietary fibre, protein, and other nutrients that result in a relatively low glycemic index rating.

2. Spinach

This is an all-season vegetable that is a very good source of dietary fibres, vitamins, folate, chlorophyll, manganese, calcium, potassium, zinc, phosphorous, protein and carotene. Spinach’s glycemic index is almost 0 and which is why it is very helpful for diabetic patients for stabilizing blood glucose levels.

3. Collard green

These are a part of the cruciferous vegetable family and include; kale, rutabaga, Brussels, broccoli, sprouts, cabbage, turnips etc. They provide a lot of nutrients at low calories & are known to lower the blood glucose level in patients with type 1 diabetes and stabilized the lipids, insulin and blood glucose level in type 2 diabetics.

4. Mustard greens

Leaf-mustard is very low in calories (27 calories per 100g raw leaves) and fats. However, its dark-green leaves carry ample amounts of phytonutrients, vitamins, and minerals. Additionally, it contains a very good amount of dietary fibre that helps control cholesterol level by interfering with its absorption in the gut.

5. Sweet potatoes

Best amongst the potato family, boiled sweet potatoes have a glycemic index of 44 which is why they are considered a superfood for diabetics. According to the American Journal of Clinical Nutrition, eating sweet potatoes in moderate amounts will help you keep your blood sugar levels in the healthy range even if you have diabetes.

6. Berries

Berries contain a natural sugar called fructose which does not need to be metabolized; hence, the fruit is well tolerated in the body. It’s advisable to take two servings but always monitor what works best for you.

7. Tomatoes

Fresh tomatoes, when consumed in moderation, are not a problem for managing your blood sugar levels. For example, 1 cup of cherry tomatoes contains 5.8 g of carbohydrates and 1.8 g of fibre, which is the equivalent of 4 g of net carbs, while 1 medium whole tomato has 4.8 g of carbohydrates and 1.5 g of fibre, or the equivalent of 3.3 g of net carbs. Its estimated glycemic index is 2 to 4.

8. Oatmeal

Studies have confirmed that eating whole grains and high-fibre foods helps in reducing the risk of diabetes by almost 35 to 42%. Oatmeal consists of high fibre and whole grains. In addition, it consists of soluble fibre that slows down the rate of glucose absorption in the GIT thus ensuring the blood-sugar levels are kept at the right levels.

9. Nuts

According to research from St. Michael’s Hospital and the University of Toronto, eating nuts every day could help control diabetes type 2. It is important to note that nuts have a much lower glycemic index which ranges from 14 to 21. They contain relatively minimal amounts of carbohydrates in comparison to the favourite snacks consumed by most people such as crackers.

10. Mushrooms

Depending on the kind of mushroom you go for, the glycemic index might fluctuate although it is always considered as low. With their unique line of nutritional benefits, it also has the benefit of adding a whole new flavour to a meal. Portabella mushrooms are used as a meat replacement because of their beefy texture and nutritional value. It contains 22 calories per 100g.

11. Cauliflower

Cruciferous vegetables such as cauliflower are very beneficial in terms of glycemic load. These vegetables are often seen in the health news since they are known for their heart disease and anti-cancer characteristics. If taken regularly, this unique blend of phytonutrients is very healthy and absorbed well in the body. One can rotate this kind of vegetables so as to avoid eating the same kind every day.

12. Cherries

These fruits rank pretty low when it comes to the glycemic index. Though not as low as some vegetables it’s considered healthy for diabetic people. It’s definitely a fruit to consider when making a listing of low glycemic index food diet.

13. Coconut

Coconut ranks highly in saturated fats, but if used sparingly, it is not a big threat to your blood glucose levels. Coconuts are used to flavour different types of dishes. Its different parts can be used, be it, coconut milk, coconut flour, its flesh and also coconut water. However, it’s important to know which part you are using to determine the glycemic index as well as nutritional benefits.

14. Apple

They say, an apple a day keeps the doctor away. This is because apples provide you with fibre, vitamin and minerals and a wide range of nutritional benefits while having a low glycemic index of 39. It requires very little preparation, no special storage and is also easy to carry.

15. Peaches

Peaches are a great food to stock in the season. You can enjoy the natural sweetness in them, and when eaten in moderation they can keep the levels of blood sugars in check. Though the GI changes when peaches are used as a part of the dessert, eating fresh peaches shouldn’t raise concerns. Its GI ranking is 28.

16. Whole wheat bread

Whole wheat bread has gained popularity in recent years. This is because white bread is regarded as unhealthy. However, wheat bread is ranked 49 in terms of GI. This is because it’s processed differently from white bread hence, has more nutritional benefits.

17. Carrots

Beta carotene in carrots is known to help with eyesight and also high in vitamin A. When mixed with peas, they can make a very delicious meal and still keep low glycemic. Carrots have a glycemic index of 19.

18. Broccoli

Broccoli is a superfood often seen in almost every healthy food listing. They are known for providing fibre, minerals, vitamins and nutritional value. They have a very low value of 10 on GI scales and therefore, the body can handle it very well.

19. Peas

These contain 81 calories in every 100g serving. They also have high amounts of fibre and a fair amount of potassium. Also, it is a source of vitamin c and protein. Its glycemic index is 39.

20. Milk

Milk is known for providing calcium and vitamin D as well as high protein. Having a glass of milk when you are diabetic is totally acceptable since it falls under the low GI foods with a glycemic index of 31.

21. Yogurt

Yoghurt is known because of its active and live cultures which help in the digestive issues by providing good bacteria. Whether you are eating unsweetened yoghurt or one with artificial sugars, it will still fall under low GI foods. However, low-fat yoghurt is recommended. Its glycemic index is 33. Also, it is advisable to consume natural flavoured yoghurt that is free of any type of artificial sweeteners.

22. Lentils

Lentils are very rich in fibre, minerals and vitamins. They are slowly gaining popularity and are often overlooked when it comes to a blood sugar conscious diet. Their Glycemic index rank is 30.

23. Grapes

Grapes are very sweet and many mistakenly believe they should be avoided when it comes to diabetics dieting. There are various types of grapes one can enjoy eating, be it red or white. Whichever kind you love the glycemic index is considered low & lies between 43 to 53 depending on the kind.

24. Pears

These are often compared to apples but they contain different nutrients as well as taste. They are a great choice when one is considering a low glycemic index food. Their glycemic index rank is 41.

25. Brown rice

Brown rice is one of the common foods that most diabetic people consume. This is because, compared to white rice, a serving is considered to have a glycemic rank of 87 whereas that of brown rice is 55.

26. Peanuts

Peanuts can either be enjoyed as a snack, with butter or even sauce. They are considered legumes and are very good at keeping someone alert. They are also very good at stabilizing blood sugars. Their glycemic index is rank is 6.

27. Hummus

Hummus is made up of chickpeas but ranks lower than them. This is due to other ingredients in them such as lemons, tahini, and olive oil. Their GI is virtually zero but you still need to watch portions so as to avoid gastrointestinal discomfort. The glycemic index is 6.

28. Cashews

These are healthy nuts and can be taken as desired. They act to give you the helping the health of polyunsaturated and monounsaturated fats. It’s also a great source of magnesium and iron. Cashew nut butter is also healthy if one opts for an organic variety. They have a very low GI of 2.

29. Green beans

Green beans are one of the most popular foods often consumed as a side dish. They are relatively low when subjected to GI scale and are also an excellent source of fibre, vitamin c, and minerals. They help strengthen the immune system and also provide antioxidants that help battle free radicals so as to help avoid inflammation. Their Glycemic index rank is 15.

30. Oranges

Oranges are known for their vitamin C content and it’s a great fruit to eat to boost your immune system when you notice early symptoms of a cold. They can be used as a smoothie, morning fruit or an all-time top-up. Its glycemic rank is 40.

31. Plums and prunes

These are considered to be low glycemic foods. Though they may vary in scale, they have a considerable amount of nutrition. The glycemic index for plums is 24 and 29 for prunes.

32. Fish

Fish are good for diabetic patients since it’s an excellent source of low proteins. They are known to be rich in omega 3, a kind of fat that strengthens the heart and prevent diabetes. Including seafood in your diet and having at least two or more servings a week will help a great deal in blood sugar levels reduction.

33. Cinnamon

Although many sprinkle this in our drinks every morning, you might be surprised to realize the health benefits of this wonderful spice. Other than lowering the bad cholesterol, and raising the good cholesterol, cinnamon has been proven to lower blood sugars.

34. Garlic

Many people tend to fear garlic due to bad breath. But garlic extract is known to increase the levels of insulin available for diabetics. It has thereby been proven to reduce the levels of blood sugars.

35. Healthy fats

These are foods such as avocados, nuts, and salmon, tuna, trout and olive oil. They all contain monounsaturated fats that help lower insulin resistance.

36. Chia seeds

Chia seeds are minute dark, seeds with nutty flavours. They are rich in healthy fats, vitamins, fibre, and antioxidants. One of the studies published in ‘Diabetes Care’ found out that Chia seeds play a role in improving blood sugar. Also, it reduces the chances of heart diseases occurring in type-2-diabetic patients.

37. Chili peppers

Capsicum is known to be cultivated for thousands of years and used for food, medicine and also for decorative purposes. The effectiveness of chilli peppers as medicine is that they can activate the transient receptor vanillin. This receptor is associated with neuropathic and inflammatory pain, anxiety and how our bodies process fats. It’s also an important insulin regulator. This study has led to the production of extracts aiming at pharmacological strategies to treat medical conditions such as diabetes.

38. Vinegar

Vinegar has been used for centuries for a variety of health problems, including glucose management, dandruff, excessive sweating, fungal infections, and even heartburn. In a study published in Diabetes Care, two tablespoons of ACV at bedtime helped to regulate fasting blood glucose levels in patients with type II diabetes.

39. Lean meats

Protein foods are an important part of a diet plan. They include; fish, chicken, meats, soy products, and cheese. The difference between these foods is how much fat they contain and protein.

40. Figs

Although dried figs are available throughout the year, there is nothing more refreshing than the unique texture and taste of fresh figs. The leaves of fig have been known to contain anti-diabetic properties and can reduce the level of insulin needed by persons with diabetes.

41. Dates

Dates, along with other healthy but relatively unsafe foods for diabetes like peanuts and honey, often get a bad rap. These foods are, however, good for reducing bad cholesterol or LDL. For diabetics, in particular, portion control of these foods becomes very important.

42. Barley

A cup of cooked whole-grain barley consists of 14 grams of fibre. The fibre is 3g soluble and 11g insoluble. 1 cup of cooked pearl barley consists of 6g fibre which is 2g soluble and 4g insoluble. Diabetic patients experience alterations in blood glucose level after consuming carbohydrate-rich foods. Barley consists of a GI of 25.

43. Pasta

Unlike white bread or potatoes, pasta is pretty low in terms of its glycemic impact. Many people of diabetics fear pasta because of its infamously high carbohydrate nutrients. However, with proper proportions, pasta can be safely indulged in a diabetic diet. Limiting portion size and choosing high-fibre whole grain pasta is the key to keeping the blood sugars low.

44. Quinoa

Quinoa is an excellent item to control your blood sugar. Whole grain with a low glycemic index to support even blood sugar, is packed with protein, fibre, vitamins, minerals, and phytochemicals. Quinoa is easy to cook and flavorful, and you can incorporate it into a healthy diabetic diet in a variety of ways.

45. Apricots

Apricots are sweet and have a delicate flavour. They have a wide range of nutrients and this makes them worthwhile to be added to a diabetic diet. Apricots can help you satisfy your sweet tooth without worrying about your blood sugars due to their low glycemic index. Dried apricots are also a great alternative when eaten in small amounts.

Apart from lowering the blood sugar within a short duration the foods also offer the body other benefits that include boosting body immunity, repairing worn-out cells and checking on most of the lifestyle diseases. However, this is not an exhaustive list of food items that can be eaten to control blood sugars. This list is meant to guide you on some of the locally available foods that have a low GI and which can be considered when regulating the blood sugar in the body. For those who are suffering from very high blood sugar levels, it is advisable that they seek the advice of a dietitian, clinical nutritionist and their family doctors so as to come up with the best treatment plan besides healthy eating.

Breathing Exercise and Techniques for Stress Relief

Breathing Exercise and Techniques for Stress Relief/Breathing is a necessity of life that usually occurs without much thought. When you breathe in air, blood cells receive oxygen and release carbon dioxide. Carbon dioxide is a waste product that’s carried back through your body and exhaled.

breathing also goes by the names of diaphragmatic breathing, abdominal breathing, belly breathing, and paced respiration. When you breathe deeply, the air coming in through your nose fully fills your lungs, and the lower belly rises.

For many of us, deep breathing seems unnatural. There are several reasons for this. For one, body image has a negative impact on respiration in our culture. A flat stomach is considered attractive, so women (and men) tend to hold in their stomach muscles. This interferes with deep breathing and gradually makes shallow “chest breathing” seem normal, which increases tension and anxiety.

Shallow breathing limits the diaphragm’s range of motion. The lowest part of the lungs doesn’t get a full share of oxygenated air. That can make you feel short of breath and anxious.

Deep abdominal breathing encourages full oxygen exchange — that is, the beneficial trade of incoming oxygen for outgoing carbon dioxide. Not surprisingly, it can slow the heartbeat and lower or stabilize blood pressure.

Improper breathing can upset the oxygen and carbon dioxide exchange and contribute to anxiety, panic attacks, fatigue, and other physical and emotional disturbances.

Breathing Exercise and Techniques for Stress Relief

If you’re interested in trying breathing exercises to reduce stress or anxiety or improve your lung function, we’ve got 10 different ones to sample. You may find that certain exercises appeal to you right away. Start with those so that the practice is more enjoyable.

How to add breathing exercises to your day

Breathing exercises don’t have to take a lot of time out of your day. It’s really just about setting aside some time to pay attention to your breathing. Here are a few ideas to get started:

  • Begin with just 5 minutes a day, and increase your time as the exercise becomes easier and more comfortable.
  • If 5 minutes feels too long, start with just 2 minutes.
  • Practice multiple times a day. Schedule set times or practice conscious breathing as you feel the need.

1. Pursed lip breathing

  • This simple breathing technique makes you slow down your pace of breathing by having you apply deliberate effort in each breath.
  • You can practice pursed-lip breathing at any time. It may be especially useful during activities such as bending, lifting, or stair climbing.
  • Practice using this breath 4 to 5 times a day when you begin in order to correctly learn the breathing pattern.

To do it

  • Relax your neck and shoulders.
  • Keeping your mouth closed, inhale slowly through your nose for 2 counts.
  • Pucker or purse your lips as though you were going to whistle.
  • Exhale slowly by blowing air through your pursed lips for a count of 4.

2. Diaphragmatic breathing

  • Belly breathing can help you use your diaphragm properly. Do belly breathing exercises when you’re feeling relaxed and rested.
  • Practice diaphragmatic breathing for 5 to 10 minutes 3 to 4 times per day.
  • When you begin you may feel tired, but over time the technique should become easier and should feel more natural.

To do it

  • Lie on your back with your knees slightly bent and your head on a pillow.
  • You may place a pillow under your knees for support.
  • Place one hand on your upper chest and one hand below your rib cage, allowing you to feel the movement of your diaphragm.
  • Slowly inhale through your nose, feeling your stomach pressing into your hand.
  • Keep your other hand as still as possible.
  • Exhale using pursed lips as you tighten your stomach muscles, keeping your upper hand completely still.

You can place a book on your abdomen to make the exercise more difficult. Once you learn how to do belly breathing lying down you can increase the difficulty by trying it while sitting in a chair. You can then practice the technique while performing your daily activities.

3. Breath focus technique

  • This deep breathing technique uses imagery or focuses words and phrases.
  • You can choose a focus word that makes you smile, feel relaxed, or that is simply neutral to think about. Examples include peacelet go, or relaxation, but it can be any word that suits you to focus on and repeat through your practice.
  • As you build up your breath focus practice you can start with a 10-minute session. Gradually increase the duration until your sessions are at least 20 minutes.

To do it

  • Sit or lie down in a comfortable place.
  • Bring your awareness to your breaths without trying to change how you’re breathing.
  • Alternate between normal and deep breaths a few times. Notice any differences between normal breathing and deep breathing. Notice how your abdomen expands with deep inhalations.
  • Note how shallow breathing feels compared to deep breathing.
  • Practice your deep breathing for a few minutes.
  • Place one hand below your belly button, keeping your belly relaxed, and notice how it rises with each inhales and falls with each exhale.
  • Let out a loud sigh with each exhale.
  • Begin the practice of breath focus by combining this deep breathing with imagery and a focused word or phrase that will support relaxation.
  • You can imagine that the air you inhale brings waves of peace and calm throughout your body. Mentally say, “Inhaling peace and calm.”
  • Imagine that the air you exhale washes away tension and anxiety. You can say to yourself, “Exhaling tension and anxiety.

4. Lion’s breath

  • Lion’s breath is an energizing yoga breathing practice that is said to relieve tension in your chest and face.
  • It’s also known in yoga as Lion’s Pose or simhasana in Sanskrit.

To do this

  • Come into a comfortable seated position. You can sit back on your heels or cross your legs.
  • Press your palms against your knees with your fingers spread wide.
  • Inhale deeply through your nose and open your eyes wide.
  • At the same time, open your mouth wide and stick out your tongue, bringing the tip down toward your chin.
  • Contract the muscles at the front of your throat as you exhale out through your mouth by making a long “ha” sound.
  • You can turn your gaze to look at the space between your eyebrows or the tip of your nose.
  • Do this breath 2 to 3 times.

5. Alternate nostril breathing

  • Alternate nostril breathing, known as nadi shodhana pranayama in Sanskrit, is a breathing practice for relaxation.
  • Alternate nostril breathing has been shown to enhance cardiovascular function and lower heart rate.
  • Nadi shodhana is best practiced on an empty stomach. Avoid the practice if you’re feeling sick or congested. Keep your breath smooth and even throughout the practice.

To do this

  • Choose a comfortable seated position.
  • Lift up your right hand toward your nose, pressing your first and middle fingers down toward your palm and leaving your other fingers extended.
  • After an exhale, use your right thumb to gently close your right nostril.
  • Inhale through your left nostril and then close your left nostril with your right pinky and ring fingers.
  • Release your thumb and exhale out through your right nostril.
  • Inhale through your right nostril and then close this nostril.
  • Release your fingers to open your left nostril and exhale through this side.
  • This is one cycle.
  • Continue this breathing pattern for up to 5 minutes.
  • Finish your session with an exhale on the left side.

6. Equal breathing

  • Equal breathing is known as sama vritti in Sanskrit. This breathing technique focuses on making your inhales and exhales the same length. Making your breath smooth and steady can help bring about balance and equanimity.
  • You should find a breath length that is not too easy and not too difficult. You also want it to be too fast, so that you’re able to maintain it throughout the practice. Usually, this is between 3 and 5 counts.
  • Once you get used to equal breathing while seated you can do it during your yoga practice or other daily activities.

To do it

  • Choose a comfortable seated position.
  • Breathe in and out through your nose.
  • Count during each inhale and exhale to make sure they are even in duration. Alternatively, choose a word or short phrase to repeat during each inhale and exhale.
  • You can add a slight pause or breath retention after each inhales and exhales if you feel comfortable. (Normal breathing involves a natural pause.)
  • Continue practicing this breath for at least 5 minutes.

7. Resonant or coherent breathing

  • Resonant breathing, also known as coherent breathing, is when you breathe at a rate of 5 full breaths per minute. You can achieve this rate by inhaling and exhaling for a count of 5.
  • Breathing at this rate maximizes your heart rate variability (HRV), reduces stress, and, according to one 2017 study, can reduce symptoms of depression when combined with Iyengar yoga.

To do this

  • Inhale for a count of 5.
  • Exhale for a count of 5.
  • Continue this breathing pattern for at least a few minutes.

8. Sitali breath

  • This yoga breathing practice helps you lower your body temperature and relax your mind.
  • Slightly extend your breath in length but don’t force it. Since you inhale through your mouth during Sitali breath, you may want to choose a place to practice that’s free of any allergens that affect you and air pollution.

To do this

  • Choose a comfortable seated position.
  • Stick out your tongue and curl your tongue to bring the outer edges together.
  • If your tongue doesn’t do this, you can pursue your lips.
  • Inhale through your mouth.
  • Exhale out through your nose.
  • Continue breathing like this for up to 5 minutes.

9. Deep breathing

  • Deep breathing helps to relieve shortness of breath by preventing air from getting trapped in your lungs and helping you to breathe in the more fresh air. It may help you to feel more relaxed and centered.

To do this

  • While standing or sitting, draw your elbows back slightly to allow your chest to expand.
  • Take a deep inhalation through your nose.
  • Retain your breath for a count of 5.
  • Slowly release your breath by exhaling through your nose.

10. Humming bee breath (bhramari)

  • The unique sensation of this yoga breathing practice helps to create an instant calm and is especially soothing around your forehead.
  • Some people use humming bee breaths to relieve frustration, anxiety, and anger. Of course, you’ll want to practice it in a place where you are free to make a humming sound.

To do this

  • Choose a comfortable seated position.
  • Close your eyes and relax your face.
  • Place your first fingers on the tragus cartilage that partially covers your ear canal.
  • Inhale, and as you exhale gently press your fingers into the cartilage.
  • Keeping your mouth closed, make a loud humming sound.
  • Continue for as long as is comfortable.

You can try most of these breath exercises right away. Take the time to experiment with different types of breathing techniques. Dedicate a certain amount of time at least a few times per week. You can do these exercises throughout the day.

Check-in with your doctor if you have any medical concerns or take any medications. If you want to learn more about breathing practices you can consult a respiratory therapist or a yoga teacher who specializes in breathing practices. Discontinue the practice if you experience any feelings of discomfort or agitation.

The 9 Best Breathing Techniques for Sleep

If you find it difficult to fall asleep, you’re not alone.

According to the American Sleep Association (ASA), insomnia is the most common sleep disorder. About 30 percent of American adults report short-term problems, and 10 percent experience chronic trouble falling or staying asleep.

Our busy and fast-paced society, filled with homework, long work days, financial strains, parenting burnout, or other emotionally exhausting situations, can make it difficult to unwind, calm down, and get restful sleep. When it’s hard to sleep, focusing on your breath may help.

Let’s take a look at some breathing exercises to calm your mind and body to help you fall asleep.

Things to remember before getting started

Although there are a number of breathing exercises you can try to relax and fall asleep, a few basic principles apply to all of them.

It’s always a good idea to close your eyes, which may help you shut out distractions. Focus on your breathing and think about the healing power of your breath.

Each of these nine different exercises has slightly different benefits. Try them and see which one is the best match for you. Soon you’ll be sleeping like a baby.

1. 4-7-8 breathing technique

Here’s how to practice the 4-7-8 breathing technique:

  • Allow your lips to gently part.
  • Exhale completely, making a breathy whoosh sound as you do.
  • Press your lips together as you silently inhale through the nose for a count of 4 seconds.
  • Hold your breath for a count of 7.
  • Exhale again for a full 8 seconds, making a whooshing sound throughout.
  • Repeat 4 times when you first start. Eventually, work up to 8 repetitions.

Dr. Andrew Weil developed this technique as a variation of pranayama, an ancient yogic technique that helps people relax as it replenishes oxygen in the body.

2. Bhramari pranayama breathing exercise

These steps will help you perform the original Bhramari pranayama breathing exercise:

  • Close your eyes and breathe deeply in and out.
  • Cover your ears with your hands.
  • Place your index fingers one each above your eyebrows and the rest of your fingers over your eyes.
  • Next, put gentle pressure to the sides of your nose and focus on your brow area.
  • Keep your mouth closed and breathe out slowly through your nose, making the humming “Om” sound.
  • Repeat the process 5 times.

In clinical studies Bhramari pranayama has been shown to quickly reduce breathing and heart rate. This tends to be very calming and can prepare your body for sleep.

3. Three-part breathing exercise

To practice the three-part breathing exercise, follow these three steps:

  • Take a long, deep inhale.
  • Exhale fully while focusing intently on your body and how it feels.
  • After doing this a few times, slow down your exhale so that it’s twice as long as your inhale.

4. Diaphragmatic breathing exercise

To do diaphragmatic breathing exercises:

  • Lie on your back and either bend your knees over a pillow or sit in a chair.
  • Place one hand flat against your chest and the other on your stomach.
  • Take slow, deep breaths through your nose, keeping the hand on your chest still as the hand on your stomach rises and falls with your breaths.
  • Next, breathe slowly through pursed lips.
  • Eventually, you want to be able to breathe in and out without your chest moving.

This technique slows your breathing and decreases your oxygen needs as it strengthens your diaphragm.

5. Alternate nasal breathing exercise

Here are the steps for the alternate nasal or alternate nostril breathing exercise, also called nadi shodhana pranayama:

  • Sit with your legs crossed.
  • Place your left hand on your knee and your right thumb against your nose.
  • Exhale fully and then close the right nostril.
  • Inhale through your left nostril.
  • Open your right nostril and exhale through it, while closing the left.
  • Continue this rotation for 5 minutes, finishing by exhaling through your left nostril.

2013 study reported that people who tried nasal breathing exercises felt less stressed afterward.

6. Buteyko breathing

To practice buteyko breathing for sleep:

  • Sit in bed with your mouth gently closed (not pursed) and breathe through your nose at a natural pace for about 30 seconds.
  • Breathe a bit more intentionally in and out through your nose once.
  • Gently pinch your nose closed with your thumb and forefinger, keeping your mouth closed as well, until you feel that you need to take a breath again.
  • With your mouth still closed, take a deep breath in and out through your nose again.

Many people don’t realize that they are hyperventilating. This exercise helps you to reset to a normal breathing rhythm.

7. The Papworth method

In the Papworth method, you focus on your diaphragm to breathe more naturally:

  • Sit up straight, perhaps in bed if using this to fall asleep.
  • Take deep, methodical breaths in and out, counting to 4 with each inhale — through your mouth or nose — and each exhale, which should be through your nose.
  • Focus on your abdomen rising and falling, and listen for your breath sounds to come from your stomach.

This relaxing method is helpful for reducing habits of yawning and sighing.

8. Kapalbhati breathing exercise

Kapalbhati breathing involves a series and inhaling and exhaling exercises, involving these steps, as outlined by the Art of Living:

  • Sit in a comfortable position with your spine straight. Place your hands on your knees, palms facing the sky. You may choose to sit cross-legged on the floor, on a chair with feet flat on the floor, or in Virasana Pose (sitting on your heels with knees bent and shins tucked beneath the thighs).
  • Take a deep breath in.
  • As you exhale, contract your belly, forcing the breath out in a short burst. You may keep a hand on your stomach to feel your abdominal muscles contract.
  • As you quickly release your abdomen, your breath should flow into your lungs automatically.
  • Take 20 such breaths to complete one round of Kapalbhati pranayama.
  • After completing one round, relax with your eyes closed and observe the sensations in your body.
  • Do two more rounds to complete your practice.

Kapalbhati breathing has been reported as helping open the sinuses and improving concentration. It’s considered an advanced breathing technique. It’s advisable to master other techniques, such as Bhramari pranayama, before attempting this one.

9. Box breathing

During box breathing, you want to focus intently on the oxygen you’re bringing in and pushing out:

  • Sit with your back straight, breathe in, and then try to push all the air out of your lungs as you exhale.
  • Inhale slowly through your nose and count to 4 in your head, filling your lungs with more air with each number.
  • Hold your breath and count to 4 in your head.
  • Slowly exhale through your mouth, focusing on getting all the oxygen out of your lungs.

Box breathing is a common technique during meditation, a very popular method of finding mental focus and relaxing. Meditation has a variety of known benefits for your overall health.

No matter which type of breathing exercise you prefer, the evidence is clear that breathing exercises can help you on relax, sleep, breathe more naturally and effectively

With so many varieties to choose from, you may find yourself fast asleep before you know it.

Breathing Exercises with COPD

Chronic obstructive pulmonary disease (COPD) is a health condition that affects an individual’s ability to breathe well. It’s often associated with other conditions such as emphysema and chronic bronchitis.

Symptoms include:

  • wheezing
  • chest tightness
  • shortness of breath
  • large amounts of mucus that collect in the lungs

These can worsen with time, but practicing breathing exercises can help you manage them.

When you practice regularly, breathing exercises can help you exert yourself less during daily activities. They can also potentially aid in your return to exercising, which can lead to you feeling more energetic overall.

Read on to learn about these five exercises that can be especially useful for people with COPD

  • pursed-lip breathing
  • coordinated breathing
  • deep breathing
  • huff cough
  • diaphragmatic breathing

Pursed lip breathing

According to the Cleveland Clinic, pursed-lip breathing has a range of benefits:

  • It’s been shown to reduce how hard you have to work to breathe.
  • It helps release the air trapped in the lungs.
  • It promotes relaxation.
  • It reduces shortness of breath.

Practicing this technique 4 to 5 times daily can help. Here’s how to practice pursed-lip breathing

  • While keeping your mouth closed, take a deep breath in through your nose, counting to 2. Follow this pattern by repeating in your head “inhale, 1, 2.” The breath doesn’t have to be deep. A typical inhale will do.
  • Put your lips together as if you’re starting to whistle or blow out candles on a birthday cake. This is known as “pursing” your lips.
  • While continuing to keep your lips pursed, slowly breathe out by counting to 4. Don’t try to force the air out, but instead breathe out slowly through your mouth.

Exercise tip: Pursed lip breathing is best for performing strenuous activities, such as climbing stairs.

Coordinated breathing

Feeling short of breath can cause anxiety that makes you hold your breath. To prevent this from occurring, you can practice coordinated breathing using these two steps:

  • Inhale through your nose before beginning an exercise.
  • While pursuing your lips, breathe out through your mouth during the most strenuous part of the exercise. An example could be when curling upward on a bicep curl.

Exercise tip: Coordinated breathing can be performed when you’re exercising or feeling anxious.

Deep breathing

Deep breathing prevents air from getting trapped in your lungs, which can cause you to feel short of breath. As a result, you can breathe in more fresh air.

Here’s how to practice deep breathing

  • Sit or stand with your elbows slightly back. This allows your chest to expand more fully.
  • Inhale deeply through your nose.
  • Hold your breath as you count to 5.
  • Release the air via a slow, deep exhale, through your nose, until you feel your inhaled air has been released.

Exercise tip: It’s best to do this exercise with other daily breathing exercises that can be performed for 10 minutes at a time, 3 to 4 times per day.

Huff cough

  • When you have COPD, mucus can build up more easily in your lungs. The huff cough is a breathing exercise designed to help you cough up mucus effectively without making you feel too tired.

Here’s how to practice the huff cough

  • Place yourself in a comfortable seated position. Inhale through your mouth, slightly deeper than you would when taking a normal breath.
  • Activate your stomach muscles to blow the air out in three even breaths while making the sounds “ha, ha, ha.” Imagine you’re blowing onto a mirror to cause it to steam.

Exercise tip: A huff cough should be less tiring than a traditional cough, and it can keep you from feeling worn out when coughing up mucus.

Diaphragmatic breathing

  • The diaphragm is an important muscle involved in the work of breathing.
  • People with COPD tend to rely more on the accessory muscles of the neck, shoulders, and back to breathe, rather than on the diaphragm.

Diaphragmatic or abdominal breathing helps to retrain this muscle to work more effectively. Here’s how to do it

  • While sitting or lying down with your shoulders relaxed, put a hand on your chest and place the other hand on your stomach.
  • Take a breath in through your nose for 2 seconds, feeling your stomach move outward. You’re doing the activity correctly if your stomach moves more than your chest.
  • Purse your lips and breathe out slowly through your mouth, pressing lightly on your stomach. This will enhance your diaphragm’s ability to release air.
  • Repeat the exercise as you are able to.

Exercise tip: This technique can be more complicated than the other exercises, so it’s best for a person with a little more practice under their belt. If you’re having difficulty, talk to your doctor or respiratory therapist.

According to the American Academy of Family Physicians (AAFP), people with COPD who use breathing exercises experience greater improvements in exercise capacity than those who don’t.

9 Home Treatments for Shortness of Breath (Dyspnea)

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Shortness of breath, or dyspnea, is an uncomfortable condition that makes it difficult to fully get air into your lungs. Problems with your heart and lungs can harm your breathing.

Some people may experience shortness of breath suddenly for short periods of time. Others may experience it over the long term — several weeks or more.

In light of the 2020 COVID-19 pandemic, shortness of breath has become widely associated with this illness. Other common symptoms of COVID-19 include dry cough and fever.

Most people who develop COVID-19 will only experience mild symptoms. However, seek emergency medical attention if you experience:

  • trouble breathing
  • persistent tightness in your chest
  • blue lips
  • mental confusion

If your shortness of breath isn’t caused by a medical emergency, you could try several types of home treatments that are effective at helping alleviate this condition. Many simply involve changing position, which can help relax your body and airways.

Here are nine home treatments you can use to alleviate your shortness of breath:

1. Pursed-lip breathing

  • This is a simple way to control shortness of breath. It helps quickly slow your pace of breathing, which makes each breath deeper and more effective
  • It also helps release air that’s trapped in your lungs. It can be used any time you’re experiencing shortness of breath, especially during the difficult part of an activity, such as bending, lifting objects, or climbing stairs.

To perform pursed-lip breathing

  • Relax your neck and shoulder muscles.
  • Slowly breathe in through your nose for two counts, keeping your mouth closed.
  • Purse your lips as if you’re about to whistle.
  • Breathe out slowly and gently through your pursed lips to the count of four.

2. Sitting forward

Resting while sitting can help relax your body and make breathing easier.

  • Sit in a chair with your feet flat on the floor, leaning your chest slightly forward.
  • Gently rest your elbows on your knees or hold your chin with your hands. Remember to keep your neck and shoulder muscles relaxed.

3. Sitting forward supported by a table

If you have both a chair and table to use, you may find this to be a slightly more comfortable sitting position in which to catch your breath.

  • Sit in a chair with your feet flat on the floor, facing a table.
  • Lean your chest slightly forward and rest your arms on the table.
  • Rest your head on your forearms or on a pillow.

4. Standing with a supported back

Standing can also help relax your body and airways.

  • Stand near a wall, facing away, and rest your hips on the wall.
  • Keep your feet shoulder-width apart and rest your hands on your thighs.
  • With your shoulders relaxed, lean slightly forward, and dangle your arms in front of you.

5. Standing with supported arms

  • Stand near a table or other flat, sturdy piece of furniture that’s just below the height of your shoulder.
  • Rest your elbows or hands on the piece of furniture, keeping your neck relaxed.
  • Rest your head on your forearms and relax your shoulders.

6. Sleeping in a relaxed position

  • Many people experience shortness of breath while they sleep. This can lead to waking up frequently, which can diminish the quality and duration of your sleep.
  • Try lying on your side with a pillow between your legs and your head elevated by pillows, keeping your back straight. Or lie on your back with your head elevated and your knees bent, with a pillow under your knees.
  • Both of these positions help your body and airways relax, making breathing easier. Have your doctor assess you for sleep apnea and use a CPAP machine if recommended.

7. Diaphragmatic breathing

Diaphragmatic breathing can also help your shortness of breath. To try this breathing style

  • Sit in a chair with bent knees and relaxed shoulders, head, and neck.
  • Place your hand on your belly.
  • Breathe in slowly through your nose. You should feel your belly moving under your hand.
  • As you exhale, tighten your muscles. You should feel your belly fall inward. Breathe out through your mouth with pursed lips.
  • Put more emphasis on the exhale than the inhale. Keep exhaling for longer than usual before slowly inhaling again.
  • Repeat for about 5 minutes.

8. Using a fan

  • One study found that cool air can help relieve shortness of breath. Pointing a small handheld fan toward your face can help your symptoms.

9. Drinking coffee

  • An early study indicated that caffeine relaxes the muscles in the airways of people with asthma. This can help improve lung function for up to four hours.

Lifestyle changes to treat shortness of breath

  • There are many possible causes of shortness of breath, some of which are serious and require emergency medical care. Less serious cases can be treated at home.

Lifestyle changes you can make to help keep shortness of breath at bay include

  • quitting smoking and avoiding tobacco smoke
  • avoiding exposure to pollutants, allergens, and environmental toxins
  • losing weight if you have obesity or overweight
  • avoiding exertion at high elevations
  • staying healthy by eating well, getting enough sleep, and seeing a doctor for any underlying medical issues
  • following the recommended treatment plan for any underlying illness such as asthma, COPD, or bronchitis

Remember, only a doctor can properly diagnose the cause of your shortness of breath.

Box Breathing

Box breathing, also known as square breathing, is a technique used when taking slow, deep breaths. It can heighten performance and concentration while also being a powerful stress reliever. It’s also called four-square breathing.

This technique can be beneficial to anyone, especially those who want to meditate or reduce stress. It’s used by everyone from athletes to U.S. Navy SEALs, police officers, and nurses.

You may find it particularly helpful if you have a lung disease such as chronic obstructive pulmonary disease (COPD).

Getting started with box breathing

Before you get started, make sure that you’re seated upright in a comfortable chair with your feet flat on the floor. Try to be in a stress-free, quiet environment where you can focus on your breathing.

Keeping your hands relaxed in your lap with your palms facing up, focus on your posture. You should be sitting up straight. This will help you take deep breaths.

When you’re ready, start with step 1.

  • Step 1: Slowly exhale – Sitting upright, slowly exhale through your mouth, getting all the oxygen out of your lungs. Focus on this intention and be conscious of what you’re doing.
  • Step 2: Slowly inhale – Inhale slowly and deeply through your nose to the count of four. In this step, count to four very slowly in your head. Feel the air fill your lungs, one section at a time until your lungs are completely full and the air moves into your abdomen.
  • Step 3: Hold your breath – Hold your breath for another slow count of four.
  • Step 4: Exhale again – Exhale through your mouth for the same slow count of four, expelling the air from your lungs and abdomen, Be conscious of the feeling of the air leaving your lungs.
  • Step 5: Hold your breath again. Hold your breath for the same slow count of four before repeating this process.

Benefits of box breathing

According to the Mayo Clinic, there’s sufficient evidence that intentional deep breathing can actually calm and regulate the autonomic nervous system (ANS).

  • This system regulates involuntary body functions such as temperature. It can lower blood pressure and provide an almost immediate sense of calm.
  • The slow holding of breath allows CO2 to build up in the blood. An increased blood CO2 enhances the cardio-inhibitory response of the vagus nerve when you exhale and stimulates your parasympathetic system. This produces a calm and relaxed feeling in the mind and body.
  • Box breathing can reduce stress and improve your mood. That makes it an exceptional treatment for conditions such as generalized anxiety disorder (GAD), panic disorder, post-traumatic stress disorder (PTSD), and depression.
  • It can also help treat insomnia by allowing you to calm your nervous system at night before bed. Box breathing can even be efficient at helping with pain management.

Tips for beginners

  • If you’re new to box breathing, it may be difficult to get the hang of it. You may get dizzy after a few rounds. This is normal. As you practice it more often, you’ll be able to go longer without dizziness. If you get dizzy, stay sitting for a minute and resume normal breathing.
  • To help you focus on your breathing, find a quiet, dimly lit environment to practice box breathing. This isn’t at all necessary to perform the technique, but it can help you focus on the practice if you’re new to it.
  • Ideally, you’ll want to repeat the box breathing cycle four times in one sitting.
  • Do box breathing several times a day as needed to calm your nerves and relieve stress

5 Ways to Keep Your Lungs Healthy and Whole

Most people want to get healthier. Rarely, though, do they think about protecting and maintaining the health of their lungs.

It’s time to change that. According to the National Heart, Blood, and Lung InstituteTrusted Source, chronic lower respiratory diseases — including chronic obstructive pulmonary disease (COPD) and asthma — were the third leading cause of death in 2010. Lung diseases, excluding lung cancer, caused an estimated 235,000 deaths that year.

Include lung cancer, and the numbers go up. The American Lung Association (ALA) states that lung cancer is the leading cause of cancer deaths in both men and women. An estimated 158,080 Americans were expected to die from it in 2016.

The truth is that your lungs, just like your heart, joints, and other parts of your body, age with time. They can become less flexible and lose their strength, which can make it more difficult to breathe. But by adopting certain healthy habits, you can better maintain the health of your lungs, and keep them working optimally even into your senior years.

1. Don’t smoke or stop smoking

  • You probably already know that smoking increases your risk of lung cancer. But that’s not the only disease it can cause. In fact, smoking is linked to most lung diseases, including COPD, idiopathic pulmonary fibrosis, and asthma. It also makes those diseases more severe. Smokers are 12 to 13 times more likely to die from COPD than nonsmokers, for example.
  • Every time you smoke a cigarette, you inhale thousands of chemicals into your lungs, including nicotine, carbon monoxide, and tar. These toxins damage your lungs. They increase mucus, make it more difficult for your lungs to clean themselves, and irritate and inflame tissues. Gradually, your airways narrow, making it more difficult to breathe.
  • Smoking also causes lungs to age more rapidly. Eventually, the chemicals can change lung cells from normal to cancerous.
  • According to the Centers for Disease Prevention and Control (CDC), more than 10 times as many U.S. citizens have died prematurely from cigarette smoking than have died in all the wars fought by the U.S. during its history. In addition, smoking causes about 90 percent of all lung cancer deaths in men and women. More women die from lung cancer each year than from breast cancer.
  • No matter how old you are or how long you’ve been a smoker, quitting can help. The ALA states that within just 12 hours of quitting, the carbon monoxide level in your blood drops to normal. Within a few months, your lung function begins to improve. Within a year, your risk of coronary heart disease is half that of a smoker’s. And it only gets better the longer you stay smoke-free.
  • Quitting usually takes several attempts. It’s not easy, but it’s worth it. Combining counseling and medication may be the best way to succeed, according to a report by the Agency for Healthcare Research and Quality.

2. Exercise to breathe harder

  • Besides avoiding cigarettes, getting regular exercise is probably the most important thing you can do for the health of your lungs. Just as exercise keeps your body in shape, it keeps your lungs in shape too.
  • When you exercise, your heart beats faster and your lungs work harder. Your body needs more oxygen to fuel your muscles. Your lungs step up their activity to deliver that oxygen while expelling additional carbon dioxide.
  • According to a recent article, during exercise, your breathing increases from about 15 times a minute to about 40 to 60 times a minute. That’s why it’s important to regularly do aerobic exercise that gets you breathing hard.
  • This type of exercise provides the best workout for your lungs. The muscles between your ribs expand and contract, and the air sacs inside your lungs work quickly to exchange oxygen for carbon dioxide. The more you exercise, the more efficient your lungs become.
  • Creating strong, healthy lungs through exercise helps you to better resist aging and disease. Even if you do develop lung disease down the road, exercise helps to slow the progression and keeps you active longer.

3. Avoid exposure to pollutants

  • Exposure to pollutants in the air can damage your lungs and accelerate aging. When they’re young and strong, your lungs can easily resist these toxins. As you get older, though, they lose some of that resistance and become more vulnerable to infections and disease.

Give your lungs a break. Reduce your exposure as much as you can

  • Avoid secondhand smoke, and try not to go outside during peak air pollution times.
  • Avoid exercising near heavy traffic, as you can inhale the exhaust.
  • If you’re exposed to pollutants at work, be sure to take all possible safety precautions. Certain jobs in construction, mining, and waste management can increase the risk of exposure to airborne pollutants.

The U.S. Consumer Product Safety Commission reports that indoor pollution is typically worse than outdoor. That, plus the fact that many spend most of their time indoors these days, increases exposure to indoor pollutants.

Here are some tips for decreasing indoor pollutants

  • Make your home a smoke-free zone.
  • Dust the furniture and vacuum at least once a week.
  • Open a window frequently to increase indoor air ventilation.
  • Avoid synthetic air fresheners and candles that can expose you to additional chemicals like formaldehyde and benzene. Instead, use an aromatherapy diffuser and essential oils to more naturally scent the air.
  • Keep your home as clean as you can. Mold, dust, and pet dander can all get into your lungs and cause irritation.
  • Use natural cleaning products when possible, and open a window when using products that create fumes.
  • Make sure you have adequate fans, exhaust hoods, and other ventilation methods throughout your home.

4. Prevent infections

  • Infections can be particularly dangerous for your lungs, especially as you age. Those who already have lung diseases like COPD are particularly at risk for infections. Even healthy seniors, though, can easily develop pneumonia if they’re not careful.
  • The best way to avoid lung infections is to keep your hands clean. Wash regularly with warm water and soap, and avoid touching your face as much as possible.
  • Drink plenty of water and eat lots of fruits and vegetables — they contain nutrients that help boost your immune system.
  • Stay up-to-date with your vaccinations. Get a flu shot each year, and if you’re 65 or older, get a pneumonia vaccination as well.

5. Breathe deeply

  • If you’re like many people, you take shallow breaths from your chest area, using only a small portion of your lungs. Deep breathing helps clear the lungs and creates a full oxygen exchange.
  • In a small study published in the Indian Journal of Physiology and Pharmacology researchers had a group of 12 volunteers perform deep breathing exercises for 2, 5, and 10 minutes. They tested the volunteers’ lung function both before and after the exercises.
  • They found that there was a significant increase in vital capacity after 2 and 5 minutes of deep breathing exercise. Vital capacity is the maximum amount of air the volunteers could exhale from their lungs. The researchers concluded that deep breathing, even for just a few minutes, was beneficial for lung function.
  • The ALA agrees that breathing exercises can make your lungs more efficient. To try it yourself, sit somewhere quietly, and slowly breathe in through your nose alone. Then breathe out at least twice as long through your mouth. It may help to count your breaths. For example, as you inhale count 1-2-3-4. Then as you exhale, count 1-2-3-4-5-6-7-8.
  • Shallow breaths come from the chest, and deeper breaths come from the belly, where your diaphragm sits. Be aware of your belly rising and falling as you practice. When you do these exercises, you may also find you feel less stressed and more relaxed

8 Deep Breathing Exercises to Reduce Anxiety

Chest vs. Abdominal Breathing

Most people aren’t really conscious of the way they’re breathing, but generally, there are two types of breathing patterns

  • Diaphragmatic (abdominal) breathing: This type of breathing is a type of deep, even breathing that engages your diaphragm, allowing your lungs to expand and creating negative pressure that drives air in through the nose and mouth, filling your lungs with air.3 This is the way newborn babies naturally breathe. You’re also probably using this pattern of breathing when you’re in a relaxed stage of sleep.
  • Thoracic (chest) breathing: This type of breathing comes from the chest and involves short, rapid breaths. When you’re anxious, you might not even be aware that you’re breathing this way. The easiest way to determine your breathing pattern is to put one hand on your upper abdomen near the waist and the other in the middle of your chest. As you breathe, notice which hand raises the most.

If you’re breathing properly, your abdomen should expand and contract with each breath (and the hand on it should raise the most). It’s especially important to be aware of these differences during stressful and anxious times when you’re more likely to breathe from your chest.

Breathing Exercises

The next time you’re feeling anxious, there are a variety of deep breathing exercises to try.

Alternate-Nostril Breathing

Alternate-nostril breathing (nadi sodhana) involves blocking off one nostril at a time as you breathe through the other, alternating between nostrils in a regular pattern.4 It’s best to practice this type of breathing in a seated position in order to maintain your posture.

  • Position your right hand by bending your pointer and middle fingers into your palm, leaving your thumb, ring finger, and pinky extended. This is known as Vishnu mudra in yoga.
  • Close your eyes or softly gaze downward.
  • Inhale and exhale to begin.
  • Close off your right nostril with your thumb.
  • Inhale through your left nostril.
  • Close off your left nostril with your ring finger.
  • Open and exhale through your right nostril.
  • Inhale through your right nostril.
  • Close off your right nostril with your thumb.
  • Open and exhale through your left nostril.
  • Inhale through your left nostril.

Do your best to work up to 10 rounds of this breathing pattern. If you begin to feel lightheaded, take a break. Release both nostrils and breathe normally.

Belly Breathing

According to The American Institute of Stress, 20 to 30 minutes of belly breathing each day will reduce anxiety and stress.5 Find a comfortable, quiet place to sit or lie down. For example, try sitting in a chair, sitting cross-legged, or lying on your back with a small pillow under your head and under your knees.

  • Place one hand on your upper chest and the other hand on your belly, below the ribcage.
  • Allow your belly to relax, without forcing it inward by squeezing or clenching your muscles.
  • Breathe in slowly through your nose. The air should move into your nose and downward so that you feel your stomach rise with your other hand and fall inward (toward your spine).
  • Exhale slowly through slightly pursed lips. Take note of the hand on your chest, which should remain relatively still.

Although the sequence frequency will vary according to your health, most people begin by doing the exercise three times and working up to five to 10 minutes, one to four times a day.

Box Breathing

Also known as four-square breathing, box breathing is very simple to learn and practice. In fact, if you’ve ever noticed yourself inhaling and exhaling to the rhythm of a song, you’re already familiar with this type of paced breathing. It goes like this

  • Exhale to a count of four.
  • Hold your lungs empty for a four-count.
  • Inhale to a count of four.
  • Hold air in your lungs for a count of four.
  • Exhale and begin the pattern anew.

4-7-8 Breathing

The 4-7-8 breathing exercise, also called the relaxing breath, acts as a natural tranquilizer for the nervous system. At first, it’s best to perform the exercise seated with your back straight. Once you become more familiar with the breathing exercise, however, you can perform it while lying in bed:

  • Place and keep the tip of your tongue against the ridge of tissue behind your upper front teeth for the duration of the exercise.
  • Completely exhale through your mouth, making a whoosh sound.
  • Close your mouth and inhale quietly through your nose to a mental count of four.
  • Hold your breath for a count of seven.
  • Exhale completely through your mouth, making a whoosh sound to a count of eight.

Lion’s Breath

Lion’s breath, or simhasana in Sanskrit, during which you stick out your tongue and roar like a lion, is another helpful deep breathing practice. It can help relax the muscles in your face and jaw, alleviate stress, and improve cardiovascular functions.

The exercise is best performed in a comfortable, seated position, leaning forward slightly with your hands on your knees or the floor.

  • Spread your fingers as wide as possible.
  • Inhale through your nose.
  • Open your mouth wide, stick out your tongue, and stretch it down toward your chin.
  • Exhale forcefully, carrying the breath across the root of your tongue.
  • While exhaling, make a “ha” sound that comes from deep within your abdomen.
  • Breathe normally for a few moments.
  • Repeat lion’s breath up to seven times.

Mindful Breathing

Mindfulness meditation involves focusing on your breathing and bringing your attention to the present without allowing your mind to drift off to the past or future.

  • Choose a calming focus, including a sound (“om”), positive word (“peace”), or phrase (“breathe in calm, breath out tension”) to repeat silently as you inhale or exhale.
  • Let go and relax. When you notice your mind has drifted, take a deep breath and gently return your attention to the present.

Pursed-Lip Breathing

Pursed-lip breathing is a simple breathing technique that will help make deep breaths slower and more intentional. This technique has been found to benefit people who have anxiety associated with lung conditions like emphysema and chronic obstructive pulmonary disease.

  • Sit in a comfortable position, with your neck and shoulders relaxed.
  • Keeping your mouth closed, inhale slowly through your nostrils for two seconds.
  • Exhale through your mouth for four seconds, puckering your mouth as if giving a kiss.
  • Keep your breath slow and steady while breathing out.

To get the correct breathing pattern, experts recommend practicing pursed-lip breathing four to five times a day.

Resonance Breathing

Resonance breathing, or coherent breathing, can help you get into a relaxed state and reduce anxiety.

  • Lie down and close your eyes.
  • Gently breathe in through your nose, mouth closed, for a count of six seconds. Don’t fill your lungs too full of air.
  • Exhale for six seconds, allowing your breath to leave your body slowly and gently without forcing it.
  • Continue for up to 10 minutes.
  • Take a few additional minutes to be still and focus on how your body feels.

Simple Breathing Exercise

You can perform this exercise as often as needed. It can be done standing up, sitting down, or lying down. If you find this exercise difficult or believe it’s making you anxious or panicky, stop for now. Try it again in a day or so and build up the time gradually.

  • Inhale slowly and deeply through your nose. Keep your shoulders relaxed. Your abdomen should expand, and your chest should rise very little.
  • Exhale slowly through your mouth. As you blow air out, purse your lips slightly, but keep your jaw relaxed. You may hear a soft “whooshing” sound as you exhale.
  • Repeat this breathing exercise. Do it for several minutes until you start to feel better.

Sometimes people with a panic disorder initially feel increased anxiety or panic while doing this exercise. This may be due to anxiety caused by focusing on your breathing, or you may be unable to do the exercise correctly without some practice.

Benefits of Breathing Exercises

  • Improves immunity – Breathing exercises increase the amount of oxygen in the body and increases the release of toxins with carbon-di-oxide. Increased oxygen in the cells and tissues makes them healthier and helps them perform better. Healthier and proper functioning organs improve the immune system of the body as well. Clean blood full of oxygen fights better against infectious bacteria and viruses. Improved breathing will also help in better absorption of vitamins and minerals in the body.
  • Clams down anxiety – Psychologists swear by deep breathing exercises to tackle anxiety attacks and also as a long-term treatment practice. Deep breathing helps in bringing heart rate to normal and increases oxygen levels. This helps in giving the brain the signal to unwind. Regular deep breathing will help in balancing the hormones releasing endorphins in the body.
  • Increases sleep quality – A deep breathing exercise that entails complete exhalation of the air out provides better sleep. Breathing detoxifies the body and signals to calm down. A deep breathing exercise before bed can help even insomnia suffering people.
  • Decreases toxicity of the body – Stress, eating habits, and shallow exhalation turns the body acidic, and with deep breathing, all the toxins are released turning the body alkaline. It detoxifies the body. Deep breathing also helps in releasing the lymph around the body and removes strain from the body.
  • Improves digestive system – Deep breathing increases oxygen in the digestive organ and they perform better relieving from any gastrointestinal issues, constipation, indigestion, etc. proper digestion keeps the body energetic and healthy.
  • Good for cardiovascular health – Breathing exercises will help strengthen the cardiovascular muscles and improve blood pressure. Regular deep breathing also decreases the chances of stroke. Deep breathing stimulates the vagus nerve which reduces the ‘fight or flight response.
  • Improve concentration and cognitive properties – Regular breathing exercises can improve focus and concentration. It also improves memory and cognitive properties and brain functioning.
  • Gives healthy and glowing skin – Breathing exercises increase the oxygen concentration in cells giving skin a healthy and inner glow. It makes your skin healthy. Breathing exercises burn fat and help in balance hormones which results in less stress and clear skin.
  • Reduces inflammation in the body – Sheetali pranayama is one such breathing exercise that helps in cooling the body down. It triggers a powerful evaporating cooling effect which brings down inflamed agitated emotions and decreases inflammation in the digestive system which stresses the whole body.
  • Helps sinusitis – Yogic breathing practices can help in sinusitis as the vibrations produced in this exercise dislodge all mucous and drain sinusitis from the body.
  • Makes the body and joints strong – Breathing exercises increase the oxygen level in the cells and it affects joints in a good way. It makes joints and muscles strong. It helps in reducing the strain of physical exercise and the chances of wearing the muscles down. Body’s ability to handle intense physical movement increases
  • Strengthen lungs – Lifestyle habits have greatly affected the lungs and their lungs. Breathing exercise helps in increasing the air build-up in the lungs and diaphragm. It increases lung elasticity which gives more breathing space.
  • Natural painkiller – When you deep breathe, the body releases endorphins, which are the feel-good hormones and a natural pain killer created by the body itself.
  • Improves blood flow –  When we take deep breaths, the upward and downward movement of the diaphragm helps remove the toxins from the body promoting better blood flow. Deep breathing brings fresh oxygen and exhales out toxins and carbon dioxide. When the blood is oxygenated, it ensures the smoother functioning of your vital organs, including the immune system. A cleaner, toxin-free, and healthier blood supply help ward off infection-causing germs from the base and strengthens your immunity. Deep breathing also acts as a natural toxin reliever. It also benefits the absorption of vitamins and nutrients in the body, making sure you recover faster as well.
  • Calms down anxiety – Practising deep breathing is a hack a lot of experts and psychologists swear by to treat anxious thoughts and nervousness in a jiffy. Deep breathing slows down your heart rate, allows the body to take in more oxygen, and ultimately signals the brain to wind down. It also balances your hormones- lowering down cortisol levels, increasing the endorphin rush in the body.
  • Increases energy level  – Due to increased blood flow, we get more oxygen into our blood. Increased oxygen results in increased energy levels.

  • Improves posture – Believe it or not, bad posture is related to incorrect breathing. If you don’t believe it, try it yourself. Try to breathe deeply and notice how your body starts to straighten up during the process. When you fill your lungs with air, this automatically encourages you to straighten up your spine.
  • Reduces inflammation – A lot is said that diseases like cancer only thrive in bodies that are acidic in nature. Deep breathing is said to reduce the acidity in your body, thereby making it alkaline. Stress also increases the acidity level in the body. Breathing also reduces stress and thus acidity.
  • It detoxifies the body – Carbon dioxide is a natural toxic waste that comes out from our bodies only through breathing. But when our lungs are compromised by shallow breathing the other detoxification system starts working harder to expel this waste. This can make our body weaker and lead to illness.
  • Stimulates lymphatic system – As our breathing is what moves the lymph, shallow breathing can lead to a sluggish lymphatic system that will not detoxify properly. Deep breathing will help you get the lymph flowing properly so that your body can work more efficiently.
  • Improves digestion – Breathing deep supplies more oxygen to all our body parts including our digestive system, thus making it work more efficiently. The increased blood flow due to deep breathing also encourages intestinal action which further improves your overall digestion. In addition, deep breathing results in a calmer nervous system, which in turn also enhances optimal digestion.
  • Breathing relaxes mind and body – When you are angry, tensed, or scared, your muscles are tightened and your breathing becomes shallow. Your breathing constricts. At this time your body is not getting the amount of oxygen it requires. Long deep breathing reverses this process, allowing your body (and mind) to become calmer.

References

How to Help Your Child Develop Fine Motor Skills

Fine motor skills refer to the coordination between your child’s small muscles, like those in their hands, wrists, and fingers in coordination with their eyes. Fine motor skills involve the small muscles of the body that enable such functions as writing, grasping small objects, and fastening clothing.

Early childhood development includes acquiring fine and gross motor skills. While both these skills involve movement, they do have differences:

  • Fine motor skills involve the movement of the smaller muscle groups in your child’s hands, fingers, and wrists.
  • Gross motor skills involve movements of the larger muscle groups, like the arms and legs. It’s these larger muscle groups that allow babies to sit up, turn over, crawl, and walk.

Both types of motor skills enable children to become more independent. Fine motor skills are especially crucial, however, because the ability to use the smaller muscles in the hands allows children to perform self-care tasks without assistance. This includes:

  • brushing their teeth
  • eating
  • writing
  • getting dressed

Examples of fine motor skills

Babies and toddlers develop fine and gross motor skills at their own pace. Some children develop some skills earlier than others, and that’s perfectly normal. Children usually begin to acquire these skills as early as 1 or 2 months old and continue to learn additional skills through preschool and early elementary school.

The most important fine motor skills children need to develop include the following:

  • The palmar arches allow the palms to curl inward. Strengthening these helps coordinate the movement of fingers, which is needed for writing, unbuttoning clothes, and gripping.
  • Wrist stability develops by early school years. It allows children to move their fingers with strength and control.
  • The skilled side of the hand is the use of the thumb, index finger, and other fingers together for precision grasping.
  • Intrinsic hand muscle development is the ability to perform small movements with the hand, where the tip of the thumb, index finger, and middle finger touch.
  • Bilateral hand skills permit the coordination of both hands at the same time.
  • Scissor skills develop by age 4 and teach hand strength and hand-eye coordination.

Here’s a brief timeline of fine motor milestones for babies and toddlers:

0 to 3 months

  • places their hands in their mouth
  • hands become more relaxed

3 to 6 months

  • holds hands together
  • moves a toy from one hand to the other
  • holds and shakes a toy using both hands

6 to 9 months

  • begins to grasp things by “raking” with the hand
  • squeezes an item with their hands
  • touches fingers together
  • grasps a toy with both hands
  • uses their index finger to touch things
  • claps hands

9 to 12 months

  • feeds themselves finger foods
  • grabs small objects with thumb and index finger
  • bangs things together
  • holds a toy with one hand

12 month to 2 years

  • builds block tower
  • scribbles on paper
  • eats with a spoon
  • turns one page of a book at a time
  • holds crayon with fingertips and thumb (pincer grasp)

2 to 3 years

  • turns a doorknob
  • washes hands
  • uses a spoon and fork correctly
  • zips and unzips clothes
  • places lids and removes lids from canisters
  • strings beads on yarn

3 to 4 years

  • unbuttons and buttons clothes
  • uses scissors to cut paper
  • traces shapes on paper

Fine motor skills development

Fine motor skills develop naturally as your child gains the ability to control and coordinate their body. Keep in mind that some children might develop fine motor skills earlier and have better coordination than others.

One baby may learn to shake a rattle at 3 months, whereas a baby of the same age might not shake a rattle until a month later. This is totally normal.

Don’t be alarmed if your child isn’t developing as fast as a child of similar age. Remember, your child’s body is still growing. In a few weeks or months, they may build enough muscle strength in their hands to acquire new fine motor skills.

Fine motor skills activities

Incorporating fun activities into your child’s daily routine can help improve their fine motor skills. The ability to learn and practice fine motor skills at an early age can benefit them academically, socially, and personally.

Here are some activities you and your child can do together:

  • Allow your child to assist with meal preparation, like stirring, mixing, or pouring ingredients.
  • Put together a puzzle as a family.
  • Play board games that involve rolling dice.
  • Finger paint together.
  • Let your child set the dinner table.
  • Teach your child how to pour their own drinks.
  • Have your child roll and flatten clay with their hands, and then use a cookie cutter to make cutouts.
  • Show your child how to use a hole puncher.
  • Practice placing rubber bands around a can.
  • Place objects in a container and have your child remove them with tweezers

The trouble with fine motor skills

Although fine motor skills develop at different rates, see your child’s pediatrician if they struggle with these skills or gross motor skills. Delays could be a sign of developmental coordination disorder. It affects about 5 to 6 percent of school-aged children.

Signs of a problem with fine motor skills include:

  • dropping items
  • unable to tie shoes
  • difficulty holding a spoon or toothbrush
  • trouble writing, coloring, or using scissors

Some fine motor skills delays aren’t detected until a child is older. Identifying a delay early can ensure your child receives the help they need to build their skills and help them grow.

Your child’s pediatrician may diagnose a coordination disorder if your child has:

  • fine motor skills below what’s expected for their age
  • poor fine motor skills that make it difficult to complete everyday tasks at school and home
  • developmental delays of motor skills that started at an early age

Your child may need to work one-on-one with an occupational therapist to learn techniques to improve coordination in their smaller muscle groups.

Takeaway

Fine motor skills are essential to living and learning. If your child has difficulty with day-to-day activities or you feel your child struggles with these skills, discuss the possibility of a developmental delay with their doctor.

With an early diagnosis, home activities, and the assistance of an occupational therapist, you can help your child thrive and reach developmental milestones.

What Is Uncoordinated Movement?

Uncoordinated movement is also known as lack of coordination, coordination impairment, or loss of coordination. The medical term for this problem is ataxia.

For most people, body movements are smooth, coordinated, and seamless. Motions such as walking, throwing a ball, and picking up a pencil don’t require a tremendous amount of thought or effort. But each movement actually involves a number of muscle groups. They’re largely controlled by the cerebellum, an important structure in the brain.

Ataxia occurs when there’s a disruption in communication between the brain and the rest of the body. This causes jerky and unsteady movements. Ataxia can have a profound effect on a person’s day-to-day activities.

What are the symptoms of uncoordinated movement?

For some, ataxia may be a slowly developing condition. For others, it may occur suddenly and without warning. The most common symptom of ataxia is loss of balance and coordination. If the condition does progress, you may experience difficulty walking and moving your arms and legs. Eventually, there can be a loss of fine motor skills, affecting activities such as writing or buttoning up your shirt.

Other common symptoms of ataxia can include:

  • dizziness
  • visual difficulties
  • problems or changes with speech
  • difficulty swallowing
  • tremors

These symptoms can be very concerning because they are often similar to a stroke. Seek emergency medical attention if these symptoms suddenly appear

What causes ataxia?

There are a number of known causes for ataxia. They range from chronic conditions to sudden onset. However, most conditions will relate to damage or degeneration of the cerebellum.

Disease and injury-related causes

Coordinated movements involve the cerebellum, the peripheral nerves of the body, and the spinal cord. Diseases and injuries that damage or destroy any of these structures can lead to ataxia. These include:

  • head trauma
  • alcoholism
  • infection
  • multiple sclerosis, a chronic disease that affects the brain and spinal cord
  • stroke
  • transient ischemic attack (TIA), a temporary decrease of blood supply to your brain
  • genetic ataxias
  • cerebral palsy, a group of disorders caused by damage to a child’s brain in early development
  • brain tumors
  • paraneoplastic syndromes, abnormal immune responses to certain cancerous tumors
  • neuropathy, disease or injury to a nerve
  • spinal injuries

Examples of some inherited conditions related to ataxia are Friedreich’s ataxia and Wilson’s disease. Friedreich’s ataxia is a genetic disease that causes problems with energy production in the nervous system and the heart. Wilson’s disease is a rare inherited disorder in which excess copper damages the liver and nervous system.

Toxins

Some substances have toxic effects that can lead to ataxia. These include:

  • alcohol (most common)
  • seizure medications
  • chemotherapy drugs
  • lithium
  • cocaine and heroin
  • sedatives
  • mercury, lead, and other heavy metals
  • toluene and other types of solvents

Sometimes people have a condition known as sporadic ataxia. This causes an ataxia not related to a genetic disorder or a specific known cause.

What to expect during your doctor visit

You should schedule a doctor’s visit right away if you experience any of the following:

  • a loss of balance
  • trouble swallowing
  • lack of coordination for more than a few minutes
  • loss of coordination in one or both legs, arms, or hands
  • slurred speech
  • trouble walking

Seeing the doctor

Your doctor will ask you about your medical history and perform a basic physical examination. They’ll perform a detailed neurological exam that includes your muscular and nervous systems. They’ll check your ability to balance, walk, and point with your fingers and toes. Another common test is the Romberg test. It’s used to see if you can balance while closing your eyes and keeping your feet together.

Sometimes the cause of ataxia is clear, such as a brain injury, infection, or toxin. Other times your doctor will ask questions about your symptoms to narrow down the possible cause of your ataxia. These questions often include:

  • When did your symptoms begin?
  • Does anyone in your family have similar symptoms?
  • What are you most common symptoms?
  • How much do your symptoms impact your life?
  • What medications do you take, including vitamins and supplements?
  • What substances have you been exposed to?
  • Do you use drugs or alcohol?
  • Do you have other symptoms, such as visual loss, speech difficulties, or confusion?

Tests to determine the cause of ataxia

Your doctor may order the following tests:

  • blood tests
  • urine tests
  • computed tomography (CT) scan
  • magnetic resonance imaging (MRI) scan
  • spinal tap
  • genetic testing

Your doctor will consider the overall picture of your symptoms and test results in making a diagnosis. They may also refer you to a neurologist, a specialist in the nervous system

Living with ataxia

There’s no cure for ataxia itself. If an underlying condition is a cause, your doctor will first treat that. For example, a head trauma may eventually heal and ataxia may subside. But in other cases, such as cerebral palsy, your doctor may not be able to treat ataxia. But there are ways to manage this condition. Some medications may lessen the symptoms associated with ataxia.

In some cases, your doctor may recommend adaptive devices or therapy. Items such as canes, modified utensils, and communications aids may help to improve your quality of life. Therapies designed to help with uncoordinated movement are other options, such as:

Physical therapy: Exercises can help strengthen your body and increase your mobility.

Occupational therapy: This therapy aims to improve your skills with daily living tasks such as feeding and another fine motor movement.

Speech therapy: This can help with communication as well as swallowing or eating.

Simple changes can also make it easier for a person with ataxia to get around the house. For example:

  • keep living areas clean and free of clutter
  • provide wide walkways
  • install handrails
  • remove rugs and other items that might cause slipping and falling

Dietary therapy

Researchers at the Albany Medical Center have discovered some treatable forms of ataxia. SAVED (Ataxia with Vitamin E Deficiency) is a type of ataxia that improves with Vitamin E supplementation. Gluten ataxia improves with a gluten-free diet.

The University of London also reported that vitamin B-3, or nicotinamide, may help people with Friedreich’s ataxia. This treatment may increase frataxin levels, a protein that is low in people with this type of ataxia. But research continues as it’s unknown if this supplementation will work long-term to slow or stop the disease.

Where to find support

Symptoms of ataxia can affect a person’s independence. This can result in feelings of anxiety and depression. Talking to counselor can help. If one-on-one counseling doesn’t sound appealing, consider a support group for people with ataxia or other chronic neurological conditions. Support groups are often available online or in person. Your doctor may have a recommendation for a support group in your area.

Ways Toddlers Benefit from Parallel Play

Sometimes as soon as their first birthday, but mostly between their second and third years of life, you’ll notice your toddler playing happily alongside other kids their age.

You’ll see it on the playground, during family gatherings, or maybe at day care. You may notice them making few if any attempts to actually play together.

That’s called parallel playing, and it’s both a normal and important step in your child’s development.

How parallel play benefits toddlers

At first your baby watches adults and other children do things, and they will often mimic, or copy, behaviors. Then they use those observations during solitary play.

Next comes parallel play, where your child simply plays on their own while observing and being near others.

Parallel playing may seem self-centered, yet there are many benefits for your toddler.

1. Language development

As your toddler sits and minds their own playing, they will also be listening and learning words from nearby children or adults.

Sometimes they may peek and see a toy or an action being called a certain word. They’ll add to their vocabulary and surprise you with it later.

2. Gross and fine motor skill development

Play is a highly imaginative pursuit that engages body and mind. Whether toddlers simply repeat an activity or experiment with something new they picked up during parallel play, it’s all part of learning and growing.

There’s no right or wrong way of playing. Keep in mind that what looks simple to you can be a challenging thing for little hands that are learning fine-tuning moves.

Also, a simple action by a child may have a complicated imaginative component behind it.

3. Freedom to express their desires and feelings

During parallel play your little one learns more than just how a toy rolls, falls down, or moves when pushed.

They’re also using everything they can get their hands on, including toys, their own hands, and even dirt and sticks, to express feelings.

They range from joy to fear to frustration or simple silliness, and are mostly based on what they experience in real life.

By observing them play, you may get a glimpse into how their mind works at this young age and better understand their budding personality.

4. Understanding social interactions and learning about boundaries

Parallel play doesn’t mean isolation. Your child is exactly where they should be: in their own world, which is situated in the middle of the bigger world they have yet to figure out.

By observing other children interact, your child gets a glimpse into social interaction. These observations will be put to good use when the time comes where they are developmentally ready for group play.

Interactions can be positive (children being nice to each other) or negative (one child pushes another or grabs a toy). There’s something to learn from both.

5. Learning to share

Don’t expect your children of this age to sit quietly and play without ever eyeing the others’ toys. It’s the age when their minds take some big leaps in terms of development when they learn to assert themselves.

Learning the word and concept “mine” is an important step in understanding boundaries.

Allow them to say “mine” to protect what’s theirs, but help them understand that toys brought to a common area can be safely shared without fear of being taken away.

Toddlers in the parallel play stage are naturally possessive of their toys, as they do not understand sharing yet. You can practice sharing at home, but don’t be surprised if they get upset when their parallel play companion grabs their toy.

References

 

What Are Gross Motor Skills? – What You Need To Know

Gross motor skills are the abilities usually acquired during childhood as part of a child’s motor learning. By the time they reach two years of age, almost all children are able to stand up, walk and run, walk upstairs, etc. These skills are built upon, improved, and better controlled throughout early childhood, and continue in refinement throughout most of the individual’s years of development into adulthood. These gross movements come from large muscle groups and whole-body movement. These skills develop in a head-to-toe order. The children will typically learn head control, trunk stability, and then standing up and walking. It is shown that children exposed to outdoor playtime activities will develop better gross motor skills.

What Are Gross Motor Skills?/As your baby grows and starts to investigate their surroundings, they develop new skills. Gross motor skills are one set of skills they’ll add to their repertoire of tricks right from the start.

Let’s take a look at some of those skills, as well as what to do if you suspect something might not be quite right.

What it means when we talk about gross motor skills

Gross motor skills are those skills that involve the whole body — your core muscles (think belly and back) and the muscles of your arms and legs.

Gross motor skills include skills such as:

  • sitting
  • standing
  • walking
  • running
  • jumping
  • lifting (a spoon, a hairbrush, a barbell — they all count)
  • kicking

Yup, these are actually skills.

And then there are the skills that need, well, a little more skill:

  • riding a bike or a horse
  • playing sports like football or baseball
  • rollerblading
  • swimming

When your child uses their gross motor skills, they’re also working on balance, coordination, hand-eye coordination, and strengthening the neural pathways in their brain.

Gross motor vs. fine motor skills

You’ve heard mothers at the park tossing these terms around with the same nonchalance they use to toss a ball. So what’s the difference?

While gross motor skills involve the bigger muscles, fine motor skills work the smaller muscles of the hands, fingers, and wrists. Fine motor skills are about dexterity.

Here’s an example, taken from the previous section: Your child uses gross motor skills to lift a hairbrush — but fine motor skills to grasp it in their hands in the first place.

Your child needs fine motor skills to do finicky things such as:

  • holding a pencil or scissors
  • writing
  • cutting
  • threading beads
  • playing with Legos
  • buttoning up their coat

The better their fine motor skills are, the easier they’ll find tasks like drawing and the faster they’ll be able to do them.

But appropriately developed gross motor skills can help your child build their fine motor skills. Knowing how to sit will give your child the ability to be at a desk and practice controlling the movements in their shoulders, arms, hands, and fingers.

Gross motor skills at different ages

Your newborn has a ways to go before they’re crawling. Your toddler has a ways to go before they’re playing baseball. So what are the age-appropriate gross motor skills to look out for at each stage?

0–3 months

  • As your baby’s startle reflex fades, you’ll notice that their movements become more voluntary and controlled. With their developing hand-eye coordination, your baby will be able to bat at brightly colored toys.
  • When you place your baby on their stomach (you’ll want to schedule plenty of tummy time into their day), you’ll notice them lift their head and chest.

3–6 months

  • At this age, babies start to move. Typically, they’ll start to roll from their back to their side. And then they’ll start to roll all the way over — first from their belly to their back and later from their back to their belly.
  • Hold your baby’s hands when they’re lying on their back and gently pull them into a sitting position. Notice that they can raise their head.

6–9 months

  • At first, your baby will sit with a little bit of help from you. Then, they’ll be able to sit as long as they’re leaning on their hands. And finally, when their back and abdominal muscles get stronger, they’ll be able to sit alone.
  • As your baby becomes more mobile, they’ll start sliding around on their tummy to explore. Watch them rising up on their hands and knees to rock back and forth. And then, just when you’re least expecting it, they’ll start to crawl.

1 year

  • Each time your baby pulls themselves up to stand, they’re working out those leg muscles. Add to this a good dose of coordination and your baby will start taking a few tentative steps — as long as there’s something there to hold on to, like the coffee table or your pants.
  • Your baby has discovered that they can see what’s going on around them much better if they’re sitting up. Watch them sit up alone.

2 years

  • Your toddler can not only walk alone pretty well, but they’re also starting to run. Watch out, though — at this stage it’s still easy for them to fall.
  • Hold on to their hand tightly and your child will enjoy the challenge of walking up and down steps.
  • By this stage, your child can jump with both feet.

3 years

  • As your child’s leg muscles get stronger and their balance improves, they can stand on one foot for a few seconds at a time.
  • Peddling a tricycle requires hand-eye coordination and arm-leg coordination that they’re starting to get the hang of.
  • Your child is now able to enjoy playing on climbing frames at the park.

4 years

  • Balancing on one foot is now a cinch, so your child begins to hop on one foot.
  • Ball games become more fun as your child can catch a ball — almost all of the time.

5 years

  • Get ready for games of jump rope now that your child can skip.
  • With well-developed gross motor skills, your child is ready to learn how to skate and swim.

What if your child has gross motor skill delays or difficulties?

Always remember that each child is absolutely unique — just like everyone else. Your unique child may not follow given guidelines and that’s perfectly OK. We all develop in sync with our own internal clock.

That said, here are some things that you may want to look out for:

  • Your child isn’t interested in the physical activities that their peers are happy doing. In fact, they even try to wiggle out of them.
  • Your child goofs up tasks on purpose to mask that they’re having a hard time doing them.
  • Your child tells other kids how catch a ball, reach the top of a jungle gym, or skip — but they won’t take part in the game.

When should you contact your doctor about gross motor skill concerns?

If your child isn’t meeting many of the milestones above, you may want to reach out to your pediatrician for an evaluation. Very often, early intervention with a pediatric physical or occupational therapist can close the gaps you see.

Sometimes parents notice that their child has difficulty in many areas of physical activity. For example, if your little one is clumsy, has an unsteady gait that makes it hard to negotiate steps, and can’t manage to tie their shoes or complete arts-and-crafts projects.

When several signs come together, they may signal a condition known as developmental coordination disorder (DCD). Talk to your pediatrician if you have concerns.

  • Head position practice. Alternate the side that you position your baby’s head when you lay them down. Left one day; right the next day. This will encourage your baby to lift their head and to strengthen both sides of their neck.
  • Tummy time. Tummy time strengthens your baby’s neck and back muscles. Keep your baby interested by shaking a colorful toy in front of them.
  • Rattle tug. It’s never too early to start building those biceps. Put a rattle in your baby’s hand and tug gently.
  • Sitting your baby up. Prop your little one up to encourage them to develop the motor skills to sit independently. As they’re learning, offer a hand to keep them stable.
  • Sticky notes on the wall. Once your baby can pull themselves up to a wobbly stand, try putting Post-It notes on the wall just out of their sitting reach. They’ll delight in pulling themselves up to grab the notes and pull them off the wall.
  • Free movement. Once you’ve babyproofed and created a safe space for baby, spending less time with them in bouncers and jumpers and more time encouraging them to move on their own is best. Try scattering favorite toys around a room and watch them crawl to their treasures.

Toddlers

  • Going for walks. It won’t be as fast as cruising in the stroller, but your new walker needs lots of opportunities to practice walking. Create a safe space in your home for this by childproofing and setting up a play pen. Allow your toddler lots of time to walk around when on a grassy lawn or at the park.
  • Sand play. It may look like child play, but as your child digs, scoops, pours, and sifts, they’re working on their gross motor skills.
  • Create obstacle courses. Set up (safe!) objects around a room so that your toddler needs to duck, crawl, sidestep, reach, pull themselves up and even move items to get from one side to the other.

Preschoolers

Gross motor skills are mostly developed early and, as noted above, involve just the large muscle groups. Once your child has those skills in their repertoire, they can add other layers of skill like coordination, muscle development, posture, balance, and more.

Some examples of building upon their gross motor skills include:

  • hopscotch and skipping
  • trampoline jumping
  • swimming
  • playing musical instruments
The takeaway

Accompanying you child through their journey in life is one of the most satisfying things you’ll ever do.

When you watch your child pulling themselves up only to fall back onto that well-padded butt, you may not believe the adage that time flies. But it won’t be long and soon you’ll be eating popcorn on the sidelines while your superstar hits a home run.

Potty Training Tips: Supplies, Skills, and Secrets for Success

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The television ads of children proudly throwing their diapers in the trash make potty training look so easy. Parents with perfect hair and makeup and clean clothes stand by, smiling, as their cheerful toddler happily uses the toilet.

When it’s time to start potty training in real life, however, it might feel a bit messier (who are we kidding — a lot messier!) and less than picture-perfect.

As you’re reading and researching, your head is probably already spinning with decisions like which potty training method to try — Three-day potty training? Schedule-based potty training? You might know that the average age of potty training is 27 months, but is your child ready?

While we can’t answer all these questions for you, we can give you some tips and advice, so that you’ll be better prepared to have a positive potty training experience with your child.

Before you begin potty training

Before throwing out all the diapers, there are a few things you can do to prepare for a smoother potty training process.

Ensure that your child is showing readiness signs. There is no “best” age for potty training.Instead, it’s important to look for signs that your child is developmentally ready. Indicators that your child might be ready to potty train include:

  • expressing an interest in the toilet
  • recognizing when their diaper is soiled
  • keeping their diaper dry for longer periods
  • physically being able to pull their own pants up and down

Talk it up! Make potty training sound exciting and talk about it frequently with your child. Provide examples of other kids you know who have potty trained or watch television shows that discuss the topic.

Show by example. Allow your child to follow you or a friend through the process of using the bathroom several times. Sometimes it is more effective for them to see a child close to their own age who is successfully using the potty.

Read potty books. Visit your local library or bookstore to pick up some fun children’s potty books. Let your child help choose.

Play pretend. Help your child to reenact the potty process with dolls or other toys. Talk about how happy the dolls are about going on the potty.

If you’re going to use rewards decide on the specific rewards. Ideas might include stickers on a chart, little toys, or fruit snacks.

You might also consider a special outing or more screen time, but parenting experts note rewards work best at this age if they’re immediate and used every time your child completes the desired behavior, say, sitting on the potty. Get your child excited about working towards these rewards and explain the exact system for earning them.

Stock up on potty training supplies. This can include a step stool, fun hand soap, and big kid underwear. Additional supplies that may come in handy include wet wipes, small toys and stickers for rewards, a portable potty for on the go, and Post-it notes for using on automatic flush toilets when you’re out.

Choose a potty type for your child. There are many options when it comes to child-friendly potties. Consider shopping for a standalone child-sized toilet or an insert ring for a standard toilet. Some parents offer both to their children. Keep in mind that portability is important once you’re out of the house, so consider at least introducing ways to use a standard-size toilet.

Introduce the potty in an unintimidating way. Allow the child to touch and sit on the potty without any expectations of actually using it. You may even want to start with a potty chair placed somewhere other than the bathroom.

Prepare for accidents. Make sure that you have sufficient wipes, paper towels, and cleaning sprays, and that you cover any furniture you don’t want to deal with cleaning later.

Make a schedule that’s potty-friendly. Build-in time for potty breaks during the day and ensure there is always a bathroom accessible nearby when out and about.

Tips for potty training

Once you’ve handled all the prep work, it’s actually time to start the potty training process. Here are a few tips that can help.

Consider nakedness. Don’t be afraid to let your child shed a few clothing items inside your house. (If nothing else, it’ll give you fewer pieces of clothing to have to wash if there’s an accident!)

Think about undies vs. pull-ups. This is a personal decision that depends on your child.

Wearing underwear will be very motivating for some children and can allow a child to be more aware when they are having an accident. However, it can be messy to go straight to underwear. Some children may also need a long time before they are dry at night.

Pull-up style training pants are great for avoiding accidents all over the furniture or bed; however, they can be less motivating and some children may be less aware of their body functions while using pull-ups.

Give plenty of opportunities. Make sure to offer the toilet to your child before and after meals, upon waking, and before heading out of the house. Paying attention to when they usually have to go can help you know when to encourage them to try.

Remember timing is everything. If potty training on a schedule or time-based system, use technology like timers and watches to make it fun and educational.

Use praise liberally. It works. Clapping, singing songs, and enthusiastically celebrating each win is the kind of encouragement that works for toddlers.

Have fun with reading time. Read books specifically set aside for potty time while your child is on the toilet. This will be a motivator to both want to use the potty and to stay on the potty as long as necessary.

Give age-appropriate choices to your child. Would you like to potty before or after tooth brushing? Which underwear would you like to wear?

Being able to control some aspects of the process helps encourage them to be more invested in potty training.

Change it up! If you’re feeling frustrated, let another adult try to help for a bit. There’s no shame in asking your partner, a grandparent, or a day care provider for support.

Understand regressions can happen. Just keep trying… Just keep trying… Just keep trying…

Know it’s also okay to stop trying. If you or your child is getting really frustrated, it’s okay to just take a breather and try again later. You want this to be a positive experience for all involved.

You’ve got skills

To be fully potty trained, your child will need to master a lot of self-care skills.

It can be useful to focus on individual skills during the potty training process and praise for each skill your child is able to accomplish.

If you are using a potty training chart, you may want to offer an incentive for specific skills like remembering to wash hands or recognizing the need to go to the bathroom.

We’ve gathered together a list of a few necessary self-care skills that your child will need to master during the potty training process:

  • recognizing body signals that it’s time to go — and responding promptly
  • pulling pants up and down
  • sitting on the toilet
  • learning to aim — Cheerios in the toilet bowl make great targets for little boys!
  • wiping — an advanced skill!
  • flushing
  • hand washing

As far as that last key skill goes, remind your child to use warm water and soap, scrub hands together for at least 20 seconds or the length of “Happy Birthday to You,” and dry them thoroughly with a clean towel.

Accidents happen

Once you start potty training, it’s important not to have expectations of perfection right away. Potty training is a journey, and throughout the process, it’s important for you to focus on the good and avoid shaming. (Not only will this help your child but staying positive helps you, too.)

When accidents do happen, it’s important to think through what may have been the cause and how it can be addressed. For example, accidents happening in bed are normal, as potty training through the night may take much longer.

Allowing your child to wear a pull-up style disposable (or reusable!) training pant when they sleep may help them to get a better night’s sleep without worrying until they’re developmentally ready. You might also consider limiting liquids in the evening hours and ensuring they try to go to the bathroom right before bed.

If your child is having trouble pooping on the potty, it may be beneficial to find out if there are any fears involved. Many children benefit from talking through the process and alleviating their concerns.

Pay attention to when accidents occur and address underlying emotional issues or make changes to the routine based on this information. In this case, accidents might just lead to success with potty training!

It’s a process

Even after it appears your child is fully potty trained, accidents can still happen seemingly out of the blue. It’s important to acknowledge that accidents can happen to anyone and to try to avoid shame or guilt. Remember to praise and/or reward your child and yourself for all the progress they have made.

No matter the number of small setbacks, your child will eventually learn how to use the toilet. Every child has their own timeline. As you work towards consistent, 100 percent mastery, you may face new challenges.

Potty training outside the house is different than feeling comfortable at home:

  • Keep your Post-its at the ready to cover up the automatic flush features of the many public toilets you’ll visit.
  • Consider bringing along a portable potty seat for larger public toilets.
  • Keep up an open dialogue with your child to address their concerns and challenges with going to the potty outside the home.

The process of being potty trained is in many ways just as important as the final result. Potty training can be an opportunity to bond with your child and to witness their self-confidence grow.

Takeaway

Although potty training may not always look as simple as it does on television ads, it can be a positive experience for you and your child.

Just remember that every challenge is one step closer to success, test out some of the advice above, and before you know it, diapers will no longer be on the shopping list!

 

Indications of Cervical Traction? – Procedure, Warning

Indications of Cervical Traction?/Cervical traction gently extends the neck, opening the spaces between the cervical vertebrae. This temporarily alleviates pressure on the affected discs.

The practice of spinal traction goes back to the fourth century BC, where Hippocrates first described it as a treatment for kyphosis. It was subsequently implemented in other spinal pathologies including cervical pain and myelopathy. In the 1600s, the Germans employed cervical traction in their medical practice, as an adjunct to open reduction of cervical dislocations, and fractures. In 1929, the Halter device was introduced for the reduction of cervical injuries; then several other devices followed to ensure more efficient traction. To date, there is no accurate description of the mechanism of relief provided by cervical traction. The theory behind its efficiency emphasizes on the widening of the intervertebral foramen upon traction, with separation of the facet joint. This will relieve the sustained pressure on the nerve roots, and hence alleviate symptoms of radiculopathy. Other theories suggest that traction allows for cervical muscle relaxation, and is not involved in intervertebral separation.

Types of Cervical Traction

  • Manual cervical traction – Manual cervical traction is done by a physical therapist. While you’re lying down, they’ll gently pull your head away from your neck. They’ll hold this position for a period of time before releasing and repeating. Your physical therapist will make adjustments to your exact positioning in order to get the best results.
  • Mechanical cervical traction – Mechanical cervical traction is done by a physical therapist. A harness is attached to your head and neck as you’re lying flat on your back. The harness hooks up to a machine or system of weights that apply a traction force to pull your head away from your neck and spine.
  • Over-the-door cervical traction – An over-the-door traction device is for home use. You attach your head and neck to a harness. This is connected to a rope that’s part of a weighted pulley system that goes over a door. This can be done while sitting, leaning back, or lying down.

Indications of Cervical Traction

Cervical traction has been used in a variety of cervical pathologies:

  • Cervical disc disease
  • Cervical spine fracture
  • Facet joint dislocation
  • Atlantoaxial subluxation
  • Occipitocervical synopsis
  • Spondylosis
  • Radiculopathy
  • Foraminal Stenosis
  • Myofascial tightness

Overall, most published studies on cervical traction for spondylosis and myelopathy are of low quality and include a small number of participants. Among the few studies with adequate statistical power, there is no evidence on the long-term benefits of cervical traction, although many articles suggest a definitive temporary relief. Likewise, intermittent traction was not able to achieve a more favorable outcome than its sustained counterpart, despite its theory of increasing blood flow to the spine parenchyma and nerve roots. However, the practice of cervical traction in fractures and facet joint dislocations is important when used along with closed reduction and fixation. In cases of facet joint dislocation, failure of traction suggests the need for surgical intervention. 

Moreover, the use of cervical traction for atlantoaxial subluxation is well established in the pediatric population as a second-line treatment. Failure to improve after a trial of soft collar and pain management for two weeks necessitates cervical traction. In cases of no improvement after the third week, surgical management is required. Cervical traction is also a standard of practice in occipitocervical synopsis where symptoms are limited to pain, along with a trial of a cervical collar. If neurological deficits are suspected, surgical evaluation is warranted.


Contraindications of Cervical Traction

There are no scientific reports that accurately describe the contraindications and relative contraindications for cervical traction. Probable contraindications and/or relative contraindications to cervical or lumbar traction include the following:

  • Acute torticollis
  • Aortic Aneurysm
  • Active peptic ulcer disease
  • Diskitis
  • Old age
  • Osteomyelitis
  • Osteoporosis
  • Ligamentous instability
  • Primary or metastatic tumor
  • Spinal cord tumor
  • Myelopathy
  • Pregnancy
  • Severe anxiety
  • Untreated hypertension
  • Vertebral-basilar artery insufficiency
  • Midline herniated nucleus pulposus
  • Restrictive lung disease
  • Hernia

Preparation

The patient’s vital signs should be monitored before and immediately following the application of cervical traction in all high-risk patients, especially in those with high blood pressure or cardiac problems. It is important to obtain a detailed history and perform a systematic physical exam, before cervical traction, to rule out any contraindications.

Technique

There are different ways to apply cervical traction to the cervical neck. 

Manual Cervical Traction

Manual traction is mainly for diagnostic purposes, with the ability to confirm a suspected diagnosis after successful relief of symptoms.

  • The head and neck are held in the hands of the practitioner, and then gentle traction of a pulling force is applied.
  • Intermittent periods of traction can be applied, holding each position for about 10 seconds.

It also allows the performer to apply controlled pressure on pressure points, which helps alleviate the patient’s pain. Ideally, it is done at a 20-degree angle of flexion, but the examiner must explore all angles, including the extension of the neck and chin rotation, with a thorough assessment of each position.

Mechanical Cervical Traction

Mechanical traction includes pinning, with the placement of a Halo device around the head; where anterior pins are placed 1 cm above each of the eyebrows, and two posterior pins are placed on the opposite end of the skull. The addition of pins can be essential if further stabilization is required.

  • A harness attaches to the head and neck of the patient while he is laying down on his/her back.
  • The harness is itself attached to a machine that applies a traction force, which can be regulated through a control panel.

Other shorter-term traction devices comprise the Gardner-Wells tongs, which constitute of two pins, pointing upward (towards the vertex of the head), to be placed below the temporal ridge, bilaterally. In both cases, careful pinning is to be applied with a torque pressure of 2 lb to 4 lb in the pediatric population, and up to 8 lb in adults.

Mechanical traction requires a 0-degree angle pull for C1 and C2 pathologies, and a 20-degree angle flexion for below C2 cases. Moreover, the force applied during pull tension must not exceed 10 lb in cases of C1-C2 subluxation, but can otherwise increase up to 45 lb. Some practices require a gradual increase of the pull tension, while others prefer choosing the lowest weight inciting an effective response.

Over-the-Door Traction

This is a more practical way of applying cervical traction, that is more accessible to outpatient practices.

  • Over-the-door traction entails strapping a harness to the head and neck of the patient that is in a seated position.
  • The harness is connected to a rope in a pulley system over a door. The force is applied using weights (a sandbar or a waterbag) attached to the other end of the rope.

Furthermore, intermittent traction is another modality where a repeated sequence of rest and traction are applied. It is believed to increase blood flow to the nerve roots and spine parenchyma. One must understand that during the rest phase, tension is not entirely released. As a general rule, intermittent traction is the method of choice for degenerative disc disease and/or joint hypomobility. On the other hand, sustained traction is most often used for neck pain of muscle or soft tissue etiology, and/or disc herniations. Cervical traction can be applied while the patient is supine or seated. The supine position is preferred, allowing for more posterior pressure loading. This will ensure cervical muscle relaxation and transmit less pressure on the temporomandibular joint (TMJ). The sitting position is favored only for patients who cannot lay supine for a prolonged period of time, as in cases of patients suffering from reflux esophagitis.


Complications

Complications are rare, providing that patients are adequately screened for conditions that are contraindicated. Postprocedural increase in peripheral nerve pain and a decrease in central pain, increase in neurological symptoms, or sudden disappearance of central pain are alarming signs of traction-induced spinal cord compromise.

Side effects and warnings

Generally, it’s safe to perform cervical traction, but remember that results are different for everyone. The treatment should be totally pain-free.

It’s possible that you can experience side effects such as headache, dizziness, and nausea upon adjusting your body in this manner. This may even lead to fainting. Stop if you experience any of these side effects, and discuss them with your doctor or physical therapist.

It’s possible for you to injure your tissue, neck, or spine. You should avoid cervical traction if you have:

  • rheumatoid arthritis
  • postsurgery hardware such as screws in your neck
  • a recent fracture or injury in the neck area
  • a known tumor in the neck area
  • a bone infection
  • issues or blockages with vertebral or carotid arteries
  • osteoporosis
  • cervical instability
  • spinal hypermobility

It’s important that you follow any safety instructions and recommendations provided by your doctor or by the manufacturer. Make sure you’re performing the movements correctly and using the appropriate amount of weight. Don’t overexert yourself by doing cervical traction for too long. Discontinue use if you experience any pain or irritation or if your symptoms get worse.

Cervical traction exercises

There are several exercises that can be done using cervical traction devices. Make sure to listen to your body and go to your own edge or threshold in terms of stretching and the duration of your exercises.

To use an air neck traction device, place it around your neck and adjust the straps as necessary. Then, pump it up and wear it for about 20–30 minutes. Do this a few times throughout the day. You can wear the device while doing activities where you tend to slouch.

To use an over-the-door neck traction device, you’ll usually you’ll start with about 10–20 pounds of pulling force, which can be increased as you gain strength. Your physical therapist can recommend the right amount of weight for you to use. Pull and hold the weight for 10–20 seconds and then slowly release. Continue this for 15–30 minutes at a time. You can do this a few times throughout the day.

A Posture Pump is used while you’re lying down. Do a warm-up before using this device. Slowly turn the head side-to-side, then forward and backward, and then lean the neck from side-to-side. Do each exercise 10 times. Then, attach the portable device to your head and increase the pressure so it tightens around your forehead. Once it’s pumped, wait 10 seconds before releasing the air. Do this 15 times. Then inflate the unit and relax in a comfortable position for up to 15 minutes. Make sure you’re not pumping it too much, especially in the beginning. Once you release yourself from the pump, keep your head in line with your spine as you come into a standing position. Repeat the warm-up routine.

You may also wish to incorporate stretching into your daily routine. You can use accessories such as exercise balls or resistance bands. Yoga is another great tool to relieve neck pain, and there is plenty of cervical traction exercises your physical therapist may be able to recommend that don’t require any equipment aside from a bed or table.

The takeaway

Cervical traction may be a safe, wonderfully effective way for you to resolve neck pain. It may provide you with numerous improvements to your body, inspiring you to do it often. Ideally, it will be effective in relieving neck pain and enhancing your overall function.

Always talk to your doctor or physical therapist before beginning any treatment. Touch base with them throughout your therapy to discuss your improvements as well as any side effects. They can also help you to set up a treatment plan that addresses exactly what you need to correct.

References

7 Day Plus Mens Bleeding – Causes, Symptoms, Treatment

7 Day Plus Men’s Bleeding/Menorrhagia is prolonged and excessively heavy menstrual bleeding at regular menstrual cycle intervals. Although several factors (e.g. anatomical defects or growths in the womb, blood component abnormality, or hormonal imbalance) may be implicated, the cause of the abnormal uterine bleeding is often unknown.

Menorrhagia is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. How do you know if you have heavy bleeding? If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding. If you have this type of bleeding, you should see a doctor.

Menorrhagia (also known as heavy menstrual bleeding) is defined as heavy, but regular, menstrual bleeding. Menorrhagia menstruation at the regular cyclical interval with excessive flow and duration; clinically, blood loss is in excess of 80 ml per cycle; or menses lasts longer than 7 days8

Types of Menorrhagia

  • Idiopathic ovulatory menorrhagia – is regular heavy bleeding in the absence of recognisable pelvic pathology or a general bleeding disorder.
  • Objective menorrhagia – is taken to be a total menstrual blood loss of 80 mL or more in each menstruation. It is difficult to incorporate the objective measurement of menstrual blood loss into everyday practice. Subjectively, menorrhagia may be defined as a complaint of regular excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms.
  • Metrorrhagia – intermenstrual bleeding occurring at any time between menstrual periods17p1355
  • Hypomenorrhea – (cryptomenorrhea)-unusually light menstrual flow, sometimes only spotting, or a deficient amount of menstrual flow17p1052
  • Menometrorrhagia – bleeding that occurs at irregular intervals or bleeding during and between menstrual periods in which amount and duration of bleeding may also vary17p1339
  • Polymenorrhea – menstrual periods occurring with abnormal frequency17p1726
  • Oligomenorrhea – periods that occur more than 35 days apart or scanty or infrequent menstrual flow17p1516

Dysfunctional menses – abnormal uterine bleeding without any obvious structural or systemic abnormality8,19

Causes of 7 Days Over Menstrual Bleeding

  • Hormone imbalance – In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormone imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
  • Dysfunction of the ovaries – If your ovaries don’t release an egg (ovulate) during a menstrual cycle (anovulation), your body doesn’t produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone imbalance and may result in menorrhagia.
  • Uterine fibroids – These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
  • Polyps – Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
  • Adenomyosis – This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful periods.
  • Intrauterine device (IUD) – Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. Your doctor will help you plan for alternative management options.
  • Pregnancy complications – A single, heavy, late period may be due to a miscarriage. Another cause of heavy bleeding during pregnancy includes an unusual location of the placenta, such as a low-lying placenta or placenta previa.
  • Cancer – Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
  • Inherited bleeding disorders – Some bleeding disorders — such as von Willebrand’s disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
  • Medications – Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to heavy or prolonged menstrual bleeding.
  • Other medical conditions – A number of other medical conditions, including liver or kidney disease, may be associated with menorrhagia.

Others Cause May Consideration

Excessive menses but normal cycle – Painless

  • Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
  • Coagulation defects (rare) — with the shedding of an endometrial lining’s blood vessels, a normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
  • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after menopause (post-menopausal bleeding or PMB)
  • Endometrial polyp
  • Omega 6 and prostaglandins – HMB is associated with increased omega-6 AA in uterine tissues.[rx] The endometrium of women with HMB have higher levels of prostaglandin (E2, F2alpha, and others) when compared with women with normal menses.[rx] It is thought that prostaglandins are a by-product of omega 6 build-up.[rx]

Painful (ie associated with dysmenorrhea)

  • Pelvic inflammatory disease
  • Endometriosis – an extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
  • Adenomyosis – an extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
  • Pregnancy related complication (i.e. miscarriage)
  • Short cycle (less than 21 days) but normal menses.
  • Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumors.
  • Polycystic ovary syndrome.[rx]
  • Systemic causes: thyroid disease, excessive emotional/physical stress.[rx]
  • Sexually transmitted infection.[rx]

Hormonal Abnormalities

  • Luteal phase defects
  • Stress
  • Exogenous hormones
  • Ovarian Cysts

Mechanical Abnormalities

  • Uterine Polyps
  • Uterine Fibroids
  • Intrauterine devices
  • Atopic pregnancy
  • Pregnancy

Clotting Abnormalities

  • Drug-induced hemorrhage
  • Dysproteinemias
  • Disseminated intravascular coagulation
  • Severe hepatic disease
  • Primary fibrinolysis

Symptoms of  7 Days Over Menstrual Bleeding

You may be experiencing menorrhagia if you have the following:
  • Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
  • Needing to use double sanitary protection to control your menstrual flow
  • Needing to wake up to change sanitary protection during the night
  • Bleeding for longer than a week
  • Passing blood clots larger than a quarter
  • Restricting daily activities due to heavy menstrual flow
  • Symptoms of anemia, such as tiredness, fatigue, or shortness of breath
  • Menstrual flow that soaks through one or more sanitary pads every hour
  • The need to use double sanitary protection to control your menstrual flow
  • The menstrual period lasts more than seven days
  • Menstrual flow that includes large blood clots
  • Excessive and prolonged menses may lead to anemia,
  • Pallor
  • Tiredness
  • Fatigue
  • Shortness of breath

According to the CDC

You might have menorrhagia if you:

  • Have a menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row.
  • Need to double up on pads to control your menstrual flow.
  • Need to change pads or tampons during the night.
  • Have menstrual periods lasting more than 7 days.
  • Have a menstrual flow with blood clots the size of a quarter or larger.
  • Have a heavy menstrual flow that keeps you from doing the things you would do normally.
  • Have constant pain in the lower part of the stomach during your periods.
  • Are tired, lack energy, or are short of breath.


Diagnosis of 7 Days Over Menstrual Bleeding

Menorrhagia is diagnosed by your doctor through a series of questions about your medical history and menstrual cycles. Usually for women with menorrhagia bleeding lasts for more than 7 days and more blood is lost (80 milliliters compared to 60 milliliters).

Your doctor may ask for information about:

  • Your age when you got your first period
  • Length of your menstrual cycle
  • Number of days your period lasts
  • Number of days your period is heavy
  • Quality of life during your period
  • Family members with a history of heavy menstrual bleeding
  • The stress you are facing
  • Weight problems
  • Current medications

Imaging and Lab Test

  • Full blood count – Hemoglobin concentration is a surrogate assessment for excessive menstrual loss. Other indices within the full blood count may more accurately assess iron state. Full blood count should be undertaken in all women presenting with menorrhagia
  • A pregnancy test – should always be performed in women of childbearing age, regardless of their history of sexual activity. In stable non-pregnant women with menorrhagia, there is no indication for other tests in the emergency department setting; however, outpatient workup can be extensive. Outpatient studies often consist of tests to assess for anemia and blood dyscrasias (ferritin, coagulation studies, complete blood count, and bleeding studies), tests to assess for thyroid disease (TSH and free T4), tests to assess for liver disease, and even advanced procedures (hysteroscopy) to look for anatomical causes of bleeding.
  • Coagulation screen – Tests for coagulopathies such as von Willebrand’s disease should only be undertaken when specifically indicated by the history
  • Thyroid function tests – There is little evidence to link hypothyroidism with the excessive menstrual loss and no evidence for hyperthyroidism to be a cause. Thyroid function tests should not be routinely undertaken
  • Other endocrine investigations – No significant endocrine abnormality has been detected in menorrhagia., There is no indication for any endocrine investigation
  • Pelvic ultrasound – Routine pelvic ultrasound has little place in evaluating the primary complaint of excessive menstrual loss. It is of value in evaluating other pelvic disorders discovered during a clinical examination
  • Endometrial sampling – As part of the initial assessment, there is no place for endometrial sampling. Sampling should be combined with further assessment of the endometrial cavity, for example, hysteroscopy, in selected cases only. Selected cases would include women over 40, women complaining of intermenstrual bleeding, and after a failed trial of medical treatment
  • Pap test – In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
  • Endometrial biopsy. Tissue samples are taken from the inside lining of your uterus or “endometrium” to find out if you have cancer or other abnormal cells. You might feel as if you were having a bad menstrual cramp while this test is being done. But, it does not take long, and the pain usually goes away when the test ends.
  • Sonohysterography – During this test, a fluid is injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses an ultrasound to look for problems in the lining of your uterus.
  • Hysteroscopy – This exam involves inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.
  • Electric hysterogram – This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This lets your doctor look for problems in the lining of your uterus. Mild to moderate cramping or pressure can be felt during this procedure.
  • Hysteroscopy – This is a procedure to look at the inside of the uterus using a tiny tool to see if you have fibroids, polyps, or other problems that might be causing bleeding. You might be given drugs to put you to sleep (this is known as “general anesthesia) or drugs simply to numb the area being looked at (this is called “local anesthesia”).
  • Dilation and Curettage (D&C) – This is a procedure (or test) that can be used to find and treat the cause of bleeding. During a D&C, the inside lining of your uterus is scraped and looked at to see what might be causing the bleeding. A D&C is a simple procedure. Most often it is done in an operating room, but you will not have to stay in the hospital afterward. You might be given drugs to make you sleep during the procedure, or you might be given something that will numb only the area to be worked on.

Treatment of 7 Days Over Menstrual Bleeding

Medications

These have been ranked by the UK’s National Institute for Health and Clinical Excellence:[rx]

  • First-line
    • An intrauterine device with progesterone
  • Second Line
  • Third line
    • An oral progestogen (e.g. norethisterone), to prevent the proliferation of the endometrium
    • An injected progestogen (e.g. Depo Provera)
  • Other options
    • Gonadotropin-releasing hormone agonist
Sample Treatment Plan for Chronic Recurring Menorrhagia
  • Bioflavonoids, 1000 mg twice per day
  • Vitamin A 60,000IU per day
  • Chaste tree (standardized extract) 175 mg per day; or ½–1 tsp daily
  • Combination herbal product using astringents and uterine tonics
  • Consider natural progesterone cream, ¼ to ½ tsp, 12–21 days/month
  • Oral micronized progesterone: 200–300 mg per day for 7–12 days followed by a cyclic hormone product for 21 days on and 7 days off

Drug Therapy

  • Iron supplements – To get more iron into your blood to help it carry oxygen if you show signs of anemia.
  • Ibuprofen (Advil) – To help reduce pain, menstrual cramps, and the amount of bleeding. In some women, NSAIDs can increase the risk of bleeding.
  • Intrauterine contraception (IUC) – To help make periods more regular and reduce the amount of bleeding through drug-releasing devices placed into the uterus.
  • Desmopressin Nasal Spray Stimate – To stop bleeding in people who have certain bleeding disorders, such as von Willebrand disease and mild hemophilia, by releasing a clotting protein or “factor”, stored in the lining of the blood vessels that help the blood to clot and temporarily increasing the level of these proteins in the blood.
  • Antifibrinolytic medicines (aminocaproic acid) – To reduce the amount of bleeding by stopping a clot from breaking down once it has formed.
  • Prostaglandin inhibitors – These are nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin or ibuprofen. They help reduce cramping and the amount you bleed.
  • Anti-inflammatory medication like NSAIDs – may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow. NSAIDs may be more effective than placebo in terms of reducing blood loss increasing women’s subjective perception of improvement, they may be less effective than tranexamic acid. It is uncertain if there is any difference between NSAIDs and tranexamic acid in terms of women’s subjective perception of bleeding.[rx] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.[rx]
  • Tranexamic acid – reduces menstrual blood loss by about half, and nonsteroidal anti-inflammatory drugs reduce it by about a third. Tranexamic acid tablets may also reduce loss by up to 50%.[rx] This may be combined with hormonal medication previously mentioned.[rx]NICE guidelines say that for women (with HMB and no identified pathology or fibroids less than 3 cm in diameter) who do not wish to have the pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. And options are hysterectomy and second-generation endometrial ablation. With hysterectomy more effective than second-generation endometrial ablation.[rx]
  • Vitamin K and chlorophyll – Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (historically in the form of crude preparations of chlorophyll) has clinical and limited research support.”
  • Hormonal therapy – for menorrhagia has been progestogens given during the luteal phase of the cycle. Such treatments are ineffective. Despite this, they remain the first choice of many general practitioners and gynecologists., Progestogens are effective when given for 21 days in each cycle, but the side effects may be such that patients choose not to continue with treatment. Although progestogens have a contraceptive effect, their use in this way may not be the best choice when contraception is required by the patient.
  • The combined contraceptive pill – is both an effective contraceptive and treatment of menorrhagia compared with other medical treatments. This statement, however, cannot be expanded upon because good-quality data are lacking, and the use of the contraceptive pill in this area has been insufficiently studied. Nevertheless, like cyclical progestogens, combined oral contraceptives are useful for anovulatory bleeding because they impose a cycle.
  • Vitamin B Complex – There may be a correlation between a deficiency of vitamin B and menorrhagia. With Vitamin B complex deficiencies, the liver looses it ability to inactivate estrogen. Some cases of menorrhagia are due to excess estrogen’s effect on the endometrium. The vitamin B complex may help to normalize estrogen metabolism.
  • Vitamin C and Bioflavonoids – Vitamin C, along with bioflavonoids, help reduce heavy bleeding by making the capillaries stronger and preventing them from becoming fragile. In one small study with 18 women who had heavy menstrual bleeding, bleeding improved in 16 out of the 18 patients when the women took Vitamin C and bioflavonoids. In addition, vitamin C can also help women who have suffered from iron deficiency from menorrhagia by increasing iron absorbency.


Specific hormonal contraceptives for the treatment of HMB

Estrogen: EE Progestin Comments
Combined hormonal contraceptives
Combined oral contraceptive pills Packaged as 21 d of active pills or 21 d of active pills + 7 d of placebo pills
20 μg EE 1 mg norethindrone Available in an extended cycle regimen with 24 d of active pills + 4 d of placebo
30 μg EE 1.5 mg norethindrone
35 μg EE 1 mg norethindrone
20 μg EE 0.1 mg levonorgestrel
20 μg EE 90 μg levonorgestrel Marketed as a continuous regimen
30 μg EE 1.5 mg levonorgestrel Available in an extended cycle regimen with 84 d of active pills + 7 d of placebo or 10 μg of EE
Patch 20 μg EE daily 150 μg of norelgestromin daily Applied weekly for 3 wk out of 4
Ring 15 μg EE daily 120 mcg of etonogestrel daily Worn 3 wk out of 4
Progestin-only contraceptives
Pills 0.35 mg norethindrone Daily
Intramuscular injection 150 mg DMPA Every 3 mo
Subcutaneous injection 104 mg DMPA Every 3 mo
Subcutaneous implant 68 mg etonogestrel Slowly released over ≥3 y; ∼60 μg daily after 3 mo, which slowly decreases to 30 μg daily at the end of 2 y
Intrauterine device 52 mg levonorgestrel Release rate of 20 μg daily, FDA-approved for 5 y of use
13.5 mg levonorgestrel Release rate of 14 μg daily, FDA approved for 3 y of use

Surgery

  • Dilation and curettage (D&C) – is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if spontaneous abortion is incomplete[rx] In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
  • Endometrial ablation – is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.[rx] For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply. During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with materials that decrease blood flow to the fibroid.
  • Uterine artery embolization (UAE) – The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.[rx]
  • Hysteroscopic myomectomy – to remove fibroids over 3 cm in diameter
  • Focused ultrasound surgery – Similar to uterine artery embolization, focused ultrasound surgery treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
  • Myomectomy – This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation – This procedure involves destroying (ablating) the lining of your uterus (endometrium). The procedure uses a laser, radiofrequency or heat applied to the endometrium to destroy the tissue. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.
  • Endometrial resection – This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
  • Hysterectomy –  Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. A hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.


Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down the questions you want to be answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

References

  1. https://www.ncbi.nlm.nih.gov/books/NBK279294/
  2. https://www.ncbi.nlm.nih.gov/books/NBK470230/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907973/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574688/
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077876/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070839/
  7. https://en.wikipedia.org/wiki/Heavy_menstrual_bleeding
  8. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
  9. https://www.nhs.uk/conditions/heavy-periods/treatment/

Prolong Menstrual Bleeding – Causes, Symptoms, Treatment

Prolong Menstrual Bleeding/Menorrhagia is prolonged and excessively heavy menstrual bleeding at regular menstrual cycle intervals. Although several factors (e.g. anatomical defects or growths in the womb, blood component abnormality, or hormonal imbalance) may be implicated, the cause of the abnormal uterine bleeding is often unknown.

Menorrhagia is menstrual bleeding that lasts more than 7 days. It can also be bleeding that is very heavy. How do you know if you have heavy bleeding? If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding. If you have this type of bleeding, you should see a doctor.

Menorrhagia (also known as heavy menstrual bleeding) is defined as heavy, but regular, menstrual bleeding. Menorrhagia menstruation at the regular cyclical interval with excessive flow and duration; clinically, blood loss is in excess of 80 ml per cycle; or menses lasts longer than 7 days8

Types of Menorrhagia

  • Idiopathic ovulatory menorrhagia – is regular heavy bleeding in the absence of recognisable pelvic pathology or a general bleeding disorder.
  • Objective menorrhagia – is taken to be a total menstrual blood loss of 80 mL or more in each menstruation. It is difficult to incorporate the objective measurement of menstrual blood loss into everyday practice. Subjectively, menorrhagia may be defined as a complaint of regular excessive menstrual blood loss that interferes with the woman’s physical, emotional, social, and material quality of life, and that can occur alone or in combination with other symptoms.
  • Metrorrhagia – intermenstrual bleeding occurring at any time between menstrual periods17p1355
  • Hypomenorrhea – (cryptomenorrhea)-unusually light menstrual flow, sometimes only spotting, or a deficient amount of menstrual flow17p1052
  • Menometrorrhagia – bleeding that occurs at irregular intervals or bleeding during and between menstrual periods in which amount and duration of bleeding may also vary17p1339
  • Polymenorrhea – menstrual periods occurring with abnormal frequency17p1726
  • Oligomenorrhea – periods that occur more than 35 days apart or scanty or infrequent menstrual flow17p1516

Dysfunctional menses – abnormal uterine bleeding without any obvious structural or systemic abnormality8,19

Causes of Prolong Menstrual Bleeding 

  • Hormone imbalance – In a normal menstrual cycle, a balance between the hormones estrogen and progesterone regulates the buildup of the lining of the uterus (endometrium), which is shed during menstruation. If a hormone imbalance occurs, the endometrium develops in excess and eventually sheds by way of heavy menstrual bleeding.
  • Dysfunction of the ovaries – If your ovaries don’t release an egg (ovulate) during a menstrual cycle (anovulation), your body doesn’t produce the hormone progesterone, as it would during a normal menstrual cycle. This leads to hormone imbalance and may result in menorrhagia.
  • Uterine fibroids – These noncancerous (benign) tumors of the uterus appear during your childbearing years. Uterine fibroids may cause heavier than normal or prolonged menstrual bleeding.
  • Polyps – Small, benign growths on the lining of the uterus (uterine polyps) may cause heavy or prolonged menstrual bleeding.
  • Adenomyosis – This condition occurs when glands from the endometrium become embedded in the uterine muscle, often causing heavy bleeding and painful periods.
  • Intrauterine device (IUD) – Menorrhagia is a well-known side effect of using a nonhormonal intrauterine device for birth control. Your doctor will help you plan for alternative management options.
  • Pregnancy complications – A single, heavy, late period may be due to a miscarriage. Another cause of heavy bleeding during pregnancy includes an unusual location of the placenta, such as a low-lying placenta or placenta previa.
  • Cancer – Uterine cancer and cervical cancer can cause excessive menstrual bleeding, especially if you are postmenopausal or have had an abnormal Pap test in the past.
  • Inherited bleeding disorders – Some bleeding disorders — such as von Willebrand’s disease, a condition in which an important blood-clotting factor is deficient or impaired — can cause abnormal menstrual bleeding.
  • Medications – Certain medications, including anti-inflammatory medications, hormonal medications such as estrogen and progestins, and anticoagulants such as warfarin (Coumadin, Jantoven) or enoxaparin (Lovenox), can contribute to heavy or prolonged menstrual bleeding.
  • Other medical conditions – A number of other medical conditions, including liver or kidney disease, may be associated with menorrhagia.

Others Cause May Consideration

Excessive menses but normal cycle – Painless

  • Fibroids (leiomyoma) — fibroids in the wall of the uterus cause increased menstrual loss if they protrude into the central cavity and thereby increase endometrial surface area.
  • Coagulation defects (rare) — with the shedding of an endometrial lining’s blood vessels, a normal coagulation process must occur to limit and eventually stop the blood flow. Blood disorders of platelets (such as ITP) or coagulation (such as von Willebrand disease) or use of anticoagulant medication (such as warfarin) are therefore possible causes, although a rare minority of cases. Platelet function studies can also be used to ascertain platelet function abnormalities
  • Endometrial cancer (cancer of the uterine lining) — bleeding can also be irregular, in between periods, or after menopause (post-menopausal bleeding or PMB)
  • Endometrial polyp
  • Omega 6 and prostaglandins – HMB is associated with increased omega-6 AA in uterine tissues.[rx] The endometrium of women with HMB have higher levels of prostaglandin (E2, F2alpha, and others) when compared with women with normal menses.[rx] It is thought that prostaglandins are a by-product of omega 6 build-up.[rx]

Painful (ie associated with dysmenorrhea)

  • Pelvic inflammatory disease
  • Endometriosis – an extension of the endometrial tissue outside of the uterus tries to shed causing painful and abnormal bleeds
  • Adenomyosis – an extension of the endometrial tissue into the wall of the uterus tries to shed causing painful and abnormal bleeds
  • Pregnancy related complication (i.e. miscarriage)
  • Short cycle (less than 21 days) but normal menses.
  • Short cycle and excessive menses due to ovarian dysfunction and may be secondary to blockage of blood vessels by tumors.
  • Polycystic ovary syndrome.[rx]
  • Systemic causes: thyroid disease, excessive emotional/physical stress.[rx]
  • Sexually transmitted infection.[rx]

Hormonal Abnormalities

  • Luteal phase defects
  • Stress
  • Exogenous hormones
  • Ovarian Cysts

Mechanical Abnormalities

  • Uterine Polyps
  • Uterine Fibroids
  • Intrauterine devices
  • Atopic pregnancy
  • Pregnancy

Clotting Abnormalities

  • Drug-induced hemorrhage
  • Dysproteinemias
  • Disseminated intravascular coagulation
  • Severe hepatic disease
  • Primary fibrinolysis

Symptoms of Prolong Menstrual Bleeding 

You may be experiencing menorrhagia if you have the following:
  • Soaking through one or more sanitary pads or tampons every hour for several consecutive hours
  • Needing to use double sanitary protection to control your menstrual flow
  • Needing to wake up to change sanitary protection during the night
  • Bleeding for longer than a week
  • Passing blood clots larger than a quarter
  • Restricting daily activities due to heavy menstrual flow
  • Symptoms of anemia, such as tiredness, fatigue, or shortness of breath
  • Menstrual flow that soaks through one or more sanitary pads every hour
  • The need to use double sanitary protection to control your menstrual flow
  • The menstrual period lasts more than seven days
  • Menstrual flow that includes large blood clots
  • Excessive and prolonged menses may lead to anemia,
  • Pallor
  • Tiredness
  • Fatigue
  • Shortness of breath

According to the CDC

You might have menorrhagia if you:

  • Have a menstrual flow that soaks through one or more pads or tampons every hour for several hours in a row.
  • Need to double up on pads to control your menstrual flow.
  • Need to change pads or tampons during the night.
  • Have menstrual periods lasting more than 7 days.
  • Have a menstrual flow with blood clots the size of a quarter or larger.
  • Have a heavy menstrual flow that keeps you from doing the things you would do normally.
  • Have constant pain in the lower part of the stomach during your periods.
  • Are tired, lack energy, or are short of breath.


Diagnosis of Prolong Menstrual Bleeding

Menorrhagia is diagnosed by your doctor through a series of questions about your medical history and menstrual cycles. Usually for women with menorrhagia bleeding lasts for more than 7 days and more blood is lost (80 milliliters compared to 60 milliliters).

Your doctor may ask for information about:

  • Your age when you got your first period
  • Length of your menstrual cycle
  • Number of days your period lasts
  • Number of days your period is heavy
  • Quality of life during your period
  • Family members with a history of heavy menstrual bleeding
  • The stress you are facing
  • Weight problems
  • Current medications

Imaging and Lab Test

  • Full blood count – Hemoglobin concentration is a surrogate assessment for excessive menstrual loss. Other indices within the full blood count may more accurately assess iron state. Full blood count should be undertaken in all women presenting with menorrhagia
  • A pregnancy test – should always be performed in women of childbearing age, regardless of their history of sexual activity. In stable non-pregnant women with menorrhagia, there is no indication for other tests in the emergency department setting; however, outpatient workup can be extensive. Outpatient studies often consist of tests to assess for anemia and blood dyscrasias (ferritin, coagulation studies, complete blood count, and bleeding studies), tests to assess for thyroid disease (TSH and free T4), tests to assess for liver disease, and even advanced procedures (hysteroscopy) to look for anatomical causes of bleeding.
  • Coagulation screen – Tests for coagulopathies such as von Willebrand’s disease should only be undertaken when specifically indicated by the history
  • Thyroid function tests – There is little evidence to link hypothyroidism with the excessive menstrual loss and no evidence for hyperthyroidism to be a cause. Thyroid function tests should not be routinely undertaken
  • Other endocrine investigations – No significant endocrine abnormality has been detected in menorrhagia., There is no indication for any endocrine investigation
  • Pelvic ultrasound – Routine pelvic ultrasound has little place in evaluating the primary complaint of excessive menstrual loss. It is of value in evaluating other pelvic disorders discovered during a clinical examination
  • Endometrial sampling – As part of the initial assessment, there is no place for endometrial sampling. Sampling should be combined with further assessment of the endometrial cavity, for example, hysteroscopy, in selected cases only. Selected cases would include women over 40, women complaining of intermenstrual bleeding, and after a failed trial of medical treatment
  • Pap test – In this test, cells from your cervix are collected and tested for infection, inflammation or changes that may be cancerous or may lead to cancer.
  • Endometrial biopsy. Tissue samples are taken from the inside lining of your uterus or “endometrium” to find out if you have cancer or other abnormal cells. You might feel as if you were having a bad menstrual cramp while this test is being done. But, it does not take long, and the pain usually goes away when the test ends.
  • Sonohysterography – During this test, a fluid is injected through a tube into your uterus by way of your vagina and cervix. Your doctor then uses an ultrasound to look for problems in the lining of your uterus.
  • Hysteroscopy – This exam involves inserting a thin, lighted instrument through your vagina and cervix into your uterus, which allows your doctor to see the inside of your uterus.
  • Electric hysterogram – This ultrasound scan is done after fluid is injected through a tube into the uterus by way of your vagina and cervix. This lets your doctor look for problems in the lining of your uterus. Mild to moderate cramping or pressure can be felt during this procedure.
  • Hysteroscopy – This is a procedure to look at the inside of the uterus using a tiny tool to see if you have fibroids, polyps, or other problems that might be causing bleeding. You might be given drugs to put you to sleep (this is known as “general anesthesia) or drugs simply to numb the area being looked at (this is called “local anesthesia”).
  • Dilation and Curettage (D&C) – This is a procedure (or test) that can be used to find and treat the cause of bleeding. During a D&C, the inside lining of your uterus is scraped and looked at to see what might be causing the bleeding. A D&C is a simple procedure. Most often it is done in an operating room, but you will not have to stay in the hospital afterward. You might be given drugs to make you sleep during the procedure, or you might be given something that will numb only the area to be worked on.

Treatment of Prolong Menstrual Bleeding

Medications

These have been ranked by the UK’s National Institute for Health and Clinical Excellence:[rx]

  • First-line
    • An intrauterine device with progesterone
  • Second Line
  • Third line
    • An oral progestogen (e.g. norethisterone), to prevent the proliferation of the endometrium
    • An injected progestogen (e.g. Depo Provera)
  • Other options
    • Gonadotropin-releasing hormone agonist
Sample Treatment Plan for Chronic Recurring Menorrhagia
  • Bioflavonoids, 1000 mg twice per day
  • Vitamin A 60,000IU per day
  • Chaste tree (standardized extract) 175 mg per day; or ½–1 tsp daily
  • Combination herbal product using astringents and uterine tonics
  • Consider natural progesterone cream, ¼ to ½ tsp, 12–21 days/month
  • Oral micronized progesterone: 200–300 mg per day for 7–12 days followed by a cyclic hormone product for 21 days on and 7 days off

Drug Therapy

  • Iron supplements – To get more iron into your blood to help it carry oxygen if you show signs of anemia.
  • Ibuprofen (Advil) – To help reduce pain, menstrual cramps, and the amount of bleeding. In some women, NSAIDs can increase the risk of bleeding.
  • Intrauterine contraception (IUC) – To help make periods more regular and reduce the amount of bleeding through drug-releasing devices placed into the uterus.
  • Desmopressin Nasal Spray Stimate – To stop bleeding in people who have certain bleeding disorders, such as von Willebrand disease and mild hemophilia, by releasing a clotting protein or “factor”, stored in the lining of the blood vessels that help the blood to clot and temporarily increasing the level of these proteins in the blood.
  • Antifibrinolytic medicines (aminocaproic acid) – To reduce the amount of bleeding by stopping a clot from breaking down once it has formed.
  • Prostaglandin inhibitors – These are nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin or ibuprofen. They help reduce cramping and the amount you bleed.
  • Anti-inflammatory medication like NSAIDs – may also be used. NSAIDs are the first-line medications in ovulatory heavy menstrual bleeding, resulting in an average reduction of 20-46% in menstrual blood flow. NSAIDs may be more effective than placebo in terms of reducing blood loss increasing women’s subjective perception of improvement, they may be less effective than tranexamic acid. It is uncertain if there is any difference between NSAIDs and tranexamic acid in terms of women’s subjective perception of bleeding.[rx] For this purpose, NSAIDs are ingested for only 5 days of the menstrual cycle, limiting their most common adverse effect of dyspepsia.[rx]
  • Tranexamic acid – reduces menstrual blood loss by about half, and nonsteroidal anti-inflammatory drugs reduce it by about a third. Tranexamic acid tablets may also reduce loss by up to 50%.[rx] This may be combined with hormonal medication previously mentioned.[rx]NICE guidelines say that for women (with HMB and no identified pathology or fibroids less than 3 cm in diameter) who do not wish to have the pharmacological treatment and who do not want to conserve their fertility, surgical options could be considered as a first-line treatment option. And options are hysterectomy and second-generation endometrial ablation. With hysterectomy more effective than second-generation endometrial ablation.[rx]
  • Vitamin K and chlorophyll – Although bleeding time and prothrombin levels in women with menorrhagia are typically normal, the use of vitamin K (historically in the form of crude preparations of chlorophyll) has clinical and limited research support.”
  • Hormonal therapy – for menorrhagia has been progestogens given during the luteal phase of the cycle. Such treatments are ineffective. Despite this, they remain the first choice of many general practitioners and gynecologists., Progestogens are effective when given for 21 days in each cycle, but the side effects may be such that patients choose not to continue with treatment. Although progestogens have a contraceptive effect, their use in this way may not be the best choice when contraception is required by the patient.
  • The combined contraceptive pill – is both an effective contraceptive and treatment of menorrhagia compared with other medical treatments. This statement, however, cannot be expanded upon because good-quality data are lacking, and the use of the contraceptive pill in this area has been insufficiently studied. Nevertheless, like cyclical progestogens, combined oral contraceptives are useful for anovulatory bleeding because they impose a cycle.
  • Vitamin B Complex – There may be a correlation between a deficiency of vitamin B and menorrhagia. With Vitamin B complex deficiencies, the liver looses it ability to inactivate estrogen. Some cases of menorrhagia are due to excess estrogen’s effect on the endometrium. The vitamin B complex may help to normalize estrogen metabolism.
  • Vitamin C and Bioflavonoids – Vitamin C, along with bioflavonoids, help reduce heavy bleeding by making the capillaries stronger and preventing them from becoming fragile. In one small study with 18 women who had heavy menstrual bleeding, bleeding improved in 16 out of the 18 patients when the women took Vitamin C and bioflavonoids. In addition, vitamin C can also help women who have suffered from iron deficiency from menorrhagia by increasing iron absorbency.


Specific hormonal contraceptives for the treatment of HMB

Estrogen: EE Progestin Comments
Combined hormonal contraceptives
Combined oral contraceptive pills Packaged as 21 d of active pills or 21 d of active pills + 7 d of placebo pills
20 μg EE 1 mg norethindrone Available in an extended cycle regimen with 24 d of active pills + 4 d of placebo
30 μg EE 1.5 mg norethindrone
35 μg EE 1 mg norethindrone
20 μg EE 0.1 mg levonorgestrel
20 μg EE 90 μg levonorgestrel Marketed as a continuous regimen
30 μg EE 1.5 mg levonorgestrel Available in an extended cycle regimen with 84 d of active pills + 7 d of placebo or 10 μg of EE
Patch 20 μg EE daily 150 μg of norelgestromin daily Applied weekly for 3 wk out of 4
Ring 15 μg EE daily 120 mcg of etonogestrel daily Worn 3 wk out of 4
Progestin-only contraceptives
Pills 0.35 mg norethindrone Daily
Intramuscular injection 150 mg DMPA Every 3 mo
Subcutaneous injection 104 mg DMPA Every 3 mo
Subcutaneous implant 68 mg etonogestrel Slowly released over ≥3 y; ∼60 μg daily after 3 mo, which slowly decreases to 30 μg daily at the end of 2 y
Intrauterine device 52 mg levonorgestrel Release rate of 20 μg daily, FDA-approved for 5 y of use
13.5 mg levonorgestrel Release rate of 14 μg daily, FDA approved for 3 y of use

Surgery

  • Dilation and curettage (D&C) – is not recommended for cases of simple heavy menstrual bleeding, having a reserved role if spontaneous abortion is incomplete[rx] In this procedure, your doctor opens (dilates) your cervix and then scrapes or suctions tissue from the lining of your uterus to reduce menstrual bleeding. Although this procedure is common and often treats acute or active bleeding successfully, you may need additional D&C procedures if menorrhagia recurs.
  • Endometrial ablation – is not recommended for women with active or recent genital or pelvic infection, known or suspected endometrial hyperplasia or malignancy.[rx] For women whose menorrhagia is caused by fibroids, the goal of this procedure is to shrink any fibroids in the uterus by blocking the uterine arteries and cutting off their blood supply. During uterine artery embolization, the surgeon passes a catheter through the large artery in the thigh (femoral artery) and guides it to your uterine arteries, where the blood vessel is injected with materials that decrease blood flow to the fibroid.
  • Uterine artery embolization (UAE) – The rate of serious complications is comparable to that of myomectomy or hysterectomy; however, UAE presents an increased risk of minor complications and requiring surgery within two to five years.[rx]
  • Hysteroscopic myomectomy – to remove fibroids over 3 cm in diameter
  • Focused ultrasound surgery – Similar to uterine artery embolization, focused ultrasound surgery treats bleeding caused by fibroids by shrinking the fibroids. This procedure uses ultrasound waves to destroy the fibroid tissue. There are no incisions required for this procedure.
  • Myomectomy – This procedure involves surgical removal of uterine fibroids. Depending on the size, number and location of the fibroids, your surgeon may choose to perform the myomectomy using open abdominal surgery, through several small incisions (laparoscopically), or through the vagina and cervix (hysteroscopically).
  • Endometrial ablation – This procedure involves destroying (ablating) the lining of your uterus (endometrium). The procedure uses a laser, radiofrequency or heat applied to the endometrium to destroy the tissue. After endometrial ablation, most women have much lighter periods. Pregnancy after endometrial ablation has many associated complications. If you have endometrial ablation, the use of reliable or permanent contraception until menopause is recommended.
  • Endometrial resection – This surgical procedure uses an electrosurgical wire loop to remove the lining of the uterus. Both endometrial ablation and endometrial resection benefit women who have very heavy menstrual bleeding. Pregnancy isn’t recommended after this procedure.
  • Hysterectomy –  Hysterectomy — surgery to remove your uterus and cervix — is a permanent procedure that causes sterility and ends menstrual periods. A hysterectomy is performed under anesthesia and requires hospitalization. Additional removal of the ovaries (bilateral oophorectomy) may cause premature menopause.


Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down the questions you want to be answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

References

  1. https://www.ncbi.nlm.nih.gov/books/NBK279294/
  2. https://www.ncbi.nlm.nih.gov/books/NBK470230/
  3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907973/
  4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4574688/
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2077876/
  6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1070839/
  7. https://en.wikipedia.org/wiki/Heavy_menstrual_bleeding
  8. https://www.cdc.gov/ncbddd/blooddisorders/women/menorrhagia.html
  9. https://www.nhs.uk/conditions/heavy-periods/treatment/

Knee Meniscus Injury – Causes, Symptoms, Treatment

Knee Meniscus Injury is a crescent-shaped, cartilaginous band found between the medial tibia and medial femur. The primary function is to decrease the amount of stress on the knee joint. The medial meniscus receives vascular supply via a capillary network formed by the medial, lateral and middle geniculate arteries and receives its innervation from the posterior tibial, obturator, and femoral nerves.

The medial meniscus is a fibrocartilage semicircular band that spans the knee joint medially, located between the medial condyle of the femur and the medial condyle of the tibia. It is also referred to as the internal semilunar fibrocartilage. The medial meniscus has more of a crescent shape while the lateral meniscus is more circular. The anterior aspects of both menisci are connected by the transverse ligament. It is a common site of injury, especially if the knee is twisted.

A tear to the meniscus (also known as a cartilage tear) is a common injury that can cause pain and problems with sports and daily activities. The meniscus is a vital component of the knee that acts like a cushion between the femur (thigh) and tibia (shin) bones, providing shock absorption and stability.

Anatomy and Physiology

The meniscus is a C-shaped cartilage that serves as a cushion between the proximal tibia and the distal femur, comprising the knee joint.  The average width is 10 mm to 12 mm, and the average thickness is 4 mm to 5 mm. The meniscus is made of fibroelastic cartilage. It is an interlacing network of collagen, glycoproteins, proteoglycan, and cellular elements, and is about 70% water. Three ligaments attach to the meniscus. The coronary ligaments connect the meniscus peripherally. The transverse (inter-meniscal) ligament is anterior and serves as a connection between the medial and lateral meniscus. The meniscofemoral ligament joins the meniscus to the posterior cruciate ligament (PCL) and has two components: the Humphrey ligament anteriorly, and the ligament of Wrisberg posteriorly. The meniscofemoral ligament originates from the posterior horn of the lateral meniscus. The meniscus is supplied blood from the medial inferior genicular artery and the lateral inferior genicular artery. The meniscus is known to have a very poor blood supply, especially the central portion, which gets most of its nutrition via diffusion. The cartilage structure of the meniscus serves as a shock absorber and cushion or for the knee joint. There are several types of possible tears of the meniscus. These include flap tear, radial tear, horizontal cleavage, bucket handle tear, longitudinal tear, and degenerative tear.

Types of Knee Meniscus Injury

There are two categories of meniscal injuries – acute tears and degenerative tears.

  • An acute tear – usually occurs when the knee is bent and forcefully twisted, while the leg is in a weight-bearing position. Statistics show that about 61 of 100,000 people experience an acute tear of the meniscus.
  • Degenerative tears – of the meniscus are more common in older people. Sixty percent of the population over the age of 65 probably has some sort of degenerative tear of the meniscus. As the meniscus ages, it weakens and becomes less elastic. Degenerative tears may result from minor events and there may or may not be any symptoms present.

A meniscal tear can be classified in various ways, such as by anatomic location or by proximity to the blood supply. Various tear patterns and configurations have been described.[rx] These include

  • Radial tears
  • Flap or parrot-beak tears
  • Peripheral, longitudinal tears
  • Bucket-handle tears
  • Horizontal cleavage tears
  • Complex, degenerative tears

These tears can then be further classified by their proximity to the meniscus blood supply, namely whether they are located in the “red-red,” “red-white,” or “white-white” zones.

The functional importance of these classifications, however, is to ultimately determine whether a meniscus is repairable. The repairability of a meniscus depends on a number of factors. These include:

  • Age/strength
  • Activity level
  • Tear pattern
  • Chronicity of the tear
  • Associated injuries (anterior cruciate ligament injury)
  • Healing potential

or

There are different types of meniscal tears, describing the morphology of the injury. Identifying and accurately describing the type of meniscal tear can help the surgeon in patient education and planning of the surgical procedure. Meniscal tear types include

Basic tears

  • longitudinally oriented tears
      • horizontal tear (cleavage tear)
        • parallel to the tibial plateau involving one of the articular surfaces or free edge
        • divides the meniscus into superior and inferior parts
      • longitudinal tear (vertical tear)
        • perpendicular to the tibial plateau and parallel to the long axis of the meniscus
        • divides the meniscus into medial and lateral parts
        • Wrisberg rip – is a specific subtype
        • ramp lesion – is a specific subtype
  • radial tear – perpendicular to both the tibial plateau and the long axis of the meniscus
  • root tear – typically radial-type tear located at the meniscal root
  • complex tear – a combination of all or some of horizontal, longitudinal and radial-type tears
  • displaced tear – tear involving a component that is displaced, either still attached to the parent meniscus or detached:
    • flap tear: displaced horizontal or longitudinal tears
    • bucket-handle tear: displaced longitudinal tear
    • parrot beak tear: oblique radial tear

Medial Meniscus Injury

Causes of Knee Meniscus Injury

  • Inward (valgus) force – Usually, the medial collateral ligament, followed by the anterior cruciate ligament, then the medial meniscus (this mechanism is the most common and is usually accompanied by some external rotation and flexion, as when being tackled in football)
  • Outward (varus) force –  Often, the lateral collateral ligament, anterior cruciate ligament, or both (this mechanism is the 2nd most common)
  • Anterior or posterior forces and hyperextension –  Typically, the cruciate ligaments
  • Weight-bearing and rotation at the time of injury – Usually, menisci
  • Motor vehicle accidents – A “dashboard injury” occurs when the driver’s or passenger’s bent knee slams against the dashboard, pushing in the shinbone just below the knee and causing the posterior meniscus tear.
  • Contact sports – Athletes in sports such as football and soccer can tear their posterior meniscus ligament when they fall on a bent knee with their foot pointed down. The shinbone hits the ground first and it moves backward. Being tackled when your knee is bent also can cause this injury.
  • The knee is hit directly – especially during sports like soccer, rugby, and football
  • A person lands on a bent knee – such as during a fall or misstep
  • Landing directly on the front of the shinbone – such as when a dancer comes down from a leap and falls
  • A person makes cutting or pivoting maneuvers – such as when an athlete plants a foot and shifts directions
  • A person lands on one leg – which can happen after a jump in basketball or volleyball
  • A direct blow to the bent knee in an automobile injury
  • A sports-related injury in which the knee bends
  • Pulling on the ligament in a twisting injury or hyperextension
  • A misstep on uneven terrain

Symptoms of Knee Meniscus Injury

If you’ve torn your meniscus, you might have the following signs and symptoms in your knee:

  • Localized pain near the area of the tear – In tears of the lateral meniscus, this discomfort will be present along the outside edge of the knee. The pain will manifest on the inside edge of the injured knee for tears of the medial meniscus.
  • Immediate pain after the injury – A torn meniscus will often be obvious from the moment that the injury occurs. In these instances, the tearing of the meniscus is typically accompanied by the feeling of a pop or snap within the leg during an overexerting twisting or stretching motion.
  • Slow onset of symptoms – Conversely, for some, the meniscus can tear without much of a sign or initial pain. This slow onset of symptoms is more common in older individuals and those with damaged knee cartilage from osteoarthritis.
  • Pain with movement – The pain will reflect the location of the tear but extend throughout the knee with movement. In the event that the knee has locked, bending it will cause searing pain to worsen.
  • Pain after resting – Pain will likely diminish somewhat with rest; however, it will return with movement in most cases. Movement may also exacerbate swelling.
  • Fluid accumulation within the knee joint – This accumulated fluid will cause the entire area to swell up and reduce mobility. This symptom, which may occur as a result of a number of knee injuries, is known as “water on the knee.”
  • Knee locking – If a piece of the meniscus breaks free of the disc structure due to a tear, it may lodge within the joint of the knee itself. This lodging can cause knee locking, in which a person loses the ability to fully straighten the leg when sitting or standing.
  • A popping sensation
  • Swelling or stiffness
  • Pain, especially when twisting or rotating your knee
  • Difficulty straightening your knee fully
  • Feeling as though your knee is locked in place when you try to move it
  • difficulty moving your knee or inability to move it in a full range of motion
  • the feeling of your knee locking or catching
  • the feeling that your knee is giving way or unable to support you
  • The feeling of your knee giving way
  • Pain in the knee
  • A popping sensation during the injury
  • Difficulty bending and straightening the leg
  • A tendency for your knee to get “stuck” or lock up

What are the signs?

You might feel a ‘pop’ if you tear your meniscus. Many people find they can still walk on their injured knee. However, it might become gradually stiffer and more swollen over the next day or so. Common symptoms include the following.

  • Pain in your knee, although this can vary. Some people only have mild pain, and for others, the pain may come and go.
  • Swelling, usually several hours after the injury.
  • Feeling as though your knee is catching or locking, usually when your knee is bent. You may notice it making clicking or popping sounds too.
  • Your knee feeling ‘loose’, as though it’s going to give way.
  • Being unable to bend and extend your knee fully.

Symptoms of severe meniscus tears

  • Popping, locking or catching
  • Inability to straighten the knee
  • A knee that gives way
  • Stiffness and swelling right after the incident

Diagnosis of Knee Meniscus Injury

Medical History

During your doctor’s appointment, he will ask you several questions about your knee pain. Examples of such questions include:

  • Where exactly is your knee pain located?
  • Did your knee swelling come on suddenly or did it gradually develop over days?
  • Are you experiencing any other symptoms besides pain and swelling, like your knee giving out or an inability to bend or extend your knee?
  • Have you experienced any trauma or injury to the knee?
  • Do you have a known history of knee osteoarthritis?

Physical examination

After noting symptoms, a physician can perform clinical tests to determine if the pain is caused by compression and impingement of a torn meniscus. The knee is examined for swelling. In meniscal tears, pressing on the joint line on the affected side typically produces tenderness.

  • Stress testing – Stress testing to evaluate ligament integrity helps distinguish partial from complete tears. However, if patients have significant pain and swelling or muscle spasm, testing is typically delayed until x-rays exclude fractures. Also, significant swelling and spasm may make joint stability difficult to evaluate. Such patients should be examined 2 to 3 days later (after swelling and spasm have subsided). A delayed physical examination of the knee is more sensitive than MRI of the knee (86% vs 76% [rx]) for the diagnosis of meniscal and anterior cruciate ligament injuries.
  • Steinmann test – Steinman test is done to diagnose meniscal pathology at the knee joint. The test is divided into 2 parts i.e Steinman part 1 and Steinman part 2 or Steinman’s tenderness displacement test. This test is useful to distinguish meniscal pathology from injury to the ligament or osteophytes.
  • The McMurray test – involves pressing on the joint line while stressing the meniscus (using flexion-extension movements and varus or valgus stress). The test is often used to indicate cartilage injuries. With the patient laying on their back the therapist holds the knee with the upper hand and the heel with the lower hand. The therapist then applies a valgus (inward) stress to the knee whilst the other hand rotates the leg externally (outwards) and extends the knee. Pain and/or an audible click while performing this maneuver can indicate a torn medial meniscus.
  • Apley’s grind test – (a grinding maneuver while the person lies prone and the knee is bent 90°) and the Thessaly test (flexing the affected knee to 20 degrees, pivoting on the knee to see. Apley’s test is also used in cases of suspected meniscal tears. The patient is positioned on their front with the knee bent. The therapist grasps the heel and ankle and applies a compressive force through the lower leg. At the same time, they rotate the lower leg. Any reproduction of symptoms, pain, or clicking is a positive response, suggesting a torn meniscus.
  • The Lachman test – is the most sensitive physical test for acute anterior cruciate ligament tears (rx). With the patient supine, the examiner supports the patient’s thigh and calf, and the patient’s knee is flexed 20°. The lower leg is moved anteriorly. The excessive passive anterior motion of the lower leg from the femur suggests a significant tear.

Imaging tests

  • Imaging tests may be ordered to confirm a tear of the meniscus. These include:

Knee X-ray

  • This test won’t show a meniscus tear. However, it can be helpful to determine if there are any other causes of your knee pain, like osteoarthritis.

MRI

  • An MRI uses a magnetic field to take multiple images of your knee. An MRI will be able to take pictures of cartilage and ligaments to determine if there’s a meniscus tear.
  • While MRIs can help your doctor make a diagnosis, they aren’t considered 100 percent reliable. According to a study from 2008 published in the Journal of Trauma Management & OutcomesTrusted Source, the MRI’s accuracy for diagnosing lateral meniscus tears is 77 percent.
  • Sometimes, meniscus tears may not show up on an MRI because they can closely resemble degenerative or age-related changes. Additionally, a doctor may make an incorrect diagnosis that a person has a torn meniscus. This is because some structures around the knee can closely resemble a meniscus tear.

Ultrasound

  • An ultrasound uses sound waves to take images inside the body. This will determine if you have any loose cartilage that may be getting caught in your knee.

Arthroscopy

  • If your doctor is unable to determine the cause of your knee pain from these techniques, they may suggest arthroscopy to study your knee. If you require surgery, your doctor will also most likely use an arthroscope.
  • With arthroscopy, a small incision or cut is made near the knee. The arthroscope is a thin and flexible fiber-optic device that can be inserted through the incision. It has a small light and camera. Surgical instruments can be moved through the arthroscope or through additional incisions in your knee.
  • After an arthroscopy, either for surgery or examination, people can often go home the same day.

Treatment of Knee Meniscus Injury

Non-Surgical Injury

  • Protection  – the joint from further injury by taping/strapping the knee joint, or wearing knee support which has additional support at the sides.
  • Rest – Avoid activities that aggravate your knee pain, especially any activity that causes you to twist, rotate or pivot your knee. If your pain is severe, using crutches can take the pressure off your knee and promote healing.
  • Ice – Ice can reduce knee pain and swelling. Use a cold pack, a bag of frozen vegetables or a towel filled with ice cubes for about 15 minutes at a time, keeping your knee elevated. Do this every four to six hours the first day or two, and then as often as needed. Ice your knee to reduce pain and swelling. Do it for 15-20 minutes every 3-4 hours for 2-3 days or until the pain and swelling is gone.
  • Elevate your knee – with a pillow under your heel when you’re sitting or lying down.
  • A stabilized knee brace –  has flexible springs in the sides for additional support or for more severe injuries a hinged knee brace with solid metal supports linked by a hinge will help protect the joint from sideways or lateral movement. Compression will also help reduce swelling.
  • Rest the knee –  Limit activities to include walking if the knee is painful. Use crutches to help relieve pain.
  • Compress your knee. Use an elastic bandage or a neoprene type sleeve on your knee to control swelling.
  • Use stretching and strengthening exercises to help reduce stress to your knee – Ask your doctor to recommend a physical therapist for guidance.
  • Avoid impact activities such as running and jumping 
  • Full weight-bearing is not permitted for 1 – 6 weeks – after surgery, depending on the type of injury and repair. Crutches will be used initially following surgery. Many surgeons brace the knee and restrict motion for 6 weeks, to prevent excessive flexion and extension.
  • Range of motion exercises – begin anywhere from 0 – 6 weeks after surgery, depending on the type of repair.
  • Strengthening exercises – begin once the full range of motion has returned.
  • Return to vigorous activities – such as sports, may begin 3 – 4 months after repair.

Physiotherapy

  • A professional therapist will undertake a thorough assessment and make an accurate diagnosis to confirm cartilage meniscus injury and they may undertake an MRI scan to determine the extent of the injury.
  • A physical therapist will focus on improving mobility, strength, flexibility, and balance, which can help speed up recovery time and improve performance once the injury has healed.
  • Walking (weight-bearing) is initiated as soon as possible.
  • Knee straightening (extension) and bending (flexion) are encouraged. Pool therapy is helpful.
  • Stationary cycling is initiated as soon as adequate motion is achieved.
  • Quadriceps strengthening exercises are started, such as standing squats with toe raises and leg press.
  • Hamstring exercise may be modified for 6 months.
  • Surgery is avoided in most cases unless other major ligaments are disrupted.

Medication

If the injury is severe and pain is intolerable the following medicine can be considered to prescribe

  • Take anti-inflammatory medications. Non-steroidal anti-inflammatory drugs (NSAIDs), like will help with pain and swelling. However, these drugs can have side effects, such as an increased risk of bleeding and ulcers. They should be only used occasionally unless your doctor specifically says otherwise.
  • Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any other cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema.
  • NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include and KetorolacAceclofenacNaproxen, Etoricoxib.
  • Corticosteroids – Also known as oral steroids, these medications reduce inflammation.
  • Muscle Relaxants –  These medications provide relief from associated muscle spasms.
  • Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
  • Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • Calcium & vitamin D3 – to improve bone health and healing fracture. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. They are structural components of articular cartilage, and the thought is that a supplement will aid in the health of articular cartilage.
  • Intra-articular corticosteroid injections – may be useful for symptomatic meniscus injury especially where there is a considerable inflammatory component. The delivery of the corticosteroid directly into the knee may reduce local inflammation associated with a meniscus injury and minimize the systemic effects of the steroid.
  • Intra-articular hyaluronic acid injections (HA) – injections are another injectable option for knee meniscus injury. HA is a glycosaminoglycan that is found throughout the human body and is an important component of synovial fluid and articular cartilage. HA breaks down during the process of meniscus injury and contributes to the loss of articular cartilage as well as stiffness and pain. Local delivery of HA into the joint acts as a lubricant and may help increase the natural production of HA in the joint.
  • Platelet-rich plasma (PRP) injection – newer therapy where a blood sample is taken from the patient, spun in a centrifuge, growth factors are isolated and then they are injected back into the affected site to stimulate faster healing.

Surgery

Grade 3 meniscus tears usually require surgery, which may include:

  • Arthroscopic repair — An arthroscope is inserted into the knee to see the tear. One or two other small incisions are made for inserting instruments. Many tears are repaired with dartlike devices that are inserted and placed across the tear to hold them together. The body usually absorbs these over time. Arthroscopic meniscus repairs typically take about 40 minutes. Usually, you will be able to leave the hospital the same day.
  • Arthroscopic partial meniscectomy – The goal of this surgery is to remove a small piece of the torn meniscus in order to get the knee functioning normally.
  • Arthroscopic total meniscectomy – Occasionally, a large tear of the outer meniscus can best be treated by arthroscopic total meniscectomy, a procedure in which the entire meniscus is removed.

Trephination/ Abrasion Technique

  • This procedure is used for stable tears located on the periphery near the meniscus and joint capsule junction, where there’s a good blood supply. Multiple holes or shavings are made in the torn part of the meniscus to promote bleeding, which enhances the healing process.

Partial Resection

  • This surgical procedure is used for tears located in the inner 2/3 of the meniscus where there is no blood supply. The goal is to stabilize the rim of the meniscus by removing as little of the inner meniscus as possible. Only the torn part of the meniscus is removed. If the meniscus remains mostly intact with only the inner portion removed, the patient usually does well and does not develop early arthritis.

Complete Resection

  • This procedure involves the complete removal of the damaged meniscus. This technique is only performed if absolutely necessary. Removal of the entire meniscus frequently leads to the development of arthritis.

Meniscal Repair

  • Repairs are performed on tears near the outer 1/3 of the meniscus where a good blood supply exists, or on large tears that would require a near-total resection. The torn portion of the meniscus is repaired by using either sutures or absorbable fixation devices. These devices include arrows, barbs, staples, or tacks that join the torn edges of the meniscus so they can heal.

Meniscal Replacement

  • Experimental attempts to replace damaged meniscus are seen as important recent advances in orthopedic medicine. The new technology mentioned here has been performed at a few surgical centers across the country on a small number of patients

Collagen meniscus implant

  • This is a scaffold of collagen inserted into the patient’s knee. Over time, a new meniscus may grow within the joint. This procedure is currently in FDA trials in the United States and has just been approved as an accepted surgical procedure in Europe.

Meniscal transplant

  • This procedure involves transplanting a meniscus from a donor into the injured knee. Only a limited number of surgeons perform this procedure on a routine basis. The long-term outcomes are still being evaluated.

Meniscus transplants

Meniscus transplants are accomplished successfully regularly, although it is still somewhat of a rare procedure, and many questions surrounding its use remain. Side effects of meniscectomy include:

  • The knee loses its ability to transmit and distribute the load and absorb mechanical shock.
  • Persistent and significant swelling and stiffness in the knee.
  • The knee may not be fully mobile; there may be the sensation of knee locking or buckling in the knee.
  • The full knee may be in full motion after the tear of the meniscus.
  • Increases progression of arthritis and time to knee replacement.

Post-Surgical Rehabilitation

Typical locations of arthroscopic surgery incisions in a knee joint following surgery for a tear in the meniscus

After successful surgery for treating the destroyed part of the meniscus, patients must follow a rehabilitation program to have the best result. The rehabilitation following a meniscus surgery depends on whether the entire meniscus was removed or repaired.

If the destroyed part of the meniscus was removed, patients can usually start walking using a crutch a day or two after surgery. Although each case is different, patients return to their normal activities on average after a few weeks (2 or 3). Still, a completely normal walk will resume gradually, and it’s not unusual to take 2–3 months for the recovery to reach a level where a patient will walk totally smoothly. Many meniscectomy patients don’t ever feel a 100% functional recovery, but even years after the procedure they sometimes feel tugging or tension in a part of their knee. There is a little medical follow-up after meniscectomy and official medical documentation tends to ignore the imperfections and side-effects of this procedure.

If the meniscus was repaired, the rehabilitation program that follows is a lot more intensive. After the surgery, a hinged knee brace is sometimes placed on the patient. This brace allows the controlled movement of the knee. The patient is encouraged to walk using crutches from the first day, and most of the times can put partial weight on the knee.

Phase I

There are three phases that follow meniscal surgery. Each phase consists of rehabilitation goals, exercises, and criteria to move on to the next phase. Phase I starts immediately following surgery to 4–6 weeks or until the patient is able to meet progression criteria. The goals are to restore normal knee extension, reduce and eliminate swelling, regain leg control, and protect the knee (Fowler, PJ, and D. Pompan, 1993). During the first 5 days following the surgery, a passive continuous motion machine is used to prevent a prolonged period of immobilization which leads to muscular atrophy and delays functional recovery.[rx] During the 4–6 weeks post-surgical, active and passive non-weight bearing motions that flex the knee up to 90° are recommended. For patients with meniscal transplantation, further knee flexion can damage the allograft because of the increased shear forces and stresses.

Phase II

This phase of the rehabilitation program is 6 to 14 weeks after the surgery. The goals for Phase II include being able to restore full ROM, normalized gait, and performing functional movements with control and no pain (Fowler, PJ, and D. Pompan, 1993). Also, muscular strengthening and neuromuscular training are emphasized using progressive weight-bearing and balance exercises. Exercises in this phase can increase knee flexion for more than 90°.[rx] Advised exercises include stationary bicycle, standing on a foam surface with two and one legs, abdominal and back strengthening, and quadriceps strengthening. The proposed criteria include normal gait on all surfaces and single-leg balance longer than 15 seconds (Ulrich G.S., and S Aroncyzk, 1993).

Balance exercises on a foam surface in phase 2. The patient tries to maintain balance first with both legs, then with only the affected leg.

Phase III

Patients begin exercises in phase III 14 to 22 weeks after surgery. Phase III’s goal and final criteria is to perform sport/work specific movements with no pain or swelling (Fowler, PJ, and D. Pompan, 1993). Drills for maximal muscle control, strength, flexibility,[rx] movements specific to patient’s work/sport, low to high rate exercises, and abdominal and back strengthening exercises are all recommended exercises (Ulrich G.S., and S Aroncyzk, 1993). Exercises to increase cardiovascular fitness are also applied to fully prepare the patients to return to their desired activities.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.
  • Before your visit, write down the questions you want to be answered.
  • Bring someone with you to help you ask questions and remember what your provider tells you.
  • At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also, write down any new instructions your provider gives you.
  • Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
  • Ask if your condition can be treated in other ways.
  • Know why a test or procedure is recommended and what the results could mean.
  • Know what to expect if you do not take the medicine or have the test or procedure.
  • If you have a follow-up appointment, write down the date, time, and purpose for that visit.
  • Know how you can contact your provider if you have questions.

Prevention

Although it’s hard to prevent accidental knee injuries, you may be able to reduce your risks by:

  • Warming up and stretching before participating in athletic activities
  • Exercising to strengthen the muscles around your knee
  • Avoiding sudden increases in the intensity of your training program
  • Wearing comfortable, supportive shoes that fit your feet and your sport
  • Wearing appropriate protective gear during activities, including athletic activities, in which knee injuries are common (especially if you’ve had knee injuries before).

References

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Have you recently had an automobile accident and need fast recovery from your neck injury look at the Lumenon neck traction pillow. The cervical neck brace helps increase blood circulation at the same time and corrects your neck posture. The device has a soft fabric structure and inflates quickly. The support is fully adjustable and fits most neck sizes. To keep the neck collar secure it has adjustable Velcro straps.

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  • Makes a great travel pillow
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  • Folds compact

10. Jimugor Neck Traction Device

The Jimugor neck traction device has a unique design and offers you sufficient traction. The neck brace has a self-rotation switch to adjust the traction based on your preference. The bottom of the apparatus has a recoil pad that helps stretch the vertebra distance. There are also eight inflatable columns making it one of the most effective neck traction devices available on the market. The switch controls easily in reach.

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  • Provides excellent traction and comfortable to wear
  • Has a pump to add airflow to the back of the neck
  • Traction is done using the manually with two knobs and works with a gear system
  • Does not hold air well and you can fix it by setting the desired pressure, disconnect the hose, once clamped together the valve system helps depress air and fully closes the system to prevent air leakage.

9. Neck Ii Device, 2.4 Pound

To start our list of the best traction devices, which are available in the market, is this amazing product. This neck traction device contains a therapy function on the neck. The device is hanged on the door or placed on a substance that is high to ensure continuous support of the neck.

This is among the best neck traction devices in the market, which is simple and easy to use. It reveals neck pains and prevents further injury. The device is light and is suitable for a daily basis.

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  • Physical therapist
  • Easy to use
  • light and used daily

8. The Neck Hammock Traction Device For Neck Pain Relief And Physical Therapy

This device is the best neck traction device that helps the head and the neck to exercise. During the exercise, the neck is aligned with the spinal code to enhance the fast healing of the neck injury.

The device contains two gentle strides that push the neck smoothly to ensure the head heals. This device is very durable and easy to use. The neck hammock is medically tested and is one of the best neck traction devices.

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Reason To Buy This

  • Ease to use
  • Flexible
  • Increases blood flow

7. BigSize Cervical For Instant Neck

This neck traction device is a spinal code alignment that is put on the neck to enhance correct alignment with the head. This neck traction device has three layers that are adjustable and easy to remove.

This device is a home therapeutic that is best for neck healing. It contains a unique design that one can move with it through the day. This device is highly adjustable and used by people of all sizes.

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  • East to use
  • Adjustable
  • Has a unique design

6. Pinched Nerve Traction Device

This device is a gentle and straightforward neck traction device that enhances healing of the neck and the alignment with the spinal code. The material used to manufacture this device is very soft, and one can sleep with it at night.

Pinched nerve neck stretcher is adjustable to fit all kinds of people. It fully covers the neck with firm support to the head. This neck traction device is portable, and one can walk with it.

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  • Portable
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5. Cervical Neck Traction Device

When looking for a beautiful portable neck traction device, then cervical neck traction is the best. The device ensures speedy alignment of the neck with the spinal code for fast healing.

The device is of high-quality material is very light and durable. It is comfortable to wear, and has many purposes. The device enhances faster healing of the neck and even the head.

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Reason To Buy This

  • Easy to use
  • Made of high-quality material
  • Portable

4. Portable Head Hammock Traction

The head hammock neck traction device is portable and relieves pain, enhances head relaxation, and best for neck stretching.

The device increases faster mobility of blood from the head to other parts of the body. It is instrumental and takes only ten minutes to relieve pain. It stretches the head to help in reducing the pain on the neck, especially for long distances.

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Reason To Buy This

  • Fast healing
  • High-quality material used
  • Increases blood flow

3. WOOLALA Cervical Neck Traction Device

This neck traction device is inflatable to enhance smooth neck healing. The pain device is best for relieving neck pain and should muscles. The device is also functioning as a pillow.

This device is perfect for home for therapy purposes. The device portable and does not require any bag for carriage. The device is easy to use and works very effectively.

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  • Easy to use
  • Portable
  • Inflatable

2. Neck Traction Device + Safety Detachable

This device is a unique and safe neck traction device that is best for people with a neck injury. The ChickSoft Neck traction is very innovative that helps many people to enhance faster healing of the neck.

This traction device is safe and comfortable to use at home and work. The device is inflatable to enhance fast healing of the neck increase pressure massage the neck. The device is portable, and one can use it when having other training.

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1. Dr. Comfy Adjustable Cervical Neck Traction

This device is the best neck traction device that enhances faster healing. It is best for managing neck symptoms of chronic health conditions. This device is a secure neck traction device that is easy to use. When placed on the neck, it is inflatable to ensure proper massage. The material used to make the comfy is very comfortable and smooth.

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Reason To Buy This

  • Comfortable
  • Easy to use
  • Inflated

Conclusion

There is no need of spending thousands of dollars if you have chronic neck pain. With any of the Top Neck Traction Devices reviewed here, you can save loads of money on a chiropractor and more. Each cervical neck brace works with air pressure and has adjustable straps to ensure a perfect fit. You can treat shoulder muscle spasm and improve neck posture, headaches, and more.

Weaver’s Bottom ; Symptoms, Treatment

Weaver’s Bottom/Ischial bursitis also is known as ischiogluteal bursitis or weaver’s bottom is a condition where the bursa that lies between the ischial tuberosity and the gluteus maximus muscle becomes inflamed. This bursa is present physiologically in order to reduce the amount of frictional force generated between the gluteal muscle and the ischial tuberosity that otherwise might become damaged or irritated by this contact. This inflammation of the bursa is most commonly caused by prolonged pressure on the ischium, as occurs in sitting for extended periods of time or from the repeated movement of the Gluteus Maximus muscle in such activities as bicycling. These activities cause an inflammatory reaction that results in swelling and tenderness over the lower buttock and upper posterior thigh. Many other differential diagnoses have common presentations such as sciatica and tendonitis of hamstring muscles.

Ischial bursitis or ischiogluteal bursitis is the inflammation of the ischiogluteal bursa due to excessive or inappropriate physical exercise, prolonged sitting, running, repetitive jumping, and kicking. Since ischial bursitis is a rare, infrequently recognized pathology and is difficult to differentiate from the soft tissue disease and tumors (both malignant and benign), herein exemplified is a case with ischiogluteal bursitis whereby the role of magnetic resonance imaging (MRI) in the prompt diagnosis has been highlighted.

Pathophysiology of Weaver’s Bottom

Bursa comes in a variety of forms: adventitious, subcutaneous, submuscular, and synovial. An ischial bursa is synovial, meaning it is composed of a fatty connective tissue capsule filled with synovial fluid. When infection or irritation occurs, cells of the synovia proliferate, resulting in increased production of synovial fluid. Inflammatory mediators such as cyclooxygenase, cytokines, and metalloproteases mediate this process. The result is a thick fluid-filled cavity with high amounts of fibrin, resulting in the formation of granulation tissue. Over time, this tissue will gradually interfere with the normal motion and activity of the surrounding tissues whether they are muscle, bone, or tendon.

Types of Weaver’s Bottom

An ischial bursa is located between the hamstring muscle and the ischial tuberosity of the pelvis in the buttock area. This area bears the weight of the body when sitting. The hip joint is one of the largest joints in the body. It is composed of one osseous (contains bone) joint. The hip is built for weight-bearing and movement in several different planes. The stability of the hip joint comes from the capsule, ligaments, muscle and a cartilaginous tissue called the labrum. There are four bursae surrounding the hip joint. A bursa is a fluid-filled sack that reduces friction between tendons, and between tendons and bone. The most commonly injured bursa is the trochanteric bursa. The four major bursae of the hip are:

  • Trochanteric Bursa – located on the outside of the hip between the greater trochanter of the femur (leg bone) and the gluteal muscles
  • Ischial Bursa – located between the hamstring muscle and the ischial tuberosity of the pelvis in the buttock area. This area bears the weight of the body when sitting.
  • Iliopsoas Bursa – located in the groin area between the large psoas muscle and femur bone
  • Gluteal Medius Bursa – located between the gluteus medius muscle and the greater trochanter. It is near the trochanteric bursa.

Causes of Ischiogluteal Bursitis

  • Muscle Tightness – Tightness in the leg muscles and ischial bursitis itself increases the friction on ischial bursitis. Visit the knee stretches section for simple tests to see if your muscles are tight
  • Muscle Weakness – Weakness in the buttock muscles (glutes) puts more strain on ischial bursitis increasing your chances of developing ischial bursitis.
  • A direct blow to the ischial bursa from falling on the outside of the hip or on the buttocks can produce inflammation and irritation.
  • A fall onto the hip or ischial bursa.
  • Constant pressure on the ischial bursa from lying on that side.
  • Repeated stress or friction injury as the tendon rubs over the ischial bursa during activity. The weakness of the muscles over the ischial bursa.
  • Complications from rheumatoid arthritis, osteoarthritis or gout.
  • Infection of the ischial bursa.
  • The tightness of the structures of the hip like the psoas hip flexor, iliotibial band, and hamstrings.
  • The ischial bursa can become swollen as a response to other hip conditions.
  • Flat Feet – If you have flat feet (dropped foot arches) it slightly changes the angle of the leg, putting more friction through Ischial bursitis
  • Excessive long-distance or hill running – Overuse can also lead to ischial bursitis due to repetitive friction. Hill running puts even more tension through ischial bursitis.
  • Running on a sloped surface –  Lots of running surfaces e.g. roads and running tracks are slightly banked. The foot position on the lower leg causes ischial bursitis to be stretched
  • The sudden increase in activity – Someone who rapidly increases their training is at risk of developing due to the sudden increase in friction at the hip
  • Leg Length Discrepancy – If one leg is slightly shorter than the other it puts more strain on the hip.
  • Bowlegs – The curved nature of bow legs means there is a larger than normal space between the knees. This puts an extra stretch on the bursa

Symptoms of Ischiogluteal Bursitis

  • Pain, tenderness, swelling, warmth, or redness  may travel up or down the thigh or leg
  • Initially, pain at the beginning of an exercise that lessens once warmed up; eventually, pain throughout the activity, worsening as the activity continues; may cause the athlete to stop in the middle of training or competing
  • Pain that is worse when running down hills or stairs, on banked tracks, or next to the curb on the street
  • Pain that is felt most when the foot of the affected leg hits the ground
  • Possibly, crepitation (a crackling sound) when the tendon or bursa is moved or touched
  • Stabbing or stinging pain along the outside of the knee
  • A feeling of the snapping over the knee as it bends and straightens
  • Swelling near the outside of your knee
  • Occasionally, tightness and pain at the outside of the hip
  • Continuous pain following activity, particularly with walking, climbing, or descending stairs, or moving from a sitting to a standing position
  • Pain that is worse when running down hills or stairs.
  • Pain that is felt most when the foot of the affected leg hits the ground.
  • Possibly, a crackling sound when the bursa is moved or touched.

Diagnosis of Ischiogluteal Bursitis

A thorough subjective and objective examination from a physiotherapist may be sufficient to diagnose ischiogluteal bursitis. Further investigations such as an Ultrasound, X-ray, CT or MRI scan are often required to assist with diagnosis and assess the severity of the condition.

Treatments of Ischiogluteal Bursitis

Treatment of ischial bursitis is relatively symptom driven. Primary treatment is lifestyle modification by stopping the activity that caused bursitis in the first place, whether it was a physical activity or sitting for long periods of time on hard surfaces.

  • Rest – People with ischial bursitis may need to cut back on the intensity, duration and frequency of activity that leads to ischial bursitis pain (for example, reduce running or cycling mileage). People with moderate to severe ischial bursitis and pain may need to take time off from their sport and works. It can be frustrating and difficult for active people to cut back on their training schedules; however, rest is necessary for the injury to heal.
  • Ice – Apply ice to the affected area for 5-10 minutes at a time three to five times per day to help reduce inflammation. Make sure you wrap the ice in a thin towel to prevent an ice burn from occurring. You may need to ice the area every day for around 6-12 weeks.
  • Warm-up – Five to 10 minutes of gentle exercise and stretching can literally increase the body’s temperature, helping muscles become more elastic and responsive and reducing the chance of ischial bursitis or other injuries.
  • Change footwear – Switching out shoes and/or getting orthotic inserts can alter a person’s biomechanics and reduce the risk of ischial bursitis pain.
  • Massage – Much like the foam roller exercise, massage may help relieve tension and improve blood flow in-band thereby reducing pain.
  • Avoid Sitting on Hard Seats – Avoiding hard seats or stools is one of the best ways to reduce the pain from bursitis. If you do need to sit down for long periods, use a pillow or a doughnut cushion. Also sit upright and maintain a good posture while sitting.
  • Stretching – A doctor may recommend stretching or yoga to promote flexible muscles and other soft tissue.
  • Change running biomechanics – Runners may consider shortening their stride and running on soft, flat surfaces, such as tracks and even, grassy trails.
  • Change cycling biomechanics – Cyclists may consider adjusting saddle position and pedal clips. Even a small adjustment can alter the biomechanics of their pedaling and reduce ischial bursitis pain.
  • Ultrasound – Efforts to heal ischial bursitis and reduce pain may get a small boost from ultrasound and electrical muscle stimulation.
  • Iontophoresis – Doctors and physical therapists occasionally recommend iontophoresis, which uses a mild electrical current to administer an anti-inflammatory medicine (e.g. dexamethasone) through healthy skin and into the sore area. This treatment may be appropriate for people who can’t tolerate injections or want to avoid injections.
  • Frictional massage – It is recommended to use friction massage additional to the therapy on chronic bursitis because it affects the adhesions in chronic bursal problems. It breaks down scar tissue, increases extensibility and mobility of the structure, promotes normal orientation of collagen fibers, increases blood flow, reduces stress levels, and allows healing to take place. Friction massage is beneficial to the underlying structures. By using the Graston technique of friction massage the patient should be forewarned because it may initially aggravate a chronic subacute inflammation that is present. It is postulated that deep friction, especially with the Graston technique instruments, may initiate a new inflammatory cascade, which is necessary to reach the remodeling stage of the inflammatory process and result in healing of the area.

Medication

Longer-Term Treatment of Ischiogluteal Bursitis

  • Strengthening Exercises –  Strengthening the glutes, quads, and hamstrings improves how the hip and knee function which reduces the friction on bursitis. Visit the knee strengthening section for exercises that will help
  • Stretching Exercises – Stretching the quads, hamstrings, and ischial bursitis also helps reduce the friction at the knee. Visit the stretches section to see if tight muscles are likely contributing to your ischial bursitis
  • Gluteus stretch – Lie stretched out on your back with your head supported by a cushion. Bend one knee. With both hands around the knee, pull it slowly toward your chest and hold the position for 5 to 10 seconds. Slowly straighten your leg, and do the same with your other knee. Repeat 5 to 10 times.
  • Piriformis stretch –
  • Sit on the floor with both legs straight. Cross one leg over the other, with your foot along the knee. With the opposite hand, gently pull your bent knee across the middle of your body. Hold this position for 10 to 30 seconds. You should feel a stretch in the muscles of your outer thigh. Repeat with the other leg.
  • Taping – Taping can also be used to reduce the forces going through ischial bursitis – see you physical therapist/ sports injury specialist for more information
  • Massage – Deep tissue massage to the Iliotibial Band can reduce tightness, but it can be quite painful
  • Injections – If other treatments have failed, a cortisone injection can be given to help reduce pain and inflammation. However, it should always be accompanied by strengthening and stretching exercises to ensure the problem doesn’t return
  • Orthotics – Special insoles can be worn in your shoes to correct poor foot positions such as flat feet. See an orthopedist for a full assessment and advice

Physical Therapists

Common Physical Therapy interventions in the treatment of Hip Bursitis (Ischial Bursa) include:

  • Manual Therapeutic Technique (MTT) – hands-on care including soft tissue massage, stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the knee. The use of mobilization techniques also helps to modulate pain.
  • Therapeutic Exercises (TE) – including stretching and strengthening exercises to regain range of motion and strengthen muscles of the knee to support, stabilize, and decrease the stresses placed on the ischial bursa and tendons of the hip joint.
  • Neuromuscular Reeducation (NMR) – to restore stability, retrain the lower extremity and improve movement techniques and mechanics (for example, running, kneeling, squatting and jumping) of the involved lower extremity to reduce stress on ischial bursa and tendons in daily activities.
  • Modalities including the use of ultrasound –  electrical stimulation, ice, cold laser, and others to decrease pain and inflammation of the ischial bursa.
  • A home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
  • In addition to the home program –  it is often necessary to initiate therapy in our office to directly treat the bursa.  Our office will usually use therapeutic ultrasound, electrical stimulation, transverse friction, cross friction or active release massage in addition to manual muscle and joint manipulation to treat this painful condition.  We will also employ correct stretching and strengthening exercises as well as Kinesio or KT Tape to help stabilize the region between treatment sessions.

References

Weaver’s BottomTes

Does massage help patellar tendonitis?

Does massage help patellar tendonitis?/Patellar Tendinopathy is a painful condition of the knee caused by small tears in the patellar tendon that mainly occurs in sports requiring strenuous jumping. The tears are typically caused by accumulated stress on the patellar or quadriceps tendon. As the name implies, the condition is common in athletes from jumping sports such as volleyball, track (long and high jump), and basketball. The condition has a male predominance. Contrary to traditional belief, the jumper’s knee does not involve inflammation of the knee extensor tendons.

Jumper’s knee, or patellar tendinopathy (PT), is a chronic overuse injury of the patellar tendon. The prevalence is particularly high in jump sports athletes, such as in elite basketball players and volleyball players, respectively 32% and 45 %. However, also the prevalence among non-elite athletes is substantial and varies between 14.4% and 2.5% for different sports. Athletes with PT are often forced to reduce their training and competition levels because of patellar tendon pain. In some cases, athletes even have to quit their sporting activities. It is without a doubt that this condition can have an enormous impact on sports participation.

Stages of Patellar Tendinopathy

Depending on the duration of symptoms, Patellar Tendinopathy can be classified into 1 of 4 stages

  • Stage 1 – Pain only after activity, without functional impairment
  • Stage 2 – Pain during and after activity, although the patient is still able to perform satisfactorily in his or her sport
  • Stage 3 – Prolonged pain during and after activity, with increasing difficulty in performing at a satisfactory level
  • Stage 4 – Complete tendon tear requiring surgical repair

Does massage help patellar tendonitis?

Causes of Patellar Tendinopathy

It is an overuse injury from repetitive overloading of the extensor mechanism of the knee. The microtears exceed the body’s healing mechanism unless the activity is stopped.

  • Running – Jumping or bounding are more common overall than Running
  • Athletes in jumping sports – High jump, Basketball, Football, Gymnastics
  • Pain after Exercise, especially prolonged Exercise and with knee flexion
  • Quadriceps tightness or weakness
  • Hamstring tightness
  • Ankle dorsiflexion muscle weakness (from prior ankle injury)
  • Overweight (increased BMI)
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Diabetes mellitus
  • Paget’s disease
  • Knee local corticosteroid injections and repetitive trauma to the knee extensor tendon
  • Leg Length Discrepancy
  • Pes Cavus
  • Insidious overall onset
  • Later – During Exercise and while at rest
  • Among the risk factors for patellar tendonitis are low ankle dorsiflexion, weak gluteal muscles, and muscle tightness, particularly in the calves, quadriceps muscle, and hamstrings.[rx]

Symptoms of Patellar Tendinopathy

Tenderness on palpation of the tendon, together with a characteristic history
  • Pain and tenderness around your patellar tendon.
  • Swelling.
  • Pain with jumping, running or walking.
  • Pain when bending or straightening your leg.
  • Tenderness behind the lower part of your kneecap.
  • pain below the kneecap, especially during sports, climbing stairs and bending the knee
  • A swollen knee joint
  • Knee stiffness
  • Leg or calf weakness
  • Pain when bending the knee
  •  Strength – Knee extension weakness and Predisposing findings
    • Ankle dorsiflexion weakness
    • Hamstring tightness
    • Heel cord tightness
    • Quadriceps muscle tightness
  • Pain and decreased depth on single leg decline squat (LR+ 4 and LR- 0.5)
    • Extend unaffected knee
    • Squat with the affected leg

Diagnosis of Patellar Tendinopathy

Physical exam

  • Tenderness to palpation of the patellar tendon, just inferior to the patella, is the hallmark of the diagnosis. A clinical pearl is to palpate the tendon with the knee in extension as opposed to flexion. Palpation in flexion may mask a subtle jumper’s knee.
  • The patient may also have swelling of the tendon, and crepitus of the tendon with motion. Patients will also have pain with resisted knee extension.
  • A thorough knee exam including palpation of the joint lines, ligamentous and patellar stability and range of motion should also be performed to rule out other pathology.

Differential Diagnosis

Patellar tendon rupture

  • It can occur as an acute injury. Patients will have sudden, severe pain in the front of their knee and their knee will buckle. A defect can usually be appreciated in the patellar tendon, though sometimes this is difficult to assess if severe swelling is present. The patient will not be able to perform a straight leg raise, and they will have an extensor lag (lack of full active extension in the setting of full passive extension).
  • X-rays will show patella Alta (or high riding patella), and MRI will show the patellar tendon tear. Patients with patellar tendon ruptures should be placed in a knee immobilizer and referred to an orthopedic surgeon for urgent repair.

Patella fracture

  • It can occur as an acute injury. The patient will have pain over the patella itself. Diagnosis is usually made on an x-ray. Place in a knee immobilizer and refer to an orthopedic surgeon.

Patella chondromalacia (patellofemoral syndrome)

  • Presents with anterior knee pain. Pain is particularly bad with going up and downstairs. The pain with this condition is more proximal than with the jumper’s knee, and patients usually have no tenderness to palpation of the patellar tendon on the exam. Most often this is a diagnosis of exclusion.

Meniscus tears

  • Will have pain along the joint line. The pain is usually more lateral or medial than the jumper’s knee, but on occasion, the pain can be in the midline. Patients usually complain of clicking or popping in their knees. An MRI is diagnostic.

Fat pad syndrome

  • Inflammation of the fat pad that lies deep to the patellar tendon. Symptoms can be similar to jumper’s knee, but pain is around the tendon, and not on it. This may represent a spectrum of jumper’s knee and not a distinct entity. Regardless, the initial treatment is the same as that for the jumper’s knee.

Bone lesions

  • Tumors or infections are rare causes of anterior knee pain.

Radiograph

  • X-rays are usually negative for patients with jumper’s knee. On occasion, the x-ray can show shadows consistent with soft tissue swelling around the patellar tendon. In chronic cases, the x-ray may show calcifications in the patellar tendon. X-rays are most useful for ruling out concomitant pathology.

Advanced imaging

  • An MRI is usually not necessary in the early stages of the disease when the diagnosis is obvious on clinical exam. For more severe or chronic cases, an MRI can show if there are tears in the patella tendon. MRI’s are also most useful for ruling out concomitant pathology. For patients that cannot obtain an MRI, an ultrasound can also be diagnostic. However, an ultrasound will give limited information on intra-articular pathology.

Treatment of Patellar Tendinopathy

Treatment of Jumper’s Knee

Treatment for jumper’s knee includes

  • Rest and take a break from sports
  • Ice
  • Taping or wearing a knee support or strap just under the patella
  • Sitting with the leg raised
  • Massage therapy
  • Strengthening and stretching muscles through physical therapy or an at-home exercise program

Medication

  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Ibuprofen to help with pain and swelling. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include etodolacaceclofenacetoricoxib, ibuprofen, and naproxen.
  • Calcium & vitamin D3 – To improve bone health and healing tendon. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.

Jumper’s Knee Surgery

  • If your injury is severe and other treatments have failed, you may be required to have surgery. The procedure consists of the doctor making a longitudinal or transverse incision over the patella tendon and then removing the abnormal tissue. After the surgery, it could take anywhere from 6 to 12 months to fully recover and begin training again. You should check with your doctor before beginning rehab and strengthening exercises after surgery.


Physical Therapy for Patellar Tendinopathy

Most patients respond to a conservative management program such as the one suggested below.

  • Activity modification – Decrease activities that increase kneecap and upper leg pressure (for example, jumping or squatting). Certain “loading” exercises may be prescribed.
  • Cryotherapy – Apply ice for 20 to 30 minutes, 4 to 6 times per day, especially after activity.
  • Joint motion and kinematics assessment – Hip, knee, and ankle joint range of motion are evaluated.
  • Strengthening – Specific exercises are often prescribed.
  • Other sport-specific joint, muscle, and tendon therapies may be prescribed.
  • Ultrasound or phonophoresis (ultrasound delivered medication) – may decrease pain symptoms. A special brace with a cutout for the kneecap and lateral stabilizer or taping may improve patellar tracking and provide stability. Sometimes arch supports or orthotics are used to improve foot and leg stability, which can reduce symptoms and help prevent future injury.

 The treatment of jumper’s knee is often specific to the degree of involvement.

Stage 1

  • Stage I, which is characterized by pain only after activity and no undue functional impairment, is often treated with cryotherapy. The patient should use ice packs or ice massage after terminating the activity that exacerbates the pain and later again that evening. If aching persists, a course of regularly prescribed anti-inflammatory medications should be administered for 10 to14 days.

Stage II

  • In stage II, the patient has pain both during and after activity but is still able to participate in the sport satisfactorily. The pain may interfere with sleep. At this point, activities that cause increased loading of the patellar tendon (for example, running or jumping) should be avoided.
  • A comprehensive physical therapy program, as discussed above, should be implemented. For pain relief, the knee should be protected by avoiding high loads to the patellar tendon, and cryotherapy should continue. The athlete should be instructed in alternative conditioning to avoid injury to the affected area.
  • Once the pain improves, therapy should focus on knee, ankle, and hip joint range of motion, flexibility, and strengthening. If the pain becomes increasingly intense and if the athlete becomes more concerned about his or her performance, a local corticosteroid injection may be considered. The doctor will explain the pros and cons of these injections.

Stage III

  • In stage III, the patient’s pain is sustained, and performance and sport participation are adversely affected. Though discomfort increases, therapeutic measures similar to those described above should be continued along with not participating in activities that may worsen or prevent recovery from the injury. Relative rest for an extended period (for instance 3 to 6 weeks) may be necessary for stage III. Often, the athlete will be encouraged to continue an alternative cardiovascular and strength-training program.
  • If the condition does not improve with treatment, surgery may be considered. Some athletes will not be able to continue to participate in activities that worsen or prevent recovery from the problem.
Stage IV

  • Tendon rupture requires surgical repair.

Medical Issues and Complications

  • Knee immobilization is not recommended because it results in stiffness and may lead to other muscle or joint problems, further prolonging an athlete’s return to activity.

Consultations

  • Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment and more severe cases (Stages II, III, and IV). Primary care sports medicine physicians can also be consulted.

Recovery Phase

Physical Therapy

  • An in-depth, stage-specific description of a conservative therapy program is described above. In brief, in the recovery phase, the athlete and therapist should work to restore pain-free joint range of motion and muscle flexibility, symmetric strength in the lower extremities, and joint sensation. Sport-specific training, including high-level sport-specific exercises, should then be initiated.

Consultations

  • Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment or more severe cases (Stages II, III, IV).

Surgical Intervention

  • Surgical intervention is indicated for stage IV, and refractory stage III tendinopathy as noted above.

Maintenance Phase

Physical Therapy

An in-depth, stage-specific description of a conservative therapy program is described above. Briefly, once in the maintenance phase, the athlete should complete a sport-specific training program before returning to competition. The physician and physical therapist can assist the athlete in determining when to return to competition based on the patient’s symptoms, current physical examination findings, and functional test results. Once the athlete returns to play, he or she must work to maintain gains in flexibility and strength.

Rehabilitation Exercises

Stretching – Stretch

  • (1) flexors of the hip and knee (hamstrings, gastrocnemius, iliopsoas, rectus femoris, adductors),
  • (2) extensors of the hip and knee (quadriceps, gluteals),
  • (3) the iliotibial band (a large tendon on the outside of the hip and upper leg), and
  • (4) the surrounding tissues and structures of the kneecap.

Stretching Exercises

Test Flexibility

  • Lay on a flat surface, like a bench or couch.
  • Pull your knee up to your chest with your leg bent at the knee and your hands gripped under the knee.
  • Starting with this will prepare you for other stretches.

Quadriceps Stretch

  • In a standing position bring your leg up behind you to hold your toes in your hand.
  • Try to keep your knees together and to pull your leg up straight behind you, not to the side.
  • You will feel a stretch at the front of the leg.
  • Try to hold this position for 10 seconds when you first begin rehab and work up to 30 seconds when inflammation has gone down.

Strengthening Exercises

Does massage help patellar tendonitis?

Thera-Band Knee Flexion (Prone)

  • Tie the TheraBand Resistance Band into a loop and secure one end close to the floor.
  • Lay on your stomach and place the other end of the loop around your ankle.
  • Begin with your knee straight and bend your knee against the band.
  • Hold and slowly return.

Thera Band Lunge

Does massage help patellar tendonitis?

 

  • Start in a standing position with one leg in front of the other.
  • Hold the ends of the TheraBand Resistance Band in each hand while standing in the middle of the band with the front foot.
  • Bend the front knee, so the thigh is horizontal while the back knee goes towards the floor.
  • Try not to rest your back knee on the floor, instead of hover over it.
  • Hold and return to the starting position.

Prevention of Jumper’s Knee

  • It’s important to warm up before and cool down after exercising to prevent patellar tendonitis
  • Wear shoes that fit well and support your arch
  • Gradually increase the intensity of your workouts to reduce your risk of injury.


References

Does massage help patellar tendonitis?


Treatment of Patellar Tendinopathy, Complication

Treatment of Patellar Tendinopathy/Patellar Tendinopathy is a painful condition of the knee caused by small tears in the patellar tendon that mainly occurs in sports requiring strenuous jumping. The tears are typically caused by accumulated stress on the patellar or quadriceps tendon. As the name implies, the condition is common in athletes from jumping sports such as volleyball, track (long and high jump), and basketball. The condition has a male predominance. Contrary to traditional belief, the jumper’s knee does not involve inflammation of the knee extensor tendons.

Jumper’s knee, or patellar tendinopathy (PT), is a chronic overuse injury of the patellar tendon. The prevalence is particularly high in jump sports athletes, such as in elite basketball players and volleyball players, respectively 32% and 45 %. However, also the prevalence among non-elite athletes is substantial and varies between 14.4% and 2.5% for different sports. Athletes with PT are often forced to reduce their training and competition levels because of patellar tendon pain. In some cases, athletes even have to quit their sporting activities. It is without a doubt that this condition can have an enormous impact on sports participation.

Stages of Patellar Tendinopathy

Depending on the duration of symptoms, Patellar Tendinopathy can be classified into 1 of 4 stages

  • Stage 1 – Pain only after activity, without functional impairment
  • Stage 2 – Pain during and after activity, although the patient is still able to perform satisfactorily in his or her sport
  • Stage 3 – Prolonged pain during and after activity, with increasing difficulty in performing at a satisfactory level
  • Stage 4 – Complete tendon tear requiring surgical repair

Patellar Tendinopathy

Causes of Patellar Tendinopathy

It is an overuse injury from repetitive overloading of the extensor mechanism of the knee. The microtears exceed the body’s healing mechanism unless the activity is stopped.

  • Running – Jumping or bounding are more common overall than Running
  • Athletes in jumping sports – High jump, Basketball, Football, Gymnastics
  • Pain after Exercise, especially prolonged Exercise and with knee flexion
  • Quadriceps tightness or weakness
  • Hamstring tightness
  • Ankle dorsiflexion muscle weakness (from prior ankle injury)
  • Overweight (increased BMI)
  • Systemic lupus erythematosus
  • Rheumatoid arthritis
  • Diabetes mellitus
  • Paget’s disease
  • Knee local corticosteroid injections and repetitive trauma to the knee extensor tendon
  • Leg Length Discrepancy
  • Pes Cavus
  • Insidious overall onset
  • Later – During Exercise and while at rest
  • Among the risk factors for patellar tendonitis are low ankle dorsiflexion, weak gluteal muscles, and muscle tightness, particularly in the calves, quadriceps muscle, and hamstrings.[rx]

Symptoms of Patellar Tendinopathy

Tenderness on palpation of the tendon, together with a characteristic history
  • Pain and tenderness around your patellar tendon.
  • Swelling.
  • Pain with jumping, running or walking.
  • Pain when bending or straightening your leg.
  • Tenderness behind the lower part of your kneecap.
  • pain below the kneecap, especially during sports, climbing stairs and bending the knee
  • A swollen knee joint
  • Knee stiffness
  • Leg or calf weakness
  • Pain when bending the knee
  •  Strength – Knee extension weakness and Predisposing findings
    • Ankle dorsiflexion weakness
    • Hamstring tightness
    • Heel cord tightness
    • Quadriceps muscle tightness
  • Pain and decreased depth on single leg decline squat (LR+ 4 and LR- 0.5)
    • Extend unaffected knee
    • Squat with the affected leg

Diagnosis of Patellar Tendinopathy

Physical exam

  • Tenderness to palpation of the patellar tendon, just inferior to the patella, is the hallmark of the diagnosis. A clinical pearl is to palpate the tendon with the knee in extension as opposed to flexion. Palpation in flexion may mask a subtle jumper’s knee.
  • The patient may also have swelling of the tendon, and crepitus of the tendon with motion. Patients will also have pain with resisted knee extension.
  • A thorough knee exam including palpation of the joint lines, ligamentous and patellar stability and range of motion should also be performed to rule out other pathology.

Differential Diagnosis

Patellar tendon rupture

  • It can occur as an acute injury. Patients will have sudden, severe pain in the front of their knee and their knee will buckle. A defect can usually be appreciated in the patellar tendon, though sometimes this is difficult to assess if severe swelling is present. The patient will not be able to perform a straight leg raise, and they will have an extensor lag (lack of full active extension in the setting of full passive extension).
  • X-rays will show patella Alta (or high riding patella), and MRI will show the patellar tendon tear. Patients with patellar tendon ruptures should be placed in a knee immobilizer and referred to an orthopedic surgeon for urgent repair.

Patella fracture

  • It can occur as an acute injury. The patient will have pain over the patella itself. Diagnosis is usually made on an x-ray. Place in a knee immobilizer and refer to an orthopedic surgeon.

Patella chondromalacia (patellofemoral syndrome)

  • Presents with anterior knee pain. Pain is particularly bad with going up and downstairs. The pain with this condition is more proximal than with the jumper’s knee, and patients usually have no tenderness to palpation of the patellar tendon on the exam. Most often this is a diagnosis of exclusion.

Meniscus tears

  • Will have pain along the joint line. The pain is usually more lateral or medial than the jumper’s knee, but on occasion, the pain can be in the midline. Patients usually complain of clicking or popping in their knees. An MRI is diagnostic.

Fat pad syndrome

  • Inflammation of the fat pad that lies deep to the patellar tendon. Symptoms can be similar to jumper’s knee, but the pain is around the tendon, and not on it. This may represent a spectrum of jumper’s knee and not a distinct entity. Regardless, the initial treatment is the same as that for the jumper’s knee.

Bone lesions

  • Tumors or infections are rare causes of anterior knee pain.

Radiograph

  • X-rays are usually negative for patients with jumper’s knee. On occasion, the x-ray can show shadows consistent with soft tissue swelling around the patellar tendon. In chronic cases, the x-ray may show calcifications in the patellar tendon. X-rays are most useful for ruling out concomitant pathology.

Advanced imaging

  • An MRI is usually not necessary in the early stages of the disease when the diagnosis is obvious on clinical exam. For more severe or chronic cases, an MRI can show if there are tears in the patella tendon. MRI’s are also most useful for ruling out concomitant pathology. For patients that cannot obtain an MRI, an ultrasound can also be diagnostic. However, an ultrasound will give limited information on intra-articular pathology.

Treatment of Patellar Tendinopathy

Treatment for jumper’s knee includes

  • Rest and take a break from sports
  • Ice
  • Taping or wearing a knee support or strap just under the patella
  • Sitting with the leg raised
  • Massage therapy
  • Strengthening and stretching muscles through physical therapy or an at-home exercise program

Medication

  • Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
  • NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Ibuprofen to help with pain and swelling. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include etodolacaceclofenacetoricoxib, ibuprofen, and naproxen.
  • Calcium & vitamin D3 – To improve bone health and healing tendon. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
  • Glucosamine & DiacereinChondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.

Jumper’s Knee Surgery

  • If your injury is severe and other treatments have failed, you may be required to have surgery. The procedure consists of the doctor making a longitudinal or transverse incision over the patella tendon and then removing the abnormal tissue. After the surgery, it could take anywhere from 6 to 12 months to fully recover and begin training again. You should check with your doctor before beginning rehab and strengthening exercises after surgery.


Physical Therapy for Patellar Tendinopathy

Most patients respond to a conservative management program such as the one suggested below.

  • Activity modification – Decrease activities that increase kneecap and upper leg pressure (for example, jumping or squatting). Certain “loading” exercises may be prescribed.
  • Cryotherapy – Apply ice for 20 to 30 minutes, 4 to 6 times per day, especially after activity.
  • Joint motion and kinematics assessment – Hip, knee, and ankle joint range of motion is evaluated.
  • Strengthening – Specific exercises are often prescribed.
  • Other sport-specific joint, muscle, and tendon therapies may be prescribed.
  • Ultrasound or phonophoresis (ultrasound delivered medication) – may decrease pain symptoms. A special brace with a cutout for the kneecap and lateral stabilizer or taping may improve patellar tracking and provide stability. Sometimes arch supports or orthotics are used to improve foot and leg stability, which can reduce symptoms and help prevent future injury.

 The treatment of jumper’s knee is often specific to the degree of involvement.

Stage 1

  • Stage I, which is characterized by pain only after activity and no undue functional impairment, is often treated with cryotherapy. The patient should use ice packs or ice massage after terminating the activity that exacerbates the pain and later again that evening. If aching persists, a course of regularly prescribed anti-inflammatory medications should be administered for 10 to14 days.

Stage II

  • In stage II, the patient has pain both during and after activity but is still able to participate in the sport satisfactorily. The pain may interfere with sleep. At this point, activities that cause increased loading of the patellar tendon (for example, running or jumping) should be avoided.
  • A comprehensive physical therapy program, as discussed above, should be implemented. For pain relief, the knee should be protected by avoiding high loads to the patellar tendon, and cryotherapy should continue. The athlete should be instructed in alternative conditioning to avoid injury to the affected area.
  • Once the pain improves, therapy should focus on knee, ankle, and hip joint range of motion, flexibility, and strengthening. If the pain becomes increasingly intense and if the athlete becomes more concerned about his or her performance, a local corticosteroid injection may be considered. The doctor will explain the pros and cons of these injections.

Stage III

  • In stage III, the patient’s pain is sustained, and performance and sport participation are adversely affected. Though discomfort increases, therapeutic measures similar to those described above should be continued along with not participating in activities that may worsen or prevent recovery from the injury. Relative rest for an extended period (for instance 3 to 6 weeks) may be necessary for stage III. Often, the athlete will be encouraged to continue an alternative cardiovascular and strength-training program.
  • If the condition does not improve with treatment, surgery may be considered. Some athletes will not be able to continue to participate in activities that worsen or prevent recovery from the problem.
Stage IV

  • Tendon rupture requires surgical repair.

Medical Issues and Complications

  • Knee immobilization is not recommended because it results in stiffness and may lead to other muscle or joint problems, further prolonging an athlete’s return to activity.

Consultations

  • Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment and more severe cases (Stages II, III, and IV). Primary care sports medicine physicians can also be consulted.

Recovery Phase

Physical Therapy

  • An in-depth, stage-specific description of a conservative therapy program is described above. In brief, in the recovery phase, the athlete and therapist should work to restore pain-free joint range of motion and muscle flexibility, symmetric strength in the lower extremities, and joint sensation. Sport-specific training, including high-level sport-specific exercises, should then be initiated.

Consultations

  • Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment or more severe cases (Stages II, III, IV).

Surgical Intervention

  • Surgical intervention is indicated for stage IV, and refractory stage III tendinopathy as noted above.

Maintenance Phase

Physical Therapy

An in-depth, stage-specific description of a conservative therapy program is described above. Briefly, once in the maintenance phase, the athlete should complete a sport-specific training program before returning to competition. The physician and physical therapist can assist the athlete in determining when to return to competition based on the patient’s symptoms, current physical examination findings, and functional test results. Once the athlete returns to play, he or she must work to maintain gains in flexibility and strength.

Rehabilitation Exercises

Stretching – Stretch

  • (1) flexors of the hip and knee (hamstrings, gastrocnemius, iliopsoas, rectus femoris, adductors),
  • (2) extensors of the hip and knee (quadriceps, gluteals),
  • (3) the iliotibial band (a large tendon on the outside of the hip and upper leg), and
  • (4) the surrounding tissues and structures of the kneecap.

Stretching Exercises

Test Flexibility

  • Lay on a flat surface, like a bench or couch.
  • Pull your knee up to your chest with your leg bent at the knee and your hands gripped under the knee.
  • Starting with this will prepare you for other stretches.

Quadriceps Stretch

  • In a standing position bring your leg up behind you to hold your toes in your hand.
  • Try to keep your knees together and to pull your leg up straight behind you, not to the side.
  • You will feel a stretch at the front of the leg.
  • Try to hold this position for 10 seconds when you first begin rehab and work up to 30 seconds when inflammation has gone down.

Strengthening Exercises

Patellar Tendinopathy

Thera-Band Knee Flexion (Prone)

  • Tie the TheraBand Resistance Band into a loop and secure one end close to the floor.
  • Lay on your stomach and place the other end of the loop around your ankle.
  • Begin with your knee straight and bend your knee against the band.
  • Hold and slowly return.

Thera Band Lunge

Patellar Tendinopathy

 

  • Start in a standing position with one leg in front of the other.
  • Hold the ends of the TheraBand Resistance Band in each hand while standing in the middle of the band with the front foot.
  • Bend the front knee, so the thigh is horizontal while the back knee goes towards the floor.
  • Try not to rest your back knee on the floor, instead of hover over it.
  • Hold and return to the starting position.

Prevention of Jumper’s Knee

  • It’s important to warm up before and cool down after exercising to prevent patellar tendonitis
  • Wear shoes that fit well and support your arch
  • Gradually increase the intensity of your workouts to reduce your risk of injury.


References

Treatment of Patellar Tendinopathy


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