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Dec 17, 2014

Ischio

Pelvic rehabilitation therapists working with men who have sexual dysfunction may be aware of the work of Grace Dorey, who published a randomized, controlled trial about pelvic muscle strengthening for erectile dysfunction. A recent article published in the Journal of the American Physical Therapy Association confirms the conclusion of Dorey and colleagues that pelvic muscle rehabilitation is beneficial in improving erectile dysfunction.

 

In the study out of France by Lavosier and colleagues, 122 men with erectile dysfunction and 108 men with premature ejaculation completed twenty 30-minute sessions of pelvic muscle strengthening with active contraction and electrical stimulation. In the study, a penile cuff placed around the shaft of the penis measured intracavernous pressure, electrodes applied to the "upper face of the penis shaft" provided electrostimulation at 80 Hz to the ischiocavernosus muscles, and a vibrator device applied to the glans penis provided stimulation for erection. A large computer screen displayed contractions, and the patient was allowed to increase the level of electrotherapy stimulation to maximal sensory stimulation below pain threshold. Contractions were completed at the patient's own pace in regards to frequency and duration, but each patient did have feedback about his contraction on the computer monitor in front of him. Patients were also given an intracavernosal injection aimed to create an erection lasting 30 minutes.

 

The authors describe the erection process as being both vascular and muscular, with the ischiocavernosus muscle having a significant role in erections and in ejaculation. The ischiocavernosus muscle, which is a muscle of the superficial layer in the perineum, attaches along the ischiopubic ramus and wraps around the proximal superior portion of the penis to have an effect on penile rigidity. Contractions of the ischiocavernosus appear to maintain the rigidity of the penis through compression of the roots of the corpus cavernosum, the upper portions of the penis where blood fills in the spaces.

 


Dec 16, 2014

This post was written by H&W instructor Ramona Horton MPT, who authored and instructs the Visceral Mobilization Series. Visceral Mobilization of The Urologic System & Visceral Mobilization of the Reproductive System will be presented throughout 2015.

 

Ramona Horton

As the instructor and developer of the curriculum for the visceral mobilization series, I am frequently asked for evidence of the efficacy of VMT. In order to gain an understand of why a physical therapist who has spent their entire career treating the somatic structures would possibly want to “manipulate” the internal organs one needs to understand a few basic facts. First: the visceral structures carry a significant mass within the human body and are subject to the same laws of physics as the locomotor system. Second: VMT is simply a form of soft tissue manual therapy that addresses the connective tissue and ligamentous attachments of the above mentioned visceral structures to the somatic frame.

 

There are multiple studies that demonstrate positive clinical outcomes from VMT, to mention a few are treatment of postoperative adhesions/ilius (Bove, Chappelle), chronic constipation (Harington, Tarsuslu), dysfunctional voiding (Nemett, Helge), mechanical infertility (Kramp, Wern) and low back pain (Michallet, Tozi, McSweeney.) I could write a multitude of paragraphs reviewing the above listed publications but that would steal all of the thunder for my upcoming lecture on the topic to be presented at CSM 2015 titled “Visceral Manipulation: Fact and Fantasy”. Therefore, the following is a completely un-scientific case study complete with visual demonstration… as the saying goes, a picture is worth a thousand words, besides we all love a good patient story.

 


Dec 15, 2014

Professionals

Incontinence-associated dermatitis causes a range of signs and symptoms, and yet the potential impact of skin breakdown may lead to serious, even life-threatening consequences. Although patients of any functional status or within any treatment setting may be at risk for developing the condition. An article from Beeckman et al. in the British Journal of Nursing describes both the chemical and physical irritation of the skin that occurs when urine or feces remains in contact with the perineal skin. According to this article, urine and feces can cause an increase in the pH levels, and subsequently increase skin permeability, reduce barrier function, and increase the risk of bacterial colonization. Rubbing of the skin on clothing, pads or diapers, or surfaces such as a bed or chair creates friction and can further irritate the skin. The linked article focuses on the differentiation between incontinence-associated dermatitis (AID) and pressure ulcers, and is available for free, full access via the link above if you are interested in learning more about the concept.

 

If the skin dysfunction is limited to IAD, the pelvic rehabilitation provider may observe rash and erythema with possible skin breakdown, or infections such as candidiasis. Unless a therapist is trained in assessing for pressure ulcers, any new or worsened skin breakdown should be brought to the attention of a physician, nurse, or physician extender who is working with the patient. One of the challenges in perineal skin irritation is that the patient may not be able to easily observe the skin and report new onset or worsening of symptoms. In an outpatient setting, even when working with patients who do not have limited mobility or self-care skills, observing the perineal skin remains critical in documenting skin integrity, persistent issues, or a worsening of a condition. Because, as the authors of this study point out, care for skin ulcers and incontinence-associated dermatitis are different, early recognition and proper diagnosis aids in healing.

 

Following are some recommendations by Beeckman and colleagues for avoiding skin irritation in the presence of incontinence:

• A perineal cleanser should be used that has a pH range of 5.4-5.9
• Perineal skin should be cleaned quickly following an episode of fecal incontinence, whereas avoiding too-frequent skin washing with continual episodes of urinary incontinence is important
• Moisturizing the skin (with emolient-based rather than humectant-based moisturizer) is valuable in aiding healing and preventing further irritation
• Use a skin protectant to create a barrier between the skin and feces or urine
• Absorptive or containment products (catheter or stool diversion system) can further help keep irritants away from the skin surface

 






Dec 12, 2014

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Menopause: A Rehabilitation Approach. She will be presenting this course this February in Florida!

 

Michelle Lyons

Menopause is often euphemistically referred to as ‘The Change’. Historically it was treated with everything from hysterectomy to hormones, and even hospitalization (often in psychiatric institutions). Dr Christiane Northrup writes “Perimenopause is a normal process, not a disease.” But she also writes “It’s no secret that women experience a decrease in their sex drive during perimenopause.”

 

But according to a study presented by Gavrilov in 2007, American women aged fifty five and older enjoy sex more than women a decade ago who were the same age. Today’s menopausal women, they report, consider a healthy sex life to be part of a healthy lifestyle.

 


Dec 11, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Lauren Mansell DPT, CYT, PRPC

 

Lauren Mansell

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?

Know what questions to ask in order to refer patients to us for treatment. Our patients often feel alone, are frustrated with medical treatments, and feel like no one can address their symptoms. Pelvic rehab specialists are orthopedic specialists. Try and see our similarities rather than differences.

 

How did you get involved in the pelvic rehabilitation field?


Dec 10, 2014

Toolbox

From time to time, pelvic rehabilitation therapists ask this question: Does a pelvic rehabilitation therapist really need to "go there?" In other words, is subjective history taking, or perhaps surface electromyography (sEMG) enough of an evaluation and intervention to provide adequate care to patients with pelvic dysfunction? The short answer is no, and here's why: surface EMG is ONE tool for examination and intervention, and one that has limitations. The benefits of using sEMG are numerous: biofeedback has been utilized in much of the pelvic rehabilitation literature, with demonstration of efficacy as an intervention in conditions such as pelvic pain, incontinence, pelvic floor muscle training, and strengthening. Surface EMG, once equipment is acquired, is a relatively inexpensive method for providing feedback, or information about a typically unconscious activity, to the patient. Ideally, the patient internalizes the learned skills based on the biofeedback training and that skill is translated into functional applications such as letting go of a muscle group to avoid tension and pain, or activating a muscle to provide stabilization or protective contractions. So why is biofeedback alone not such a great approach?

 

Biofeedback does not always provide accurate information about a state of muscle contractility. Consider this fact which was highlighted effectively in Fitzgerald and Kotarinos' 2-part article about the "short pelvic floor": muscles need to produce an electrical event through firing of the motor units (action potential) in order to generate a reading on the biofeedback. When a muscle is in a contracture, or shortening without an active holding of the muscles, surface EMG readings can look "normal" even in the presence of tense, short, symptom-producing pelvic floor muscle states. Unless a therapist is using pressure biofeedback, inaccurate information is then provided to the therapist. Why else would a biofeedback-only approach not provide needed data upon which a pelvic rehabilitation provider bases his or her plan of care? Simply placing external sensors on the perineum or having a patient insert an internal sensor (without therapist observation or placement of the sensor) does not allow for appropriate inspection of the perineal skin, for the presence of prolapse, for the assessment of muscular tension or identification of tissues that are dense, tense, or pain-producing.

 

If sEMG is utilized in place of perineal observation, internal assessment, or interventions such as therapeutic activity, the therapist misses out on the opportunity to determine muscle tone, muscle tenderness in hard-to-reach places like the obturator internus muscle belly, or the nerve branches near Alcock's canal. It is impossible to know if one side of the pelvic floor is overactive, while the other side is non-functioning due to an old nerve injury or a new onset nerve dysfunction, if the sensors are testing both sides of the pelvic floor simultaneously. And finally, the lack of palpation and proper diagnosis can perpetuate a disconnect for the patient who is potentially relying upon external input rather than tuning in to her own body through the palpation, proprioception, and feedback of muscle states that the therapist can influence by using other evaluation and intervention skills. Consider also the challenge of keeping patients tethered to an sEMG device while trying to perform functional activities such as a golf swing, a lunge, or a jumping maneuver.

 


Dec 09, 2014

This post was written by H&W instructor Nari Clemons. Nari instructs her Meditation for Patients and Providers course.

 

Nari Clemons

Meditation is persistently making its way into mainstream culture. Research continues to emerge regarding the benefits of meditation, and not just for those who are seeking enlightenment. Traditionally, meditation was thought of and taught as a pathway to transcend the suffering in life, but increasingly there is evidence that meditation practice, even in small amounts, has far reaching benefits.

 

Last month, in an article titled, “Meditation is even more powerful than we thought” via the Huffington Post online, author Alena Hall states, “Consistent (meditation) practice can help alleviate symptoms of anxiety and depression in people who often need it most.” Hall describes two recent studies. The first, a recent study from Harvard University and the University of Sienna found that the powers of meditation move beyond the cultivation of self-awareness, improvement of concentration and protection of the heart and immune system-- it can actually alter the physiology of the human brain. “Cognition seems to be preserved in meditators," says Sara Lazar, a researcher at Harvard University. Lazar continues in the article to say that “meditators also have more gray matter – literally, more brain cells.” Certainly, more brain cells are something that any of us can use.

 


Dec 08, 2014

Coccyx

Can palpation of the coccyx provide an objective screening tool to assess appropriate identification of pelvic floor muscles in patients? Researchers in the UK aimed to determine if external palpation of the coccyx bone would allow an examiner to evaluate pelvic floor muscle activity in women for functions of pelvic muscle contraction or bearing down/straining. Because the pelvic floor muscles, in particular the levator ani muscles, attach to the coccyx via thickened connective tissue, an effective lifting contraction of the pelvic floor muscles should create a flexion movement in a healthy coccyx or tailbone. Likewise, a bearing down may produce an extension movement of the coccyx palpable to a finger placed over the bony landmark.

 

In this study, 24 healthy women (whom the researchers knew could appropriately contract their pelvic floor muscles) volunteered to participate. The median age of the participants was 57 years old. Results of the study include that the researchers were able to correctly evaluate a contraction, bearing down, or resting position of the coccyx in 56/58 observed.The authors conclude that the coccygeal movement test, or CMT, can be a useful screening test for determining if a woman can appropriately locate and contract the pelvic floor muscles, or PFM. The CMT can be performed in a sitting position or with the subject in a side lying position. In the research study, subjects wore light clothing and were assessed in sitting. The tester placed the middle finger on or close to the coccyx. A correct contraction was considered one in which the coccyx flexed or moved inward. (The participant chose a notecard with the requested action- contract, relax, or neutral- that were shuffled, so that the investigator was blinded to the movement the subject would be completing during the assessment.)

 

The results of the study indicated that the coccygeal movement test was sensitive (could predict if the woman correctly located her pelvic floor muscles), but not specific (some of the women who could in fact locate the PFM were identified as not being able to locate them.) The authors do not suggest that this external screening test should replace vaginal palpation in women who may require pelvic floor muscle training. Rather, they offer that this simple, non-invasive screening test may provide a method for confirmation of a correct contraction in situations when women are instructed in preventive pelvic floor exercises, such as during prenatal visits. Because many women who are instructed to complete pelvic floor exercises are not offered objective confirmation of appropriate contractions, this test may serve as a middle ground for providers in environments when a quick screen is most appropriate. The authors do caution that the test may misidentify a woman as not being able to properly contract when in fact she is able to contract.

 


Dec 05, 2014

This post was written by H&W instructor Martina Hauptmann. Martina will be presenting her new Pilates for the Pelvic Floor course in Denver in 2015!

 

Martina Hauptmann

It is commonly known that exercise while pregnant is important. In every city there are numerous pre-natal group exercise classes. These classes offer an excellent way to maintain fitness and also create a support group for these clients. Unfortunately, medical research studies conducted by physical therapists do not show that group exercise for pre-natal clients decreases the prevalence of low back pain in pregnancy (Eggen et al, Physical Therapy: June 2012.)

 

If the focus is on decreasing the prevalence of low back pain in pregnancy, the European Guideline for Physical Therapists recommend individualized exercise sessions. With individualized exercise sessions, the client’s posture, quality of movement and sequencing of muscle recruitment can be monitored and altered as necessary for the client.

 


Dec 03, 2014

SLS

A recent case report in the Journal of Physical Therapy Science describes the benefits of specific strengthening of the subdivisions of the gluteus medius in a patient with sacroiliac joint pain (SIJ). The intervention is based in prior research that demonstrated varied muscle firing patterns in the gluteus medius during different exercises. The author of the study suggests that the stabilizing role of the gluteus medius can influence sacroiliac joint pain.

 

The patient in the case report was a 32 year-old female who complained of pain in the left iliac crest area and sacroiliac joints for 6 months. Symptoms worsened with forward bending, standing for more than an hour or walking for more than thirty minutes. Before and after a 3 week intervention of specific strengthening exercises, objective tests included the Gaenslen, Patrick, and the resistive abduction (REAB) test. These tests were all positive for pain provocation. Exercises were instructed for gluteus medius strengthening and were performed over a period of three weeks. Following the 3 week exercise intervention focused on gluteus medius strengthening, the patient's Visual Analog Scale improved from a 7/10 to a 3/10, and repeated objective tests were negative. Exercises for the various portions of the gluteus medius (GM) were prescribed at 3 sets of 30 repetitions/day and are as below:

  • anterior GM: hip adduction in sidelying
  • middle GM: wall press exercise in standing
  • posterior GM: pelvic drop exercise from platform in standing
  •  

    Keeping in mind that this case represents only one clinician/patient interaction, we can ask ourselves several questions about the positive results of the intervention. Are we currently challenging the hip abductors enough with our patients who have pelvic girdle pain, and is there enough specificity in the exercises to challenge the appropriate muscle fibers? Can isolated strengthening of hip abductors in absence of other interventions have a positive effect on sacroiliac joint pain in our patients? Are there other plausible rehabilitation concepts inherent in performing these open and closed chain activities that contributed to improvement in this particular patient, rather than an isolated increase in muscle training for the gluteus medius? The sacroiliac joint can be a confounding source of pain, and at the same time, successes in treating patients who have SIJ dysfunction can be very rewarding. If you would like to learn more about evaluation and treatment of sacroiliac dysfunction, the next opportunity to take faculty member Peter Philip's course Sacroiliac Joint & Pelvic Ring Dysfunction, offered next in Seattle in January.


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    Upcoming Continuing Education Courses

    Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
    Jan 09, 2015 - Jan 11, 2015
    Location: Samuel Merritt University

    Care of the Postpartum Patient - Santa Barbara, CA
    Jan 10, 2015 - Jan 11, 2015
    Location: Human Performance Center

    Visceral Mobilization of the Urologic System - Fairlawn, NJ
    Jan 16, 2015 - Jan 18, 2015
    Location: Bella Physical Therapy

    Sexual Medicine for Men and Women - Houston, TX
    Jan 23, 2015 - Jan 25, 2015
    Location: Women's Hospital of Texas

    Pelvic Floor Level 1 - Maywood, IL (SOLD OUT!)
    Jan 23, 2015 - Jan 25, 2015
    Location: Loyola University Stritch School of Medicine

    Sacroiliac Joint Evaluation and Treatment - Seattle, WA
    Jan 24, 2015 - Jan 25, 2015
    Location: Pacific Medical Center

    Menopause: A Rehabilitation Approach - Orlando, FL
    Feb 21, 2015 - Feb 22, 2015
    Location: Florida Hospital Sports Medicine and Rehabilitation

    Breast Oncology - Phoenix, AZ
    Feb 21, 2015 - Feb 22, 2015
    Location: Spooner Physical Therapy

    Pelvic Floor Level 2B - Houston, TX
    Feb 27, 2015 - Mar 01, 2015
    Location: Texas Children’s Hospital

    Special Topics in Women's Health - San Diego, CA
    Feb 28, 2015 - Mar 01, 2015
    Location: Comprehensive Therapy Services

    Pelvic Floor Level 1 - Bayshore, NY
    Mar 01, 2015 - Mar 03, 2015
    Location: Touro College: Bayshore

    Care of the Pregnant Patient - Seattle, WA
    Mar 07, 2015 - Mar 08, 2015
    Location: Pacific Medical Center

    Pilates for the Pelvic Floor - Denver, CO
    Mar 07, 2015 - Mar 08, 2015
    Location: Cherry Creek Wellness Center

    Pelvic Floor Level 3 - Fairfield, CA
    Mar 13, 2015 - Mar 15, 2015
    Location: NorthBay HealthCare

    Male Pelvic Floor - Nashville, TN
    Mar 14, 2015 - Mar 15, 2015
    Location: Vanderbilt University Medical Center