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Jul 10, 2014

pthip

The term "sports hernia" has been used over time to describe a variety of issues, and the medical and rehabilitation community has recently been provided with more clear definitions and descriptions of the condition. Sports hernia has referred to groin and pubic injuries and dysfunctions, as well as abdominal wall disruptions. Clinical diagnosis and treatment has often been challenging because of the inconsistency in definitions, recognition of signs, symptoms, and optimal treatment approaches. A clinical article update published last year states that the term "sports hernia" is a misnomer as there is no classical herniation of soft tissue. The article further describes how the term has become synonymous with sportsman's hernia, athletic pubalgia, and Gilmore's groin.

 

Improved terminology to describe a sports hernia may be an "inguinal disruption" as referenced in this website of Dr. William Brown. (His site, www.sportshernia.com also includes anatomy images and descriptions of a sports hernia.)The anatomy most often involved is the oblique muscles and accompanying aponeurotic fascia, the adductor attachments to the pubic bone, and occasionally the pubic bone itself. Sports medicine literature, and research involving hockey players in particular, has been rich with reports of players who have had a repair of the aponeurotic fascia and/or oblique muscles, followed by a short period of rehabilitation and a full return to sport. Other commonly involved athletes are those who participate in football, soccer, and tennis. Any sport that may include explosive stops and starts with twisting, turning, and lower extremity rotations can result in a sports hernia.

 

Institute faculty member Steve Dischiavi has been on the front line of treating athletes with abdominopelvic injuries, and he has prepared an outstanding continuing education course complete with many videos, assessment techniques and intervention strategies. To learn more about differential diagnosis and treatment of the lumbo-pelvic-hip complex, join Dr. Dischiavi this August in Arlington, VA for Biomechanical Assessment of the Hip & Pelvis.


Jul 10, 2014

pelvis

More than ever, patients are recognizing the value of training themselves to breath, pause, rest, relax. With the explosion in availability of free resources available on smart phones, computers, magazines and handouts, the public has increased access to tools with which they can apply concepts in relaxation training, mindfulness, and meditation techniques. Which is the best strategy for our patients? That answer depends on many factors, and the truth is, with the variety of patient presentations, goals, and strategies, the patient may need to simply trial a few different approaches.

 

A recent radio interview I heard mentioned calm.com as a resource for relaxation training, so I decided to check it out prior to recommending the site to patients. The site is simple, with the ability to listen to 2, 5, 10, 15, or 20 minutes of guided relaxation, set a timer for the same time intervals, and download an application for the iPhone. The site is visually calming, with a very clean and intuitive interface. My sense is that users would find the site very simple to access and utilize. A simple search on the iPhone application store using the terms "free relaxation" brings up nearly 900 apps. As most of our patients (and selves, friends, families) may benefit from focused, practiced breathing and calming practices, these resources are great to know about.

 

There is a science behind finding balance, and one resource that has integrated much of the science behind techniques in relaxation and balance is the Institute of HeartMath. The website describes physiological coherence as a state characterized by heart rhythm coherence, increased parasympathetic activity, increased entrainment and synchronization between physiological systems, and efficient functioning of the cardiovascular, nervous, hormonal, and immune systems. In pelvic rehabilitation, we know that increased parasympathetic activity is important for patients who present with pain, with bowel, bladder, or sexual dysfunction. An imbalance in the autonomic nervous system can affect all of the physiologic functions taking place to aid pelvic health.

 


Jul 07, 2014

Last week in our blog, you learned about Susannah Britnell, a physiotherapist who works in a multidisciplinary pelvic pain treatment setting. I learned of her clinic when I came across this journal article) about developing an interdisciplinary clinic for patients with endometriosis and pelvic pain. Below is Part 2 of the questions that she was kind enough to answer for us so that we can hear more from her perspective!

 

Susannah Britnell

What do you find rewarding as a therapist in working in this setting?

Working with people in pain can be challenging but also extremely rewarding. I really value being able to help women realize what they can do, how they can shape their current life experience and their future. We provide tools and strategies that they can put into practice successfully. I love being able to be a part of moments when there is a shift in thinking, an opening of opportunity, when women who have seen nothing but barriers and hopelessness realize that there could be the possibility of positive change. I really find satisfaction in helping women perform daily activities, manage bladder, bowel and sexual pain concerns and increase overall activity and participation in life.

 

What would you say is powerful for the patients in terms of having the team available?


Jul 03, 2014

In patients with lumbar disc herniation, how many patients have sacroiliac joint dysfunction? Answering this question was the aim of a study published in the Journal of Back and Musculoskeletal Rehabilitation in 2013. From an outpatient clinic at a university hospital, 202 patients with lumbar disc herniation (paracentral or intraforaminal) on imaging and clinical findings suggesting lumbosacral nerve root irritation were included. Excluded were patients who pregnant, had prior lumbar surgery, osteoporosis, fractures, diabetes, severe hip DJD, and neurological deficits. Clinical examination tests for SIJ dysfunction included seated forward flexion test with palpation of the PSIS, Patrick-Faber test, long-sitting test, Gillet test, Sphinx test, and palpation tests for sacral base asymmetry. Pressure provocation tests were applied to the sacrum and the pelvic innominates, palpation to long dorsal sacral ligament and lumbosacral junction. "Positive" sacroiliac dysfunction diagnosis meant that the patient had a cluster of at least 4 anatomical and 2 provocative tests. Patients ranged in age from 19-70 years with a mean age of 42.

 

Greater than 72% of the patient sample with known lumbar disc herniation also presented with sacroiliac joint dysfunction. Females, patients with recurrent pain, those who performed heavy work, and patients with a positive straight leg raise test were more likely to have sacroiliac joint dysfunction. Of the 72% of patients who were diagnosed with SIJ dysfunction, nearly 60% were female. No correlation was found between the presence of sacroiliac joint disease, working hours, duration of low back pain, or body mass index and the rate of SIJ dysfunction. The authors conclude that sacroiliac joint dysfunction has a "…high possibility of occurrence in low back pain" and should be included in the clinical examination and decision-making process. They also point out that while the differential diagnosis of back versus SIJ pain is well-defined in manual medicine texts, the medical books do not highlight screening of the SIJ when presented with a patient who has back pain.

 

If you would like to learn skills to perform differential diagnosis of the sacroiliac joint, sign up for the Sacroiliac Joint Treatment continuing education course taking place this July in Baltimore with Peter Philip.


Jul 02, 2014

pelvis

A recent publication of a case series proposes that clinicians use intranasal calcitonin, a medication prescribed for acute vertebral fractures in osteoporotic patients, for acute coccyx pain. This medication is administered as a nasal spray, has been demonstrated to have analgesic properties, and is theorized to have effects of beta-endorphin production, and inhibition of prostaglandin and cytokine production. Nasal calcitonin, a synthetic drug, is reported to have fewer and mild side effects when compared with the injectable form of the medication.

 

 

Of the 8 subjects treated and described in the case series, all had a fall on the tailbone, either landing hard into a chair on onto the stairs or floor. Some were seen within 3 months of injury date, and others were treated after 3 months from injury. The authors report that in the subjects who were treated acutely, 3 of 5 had at least 50% improvement in pain, without injections or surgery. The subjects treated in a chronic pain condition had similar levels of improvement but with the addition of coccyx injections for treatment.

 

Based on the lack of a control group, the small number of subjects treated, and because the mechanism of nasal calcitonin is unknown as far as effects on fracture healing in the coccyx, we would not, as rehab professionals, look to our referring providers to add nasal calcitonin routinely in the management of acute coccyx fracture. This article may, however, lead to interesting conversations with referring providers who are in a position to consider the addition of calcitonin for the proposed analgesic effect and potential bone healing augmentation. (The authors do suggest using the smallest effective dose for the shortest duration required.)


Jul 01, 2014

Earlier this year, when I came across this journal article about developing an interdisciplinary clinic for patients with endometriosis and pelvic pain, I was pleased to see that rehabilitation is included in this team setting. Upon reaching out to Susannah Britnell, physiotherapist, she agreed to answer some questions about her clinic and about her passion for pelvic rehab. Below you can read her responses to my questions. Stay tuned for Part 2 that will be published next week!

 

Susannah Britnell

How long have you been working in the interdisciplinary clinic?

 

I’ve been working at the BC Women’s Centre for Pelvic Pain and Endometriosis in Vancouver, BC, since October 2012. We are a provincially funded program for women with chronic pelvic pain from all over the province of BC, Canada.

 


Jun 26, 2014

In Turkey, the rate of daytime urinary incontinence (DUI) was studied in primary school-aged children. A questionnaire was completed by parents of 2164 students. The Dysfunctional Voiding and Incontinence Symptoms Score Questionnaire was utilized and includes 14 questions about daytime and nighttime symptoms, voiding and bowel habits, and quality of life.

 

The population studied included approximately half boys and girls, with nearly half living in rural versus urban settings, and of a mean age of 10 years old. The overall prevalence of DUI was 8% (8.8% in girls, 7.3% in boys), and decreased with increasing age in this study population of children in 1st through 8th grades. 57.8% of those who did experience involuntary loss of urine were wetting less than 1x/day, 26.6% were wetting 1-2 times/day, and 15.6% were wetting greater than 2x/day. Urge incontinence was reported in nearly 59% of the children with DUI.

 

Independent risk factors for DUI included age, maternal educational level, family history of daytime wetting, urban versus rural setting, history of constipation or urinary tract infection (UTI), and urinary urgency. The authors conclude that "…educational programs and larger school-based screening should be carried out, especially in regions with low socioeconomic status." In this study, one of the strategies used to increase the survey response rate was to send medical and public health residents to the schools to speak about the study on 2 occasions.

 

Despite the numbers of therapists who have previously trained with educators such as faculty member Dawn Sandalcidi in her coursework for pediatric bowel and bladder function, the number of therapists focusing on pediatric pelvic health remains small while the need is great. Therapists who wish to expand community reach to pediatric urologists and pediatricians, and to serve the children who may unfortunately become adults who have bowel and bladder dysfunction, have the opportunity to attend the Pediatric Incontinence and Pelvic Floor Dysfunction continuing education course in Greenville, South Carolina this August.


Jun 24, 2014

In women with pelvic pain, is a pudendal nerve block effective, and how does the effectiveness correlate with findings of the history and clinical exam? These were the questions posed by a study published in 2012. Sixty-six patients were given a standardized pudendal nerve block, with Visual Analog Scores (VAS) and presence of numbness recorded prior to and up to 64 hours after the block. Inclusion criteria for the study involved having spontaneous or provoked pain in the distribution of the pudendal nerve, and patients were excluded if significant psychosocial issues, neurogenic or neuromuscular disorders, contraindication to sedation or allergy to utilized medication was present. A detailed history and physical examination was completed.

 

The pudendal nerve block was administered transvaginally and digitally, under sedation, in a lithotomy position. Following data collection, the researchers found that the presence of a positive Tinel's sign (palpation medial to the ischial spine for assessment of pain reproduction), a prior history of vulvovaginal candidiasis, or symptom worsening in the sitting position was associated with a return of the pain prior to the numbness wearing off. 92.4% of the subjects reported a "positive" response to the block, with varied lengths of time of symptom reduction. Nearly 87% of the subjects reported a reduction in one or more symptoms. This study only studied subjects for 64 hours, therefore it is not possible to discuss from this research the long-term implications of a pudendal nerve block in women with pudendal neuralgia. The authors did find a correlation between prior traumatic events including birth injuries, herniated discs, and fractures of the coccyx, pelvis or sacrum.

 

What does this research tell us about the role of pudendal blocks in the assessment and treatment of female pelvic pain? As already mentioned, the brevity of the data collection (only up to 64 hours) in addition to application of a non-guided block limit the ability to extrapolate this information to any long-term results. However, the correlations to clinical history and the return to pain prior to numbness ending may provide useful information as further clinical research is completed. The numbness was found to have inconsistent effects on a patient's symptoms such as bladder, bowel, sexual dysfunction, or sitting, and further research could measure the effects of a block on these functions. If you would like to discuss pudendal blocks with experts on pudendal dysfunction, sign up for the remaining spots in our August San Diego course!

 

Learn more about the Pudendal Neuralgia Assessment and Treatment course that we are holding at Comprehensive Therapy Services later this year.


Jun 23, 2014

A systematic review from July of 2013 addressed how interpersonal factors modulate pain. Four primary findings of the research that are found to affect pain-related responses are as follows: the degree to which social partners were active (or perceived to be able to be active), the degree to which participants could perceive the specific intentions of the social partners, the pre-existing relationship between the subject and the social partner, and individual differences in relating to others (including coping styles).

 

Some patients are negatively impacted by a partner who is attentive to pain, with increased reports of pain, worse pain outcomes when together versus alone, and with longer lasting pain states. On the other hand, some patients respond favorably to a partner's support, with lower reports of pain states when offered support such as holding the hand of a partner. Because each person's relationship and response to the pain within the context of the relationship varies, the impact of a partner on perceived pain is also varied. The authors, after describing details and evidence of pain modulation research, conclude the following: "Specifically, interpersonal exchanges affect precision or salience by socially signaling the safety or threat of the impending stimulus itself or the environment in which the stimulus occurs."

 

How can we take this information to heart within the pelvic rehabilitation practice? One of the ways that we offer support to a couple is by inviting a partner to attend a clinic session where he or she can learn to assist in application of soft tissue release techniques. The partner has the opportunity to be validated in both the gratitude that the therapist offers to the patient and partner for attending, and also in the fact that pelvic pain is commonly encountered. Because pelvic pain can interfere with a couple's intimacy, having such validation about the physicality of pain, when present, may be useful in a relationship. When a partner learns how to be of help in the healing process, this may also affect the factors mentioned in the cited research article, specifically, how partners are perceived to be able to be active or perception of specific intention.

 

It has been my clinical experience that partners are very specific in intention once being trained in how to help with pelvic pain, and that intention is to be a part of the healing process. It has also been an observation that if a partnership is struggling with their relationship, that issues can surface once asked to engage in pelvic muscle rehabilitation. This might mean that a patient chooses to pause rehabilitation and enter psychological counseling or other healing work. It also might mean that the patient chooses to not request help of the partner in the clinic or at home for the time being.


Jun 18, 2014

pelvis

When assessing sacroiliac joint (SIJ) stability and function, pelvic rehabilitation providers often use the single leg stand test. During transition from double-leg stance to single-leg stance, dynamic stability is required and there are several ways to describe the observed behaviors in patients. If a patient, for example, loses her balance when transitioning to a single leg stand, what is contributing to her loss of stability? Could it be the SIJ, abdominal and trunk strength, ankle proprioception, visual or vestibular deficits, or hip abductor weakness? Of course, these are not the only potential confounders to postural stability, yet represent some of the considerations of the rehabilitation therapist.

 

A recent study aimed to further define techniques to measure "time to stabilization" in a double-limb to single-limb stance. The authors measured 15 healthy control subjects and 15 subjects who presented with chronic ankle instability (CAI) and the researchers tested the ability to achieve stability in single-leg stance during eyes open and eyes closed tasks as well as with varied speeds of movement.

 

The research found that in subjects who had CAI, following transition to single-leg stance, increased postural sway was noted. In the same subjects, when performing the task with eyes closed, those with a history of ankle instability performed the transition much more slowly than those in the control group when allowed to choose their speed of transition. Prior research (described in the linked article) had postulated that time to stabilization (TTS) following double-limb to single-limb transition was an important variable to measure, yet this research did not find that the TTS was significantly different between the groups studied.

 


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Upcoming Continuing Education Courses

Athlete and the Pelvic Floor - Columbus, OH
Aug 02, 2014 - Aug 03, 2014
Location: OhioHealth Neighborhood Care Rehabilitation

Pudendal Neuralgia - San Diego, CA
Aug 09, 2014 - Aug 10, 2014
Location: Comprehensive Therapy Services

Biomechanical Assessment - Arlington, VA
Aug 16, 2014 - Aug 17, 2014
Location: Virginia Hospital Center

Yoga as Medicine for Labor and Delivery and Postpartum - Seattle, WA
Aug 16, 2014 - Aug 17, 2014
Location: Pilates Seattle International

Pediatric Incontinence - Greenville, SC
Aug 23, 2014 - Aug 24, 2014
Location: Proaxis Therapy

Pelvic Floor Level 1 - St. Louis, MO (SOLD OUT!)
Sep 05, 2014 - Sep 07, 2014
Location: Washington University School of Medicine

Meditation and Pain Neuroscience - Winfield, IL
Sep 06, 2014 - Sep 07, 2014
Location: Central DuPage Hospital Conference Room

Visceral Mobilization Level Two - Boston, MA
Sep 12, 2014 - Sep 14, 2014
Location: Marathon Physical Therapy

Coccyx Pain - Nashua, NH
Sep 13, 2014 - Sep 14, 2014
Location: St. Joseph Hospital Rehabilitative Services

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
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