 I'm back in the office and treating patients at East Oahu Physical Therapy, but many are still at home if they are not essential workers. Some have been laid off or know someone who has, which brings more concern and even more fear and anxiety into our lives or the lives of our loved ones. As a physical therapist, my primary concern during this COVID crisis has been the potential for poor posture problems and injuries while being more sedentary at home. But fear and anxiety adds others, as this added stress can make us more vulnerable to pain and injury. Today, we'll be talking about the risks poor posture at home presents to our bodies as adults and children, as well as strategies to improve posture using breath and decrease fear and anxiety. I'm grateful to have Dr. Mary Massery joining us today. Dr. Massery has been a physical therapist for over 43 years, achieved her doctorate in physical therapy as well as her doctor of science and has been invited to give over 900 presentations in the United States, as well as 18 countries abroad. Her research pioneered the concept of managing trunk pressures as a new way to visualize core stabilization. She's earned the highest of honors at the American Physical Therapy Association Awards, the Florence Kendall practice award for outstanding and enduring contribution to the practice of physical therapy. And recently, Dr. Massery prepared a critical webinar to physical therapists on important rehab considerations for treating the post COVID-19 patient. Welcome back, Mary. Thanks, Christine. I'm so glad to have you back. So I am back to work and I'm hearing from colleagues and patients about hunching over laptops and frustration with their kids hunching over their, their laptops and devices as they're now homeschooling, and then they're playing on their games at home and all the variety of problems that are associated with that. And you're such a master of the diaphragm that I wanted to tie it in with postural control and breathing and stress and anxiety and breathing. What kind of tips or go-tos or ideas do you have for some of these parents and kids at home to help with that? It's a really loaded question. The first thing I'd like to do is to say let's just get rid of the virus. Could we? Could someone get a vaccine please soon so we can go back to more normal lives? Of course we don't have a new normal. Yeah, it's going to be a new normal. It's not going to be the old normal. We'll see where it goes. But with that, I think we do need to be considering stress and anxiety and posture. For the families that are working at home, the kids who are homeschooled, not by choice at this point but out of necessity, they don't necessarily have desks and chairs that fit everyone. So being able to take some breaks to even being able to take some time to say, could I put a book under the computer to be able to raise the computer up? Could I use a different chair? Is there some way that I can switch one kid with another kid's pastoral setup in order to improve their posture? It won't be perfect, but could it be better? And one of the things that you and I have talked about is if you're having difficulty breathing because you're so hunched over and I know you've got a couple of pictures there that might help remind people of what we really look like at home right now. This would be just a great picture of someone. If you're a dad working at the kids' table and saying, no, it's going to work. Well, no, it's not. And doing a little bit of slouching now and again is perfectly fine. The problem is when you're going to school or going to school or going to work all day in this slouch posture, it does tend to fold you right at the point of your diaphragm where you would normally be able to expand that diaphragm. You could take this big breath not only to get air, but also perhaps to be able to calm yourself. But if you could take that deep breath in every so often and even just say, okay, this is really tough. I'm trying to do a test online as a school kid or my little brother is running in and out of the room and I'm having a hard time hearing my teacher. Just get in a nice position, take that nice cleansing breath, and maybe help to reduce your stress a little bit. It's not going to cure the virus. It's not going to cure all of your anxiety. But what if it was one more piece in the puzzle to be able to help? I think that's so well put. I was even suggesting to one of my patients who works with young kids, she happens to be an occupational therapist that works with very young children who have postural problems and she has to make it a game. So I said, yeah, it's easy for me. I'm mostly adults or teens. And so the teens and young adolescents, I can make it more of a fun exercise game. But for very young children, I was telling her like, how about we, you know, we're taking a big breath and make just something to improve their posture, make them take that deep breath. Kids are so great at playing and it's kind of fun for us to come up with some of those things. So have you seen you're, you've been at home now. Are you doing anything with your family or are they just naturally in good posture because they know who you are? We are quarantining my husband and I, and then my daughter Tina and her husband and their two young kids have a two year old who I think ran into the show on one of the prior days and then a newborn baby. So we do have quite a household and even with that, you're now juggling who sits in normal places, who gets the desk to be able to work on their computer, who's got to hold a baby while holding the computer and things are not ideal. It's just not ideal. So it goes. But some of the things people could be thinking of to just try to help with their posture, their general mobility and again maybe helping to relieve some anxiety and stress is to be thinking of their whole trunk from the pelvic floor all the way up to their neck, and recognizing that the muscles of your chest well here, the intercostal muscles, those are the deep muscles that are along the ribs. They are primary rotators of the trunk. So when you rotate your body to reach to that your left or reach to your right, you should be taking a nice deep breath with it. So you'll be using your diaphragm at the base or the base of the lungs, which is in the middle of your trunk, and your intercostal muscles, all the way around your chest. That's going to help you rotate help you have mobility and help you take a deeper breath. So it could be the kind of thing that helps to relieve some stress simply because you'll be able to breathe with less effort, rather than more. And because we tend to be hunched over and doing either our computers or video games here, what we really lack on a common day when we're stuck at home is that ability to rotate. So if I were a physical therapist working with kids or adults, I would be including in their activities every day, some kind of activities where the arm comes up and out. But while they're sitting right on their sits bones. So right on those butt bones, not slouch backwards, and very importantly that they are following with their eyes, because if I just bring my arm back here. That's actually just a shoulder activity. But if I have to watch, I don't know if you can pull back a little bit or I can. So I'll pull back. Well, you still can't see my hand so pretend you can see my hand otherwise I'm just connected from the audio. So if I have my arm up here and I look while I turn. That is now a trunk movement and that's going to go from the pelvic floor all the way up to the shoulders and up to the neck which can be just a beautiful stretch, beautiful rotation for taking that deep breath in and helping posture as well as a real key component is elbows straight. So I don't know did we do this one before I can't remember if we did this. This is a really fun one to do so if everyone would just pull back from your seats and for Christine you're standing aren't you. I'm sitting. Oh you're sitting can you stand and move back because I'll have you be my demo, since you're not wired in. Don't have shorts on like that one guy that was all dressed up in a suit on top and had his little box and they had nothing but boxers right perfect okay now. Nope, I want you back where you were that's perfect right there. Okay, so what I want you to do we're going to link your shoulders to your trunk to all those muscles here and we'll first do it just in a straight plane. So I want you to bring your thumbs forward. Elbows are straight and so all the people out there I want you to do the same thing lift your arms straight up to the ceiling, just as high as they go. Okay, good and come back down. That was perfect. Now stay right there though. I mean don't leave your spot. Do it this time and tell me tell me whether you automatically inhaled, exhaled or did nothing. So arms up elbows straight up your elbows weren't straight bring those arms back down. Okay. Thumbs forward elbows straight arms up. Okay, and down. What did you do. Inhale, exhale or do nothing. You inhale. And that's because we linked your chest to your shoulders. Now I want you to purposely do it with kind of lazy bent elbows. And coming up just kind of like this. Right. Okay, and feel the difference. Did you inhale, exhale or do nothing. I almost felt like I exhale. So exhaling or doing nothing is the wrong answer. Because with your elbows with your elbows bent, you're not actually mechanically linking your shoulders to your rib cage. So if you want someone to take a nice deep breath and you're using the arm as the conduit to make it easier for that to occur. You need to have the elbow straight and not bent. So let's do this you're ready to do it again. Okay, thumbs are forward so that your arm is slightly externally rotated. Elbows are straight this time take a nice deep breath as you come up. Bring those arms all the way up. And then blow it out and come down. That's easy to do now you're going to do the same thing only you're going to do with just one arm so thumbs are just facing forward, like facing me from where you are. You're wearing only your right arm up and follow your right arm with your eyes with your eyes there you go now you have beautiful rotation bring it back down and exhale, keep your elbow straight that's really important elbow straight, beautiful. Blow it out and come down. Now this costs nothing, zero, nothing. Maybe you could have your patients or their families do it a few times an hour. Every time you take a break wanted to do three to the right and three to the left and get that nice cleansing breath in. You also should have felt that when you did that nice arm raise up with the straight elbow that it actually brought your spine into a beautiful extension and rotation. So if you're trying to get their posture to be in a better position. That simple activity might be something that helps to cue them. Okay, you can come back. Thank you for being a demo. That felt great. I'm nervous to write away my little lack of range of motion from my right shoulder injury. I try to work on that. Yeah, I could feel the right one a lot of stretching in my right flank in my right rib cage and then with the left one. It's good and very open and has a beautiful stretch for people to do. And you know what else happened. I get nervous for these shows and felt all of it go away when I breathe. And I came down. It not only felt good but I feel, I feel calm. So something else that I would tag on to that is thinking for physical therapists in particular who deal in orthopedics, they're going to have tons of patients who have different shoulder problems. Often the patients are going to come in saying, you know, my right shoulder my left shoulder hurts and physical therapist is going to treat that shoulder. What if that shoulder was actually problematic, because nothing moved in the rib cage. So anytime a physical therapist is working with the shoulder to me the first thing they should be saying is, what about their breathing. What about the rib cage. What about their spine. This, I call it the saddle on the horse is just sitting on top of the trunk. And if the trunk isn't in the right alignment then the saddle can't be in the right alignment. So the shoulder might be what's hurting, but the problem could be their breathing or spine their pelvis something else. So I love that you said that I hope everybody is taking notes or is going to watch this back and write it again. I've been back to work since May 1, and I've been doing a lot more breathing things as I'm back because I'm on the only one in the clinic. I can think a little better when there's not a lot of action going around me with the other therapists and their patients and the noise. I've been looking at a lot more things outside of the box with my neck patients and with my scoliosis patients I do a lot of it but I've been having some of the ones that I can't get them to open their rib cage on the side that's more compressed. I've been having them land their side and use arm movement overhead while they take an inhale and my patients that I use is three. One of them is the OT and she said, that was a great session this morning. I had to adjust my rear view mirror when I sat in my car because I was taller. Isn't that fantastic. She said that when I had treated her last year at a different clinic we've reunited again but I remember her saying something about the rear view mirror and she knows when she's up tall but that was the first time that something that I did. She immediately said I need to do that every day. I couldn't believe how good I felt. Her low back was her pain complaint but she has a large curve in her middle and her midsection, the thoracic section. But doing that really gave her a great day and she does work with very small kids so she's on the floor and mobilizing them. You do that. You work with youngsters. I do but I now use a treatment table. I've had too many knee surgeries myself. I'm not working on the floor. I get to do that after 43 years. I get to say no sorry I'm not working on the floor anymore. But that's just my situation. I would come back to your patient again and say when you're doing that sidewards bending and the arm coming up make sure you're telling them elbow straight and only coming up as high as I can with the elbow straight. So if they have to come up and then bend their arm here and say no no that's okay. The goal isn't that you came all the way over. The goal is that you came up as high as your mechanics would allow and pull that breathing into it. And then you know maybe they need some rib mobilizations or spine mobilizations. There's lots of other things they need besides breathing. Just don't forget breathing is a really important part. I think that's why don't we pull up Matthew's case just so they can kind of see the dramatic difference because I think that would be nice for them to see even though a lot of people of your viewers don't have children of their own with cerebral palsy or don't treat kids with cerebral palsy but I think it really makes the point and it's a little bit more dramatic than just everyday pastoral problems. I was hoping you would say that. I was thinking the same thing. Matthew's case would be great. So Eric do you want to pull up? I think it's the first one 1A. Alright so if you can look on the far left side that is Matthew when he was one and a half years old. He was a premature baby. He has cerebral palsy. And you can see that his whole spine is really very collapsed. At a year and a half he should be able to hold himself upright but he couldn't because of the cerebral palsy. But I'm not sure if you can tell the difference. His lower spine in the red circle is very rounded. That's called a kyphosis. And that actually should be in a sway back. Your low back should be in a sway back. So it's the opposite of what it should be. His upper spine in the blue circle is actually the sway or the curve inward curve. And that one should be the outward curve. So in other words Matthew had reverse curves so that his ability to hold himself upright was actually in reverse. So on top of the cerebral palsy it just doesn't have alignment. Can we go back to his case Eric? So if you look at Matthew down in the two lower pictures you're going to see on the left hand side in the red circle which was the one I had drawn your attention to in the top left. The red circle his low back now has a nice arch to it and that's what you want to see. So he has a lumbar lordosis or that nice healthy little sway back. Because he has an abdominal binder on because he's too weak to use his own stomach muscles to hold himself upright all day. So you help him. Let him use his stomach muscles as best as he can and then add a little corset essentially to help him be upright. And if you look on the right hand side, you'll see because he has that support with abdominal pressures which we've talked about with the left hand before, you can see Matthew can now hold his head up. So can we go to the next one Eric? So for Matthew we used a body brace and that would not be for someone like you and me, Christine, who just are slumped over at the coffee table but for some patients it would be appropriate. So what I do want you to notice for Matthew inside the red circle is that it's a great big cut out to allow his diaphragm to expand so that we're supporting his spine and his rib cage, but still allowing encouraging and maximizing his diaphragm movement and chest movement. So the next slide there's just four slides for you guys. So if you look at this slide it's a busy slide normally I would be doing it with a PowerPoint. And so we would be bringing those circles up one at a time but if you would follow the green lines for me on the left side, Matthew doesn't have any support, and you're going to see that those green lines actually come together those green vertical lines come together on his thoracic spine in his back where he has maximal slouch. That's going to make it so much more likely that Matthew is going to develop a scoliosis and a kyphosis, and a scoliosis meaning his spine will curve to the side and a kyphosis meaning an extreme hunch like you're seeing in the right hand picture I want you to notice those two vertical group well one vertical one horizontal green line you're going to notice that vertical green line is very vertical okay that's what you want that it's ideal posture you see how beautiful his head position is his shoulder, his spine, his hips, and you would also be able to notice if we, you know, cleared out some of those extra circles that Matthew's actually holding his own head up. When he has the right postural support, he can lift his own head up and hold it there. So for our patients who don't have cerebral palsy, we're going to want to be thinking about, what about those patients who just have poor posture and what they come in complaining about is neck pain. When you're looking at neck pain is it really neck, or is it about their whole posture. And the final slide for Matthew I think says it off we can go back to that one era. You can see on the left hand side that was Matthew at a year and a half you can see his spine has really collapsed. And then you look in the middle Matthew is now 10 years old with a beautiful straight spine and you see him with his mom on the right. I just couldn't be happier for Matthew and his mom. He still has cerebral palsy I can't wave magic fairy dust and get rid of that anymore than I could get rid of the Coronavirus. Could, could we optimize it that's what I really want to be looking at. That's a great case and definitely shows a lot. Wow. I mean the impact that that has had on Matthew and his family is amazing and, and the point that you made about how now he's able to hold his head up. Once his posture is in the right place that's, that's great that's, that's great for kids that's great for adults. And I know with the bracing a lot of my adults are thinking, can't I just get something like that to wear at my desk and there are plaster straps and I do tell them, you can use them if you need to because you just, it's a reminder but after a couple weeks I don't want them to use them anymore because the awareness for us adults or we adults is to self monitor when we're slouching. But some of my patients say I can't I get in a project and I need something so I have amuse a strap not a brace for just a couple weeks as a oops, oops that reminds them and then pretty soon. They are in that habit like brushing your teeth every morning and washing your face every night of they feel and they pop themselves back up. Your case. Okay, go ahead. I was going to say it's like kinesio tape. You can go in the opposite direction from where the kinesio tape is holding and supporting you. You can go in the opposite way but you tend not to because the kinesio tape is saying, go this way. Go this way. So all the kinesio tape is doing is giving you a little tactile reminder. Maybe all you need is that little reminder don't forget sit up straight. Don't forget to have your shoulders back or whatever it is that you're working on. For the kids that I see in pediatrics they tend to have more serious conditions and they may need a lot more than kinesio tape, like little Matthew, needing a brace. If the adults wouldn't need a brace they would need some neuromuscular reeducation with PT some strengthening some stretching and then maybe, like you say some straps some bands, some kinesio tape, something to give them that reminder until they can do it on their own. Wow, I mean, and, and this of course, with my elbows. Right because if you don't have that elbow straight so when you have a chance or any of the viewers at home to really do it. You really want to feel that difference look in the mirror. When you do it with your elbows straight you're going to feel your chest lift and you're going to feel your spine extend. When you do it with your elbows bent, you very deeply feel actually my head is coming forward. Instead of my head being in beautiful alignment. It's actually coming forward. So you recognize that the shoulders again as that saddle of the horse. The shoulders can only work well if the trunk is working with the shoulders if the horse is working with the saddle. So you really can't separate breathing from doing shoulder rehabilitation or would be impossible. I think, and that's probably why I X I was a I didn't exhale when it came up I was able to exhale when I came up sloppily because I can still talk but when I do this. It's really hard you you want to stop your way. Because of that, we are out of time. Okay, but let's put this picture up for everyone, the picture of the plumeria flower, and let's all raise our arms with elbows straight and take a nice deep breath while we look up and our eyes follow our hand in and come down. I'm going to do it the other one too. Straight up, follow it with your eyes so that we can all have better posture and less fear and anxiety and be better able to deal with everything that's coming our way until we find a vaccine so Mary thank you. You're so much. I hope you and your family stay safe and I know that I learned a lot. I think that everyone learned a lot. So thank you to our viewers for joining us and thank you think tech Hawaii for allowing us to be here with you today and our sponsors and donors for supporting us. Aloha everyone.