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Sep 19, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy Robinson, PT, PRPC, CLT.

 

Amy Robinson

What/who inspired you to become involved in the pelvic rehabilitation field?:

I first learned about pelvic rehabilitation while I was a student at the Indiana University Physical Therapy program. The instructor brought in speakers for special topics sessions and I must admit I knew at that moment that pelvic rehab was an area of interest for me. However, I was hesitant to start in the area of pelvic health as I felt I needed to gain experience as a new graduate, and I also wasn’t sure I would feel comfortable performing pelvic examinations. I chose to work in a hospital setting for one year, a long term care setting for 2 years, and then transitioned into outpatient physical therapy. There were numerous times in each of those settings that it was apparent pelvic rehabilitation was the missing link in the patients’ treatment plan. In 1998 we had a physician, Dr. Scott Miles, approach the president of the rehabilitation company that I worked for and request that they train a women’s health physical therapist. This was my opportunity and I took my first course with Kathe Wallace, PT. I remember thinking that she was a wealth of knowledge and her enthusiasm allowed me to get over the trepidation of performing pelvic examinations. She allowed me to focus on the examination process itself, how to apply critical thinking to the patient symptoms and evaluation findings, and how to pick the appropriate treatments. I was hooked! I feel very blessed to have had the opportunity to participate in several continuing education courses all over the country from so many very talented Pelvic Health Practitioners and each and every one of them have inspired me in some way to continue to learn and perfect my skills as a pelvic practitioner.

What patient population do you find most rewarding in treating and why?

I truly enjoy treating patients who have a diagnosis of pelvic pain. There are so many different types of pelvic pain and the complexity of the cases fascinate me. I thrive on working together as a team with my client to identify the issues at the root of their pain. There are no two pelvic pain patients who are alike which allows me to create an individualized plan for each patient. It is always very rewarding when a patient who has been suffering with pain for years meets their therapy goals, has the knowledge to self treat, and can complete ADLs and work functions, all being done without pain limiting them.


Sep 18, 2014

A recent on-line survey queried fourty-four Obstetrician-Gynecologists (OB-GYNs) in British Columbia to learn more about the needs of physicians who treat women who have endometriosis and chronic pelvic pain (CPP). Physicians reported that women who present with endometroisis or chronic pelvic pain usually require more visits than other patients, for reasons including medical and pain management, lack of a clear diagnosis, and lack of improvement in condition. Evaluation techniques utilized by the physicians often included laparoscopy and ultrasound, and despite these practices, the OB-GYNS reported challenges in making a diagnosis or successfully treating their patients with CPP. In fact, survey results indicated that 5% of the respondents were able to diagnose a patient for a cause of pelvic pain in > 70% of patients. Most of the physicians reported that less than half of the women treated had a good response to interventions. Although the highest rate of referral for these providers was to another OB-GYN specializing in pelvic pain, nearly 60% of the time a referral to physical therapy was reported. 

 

 

Although some of the narrative comments encountered in this survey were positive, including one physician's report of having "…good success with physiotherapy…", more often the providers expressed frustration and annoyance when faced with not only the challenges of diagnosis and treatment, but also the poor compensation and the longer visits required for counseling and teaching of patients. In addition to wanting more clear guidelines on diagnosis and management of female CPP, physicians expressed interest in having group educational sessions for patients, and more resources such as educational brochures on self-management for patients.

 

 

How can pelvic rehabilitation providers fill in this knowledge gap? I recall asking a referring provider if he was pleased with his patients' rehabilitation outcomes, and he expressed such a relief that I was taking the "dregs of the practice." He meant nothing disparaging about the patients themselves, he explained, just that when these patients walked in the door he felt a sinking feeling because he did not know what to do for them. Now, he reported, these same patients were returning from a pelvic rehabilitation referral and excitedly reporting on progress they had made. So many physicians and other referring providers still do not understand the scope of the patient populations that we can treat in pelvic rehabilitation. We can provide a necessary bridge between the challenge of diagnosing and medically treating chronic pelvic pain and the rehabilitation approach that addresses the chronic pain issues. Differential diagnosis of chronic pelvic pain from a rehabilitation standpoint is a skill set  that every therapist must continually improve upon. If you are interested in learning more about these skills, sign up for faculty member Peter Philip's continuing education course Differential Diagnostics of Chronic Pelvic Pain next month in Connecticut. 


Sep 15, 2014

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal), when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

 

 

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness.  Surface electromyography (sEMG), a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia. 

 

 

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation. 


Sep 15, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy C. Sanderson, PT, OCS, PPRC.

 

Amy Sanderson

Describe your clinical practice.:

I am a co-owner of a private physical therapy practice in the Spokane, Washington area. We currently have 3 clinics and staff 14 providers overall. I have been an Orthopaedic Certified Specialist since 1996, and our clinic is primarily an orthopedic setting. We do, however, provide several specialties, including Pelvic Rehab, Vestibular Program, and Video Gait Analysis for athletes.

How did you get involved in the pelvic rehabilitation field?

I have been practicing since 1993 and began a Women’s Health program in 1994 at a previous place of employment. When I had interviewed for the position of a staff physical therapist for this clinic, I was asked if I would be interested in starting any new programs for the company. The manager had recommended that I develop a Women’s Health program. Truthfully, I had not heard of Women’s Health in the early 90’s, but I really wanted the job, so I said “absolutely!” I figured that I was a woman and I knew some things about health, so how hard could it be. Countless hours of continuing education and several years of marketing to the local physicians and community, we have now built our Pelvic Rehab program up to 3 physical therapists providing treatment to all of our clinics in the Spokane, Washington area.


Sep 15, 2014

This is a guest blog-post by Herman & Wallace faculty member Jennafer Vande Vegte, MSPT, BCIA-PMB, PRPC

Erica Vitek MOT, OTR, BCB-PMD, PRPC

Stress. We all have it. We all deal with it in one way or another. Sometimes stress comes and goes quickly while at other times it lasts and lasts. Research shows that at times, short bouts of stress can be good, even helpful. The surge of adrenalin and cortisol we get staying up past midnight to finish that assignment before it is due the next morning can power our brains to accomplish a task about which we procrastinated because it seemed burdensome or boring. We are very grateful for the extra burst of speed we feel in our legs as we run to catch our naughty three year old as they run off into a busy street. After these stressful events are over, our bodies recover but chronic stress can affect our bodies in negative ways and our bodies may need help finding a way to cope.

Research shows one main pathway that stress takes in the body is the Hypothalamus Pituitary Adrenal Axis or HPA axis for short. In the HPA axis there is a systematic release of chemical messengers that create a cascade of effects in our bodies. The HPA axis governs our response to stress and also affects our energy levels, digestion, sexual functioning, immune system and other body processes. We don't even need the research to tell us this because we have all experienced it firsthand.

Unfortunately when stress in any form does not go away, our bodies may not find the way back to homeostasis and chronic issues can develop. Research also points out that the function of our HPA axis could have been impaired during our development. Maternal stress can affect a developing baby in utero, and trauma or stress in infancy or early childhood can influence the function of our stress response into adulthood.

Interestingly, there are also gender differences in how stress influences behavior. In their article on the female response to stress, authors Taylor et al. describe the effects of oxytocin on the HPA axis. Oxytocin is released during nurturing behaviors and helps to decrease the activity in the HPA axis. The authors postulate that estrogen may be one reason women cope and respond to stress differently than men. Mothers comfort their babies when they cry and help sooth them. This action is beneficial to both mom and baby. Friends offer comfort with a listening ear, a hug, and emotional support. John Gray in his book Venus on Fire Mars on Ice also notes that oxytocin is released when we feel loved, appreciated and heard. As physical therapists working one-on-one with our patients we are also in a position to listen to and validate our patients which may aid in combating their stress response. Joining a support group may also be of benefit.

How do you respond to stress in your life? Dartmouth researchers found their students drink more caffeine, sleep less, and consume more alcohol. Exactly the WRONG responses when you look at the physiological effects on the HPA axis.. According to the article, "Leproult et al. found that plasma cortisol levels were elevated by up to 45 percent after sleep deprivation, an increase that has implications including immune compromise, cognitive impairment, and metabolic disruption." Caffeine and alcohol also increase cortisol release.


Sep 12, 2014

mindfulness

In an encouraging study sure to grab a lot of attention, researchers studying middle schoolers and the effect of mindfulness on suicidal thoughts have positive findings. We all know that middle school is a very challenging time, with students feeling pressure socially, academically, hormonally, and that family stressors can also be involved in this time of significant growth and change. If we think back to our time in middle school, we may recall some very challenging emotions, and a difficulty in seeing past our school environment and into our potential future. What if mindfulness training could provide an outlet for positive thoughts and a way to more effectively manage emotions?

 

In this study, highlighted in the research spotlight of the National Center for Complementary and Alternative Medicine, 100 sixth graders were randomized into an Asian history class with daily mindfulness practice and into an African history class with a matched activity unrelated to mindfulness or self-care. The mindfulness instruction included breath awareness and breath counting, body sensation, thoughts, and emotions labeling, and body sweeps. Silent meditation increased from 3 minutes to 12 minutes. Over the study period of 6 weeks, students were assessed for development of suicidal thoughts or self-harm behaviors.

 

While the researchers conclude that more studies with larger groups need to be done to validate the findings, the reports of this study are very encouraging. Keeping in mind that there are no equipment needs and little or no risk with the applied intervention, perhaps more schools will look to trainable skills in mindfulness to teach young people self-management skills. Mindfulness and meditation continue to receive significant attention in the research literature, and rightly so, as patients, providers, and family members may benefit from simple techniques that can be practiced and applied in a variety of ways.

 


Sep 12, 2014

pregnant

One thing I have decided after working with women during and after pregnancy is this: babies come when they want, and how they want to arrive. A mother's best laid birth plans will hopefully have enough flexibility to allow her to feel successful even if, and especially if, her plans have to change. A fundamental question that has been asked, from the standpoint of a mother's beliefs is, do women really feel they have a choice to deliver at home versus in a hospital?

 

Researchers in the UK asked this question of a diverse sample of 41 women who were interviewed. Despite the fact that in the UK, a woman can birth at home with a midwife (and this is covered by the National Health System) home births are unusual, accounting for only 3% of all births. And while it may seem exciting to read that in the US, the number of home births has risen by more than 50% over a decade, the actual numbers include that less than 2% of births occur at home according to the Centers for Disease Control (CDC) data.

 

Back to the concept of choice, when women were interviewed about where they planned to give birth, perceptions rather than fact ruled the day. The concept of which environments were "safe" versus "risky" were a common theme, with women having differing explanations of why a hospital might be more safe than the home environment, or vice versa. The authors describe the issue that, when healthy mothers with low-risk pregnancies give birth in hospital environments, medical interventions including surgical birth are more likely to place. Women who would choose a home birth reported beliefs such as not being able to have a 'natural' birth in a hospital, fear of contracting illness or disease, or of wanting to be at home surrounded by loves ones. Women also reported that at home, more control over the environment and increased ability to relax would be available.

 


Sep 11, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner and Herman & Wallace faculty member Jennafer Vande Vegte, MSPT, BCIA-PMB, PRPC

 

Erica Vitek MOT, OTR, BCB-PMD, PRPC

What role do you see pelvic health playing in general well-being?

Our understanding of the importance of pelvic health has increased dramatically in the past decade but I feel what we know is just the tip of the iceberg. I would love to see our society being even more proactive in utilizing our skills as pelvic floor therapists (for example evaluating every post partum mom, or having physical therapy before and after prostate or prolapse surgery part of standard protocols). Studies show that many pelvic floor dysfunctions don't become symptomatic until decades after trauma to the pelvic structures occurred (SUI/prolapse/FI for example). It would be wonderful to play a more proactive role in these disorders.

 

What do you find is the most useful resource for your practice?


Sep 09, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Erica Vitek MOT, OTR, BCB-PMD, PRPC

 

Erica Vitek MOT, OTR, BCB-PMD, PRPC

Describe your clinical practice:

I have two outpatient based practice locations. One is located right next to the Marquette campus in Milwaukee, Wisconsin at Aurora Sinai Medical Center. The second location that I offer pelvic rehabilitation is in a suburb of Milwaukee at the Aurora Women’s Pavilion, Franklin. I treat women and men and also have taken the Pediatric course with Herman and Wallace and am working on marketing that area of my practice. I also have a special interest in Parkinson disease. I am specially trained in amplitude based exercise for people with Parkinson disease and am a certified LSVT BIG provider and faculty member of LSVT global certifying clinicians in this treatment around the United States and internationally. The area of pelvic health fits in very nicely with this population as the research demonstrates approximately 60% of people affected by Parkinson disease experience urinary incontinence and 80% experience constipation.

 

What/who inspired you to become involved in pelvic rehabilitation?


Sep 08, 2014

digestive system

A recent article describing the impact of psychological factors on bowel dysfunction describes several mechanisms by which this may occur. Issues cited that may influence the bowels include psychological stress, which can lead to nausea, vomiting, abdominal pain, and changes in bowel patterns or habits. Stress can also affect the hypothalamus-pituitary-adrenal axis, or HPA axis. This axis is a major part of the neuroendocrine system that, in addition to controlling stress reactions, regulates many body functions such as digestion and immunity. During stress, cortico-releasing factor (CRF) can also be released, and act directly on the bowels or via the central nervous system. The authors point out that CRF can also affect the microbiota composition within the gut.

 

Corticotrophin-releasing factor can affect gut motility, permeability, and inflammation. The way in which motility is affected can vary, from increased movement of bowel contents to more sluggish movement, depending "…on the type of CRF family receptor expressed on the target organ." Gut permeability can also be affected by CRF, leading to bowel hypersensitivity and other issues such as nutritional absorption dysfunction. Stress-associated inflammation is also of concern, with markers of inflammation being found in patients who have irritable bowel syndrome and other conditions. Dysbiosis, or microbial imbalance, can be caused by stress, leading to changes in bowel motility , inflammation, and permeability, according to the referenced article. Diet-induced dysbiosis, discussed in this article, can lead to inappropriate inflammation and to cellular damage and autoimmunity, making a person vulnerable to chronic disease of the gastrointestinal tract. Such disease conditions may include ulcerative colitis, Chrohn's disease, celiac disease, and diabetes. Probiotics, prebiotics, and alterations in dietary intake are current therapeutic approaches, with further research needed to determine what types of interventions are most helpful for specific conditions.

 

Pelvic rehabilitation providers, especially those who are newer to the field, quickly discover that trying to treat pelvic dysfunction without knowledge of bowel health is like trying to treat low back pain while ignoring the pelvis: to truly ease symptoms both may need to be addressed. Patients often present with a combination of issues in the domains of bowel, bladder, sexual health and pain, and being able to address all with expertise aids in effectiveness of care. If you are interested in learning more about bowel dysfunction, faculty member Lila Abbate teaches her continuing education course "Bowel Pathology and Function" in California in early November. There is also an opportunity to learn about how to ameliorate stress and its potentially negative affects on bowel health by attending the Mindfulness-Based Biopsychological Approach to the Treatment of Chronic Pain taking place in Seattle in November.


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Upcoming Continuing Education Courses

Visceral Mobilization of the Urologic System - Scottsdale, AZ
Sep 19, 2014 - Sep 21, 2014
Location: Womens Center for Wellness and Rehabilitation

Care of the Postpartum Patient - Maywood, IL
Sep 20, 2014 - Sep 21, 2014
Location: Loyola University Stritch School of Medicine

Pelvic Floor/ Pelvic Girdle - Atlanta, GA
Sep 27, 2014 - Sep 28, 2014
Location: One on One Physical Therapy

Assessing and Treating Vulvodynia - Waterford, CT
Sep 27, 2014 - Sep 28, 2014
Location: Visiting Nurses Association - Southeastern

Pelvic Floor Level 2B - Durham, NC (SOLD OUT!)
Oct 03, 2014 - Oct 05, 2014
Location: Duke University Medical Center

Male Pelvic Floor - Tampa, FL
Oct 04, 2014 - Oct 05, 2014
Location: Florida Hospital - Wesley Chapel

Pelvic Floor Level 2A - St. Louis, MO (SOLD OUT!)
Oct 10, 2014 - Oct 12, 2014
Location: Washington University School of Medicine

Chronic Pelvic Pain - New Canaan, CT
Oct 10, 2014 - Oct 12, 2014
Location: Philip Physical Therapy

Pelvic Floor Level 3 - Maywood, IL
Oct 17, 2014 - Oct 19, 2014
Location: Loyola University Stritch School of Medicine

Lymphatic Drainage - San Diego, CA
Oct 18, 2014 - Oct 19, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Oct 24, 2014 - Oct 26, 2014
Location: Marathon Physical Therapy

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College