breastfeeding

MASTITIS… and a hangry baby! — what to look out for and practical tips from Clifton Hill Physiotherapy

The dreaded “M” word

What is mastitis?

 

  • Defined as “inflammation of the breast”. The term is generally used in reference to the lactating breast.
  • Is thought to occur when pressure within the ducts is greater than the surrounding tissue. This causes milk products to leak into surrounding tissue and the body produces a dramatic inflammatory response.
  • This in turn can cause painful, red, hot and inflamed breast tissue.
  • Incidence of mastitis has been reported to be as high as 1 in 3 women post partum, with the highest incidence occurring 2-3 weeks post partum. Mastitis is the most common reason to wean in the first 12 weeks post partum (Wöckel et al 2008).

Symptoms may include:

  • Breast tissue feeling tender
  • Increased temperature of the breast tissue
  • Redness in a wedge-shaped or striped pattern on the breast tissue
  • Chills, ache and flu-like symptoms, similar to a systemic illness
  • The inflammation may or may not involve a bacterial infection (the only way to rule out a true infection is by doing a milk sample testing – but this step is often skipped as it takes a long time)

“A tender, hot, swollen, wedge-shaped area of breast associated with increased temperature, chills, ‘flu-like’ aching and systemic illness. The inflammation may or may not involve a bacterial infection” (Amir 2014).

Risk factors and things to avoid:

  • A previous episode of mastitis
  • A sudden change in number of feeds (ie. infant sleeping longer overnight, skipped feeds)
  • Switching to 2nd breast before 1st breast is finished
  • Suckling replaced by pacifiers or bottles
  • Compression- including flange of expressing pump, tight bra/garment
  • Positioning and attachment problems (eg. from tongue tie, nipple damage)
  • Pendulous large breast tissue
  • A direct blow to the breast

 

Here, at Clifton Hill Physio, we have a great team of Women’s Health Physiotherapists, including: Adriane, Issy, Kiera, Ali, Clare, Jane, Jen and Sal.

 

Our physio’s can help you with:

 

  • Diagnosis and advice- including appropriate referral
  • Treatment:
  • Therapeutic Ultrasound can be very effective in the management and treatment of mastitis. This will likely form part of your treatment and will be explained by your physiotherapist.
  • Education regarding manual handling of your breast: This must always be gentle. Respect your pain.
  • Self-management techniques: Effleurage or draining massage, breast rotating/breast lifting techniques. 
  • Kinesiotape can be very helpful in facilitating lymphatic drainage of swelling. Your physiotherapist will show you how to apply this if necessary.
  • Positioning advice:

It is important to have a number comfortable positions to rely on for feeding.

Recumbent or ‘laid back feeding’, football hold and side lying hold.

Special extra tips:

 

  • If possible try to bring you baby with you as it is helpful to have your baby feed immediately after the session.
  • Develop the habit of feeling each breast after each feed to highlight any areas of tension.
  • Always maintain adequate hand hygiene and breast pad hygiene.
  • If it is safe to do so, Non-Steroidal Anti-Inflammatory medications (NSAIDs) may be recommended.
  • It is almost always ok for your baby to continue feeding if comfortable.
  • Avoid over-stimulating the breast tissue
  • Ensure the duration between feeds is short enough so breasts do not feel uncomfortably full.
  • Expressing must be comfortable and/ or relieving.
  • Take care that the flange does not compress the breast
  • Avoid wearing tight compressive garments, ie, tight bra/flange of expressing pump. Garments should not indent skin.
  • Catch it early: look out for early signs to prevent the condition from becoming debilitating or a more serious health problem that might threaten yours and the baby’s well-being.

 

At Inner North Physiotherapy, we understand how distressing mastitis can be and will always try our best to book you in as early as possible.

Our physio’s will strive to fit you in within the day to help reduce your symptoms and provide you and the baby with some relief as quickly as possible.

 

 

WHEN TO SEE YOUR GP/LACTATION CONSULTANT:

 

  • If your symptoms are persisting
  • If you have a nipple infection
  • If you have signs of thrush
  • If you require a breast ultrasound (as advised by your physiotherapist)
  • If you become acutely unwell

Adriane Kabulyuk

Physiotherapist

 

References:

 WEBSITES:

The Australian Breastfeeding Association

https://www.breastfeeding.asn.au/aboutaba

The International Breastfeeding Journal

http://www.internationalbreastfeedingjournal.com/

Positioning advice:

www.biologicalnurturing.com

 

ARTICLES:

-Amir, L., (Revised March 2014). Clinical Protocol #4: Mastitis. The Academy of Breastfeeding Medicine Protocol Committee ABM.

-Cooper, M., (2015) The lactating breast for physiotherapists. Course Notes – Continence & Women’s Health Physiotherapy Australia Group, Australian Physiotherapy Association.

Struebe, A., & Schwartz, E., (2010). The risks and benefits of infant feeding practices for women and their children.Journal of Perinatology, 30, 155-162

– Wöckel, A., Abou-Dakn, M., Beggel, A., Arck (2008). Inflammatory breast diseases during lactation: health effects on the newborn – a literature review. Mediators of Inflammation, Article ID 298760, 7 pages doi: 10,1155/2008/298760.

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BETTER BONES PROGRAM- CLIFTON HILL PHYSIOTHERAPY

Busting the myth of Osteoporosis – Physiotherapy can help more than you think.

Osteoporosis – what does it mean?
Osteoporosis is a condition that affects bone density, due to a depletion of minerals like Calcium. This results in the bones in your body being more brittle and more prone to fractures, even with minor bumps or falls.

How would I know if I have Osteoporosis?
Osteoporosis is very common: it has been found to affect over 1 million Australians! 1 in 3 women, and 1 in 5 men over the age of 50 years old are affected and will suffer an osteoporotic fracture (International Osteoporosis Foundation).

Check you risk factors:
– Age: > 50 years old.
– Gender: Females at greater risks due to hormonal changes through life.
– Family history: Genetic predisposition.
– Calcium intake: low calcium results in lower bone density.
– Vitamin D levels: Vitamin D helps absorb Calcium and can also have an effect on bone density.
– Medical history: corticosteroid medication side effects can include low bone density, digestive  malabsorption disorders and chronic illnesses such as rheumatoid arthritis chronic kidney/liver disease can lead to osteoporosis.
– Lifestyle factors and exercise history: low levels of physical activity or low osteogenic exercise levels result in low bone density. Smoking, excessive alcohol consumption and being overweight have also been shown to increase risks of osteoporosis.

There usually are no symptoms until a fracture occurs, so having regular bone scans past the age of 50 is recommended, in consultation with your GP (Osteoporosis Australia).

What type of exercise should I do if I have Osteoporosis? – Osteogenic Exercises

Osteogenic exercises – quite surprisingly, they are actually impact-based exercise training. Unlike the common belief that patients with osteoporosis should stay away from any impact to protect their bones, controlled impact training actually provides an appropriate stimulus of ground reaction force to help stimulate and promote stronger bone density.
This contradicts the commonly thought myth of having to avoid activities like jumping, running or any other impact type of activities when one has been diagnosed with osteoporosis.

Playing basketball or netball is more osteogenic than swimming or cycling – because the body has to adapt to the jumping and impact landing involved in basketball and netball. In other words, our bone production centres react to the specific type of exercise we perform (stimulus) and adapt to the amount of force our body is exposed to.

That’s where your Physiotherapist can help!

Physiotherapists are experts in exercise rehabilitation and will help tailor an exercise program that will match your physical levels and start some impact and resistance training in a safe way for you to slowly and gradually build up your bone density and lean muscle mass.

Introducing: the “Better Bones Program”

– Based on the research study LIFTMOR from Griffith University, in Queensland, published in 2017: “High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial”.

The LIFTMOR study compared a control group, who performed home-based exercises focused on prevention of falls, to a High Intensity Resistance and Impact Training (HIRIT) group, who performed twice weekly physiotherapist-supervised exercise classes for a period of 8 months.
It was found that the HIRIT group had significant improvements at multiple levels compared to the control group at follow-up.

Benefits shown from the LIFTMOR study:
– Increased bone mineral density, measured at the femoral neck and lumbar spine
– Improvement in height (reduction in thoracic kyphosis)
– Increased back extensor strength which has been associated with a reduced risk of vertebral fractures
– Improved general function

Here at Clifton Hill Physiotherapy, we have decided to apply this evidence into clinical practice and we are excited to announce the launching of Bone Health classes!

Brief overview of the class:

– Targeted for anyone 55 years of age and above

– Involves 4 key exercises based on the LIFTMOR study: 1. Deadlifts
2. Overhead press
3. Back squats
4. Jumping chin-ups with drop landings.
The other exercises will aim at improving balance and core strength, arm and leg strength to achieve better function.

– Performed ideally x2/week as per research recommendations

You will first have an individual consult with one of our Physiotherapists to determine your base starting level of fitness and physical capacity to ensure that the exercise and weights you will use are appropriate and safe. The Physiotherapist will also introduce you to the 4 key exercise components and familiarize yourself to the gym prior to joining classes.

Contact our physiotherapists to enquire for more information and for class registrations.

References:

Websites
https://www.iofbonehealth.org/facts-statistics

https://www.osteoporosis.org.au/

https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/estimating-the-prevalence-of-osteoporosis-in-austr/contents/summary

Watson, S. L., Weeks, B. K., Weis, L. J., Harding, A. T., Horan, S. A. and Beck, B. R. (2018), High‐Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res, 33: 211-220. doi:10.1002/jbmr.3284

Adriane Kablyuk
Physiotherapist

AFL NM

Women in sport, footy, ACL prevention-Mel Haberfield

It’s an exciting time to be involved in woman’s sport. In fact, it makes me wish I was a teenager again with the opportunities that our young women have to pursue their dreams of becoming a professional athlete. From the rise of the Matilda’s, to the restructuring of the National Netball League, and of course the introduction of the AFLW. There are more pathways than ever for young female athletes to follow into the professional ranks.

But with this rise in popularity, we have also seen a rise in the rate of serious knee injuries in female athletes.

I am excited to be taking up a role in the AFLW for the upcoming 2019 season as one of the team physiotherapists for North Melbourne Football Club. It will be the inaugural season for North Melbourne in the AFLW. Exciting times for all involved.

The AFLW Injury Report shows that compared to their male counterparts, woman in the AFLW have a 9.2x greater risk of suffering an ACL injury. This figure sits even above the 2-5x greater risk that woman participating in all sports have of rupturing their ACL. Should we be concerned? The reasons for the increased risk in the female athlete are complex and multifactorial – from our genetics/anatomy, to hormonal considerations, to overall strength and conditioning, quality and skill of movement patterns, as well as factors such as footwear. There is much discussion and research occurring around this topic as we speak. Although the injury rates have been high in the first 2 seasons, there is plenty that can be done to reduce injury risk and enhance athletic performance. Injury Reduction Programs (IRP’s) have been shown to be an effective way to reduce the risk of injury by up to 50%!

IRP’s include different components of warm up, preparation, movement quality training, and strengthening exercises for key muscle groups. In the AFLW, teams have all developed programs for the female athletes to undertake at training and before games to help decrease their risk of injury. Professional athletes themselves are becoming more aware of the importance of participating in IRP’s. But there is still much work to be done at the grassroots and community level.

With the massive uptake of sport, especially footy, in girls at the grassroots level, it’s important we begin to educate and talk to our community level athletes about how they too can reduce their risk of injury and enhance their performance. As physio’s we want to encourage our young female athletes to take up sport, and participate fully in their passion of footy, without having an overshadowing fear of impending injury. The benefits of young people participating in sport still far outweigh the risks! The key is for young female (and male) athletes to develop good movement patterns and skills specific to their sport, progressively develop their strength and load capacity as they grow and develop, and be aware of how to prepare their bodies for training and game day with an appropriate warm up. Recovery is also a big key and should be holistic in nature. Gone are the days where recovery is just putting an ice pack on after a game. Recovery should include considerations such as appropriate sleep patterns, nutrition, training load management, general wellness, and self-management strategies.

As a physio, my passion is to not only work with elite athletes in exciting opportunities such as the AFLW, but also with community level and young athletes.

If you or an aspiring young athlete you know want to learn more about what IRP’s involve, or how to recover better, come in and see us at Inner North Physiotherapy. Remember prevention is better than cure!

Mel is part of the Research team at La Trobe University looking at injury prevention in Women’s footy.

Melissa Haberfield

Physiotherapist

Headshot for CHP (1)

A WARM WELCOME TO CLARE WILLIAMSON

Clare qualified as a physiotherapist in 2000 from the University of the West of England. Since then Clare has worked in the UK, New Zealand and Australia in hospital and private settings. Clare has also completed a Certificate IV in fitness and clinical pilates and recently decided to return to studies and has just completed her Masters in Musculoskeletal Physiotherapy at La Trobe University.

Clare has managed a wide range of acute and chronic musculoskeletal, orthopaedic and sporting conditions over the years and particularly enjoys post-operative rehabilitation of clients.

Clare has experience in hydrotherapy, clinical pilates, and exercise prescription and utilises these skills in combination with hands-on techniques to provide an individualised management plan to promote optimal function and movement, required for returning to work and day-to-day activities. When not working Clare can be found walking the dog, in the gym,  scuba diving in the bay or completing DIY projects around the house.

Professional memberships:

Australian Physiotherapy Association (APA)

Musculoskeletal Physiotherapy Australia

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Congratulations Fitzroy Football Club-Premiers 2018

 

 

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Congratulations to Fitzroy Football Club on another successful season, and especially to the Men’s Senior and Reserve teams who both impressively took out VAFA Premier C Premierships on Saturday at Trevor Barker Oval!!! Both teams have enjoyed spectacular seasons.

In the senior game, Fitzroy were far too strong for Old Geelong and after 8 goals in the first quarter they continued to increase their lead, finishing 15.10.100 to 4.6.30.

The Reserves was a tight game in tough conditions. Fitzroy were able to keep Old Geelong goalless for the first half before surviving a late surge, eventually winning 4.6.42 to 4.9.33.

Team physiotherapists Billy Williams and Lizzy Barnes-Keoghan, along with all of us here, would like to congratulate all teams and thank them for their efforts during the 2018 season.

#GoRoys

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acl

ACL injuries- Jane Higgs Physiotherapist

What’s the big deal?

ACL – anterior cruciate ligament- is a major stabilising ligament of the knee- it controls the forward sliding motion of the lower leg and provides rotational stability with movement.

 

Commonly there will be accompanying bone bruising or fracture, possible cartilage or meniscus tears, or damage to other ligaments in the knee.

 

In the short term, the injury can result in time off work, inability to participate in sport, and prolonged rehabilitation. On average, professional elite athletes require 9 months out of sport and recreational athletes will take 12 months.  Longer term, there is a high risk of osteoarthritis in people who have suffered an ACL injury, particularly if you sustained a concurrent meniscus injury. The cost of primary ACL reconstructive surgery in Australia between 2014-2015 has been estimated at $142 million, which includes surgical costs only and not the rehabilitation, burden of injury or time off work (Zbrojkiewicz, D., Vertullo, C. & Grayson, J., 2018).

 

How do they occur?

There is a small subgroup of ACL injuries that occur with contact- that is a direct blow to the knee- e.g. another skier collides with your leg resulting in injury.

The vast majority of these injuries however occur in a “non contact” manner.  In other words, because of a landing error or twisting movement.  It may be a movement that you have done countless times before, a small bump in the air prior to landing, or a timing error causing an awkward movement.

What can we do about them?

There is a growing body of evidence that many of these non-contact injuries can be prevented, and with the cost of ACL injury and the rate of injury on the rise it is crucial that we do everything that we can to avoid them.

“Neuromuscular” training programs have been shown to be effective in reducing the rates of ACL injuries.  These programs are warmup routines that include balance, agility, plyometrics and landing control.   Soccer, netball and AFL have all released sport specific programs that are readily available and should become part of your team’s warm up today (see links below).
A 2018 study (Webster & Hewett) showed neuromuscular training programs reduce the overall rates of ACL injuries by 50%, and in females by 67%. The research shows that the more you do these routines, the more effective the programs are at reducing the rate of injury.  They are not only effective at reducing the rate of serious knee injury, but also all lower limb injuries.  And if that’s not enough to get you started they have also been shown to be PERFORMANCE ENHANCING!  Vertical jump and sprinting ability can improve with regular performance of a neuromuscular program (Garrison et al, 2011).

It is essential that we implement these widely from grass roots level up, and that if you’re not already doing them that you start today!

 

Footy First http://www.aflcommunityclub.com.au/index.php?id=906

Netball Knee https://knee.netball.com.au/

FIFA 11 Soccer http://www.footballfedvic.com.au/fifa-11plus/

 

Jane Higgs

Musculoskeletal Physiotherapist

Clifton Hill Physiotherapy

 

References

Dargo, L., Robinson, K. & Games, K. (2017). Prevention of Knee and Anterior Cruciate Ligament Injuries Through the Use of Neuromuscular and Proprioceptive Training: An Evidence-Based Review. Journal of Athletic Training, 52 (12), p 1171-1172.

 

Donnell-Fink, L. et al, (2015). Effectiveness of Knee Injury and Anterior Cruciate Ligament Tear Prevention Programs: A Meta-Analysis. PLoS ONE 10(12): e0144063.

 

Garrison, T., Smith, T., Tutalo, S., Barber-Westin, S., Campbell, D. & Noyes, F. (2011). Benefits of neuromuscular training program for knee injury prevention and performance enhancement in high school female basketball players. Journal of Strength and Conditioning Research, 25, pS12-S13.

 

Ramirez, R., Baldwin, K. & Franklin, C. (2014). Prevention of anterior cruciate ligament injuries in female athletes. Journal of Bone and Joint Surgery, 2 (9): e3.

 

Shaw, L. & Finch, C. (2017). Trends in Pediatric and Adolescent Anterior Cruciate Ligament Injuries in Victoria, Australia 2005–2015. International journal of environmental research and public health, 14, 599.

 

Webster, K. & Hewett, T. (2018). Meta-analysis of meta-analyses of anterior cruciate ligament injury reduction training programs. Journal of orthopaedic research. doi: 10.1002/jor.24043. [Epub ahead of print]

 

Zbrojkiewicz, D., Vertullo, C. & Grayson, J. (2018). Increasing rates of anterior cruciate ligament reconstruction in young Australians, 2000–2015. The Medical Journal of Australia, 208 (8): 354-358.

 

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PICK MY PROJECT- educating women in pelvic health

The recent state government initiative is currently in full swing and voting is underway! 30 million dollars worth of funding has been invested to encourage individuals to submit project ideas to benefit their local community and our women’s health physio, Ali has submitted a project!

Ali’s project is aimed at women of all ages and backgrounds. It will involve a quarterly education seminar addressing common concerns and important areas of pelvic health in an interactive manner. The sessions follow the lifespan of women, beginning with adolescent females, through pre & post natal phases and menopause. Common concerns will be addressed for each stage of life, including normal pelvic floor health, good bladder and bowel habits and sexual function.

We know that pelvic floor dysfunction is a common concern and affects up to 1 in 3 women! Here at Clifton Hill and Inner North Physiotherapy we continue to work hard to promote education around pelvic health within our communities. These seminars will be able to reach further audiences and will be presented in a captivating and interactive fashion to inform, educate and provide solutions to these everyday problems. Ali’s project aims to empower women to liberate themselves from the ongoing stigma around pelvic health.

Please check out Ali’s project on the link below, and if you live within 5km of Thornbury register to vote and get voting! There are many excellent community initiatives so have a look through the projects and help someone make a difference! Voting closes September 18th!

 

https://pickmyproject.vic.gov.au/rounds/pick-my-project/ideas/the-lifespan-of-a-woman-s-pelvic-health-an-education-series

 

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MAT PILATES AT CLIFTON HILL PILATES AND REHAB

Mat pilates is a great opportunity to get a full body work out! It is suitable for all levels, and challenges the individual to work within their own body. The class draws on key pilates principles of breathing, centering, alignment, and core control to improve posture, balance, strength, flexibility and coordination which will have you moving well and feeling fantastic!

Classes are limited to a maximum of 5 participants to ensure that feedback and corrections can be given to promote optimal quality movement. Small pieces of equipment may be used including foam rollers, theraband, balls and magic circles.

Mat classes can be a great compliment to your regular studio pilates sessions and home pilates programme!

 

These classes are run by Cathy Derham, our Titled Sports Physiotherapist and Polestar Pilates certified Rehab Pilates Instructor.

Get in touch with reception to express your interest and book a spot today!

 

Cathy Derham

APA Titled Sports Physiotherapist

B Physio (Hons)

M Physio (Sports Physio)

 

learning

We have been teaching about Endometriosis and Physiotherapy, Gastroenterology Conditions, Sexual pain and Pain education !

Our staff have been busy sharing their knowledge and expertise with Doctors and other Physios.

Issy has been busy presenting on two different topics this month!

Issy was asked to present to a support group of women who suffer with Endometriosis at the Epworth Hospital in East Melbourne. Issy presented on how physiotherapy can help women with pelvic pain and endometriosis. This common and debilitating illness is something our women’s health team sees frequently. They are able to help women with pain and bladder and bowel dysfunction.

The presentation went really well with many women asking questions on how they could be helped by physiotherapy. They were all amazed to hear of the self-help strategies that they could use at home with some simple steps. It was also pleasing to see so many of them came with a friend or partner to assist in managing their condition.

In that same week Issy presented her knowledge of gut focused treatment to a large group of GPs as part of their continuing education. She discussed some case studies of patients with constipation and incontinence and was able to inform the GPs of how they could manage their patients better.

There was lots of interest from the group not only on irritable bowel syndrome but also male pelvic pain and female sexual pain. The group was most interested by how physiotherapists can teach patients to regulate their bowel and be more in-control of their own health. It was exciting to see so many GPs (about 70) come out for this event, which was run by St Vincent’s Private Hospital.

Issy and Jen have also just tutored on a course on Female sexual pain for Physiotherapists and Brendon has just run 3 busy days in Bendigo teaching Health Professionals about Graded Motor Imagery and Explain Pain.

We are always striving to share our knowledge and continue our own learning.

If you have a endometriosis related pain, bladder, bowel or sexual dysfunction, consider coming in to see one of our experienced pelvic health physiotherapists who are able to sensitively navigate a management plan or chat with your GP, help is available.

breath

The use of breath with exercise and Pilates- Cathy Derham

Cath is a very experienced Sports (titled) Physiotherapist and Pilates Instructor and recently ran a workshop for us on the use of breath in exercise and pilates…

 

Effective breathing while exercising and doing Pilates helps to improve oxygenation to the body, enhance relaxation and engage the mind. Breath is often used to assist with facilitating a muscle, and the coordination of movement patterns. An exhale (breath out) is often used during the more effortful component of a movement (for example lifting or lowering a load, or moving a limb). Breathing can be regressed so that movements always occur on an exhale, with pauses in movements occurring on inhale. As people progress, and are able to achieve greater dynamic stability, breathing patterns can be progressed making movements more fluid. The focus on breath during exercise can be helpful for some to improve timing and coordinate movements. For others it can create too many things to have to attend to in addition to just doing the movement! The important thing is to ensure that you avoid holding your breath during exercise, as this can result in increased blood pressure while exercising.

Breathing also has a significant impact on the mechanics of an exercise. For example, when looking to facilitate extension through the upper back/ trunk we can time these movements with an inhalation (breath in), as the extra air going into the lungs will facilitate this movement. For some we may want to promote more stability with this movement (instead of mobility), and we may cue to do these movements on an exhalation

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Figure 1. An inhalation will facilitate getting an increased range of thoracic extension as the trunk goes upwards towards the ceiling during the Swan exercise on the Wunda Chair.

Some words to ponder which draws upon the relationship between breath and its relationship to engaging the mind –

“Breath, prana and mind are mutually and inherently related; cultivate one well and the other two will fall into line. Prana is the energy that drives life, the power that animates the body, enlivens the mind, spurs the soul. Prana is life’s inspiration, its foundation, its tenacity; it is the sure hand on the tiller, the wise voice of good counsel, the urge to health and harmony that craves to turn our bodies into havens where we can take shelter from the storms of the hectic modern world. Prana is at work every instant in every cell of every living organism.” (Robert E. Svoboda, as cited by Polestar Pilates Rehabilitation Series Course Notes, pp. 21).

Cathy Derham

 

References

Balance and Control Training College (2012) Foundation Level Manual (pp.42-46)

Norkin CC, and Levangie PK (1992): Joint Structure and Function, (2nd edition), pp.178-192.

Polestar Pilates Education (2012) Studio/ Rehabilitation Series Manual – Principles of Movement, pp. 16-26.