What is the NEUBIE?

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

For those of you who have been around in the clinic recently, you may have observed (or been part of yourself!) a treatment session where a patient is doing exercises and movements while hooked up to a machine via electrodes. Just this past March (right before the COVID-19 shelter-in-place requirements began), Ellen was able to go to Florida to be trained on a machine that uses a new version of an old technology, direct current electrical stimulation, called the NEUBIE. You may be wondering what NEUBIE stands for: Neuro Biological Electrical Stimulation. Ellen became intrigued in bringing this technology into our clinic after learning more about it at a national conference in January of this year.

The timing was not ideal, as Ellen could not have anticipated that there would be a dramatic drop in patients as folks stayed home in those initial months of the global pandemic. However, with the few patients that remained coming into the clinic in a safe manner for their high-priority rehabilitation (which consisted of a majority of people who had just had surgery before the shelter-in-place requirements began), Ellen and the other therapists began working with the NEUBIE machine and seeing the prospective benefit of this piece of equipment as an integral part of getting many of our patients to meet their goals. Once I returned back to the clinic in late April, I was also introduced to the NEUBIE machine and began learning about it’s practical uses.

Now, I’m not going to lie, I’m a bit of a skeptic by nature when it comes to “gadgets” that are supposed to enhance physical therapy. As a PT that has been trained in the specialty of manual therapy, I have a hard time thinking that our patients would need anything beyond my hands and my brain (to come up with beneficial exercises and activity progressions) to improve toward reaching their goals. However, although my uptake was slow in utilizing this technology within my patient care, I have been finding an outstanding benefit for many patients when I have used the NEUBIE machine to enhance their current exercise program. I’m not going to lie, I have been surprised to hear from many of our patients, especially those with chronic pain, how beneficial they have felt this addition to be by impacting their pain and quality of life in a positive way.

Though clinical research with this device is still in its infancy due to its relative novelty in use, we have seen many anecdotal cases of our patients in real-time benefit from the use of the NEUBIE as part of their rehab program. In order to understand a little more about how the the technology works to address the nervous system and aide in the brain to muscle connection that we often speak so fondly of when prescribing exercises, I think this video does the best job at explaining the basics:

As one of only three clinics in Colorado that have this technology available (with the other two located on the Front Range), we’d love to have you come in and learn more about how the NEUBIE can enhance your return to everything you love with better mobility, less pain, and improved quality. With an individualized approach to examination and coming up with a treatment plan and progression, we can discuss if the NEUBIE might be a good fit for your rehabilitation plan!

COVID-19 Recovery and Exercise

With the continuing threat of COVID-19 world-wide, it seems as if new information is coming out nearly daily. From trying to understand how the virus is transmitted to who is more susceptible to getting the virus and having serious health impacts from it (and everything in between), we are working our hardest to stay up-to-date with the latest information about COVID-19 and how it impacts ourselves, our patients, and the clinic. As we continue to remain open through the pandemic, we continue to use screening and cleaning techniques along with proper hygiene (friendly reminder- face masks required!) from our staff and within the patients as ways to stay safe and healthy during this time.

That being said, it is clear that this virus will be sticking around for a while and many questions will continue to arise as more people in our community are affected by COVID-19. In the physical therapy realm, one of the questions of interest to us is “when is it safe to start exercising again after recovering from COVID-19?”. This question was recently discussed in the open-access article “Exercise and Athletics in the COVID-19 Pandemic Era” on the American College of Cardiology’s website.(1)

The article provides an interesting discussion, from the perspective of cardiologists, regarding COVID-19’s effects on the heart, the inflammatory-reducing effects of exercise, and what the recommendations are for returning to exercise and sport after recovering from COVID-19.(1) Knowing that, based on early data and observations, “COVID-19 infected patients with hypertension, diabetes, cerebrovascular or cardiovascular disease are more likely to require hospitalization, ICU level care, and die from the infection,” these pre-existing conditions must be taken into account when considering a return to exercise after being infected.(1) Ultimately, the current recommendations from the authors were as follows:

  • “… the recreational exerciser seeking to resume activity for general physical fitness after COVID-19 who experienced only mild to moderate symptoms, were not hospitalized, and had no concerning cardiac symptoms should be able to resume recreational exercise at moderate intensity once completely recovered.”(1)
  • “However, patients with pre-existing cardiac disease who are potentially at higher risk of complications with COVID-19 may require additional testing and risk assessment prior to return to regular exercise levels.”(1)
  • Based on two recently published statements quoted by the authors, it is suggested that athletes who tested positive for COVID-19 who were either asymptomatic or had mild symptoms and were not hospitalized take a rest period of 2 weeks from either the time of the positive test for asymptomatic individuals or from the time of symptom resolution for those people who had symptoms before considering return to exercise in a slow, progressive manner with guidance by their doctor.
  • Furthermore, for athletes who tested positive for COVID-19 who had significant symptoms and were hospitalized, a recovery period of at least two weeks after symptom resolution followed by further cardiac assessment and monitoring is recommended. Those with known myocardial injury need to wait 3-6 months before re-evaluation by a cardiologist before considering a return to exercise.

The authors of this article are quick to point out that this information is based on expert opinion, due to the fact that there are no higher level research studies performed on this topic because of the novelty of this virus. However, their concern for the impact of COVID-19 on the heart came through in their recommendations. Ultimately, if you have tested positive for COVID-19 (regardless of whether you were asymptomatic or had such significant symptoms that you were hospitalized), you should make sure to discuss how to safely return to exercise with your healthcare time. As information is quickly evolving, these recommendations may change as further research can be performed and observations are made, but the bottom line for now is that you should REST for at least a two week period regardless of how severely you felt impacted by the virus. Stay safe, stay healthy, wash your hands, and wear your mask!

  1. Emery MS, Phelan DMJ, Martinez MW. Exercise and Athletics in the COVID-19 Pandemic Era. https://www.acc.org/latest-in-cardiology/articles/2020/05/13/12/53/exercise-and-athletics-in-the-covid-19-pandemic-era.

The Importance of Movement During the COVID-19 Pandemic

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

I’m sure I’m speaking for everyone when I say- It’s been quite a month. A month full of different emotions including anxiety, fear, hope, gratefulness, and worry to name a few. Sometimes, all of those emotions are experienced within an hour, depending on the day. Like many of you, my previously defined version of “life” has changed wholly during this COVID-19 pandemic. Where I used to pride myself on being able to separate out my different roles- physical therapist, wife/mom, individual- into nice boxes, I found myself all of a sudden dealing with the fact that my boxes all completely melded into one, with a continuous flow of trying to figure out how to be a PT, wife/mother, and individual (as well as a new role of homeschool teacher and stay-at-home mom) all simultaneously. The first few days, weeks, of this were rough: Learning telehealth and how to still provide quality PT via a video platform instead of face-to-face, learning how to help my son best with remote learning, learning how to provide my daughter with the time and attention she needs especially with working on her PT as she is experiencing some gross motor developmental delays, learning how to help support my husband emotionally while we are both home from work and out of our usual routines. And, oh yeah, learning how to continue taking opportunities to take care of myself through all of the uncertainty and evolving roles. However, I find that day-by-day, a new sense of understanding and “routine” emerges, at least as best as it can during such a tenuous time.

Continuing my weekly dance class in my living room!

One thing that has been crucial to my sense of staying grounded has been finding continued opportunities for movement. Sure, we all know that exercise is the best medicine- something that I teach my patients day in and day out. When in doubt, MOVE! But, now more than ever, finding opportunities for movement is my best recommendation for helping our minds and our bodies during this time. I implore anyone who reads this to find ways to continue to move safely: maintaining social distancing guidelines while on the trails or in your neighborhood, getting that yoga mat out and finding a free online yoga class to try (I love doyogawithme.com), still participating in your favorite dance class or pilates class with your friends and teachers that you used to see on a weekly basis, or even trying something new as the world of online exercise guidance has exponentially increased in the past few weeks with many free offerings! MOVE for your brain, your body, your health, your family… I hope you all are staying safe and healthy out there. Remember, Tomsic PT is still offering appointments both via telehealth (including new evaluations and ergonomic assessments!) as well as in the clinic where we are following all of the CDC and San Juan Basin Health recommendations for cleanliness, hygiene, and safety during this time. Don’t hesitate to reach out to us for more information on how to reach your physical therapy goals- we are here to help you!

CrossFit and Stress Urinary Incontinence

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

CrossFit, or CrossFit-style classes, have gained popularity in the past 10 or so years for a good reasoning: they are challenging, fun, and create camaraderie around strength and health. There are a number of great gyms in the Durango area that provide these kinds of classes, and many of our patients are regular participants. Although I have not yet ever participated in a strength and fitness class like CrossFit, I’ve recently become particularly interested in learning more about these workouts so that I can better serve my patients. I’ve also had a recent string of patients that happen to be pregnant or in their postpartum period, so I was especially excited to partake in a continuing education course called “Clinical Management of the Fitness Athlete: Pregnancy and Potspartum” that focuses on these specific types of patients.

Picture of strong, weight-lifting mama-to-be from https://boxlifemagazine.com/crossfit-training-during-pregnancy/

One statistic that came out from a recent study that was shocking to me was that 84% of female CrossFit athletes that participated in the study reported urinary incontinence, otherwise known as leakage.(1) This was in comparison to another group of women who participated in non-CrossFit fitness classes of which only 48% reported urinary incontinence.(1) This leakage was most common with jumping and weightlifting actions, which of course are very common staples of CrossFit workouts.(1) This also makes me wonder about all of the other Durango athletes I see that do jumping or weightlifting as part of their exercise routine whether or not they are participating in CrossFit style classes. How many women might be out there that are leaking when they do activity that just think it is a “normal” part of life, especially after pregnancy, labor, & delivery?!?

A picture that was recently circulating the web and sparking a big discussion in peeing while weightlifting. (Photo source https://www.thegreatfitnessexperiment.com/2009/05/bodily-functions-fitness-101-pee.html)

The big takeaway from the course that I took is that, although it may be common, urinary incontinence is certainly not normal, and there are many tools that physical therapists can use to help you with this problem if you are experiencing it! Also, even as a physical therapist that is not certified in pelvic floor therapy that includes internal examination and treatment, there are a lot of assessments and treatments that I can do to address this problem as well as guide patients that are pregnant or postpartum through their exercise programs in order to continue being active as safely as possible given the stage they are in along their journey. Of course, check in with your physician or midwife to ensure you are cleared for exercise both during pregnancy and postpartum. If you’ve been cleared for exercise and you are not sure how to best navigate activity and exercise during and after pregnancy (even many years after pregnancy!), don’t hesitate to schedule an evaluation appointment to figure out the optimal treatment plan for you.  Babies are always welcome at appointments if childcare is a challenge for you, too!

1. Elks W, Jaramillo-Huff A, et al. The Stress Urinary Incontinence in CrossFit (SUCCeSS) Study. Female Pelvic Med Reconstr Surg. 2020 Feb;26(2):101-106.

Return to Sport after ACL Reconstruction

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

Many people in Durango know someone who has had an anterior cruciate ligament (ACL) injury of their knee if they have been lucky enough to have not had one them self. Much of the time, these injuries end up needing a surgical reconstruction depending on the severity of the sprain or tear to the ligament. One of the most common questions that we hear after an ACL reconstruction is when returning to sport activities is safe. The surgeon will often give strong recommendations to wait as long as possible, especially depending on the type of sport that the individual is getting back into. This is especially true in sports that require any twisting or pivoting of the knee, such as soccer, skiing, and football. In general, most people don’t love hearing this and I have often encountered patients who push back into their sport fairly quickly. 

A recent study published in one of my favorite peer-reviewed PT journals, the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), sought to find out what the implications are of returning to sport too soon.(1) The study specifically looked at young athletes (late teens to early and mid-20s) in regards to how quickly they returned to sport and how this impacted their rate of re-injury to the affected ACL.(1) Ultimately, this study found that “returning to knee-strenuous sport before ACL reconstruction was associated with an approximately 7-fold increased rate of sustaining a second ACL injury.”(1) “Knee-strenuous sports” included baseball, snowboarding, skiing, volleyball, basketball, football, soccer, and ice hockey” among others.

Something also very interesting that the researchers found was that the risk of re-injury was unaffected by whether or not the person achieved symmetrical muscle function or quadriceps muscle strength.(1) So, even if the person did everything they could to get strong and their strength of the surgical leg was equal to the non-surgical leg, they still had a significantly higher chance of reinjuring their ACL if they returned to sports before that 9 month mark.(1) The take away from all of this: if it is at all possible, you should WAIT to return to sport after an ACL reconstruction if you are a young athlete. Even though this study was not performed in older athletes, the argument may be made that this advice applies to them as well. If you have experienced an ACL injury and subsequent surgery and you want more information about when and how to safely return to sport, make sure you talk to your PT and surgeon about this timeframe. 

  1. Beischer S, Gustavsson L, et al. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther 2020;50(2):83-90. doi:10.2519/jospt.2020.9071

Sleep and Its Relationship to Pain

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

I recently attended the annual American Academy of Orthopedic Manual Physical Therapy conference in Orlando, Florida, where I got to learn from a lot of leaders in the field of physical therapy on a variety of topics. One of the presentations that I was eager to attend was one regarding a topic that is very near and dear to my heart these days: the importance of sleep and how Physical Therapist’s play a role in discussing sleep with our patients!

The presenters did a great job outlining the role that sleep plays for our health, especially the relationship between sleep deprivation and increased risk of cardiovascular disease. Furthermore, and strongly related to what we deal with each day in physical therapy, the relationship between sleep and pain was discussed. There are multiple research studies performed in the past couple of decades attempting to find out the relationship between sleep and pain. For example, a 2015 study of over 10,000 participants found that impaired sleep (reports of insomnia more than once a week, sleep latency greater than one hour, or decreased sleep efficiency) was associated with increased pain sensitivity.(1) Another study that was published this year (2019) showed that baseline sleep disturbance negatively affects pain response to treatment of chronic pain, even with the use of opioid and nonopioid medications.(2) Things that qualified as “sleep disturbance” in this study included difficulty falling asleep and trouble staying asleep.(2)

Ultimately, the research shows that sleep- or rather, difficulty sleeping- has a relationship with multiple bodily functions, including our pain experience. For anyone who has experienced a poor night’s sleep (or experiences this frequently), this isn’t surprising news. The big question to ask is, “How can I improve my sleep?”. The presentation that I attended in October gave some great suggestions for better sleep hygiene:(3)

  • Consistent timing: plan to go to bed and wake up around the same time every day
  • Limit bedroom activity: the bedroom should be for sleep and intimacy only (not reading, work, watching TV, etc.)
  • Eliminate pre-bedtime stimulation
  • Try not to exercise within 2 hours of bedtime
  • Eliminate caffeine at least 4 hours before bedtime
  • Avoid large meals, spicy food, and liquid 2-3 hours before bedtime
  • Eliminate electronics at least 30 minutes before bedtime
  • Create a dark, cool environment
  • No sleeping pills
  • No naps
  • Refrain from alcohol 3-4 hours before bedtime

If you’re struggling with sleep, start by looking at this list of suggestions and identify areas where you currently do things differently. Think about one to two changes you can make in your pre-bedtime habits to start to work toward better sleep and, ultimately, better function. Remember to mention disturbed sleep to your health providers, including physical therapists, to get further individualized suggestions to help your sleep hygiene.

  1. Sivertsen B, Lallukka T, et al. Sleep and pain sensitivity in adults. Pain Journal. 2015;156:1433-1439.
  2. Koffel E, Katz AM, et al. Sleep Disturbance Predicts Less Improvement in Pain Outcomes: Secondary Analysis of the SPACE Randomized Clinical Trial. Pain Medicine. Doi: 10.1093/pm/pnz221
  3. Shepherd M, Dickerson C. Sleep Quality Assessment and Intervention in OMPT. American Academy of Orthopaedic Manual Physical Therapists Annual Conference. Orlando, FL. October 26, 2019.

PT First for Low Back Pain

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

You’ve heard the news: our country has an opioid epidemic. This history of this epidemic is not a pretty one, and it is one that our country is attempting to take steps toward fixing. From policy-makers trying to affect change via rules and regulations for prescribing providers to trying to get physical therapists included on national loan repayment programs for underserved and rural communities in our country, there are a lot of people putting their heads together to try and figure out how to solve this national problem. One such group of people is the American Physical Therapy Association, or APTA, that recently co-sponsored a very large study to assess the effects of which provider someone sees first for low back pain on the use of opioids both in the short- and long-term.

When I say very large, I mean it: the study analyzed more than 200,000 insurance claims from adults with a new onset of low back pain.(1) The researchers were looking to see if the type of provider seen at the initial visit (specifically primary care physicians versus PTs, chiropractors, or acupuncturists) affected the patient’s use of opioids either short-term (filled their prescription within 30 days of the initial visit) or long-term (filled their prescription within 60 days of the initial visit and continued taking opioids over the next 4-12 months).(1) Here are the key take-aways from the results of the study:(1)

  • Of all of the patients looked at, about 18% filled an opioid prescription within 3 days of their initial visit, and 22% filled a prescription within 30 days of their initial visit. 1.2% of the entire group studied fit the criteria for long-term use.
  • Looking at the patients with short-term opioid use, those who saw a PT first had 85% less chance of filling an opioid prescription within the first 30 days of their visit versus patients who saw a primary care physician first.
  • Furthermore, the patients who saw a PT first for their back pain had 73% decreased odds of long-term opioid use versus patients who saw a primary care physician first.
As PTs, we have many tools- including manual therapy- to treat low back pain

This study provides strong evidence for patients who are experiencing a new onset of low back pain to come to PT first.(1) After all, we are the musculoskeletal specialists, and low back pain a condition we treat frequently. Ultimately, if you come to PT first to get a thorough evaluation and treatment for your low back pain, your likelihood of taking opioids is significantly decreased. If you are experiencing low back pain and not sure where to go, make sure you give our office a call so we can get you in to see one of our specialized physical therapists for a timely evaluation and get you on the road to feeling better without delay.

1. Kazis LE, Ameli O, et al. Observation retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use. BMJ Open. 2019;9:e028633. doi:10.1136/bmjopen-2018-028633

CBD Use and Musculoskeletal Pain

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

There has been a lot of buzz around the use of cannabidiol (CBD) lately, as more states have made CBD legal for use both with and without medical prescription. I have many patients that ask me about the use of CBD for their aches and pains, and have even more that tell me that they already use it and find relief with it. Just yesterday, a patient came in and reported that her sleep, which used to be interrupted 3-4 times per night because of hip pain, has significantly improved since she started using oral CBD before bed. Based on these stories, I wanted to learn more about the research behind CBD use when it comes to musculoskeletal pain, and I was pointed to a great research review titled, “Cannabinoids in the Management of Musculoskeletal Pain: A Critical Review of the Evidence”.(1) I’ll share with you what the research says, but I do want to remind you that you should always consult with your primary care physician when considering taking any new medication.

The review by Madden et al looked at 33 studies looking at the use of cannabinoids, including CBD (the form that does not have THC in it) as well as cannabis (which does have THC, a psychoactive property, in it), in regards to treating orthopedic pain.(1) This included pain from arthritis, post-operative pain, back pain, and trauma-related pain.(1) Overall, the quality of these studies was not very high, as they were mostly observational and did not control for other variables. Essentially, it is best to take this information with a grain of salt, and there is a lot of room for research to dive further into this topic in order to gather more quality information on its effectiveness. However, the researchers reported that 22 of the 33 studies (67%) indicated that cannabinoids were effective in treating musculoskeletal conditions.(1) Furthermore, these studies were looking more at the use of cannabis, with limited information on how CBD can be effective as a treatment.

Ultimately, when asking the question, “Is CBD something that can help with my musculoskeletal pain?”, the answer is, “Maybe”. There is currently not enough information to make an evidence-based recommendation regarding the use of CBD, but you should certainly discuss this with your primary care physician if you are considering the use of it either orally or topically. Hopefully, as the use of CBD becomes more popularized across the nation as an alternative to other medications, further research using higher-quality standards can be performed so that clinicians can make better evidence-informed recommendations.

1. Madden K, van der Hoek N, et al. Cannabinoids in the Management of Musculoskeletal Pain: A Critical Review of the Evidence. JBJS Review. 2018:6(5):e7.

Physical Therapy Bike Fit

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

For many of us, biking is a way of life in Durango. Whether it’s just for fun, for exercise, or for commuting, biking is enjoyed in many ways and on many kinds of bikes. As fun as biking can be, the unfortunate reality is that it can sometimes cause aches in pains in our body. Common complaints related to cycling can include pain of the neck, back, wrists, or knees. Many times, these aches and pains can be remedied by adjustments made to the positioning of your bike to accommodate your body. This type of assessment is something we offer here with the help of our own Dr. Josh MacNaughton, PT.

Josh has been certified to perform Physical Therapy Bike Fits, where he takes a holistic approach to making your bike fit to your body. The two hours that he spends with you includes these components of the in-depth assessment and fitting:
• Functional Movement Systems (FMS) Assessment
• Physical Therapy Assessment of any current problems
• Custom Bike Fit and Measurements
• Video Analysis (Before and After comparisons)
• Home Interventions/Exercises for on and off the bike

Dr. Josh MacNaughton performing a functional movement assessment on local biking legend, Ned Overend
The squat is an integral part of the functional movement screen to assess your flexibility and strength off the bike
Making sure that our very own Dr. Ellen Tomsic has the best bike fit

Josh’s main goal is to analyze your individual movement patterns and identify any limitations in flexibility, weakness, and posture. He takes this information and transfers it to how you fit on your bike to make sure that you get the most comfort and efficiency while riding. Josh has experience with bike fitting for any level of rider: from amateur cyclists riding for fun to professional cyclists looking to make their competitive edge stronger while remaining injury-free. If you’re interested in a Physical Therapy Bike Fit, whether or not you are currently dealing with an injury, reach out to us today to learn more information about these in-depth assessments.

Exercise for Health During Pregnancy

By: Dr. Laura Wenger, PT, OCS

I found it fitting to write a blog about health and exercise during pregnancy given that I’m 39 weeks pregnant and getting ready to welcome baby girl any day now! The good news is that there is a lot of content to pull from out there, as researchers continue to find more and more benefits of exercise whether or not you are growing another human inside of you. One of the latest research studies, a randomized controlled trial out of Brazil, confirms some of these benefits.(1)

The researchers split up 456 pregnant women into two groups: one was the “control group” that received standardized obstetrics care, and general nutrition and physical activity counseling, while the other was the “exercise group” that participated in a structured and supervised hour-long exercise program three days per week from weeks 8-10 of pregnancy until the the end of their third trimester right before having their babies.(1) This supervised exercise program consisted of a gradual warm-up, aerobic exercises, light muscle strengthening, coordination and balance exercises, stretching exercises, pelvic floor strengthening, and relaxation at the end.(1)

Sneaking in a little exercise between patients on my second to last day before maternity leave!

The research looked at two main outcomes, maternal weight gain and gestational diabetes diagnosis, to try to compare the two groups and to see if there were any positive effects of the structured and supervised exercise, and here is what they found(1):

  • The women in the exercise group had significantly lower weight gain, within normal amounts
  • The amount of women diagnosed with gestational diabetes was lower in the exercise group

Given all that is known about the positive effects of exercise in general, those results should not be surprising to anyone. However, it’s nice to see that just three hours of low- to moderate- exercise per week- which can feel tough for some women to accomplish during pregnancy depending on how they are feeling on any given day- can make such a positive difference in health. I feel fortunate that I’ve been able to use the daily movements and tasks of my job as my main exercise program throughout this pregnancy, and I definitely credit a lot of my ability to maintain good health throughout these past 39 weeks to my sustained activity levels even if I haven’t felt up to my usual exercise regimen of hiking, running, and biking during this time. If you are pregnant, make sure you talk with your care provider to ensure that exercise is safe for you and make sure to reach out to physical therapist if you need help establishing a well-rounded and safe exercise program to help as your body changes.

  1. Barakat R, Refoyo I, et al. Exercise during pregnancy has a preventative effect on excessive maternal weight gain and gestational diabetes. A randomized controlled trial. Braz J Phys Ther. 2019;23(2):148-155.