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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 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 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.


Sep 04, 2014

pelvic pain

According to the APTA's Guide to Physical Therapist Practice, physical therapists use a systematic process, also termed differential diagnosis, to place a patient into a diagnostic category. This diagnosis is aimed towards defining the dysfunctions that will be treated, and in determine the needs of the patient based on each individual's presentation. Rehabilitation professionals must also consider symptoms and clinical examination findings that point to a need for other health care providers' involvement. In pelvic rehabilitation, this becomes a challenging process. In an article in Canadian Family Physician, physicians Bordman & Jackson list conditions that can cause chronic pelvic pain, and these conditions cover a variety of body systems and conditions. For example, bladder, bowel, or gynecologic malignancies, endometriosis, pelvic congestion, interstitial cystitis, urethral syndrome, constipation, inflammatory or irritable bowel syndrome can all cause pelvic pain. Abdominal wall or pelvic floor muscle myofascial trigger points, coccyx pain, neuralgia, and even depression can be other sources for pain. Certainly, it is uncommon to find only one source of pain in our population of patients with chronic pelvic pain.

 

Within a multidisciplinary approach, which is more often the recommended approach to treating chronic pelvic pain, physical therapy will ideally work with other practitioners to develop the best course of care for the patient. In my professional experience mentoring students and therapists, once a pelvic rehabilitation provider has learned basic skills and has treated many patients, the therapist develops a keen interest in improving skills of differential screening. The ability to diagnose requires learning which keys unlock certain doors, whether from an organs systems standpoint or a musculoskeletal standpoint. The Institute offers several courses that focus on the ability of a therapist to test specific tissues and movement patterns to determine the most appropriate plan of care. Steve Dischiavi's Biomechanical Assessment of the Hip and Pelvis includes a sports medicine approach to evaluating and treating hips and pelvic dysfunction, which can often confound one another. Finding the Driver in Pelvic Pain is another popular course instructed by faculty member Elizabeth Hampton and the course emphasizes pelvic pain and the musculoskeletal co-morbidities that often accompany pelvic floor dysfunction. More dates are being scheduled for these 2 continuing education courses, sign up early to hold your spot!

 

You still have an opportunity to take Peter Philip's Differential Diagnostic of Chronic Pelvic Pain & Dysfunction this course takes place in Connecticut in mid-October. In this course, Peter emphasizes anatomical palpation, nervous system influence on pelvic pain, and biomechanical examination of nearby joints and tissues. Internal labs are included in this 2-day continuing education course. If you are interested in hosting any of these courses, contact the Institute today to get the process started!


Sep 04, 2014

Male chronic pelvic pain (CPP) is well-known to be associated with sexual health impairments including, but not limited to, pain limiting sexual activity, premature ejaculation, erectile dysfunction. In addition to potential interference in sexual activity due to pelvic pain associated alteration in libido and function, does CPP affect sperm health? According to a systematic review and meta-analysis published this year, semen parameters are impacted in men who present with chronic pelvic pain. 12 studies were utilized, including nearly 999 cases and 455 controls. Semen parameters studied included seminal plasma volume, sperm concentration, total sperm count, motility, vitality, and morphology. Men diagnosed in the studies with CPP or chronic pelvic pain syndrome (CPPS) met the NIH criteria for the condition.

 

The results of the analysis indicate that sperm concentration, percentage of progressively motile sperm, and morphologically normal sperm in patients with CPP/CPPS were significantly reduced when compared with controls. Semen volume was higher in the CPP pain group than in controls, and the results suggested no significant difference in sperm total motility, sperm vitality, and total sperm count. How do these factors affect fertility? The authors point out that semen parameters are "the mainstay of male fertility and reproductive health assessment" and and that the percentage of morphologically normal sperm is an indicator of male fertility potential. While the sperm concentration was identified to be lower in male patients who have CPP, the semen volume being elevated may affect these numbers. Sperm motility, being necessary for fertilization, would logically be a factor in potential impairment of fertility.

 

The authors discuss the possibility that an inflammatory response associated with chronic pelvic pain, or an autoimmune response against prostate specific antigens factor into the alterations in semen analysis observed in men who have chronic pelvic pain. While the issue of fertility and pelvic pain is controversial, and not entirely understand, we can hypothesize about local factors affecting pelvic and sexual health, as well as autonomic nervous system implications mediated by the chronic pain state. As science aids in the understanding of the mechanisms affecting semen parameters, pelvic rehabilitation professionals will continue to address the potential causes of the dysfunction: nervous system dysfunction such as anxiety, depression, hormonal regulation, and neuromuscular pain states that may affect local blood and lymph flow (and therefore affect cellular nutrition and removal of waste products of cellular metabolism). If you are interested in learning more about male anatomy, sexual dysfunction, pelvic pain, and incontinence, come to the Male Pelvic Floor Function, Dysfunction, & Treatment continuing education course in Tampa in October!


Sep 02, 2014

c-section

When a woman is interested in a trial of labor after previous cesarean delivery (TOLAC), she and her health care providers will consider the pros and cons of delivery methods. Researchers have aimed to predict success with vaginal birth after cesarean section (CS), with the intention of limiting the risk factors for both the mother and the fetus. A failed trial of labor following a CS may be associated with higher maternal and perinatal morbidity, according to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin.

 

The goal of a study published last year was to develop a model for predicting success in women desiring a vaginal birth after cesarean (VBAC) section. All women had one prior CS, all were carrying singletons. Transvaginal ultrasound was utilized to evaluate the Cesarean scar (CS) at 11-13, 19-21, and 34-36 weeks' gestation in 320 women. The measurement of the scar was termed residual myometrial thickness (RMT), and the measurements also included the change in RMT from the 1st to 2nd trimester. With increased evidence that CS healing and myometrial thickness in the lower uterus may improve success with VBAC, this study is the first to assess scar dimensions across the first and second trimesters.

 

The CS scar was visible in 89% of the women. Of these, 153 of the 284 were excluded from the prediction model development due to having had more than one prior cesarean delivery, so the hospital protocol of scheduling cesarean was followed. The remaining women were offered a vaginal birth trial, with 10 of the 131 undergoing CS prior to labor for varied reasons. The final count of women included in the analysis was 121, and of these cases, 74 had successful VBAC, 47 experience failed trials of labor, primarily due to fetal distress, failure to progress, or possible scar rupture. (In the women who did not have a visible scar, 82% had a successful vaginal delivery.)

 


Aug 29, 2014

c-section

A systematic review aimed to identify the burden of the most significant complications of postoperative abdominopelvic adhesions. Of the nearly 200 studies included in the review, the following categories were included: small bowel obstruction (n=125), difficulties during subsequent operation (n=62), infertility (n=11), and chronic pain (n=5). The incidence of postoperative small bowel obstruction, assessed among nearly 108,000 patients in 92 studies, was 9% overall. The incidence of adhesive small bowel obstruction was 2.4% and was highest in pediatric and in lower gastrointestinal tract surgery. The authors report a high rate of chronic abdominal pain in patients who were followed after lower gastrointestinal tract surgery, with adhesions identified as a significant cause of this pain. Following colorectal surgery for small bowel disease, pregnancy rates were found to be dramatically lower than the pregnancy rates in those who were medically treated. Additionally, patients who have had a prior surgery may require additional time in a subsequent procedure due to scar tissue, and adhesiolysis, used to break up adhesions, can lead to bowel injury.

 

Patients with postoperative adhesions, according to the systematic review, are most often treated by providers other than the one who did the surgery; the lack of awareness of the complication may be one reason that the incidence of adhesions is underestimated. The value of being aware of the higher incidence of postoperative adhesions may be in early recognition of a complication, surgical decision-making, and patient counseling. While the research is young in relation to adhesions and pelvic rehabilitation, one study that we previously discussed in the blog addresses visceral mobilization techniques in an animal model. While the animal model research is promising, there are numerous case reports describing the positive effects of visceral mobilization techniques for abdominopelvic pain, and therapists always report on the equally positive changes to their clinical practice outcomes after adding visceral techniques to their toolbox.

 

There are 2 upcoming opportunities to learn visceral mobilization: Level 1 in Scottsdale covering the Urologic system and Level 2 in Boston covering the reproductive system.


Aug 28, 2014

One of the questions we frequently receive at the Institute is "Do you have any research about ___________?" At times, therapists are looking for information that can help with patient care, or they might be looking for support in a claims denial letter, or foundational material for a presentation. If you have been taught how to find articles, this may seem like a simple task. Many of us therapists went to school when the only use of a computer was for word processing, if we were lucky enough to have progressed from the typewriter or even the electronic typewriter. (Imagine no Google, no Wikipedia, and no Amazon to purchase textbooks!) There are basic search skills that can be shared so that every person interested in a particular topic can find recent articles in free search engines. While the full article may not be available, many times you will have access to full articles that synthesize recent works. (One website that you can use that offers full text article access is PubMed Central.) If you are not interested in reading articles, but prefer to read a scholarly summary of a health topic, check out www.uptodate.com, where you can subscribe to have full access to excellent evidence-based summaries. You can read through the reference lists on the site as well to see if there is a resource that you want to track down.

 

One method of finding articles is to go to www.googlescholar.com. In the search bar, type in the topic you are interested in, such as "urinary incontinence." You will then be provided with a list of all articles that have urinary and/or incontinence in the title or in the key words of the research. An even more refined way to conduct your search is by using Boolean terms, in which you connect your search words by "AND" or other key terms. To see this in action, let's say you want to know if there is any research about urinary incontinence and prostatectomy surgery. Try completing a google scholar search by typing in the following: "urinary incontinence" AND "prostatectomy". (Be sure to use the quotation marks and type the word "AND" in capital letters.) You will see that you come up with some very nice articles about the specific topic you searched. To make sure you are looking at recent articles, go to the left side of the search page and under the words "Any time" choose an option such as "Since 2010" so that you are seeing articles from within the last 5 years. Next, maybe you want to know if there is evidence for rehabilitation. Add the word rehabilitation, like this: "urinary incontinence" AND "prostatectomy" AND "rehabilitation". You will see that you now have even more results specific to rehabilitation of the condition. On the right side of the page you might see a link that starts with [PDF] where, if you click on it, you will usually be brought to the full article rather than just the abstract. If you see an article that you think fits your search, you can also click on "Related articles" located under the brief description of the article.

 

Being able to look up articles serves many purposes, including staying updated on patient care, and discussing evidence with peers, providers, and patients. Another valuable reason to find your own research is when studying for certification exams such as the Pelvic Rehabilitation Practitioner Certification (PRPC). On the PRPC certification page on our website, you can find a list of some articles for which we have added links. (Remember that there is no need to print out articles anymore! Save a tree and simply save the articles as a PDF file. You can name the article by the author's last name, year and main topic, and store in a folder on your computer so it is easy to access- no file drawer required!) If you are thinking about taking the PRPC exam, there is no time like the present to get your application put together! The deadline for applying is October 1 of this year, with the test taking place in the first couple weeks of November. Personally, I have enjoyed reading the blog posts introducing therapists who have earned their PRPC title- the reasons for seeking the distinction are very interesting and meaningful. We would love to see your name on the list of certified therapists, so check out the details on the website and contact us if you have any questions about the PRPC application process!


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Upcoming Continuing Education Courses

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

Pelvic Floor Level 2B - St. Louis, MO
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic