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Apr 16, 2014

While hysterectomy is the second most common surgery performed on women; hysterectomy rates in the US have been declining as awareness improves about minimally invasive alternatives. According to the National Women's Health Network (NWHN), hysterectomy may be associated with increased risk of heart attack, surgical complications, urinary dysfunction, fistula, UTI's, sexual dysfunction, depression, and hormonal deficiencies. The NWHN describes medical necessity for hysterectomy as occurring in cases of invasive cancer, unmanageable infection or bleeding, and uterine rupture or other serious peripartum complications. 

 

 

 

What can a woman do as an alternative to surgery? For fibroids, medication, laser ablation, cryosurgery, and myomectomy may be options available to a woman. For precancerous cells or non-cancerous growths, a LEEP procedure or cryosurgery can be performed, or a partial rather than a complete hysterectomy can be completed. Endometrial ablation or dilation and curettage (D&C) can be used to remove the lining of abnormal tissue. Endometroisis may be managed with laparoscopy, pain medication, and hormone therapy, and symptoms of a uterine prolapse may be aided by a pessary, suspension surgery, or by pelvic rehabilitation. (Hysterectomy, 2005)


Apr 10, 2014

 

back

 

Research completed by medical faculty of Heidelberg University in Germany aimed to better understand the characteristics of pain that can be caused by different structures or tissues within the low back. Is the information gained applicable to all layers of tissues in the body? If so, how does that assist with our structural evaluation and interventions? If not, how do various body regions reflect the findings of this study?

 


Apr 09, 2014

What is a hymenectomy, and how does it relate to pelvic rehabilitation? To answer this question, an understanding of hymenal anatomy is useful. The hymen is tissue that lines and sometimes covers the vaginal opening. This layer of tissue can be thick or thin, and can have a variety of presentations based on embryological development such as micro perforations, bands, or septa which create distinct openings into the vaginal canal. During menstruation, having an opening through the hymen is critical so that menstrual discharge does not become blocked, and sexual function is optimized when the hymen does not create any narrowing or blockage. When the hymen completely covers the vaginal opening the condition is known as "imperforate hymen." Sometimes this anatomical variation is noticed during neonatal and early childhood examinations, unfortunately, the condition may also be undiagnosed. 

 

 

Prior to her first gynecological examination, an adolescent female may be at risk for consequences of an imperforate hymen. Depending on the hymenal variation, a young female may experience urinary dysfunction or vaginal infection, but more typical is recognition of the issue when her menstrual cycle begins. Case reports in the literature describe the condition as presenting clinically as low back pain, or as abdominal pain. Complaints that may increase our suspicion about the condition in an adolescent patient may include amenorrhea, abdominal mass, abdominal pain, urinary retention, or constipation. 

 


Apr 08, 2014

Do women who have pelvic girdle pain in pregnancy have altered gait patterns? The answer to this question was the aim of a study published in the European Spine Journal in 2008 by Wu and colleagues. Pelvic girdle pain, defined by Vleeming and colleagues as "…a specific form of low back pain (LBP) that can occur separately or in conjunction with LBP…" has been estimated to occur as often as 50% in pregnancy. (Gutke et al., 2006) Unfortunately, of the women who develop pelvic girdle pain in pregnancy, research has demonstrated that 1 in 4 women will develop chronic postpartum pain. (Ostgaard et al., 1991) Pelvic girdle pain can appear as mild, moderate, or severely debilitating, and can be confirmed using provocation tests such as the posterior pelvic provocation test and the active straight leg raise (ASLR). Our role as pelvic rehabilitation providers is critical in minimizing the functional impact of pelvic girdle pain during and following pregnancy. 

 

 

In regards to gait changes in women who present with PGP in pregnancy, in general, walking velocity is reduced, is negatively correlated with fear of movement, and there are changes in thorax and pelvic rotations. In the study by Wu and colleagues, kinematics were examined in 11 women with PGP and 12 pelvic-healthy controls. Findings within the patients with PGP include that transverse segmental rotation amplitudes were larger, and peak thorax rotation occurred earlier in the stride cycle at higher velocities. The authors suggest that this change in thorax rotation may aid in avoiding excessive spinal rotations caused by larger segmental rotations, or in limiting the motion in the lumbopelvic region.. They further describe that in healthy subjects, pelvic rotations are relatively out-of-phase with the lower extremities at lower velocities, and more in-phase during higher velocities, and that this pattern may be altered in the presence of PGP.

 


Apr 03, 2014

Peter

 

 

This post was written by H&W faculty member Peter Philip, who developed a course on chronic pelvic pain and differential diagnosis for the Institute. 

 


Apr 01, 2014

What happens to pelvic floor muscle activation in women who have prolapse and a pessary in place? Kari Bo, an extraordinary contributor to the field of pelvic health, and colleagues in Norway investigated this question. Twenty two women (who acted as their own controls) were measured for vaginal resting pressure and maximal voluntary pelvic muscle contraction with and without a ring pessary in place. The aim of the investigation was to determine if the pelvic floor muscles could improve in activation if the prolapse was repositioned. (The authors take the reader through prior research examples to build this clinical question and theory.) Conclusions of this research indicate that having a pessary in place improved the vaginal resting pressure (VRP) but did not create a statistically significant difference in maximal voluntary contraction (MVC). 

 

 

For this study, 22 women with grade II-IV prolapse (according to POP-Q) who were able to demonstrate a voluntary pelvic muscle contraction were included.  Excluded were women who could not tolerate a ring pessary, those who were breastfeeding or pregnant, women with neurological or musculoskeletal disease that could interfere with ability to contract, and cases in which the prolapse was so severe that measurement with the catheter was prohibited. Maximal contractions and an endurance contraction were measured in supine. No significant difference was noted in MVC or in endurance. A higher vaginal resting pressure, however, was recorded. The authors discuss several theories to explain the increase in resting pressure, but do not provide a conclusion as to the reason for this change. Is there a length change in puborectalis that optimizes the length/tension curve, for example? 

 


Mar 31, 2014

shoulder

 

Scapular winging, also known as scapula alata (SA), describes the lack of proper muscular support that keeps the medial scapula positioned snugly against the thoracic wall. Potential causes of this condition include weakness of the serratus anterior, trapezius, and rhomboids, often related to nerve injuries of the long thoracic, spinal accessory, or the dorsal scapular nerve. Breast cancer and axillary surgery is a known risk factor for scapular winging, and the aim of a recent article was to identify patients who were at increased risk of developing the condition following radiotherapy.

 

  Adriaenssens and colleagues report an incidence rate of scapular alata in the literature of 0-74.7%, a variability that does not help to deduce patients who are truly at risk. Women age 18 or older with a diagnosis of primary breast cancer removed by mastectomy or by breast-conserving surgery were included in their study. The pathological stage, treatment doses for radiotherapy and when applicable, the treatment doses for chemotherapy are described for the control and for the intervention group. The original study from which the data was collected is known as the TomoBreast clinical trial and focused on pulmonary and cardiac toxicity measurement. Within the data collection, scapular position was measured in physiotherapy prior to and 1-3 months following radiotherapy. (Check this link to learn more about radiotherapy.) 


Mar 29, 2014

As therapists are increasingly immersed in understanding of mechanisms of chronic pain and central nervous system phenomena, a question persists: what should we do with the peripheral tissues? As is usual in discussions that can take an either/or approach, the answer may lie somewhere in the middle. A recent article discussing myofascial trigger points (TrP) discusses the hypotheses surrounding this phenomena as a peripheral versus central mechanism. In a very well-cited summary of the issue, the authors come to some very helpful conclusions that you may find useful in your clinical practice. 

 

 If a trigger point, by definition, is a hyperirritable spot in a taut band of skeletal muscle that may or not have referred pain, what then, is driving the soft tissue dysfunction? Some authors argue that the peripheral nervous system is at fault, while others point to the central nervous system as the driver. Peripherally, nociceptive input may sensitize dorsal horn neurons. Centrally, patients who have chronic pain will have larger areas of pain, described as being a result of higher central neural plasticity. This is a controversial topic, and the authors are quick to point out that experimental evidence is "sparse." While there is support in the literature for peripheral trigger points creating central sensitization, the article states that "…preliminary evidence suggests that central sensitization can also promote TrP activity." 

 

 While this study does an excellent job describing various clinical and experimental research, hypotheses, and strength of evidence to support the hypotheses, the summary points are that trigger points may be both a central and peripheral phenomena, and that chronicity of the condition may drive the focus of rehabilitation efforts. Specifically, the authors state that when a patient presents with peripheral sensitization, treatment should be directed towards inactivation of the trigger point, mobilizing joints and nerves, and functional activity. Patients who present with persistent pain may require more attention directed to the central system utilizing a multidisciplinary approach such as medications, medical and physical therapy management, and psychological therapy. Fear, anxiety, and the neuroscience approach to pain should be addressed. 


Mar 24, 2014

Psychological distress and cognitive impact are common sequelae of a cancer diagnosis, even once a patient is considered disease-free. Fear of cancer recurrence or progression is a significant issue for many patients, and can have severe impacts on a patient's well-being and function. Research published in August of last year describes predictors of this fear of recurrence, or FOR, in almost 1300 patients who completed a range of validated measures. The study reports that patients within a lower social class, this with skin cancer, colon or blood cancer, palliative treatment intention, pain, an increased number of physical symptoms, depression, and decreased social support were at higher risk of having fear of cancer. 

 

 

Fear and psychological distress could potentially impact a patient's life in many ways, and also may have an effect on a patient's ability to maximally participate in recommended rehabilitation. If a patient is experiencing anxiety and/or depression, getting out of the house, making it to appointments on time, and participating in health programs may be very difficult. Cognitive impact from treatment or from psychological stress can also make remembering a home program or other instruction from you very challenging. What are things we can do to support a patient who has been impacted by a diagnosis of prior cancer? We can ask some simple questions…

 


Mar 22, 2014

Brigid Ellingson, MPT, OCS

This blog post was written by faculty member Bridgid Ellingson, DPT, MPT, OCS, BCB-PMD. Bridgid is a private practice owner in the Chicago area and she is an instructor for the Institute's pelvic floor course series Level 2B course.


For years I resisted taking a physical therapy student into my clinic for their final rotation.  The traditional physical therapy curriculum does not adequately prepare a student for the experience and I do not believe that physical therapy for the pelvic floor is entry level work.  However, I recently had a particularly motivated student convince me to give it a try and I’d like to share my experience to help prepare other clinicians interested in taking students. 

 


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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Durham, NC (SOLD OUT)
Apr 25, 2014 - Apr 27, 2014
Location: Duke University Medical Center

Myofascial Release for Pelvic Dysfunction - Portland, OR
Apr 25, 2014 - Apr 27, 2014
Location: Legacy Meridian Park Medical Center

Finding the Driver in Pelvic Pain - Milwaukee, WI
May 01, 2014 - May 03, 2014
Location: Marquette University

Visceral Mobilization of the Urologic System - Winfield, IL
May 02, 2014 - May 04, 2014
Location: Central DuPage Hospital Conference Room

Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics - Seattle, WA
May 03, 2014 - May 05, 2014
Location: Swedish Hospital - Issaquah campus

Rehabilitative Ultrasound Imaging Orthopedic Topics - Seattle, WA
May 03, 2014 - May 04, 2014
Location: Swedish Hospital - Issaquah campus

Pelvic Floor Level 1 - Scottsdale, AZ (SOLD OUT)
May 16, 2014 - May 18, 2014
Location: Womens Center for Wellness and Rehabilitation

Pelvic Floor Level 2A - Maywood, IL (SOLD OUT!)
May 16, 2014 - May 18, 2014
Location: Loyola University Stritch School of Medicine

Pelvic Floor Level 3 - San Diego, CA
May 30, 2014 - Jun 01, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Arlington, VA (SOLD OUT)
Jun 06, 2014 - Jun 08, 2014
Location: Virginia Hospital Center

Care of the Postpartum Patient - Houston, TX
Jun 07, 2014 - Jun 08, 2014
Location: Texas Children’s Hospital

Bowel Pathology and Function - Minneapolis, MN
Jun 07, 2014 - Jun 08, 2014
Location: Park Nicollet Clinic--St. Louis Park

Oncology and the Female Pelvic Floor - Orlando, FL
Jun 21, 2014 - Jun 22, 2014
Location: Florida Hospital Sports Medicine and Rehabilitation

Myofascial Release for Pelvic Dysfunction - Dayton, OH
Jun 22, 2014 - Jun 23, 2014
Location: Southview Hospital

Pelvic Floor Level 2A - Derby, CT
Jun 27, 2014 - Jun 29, 2014
Location: Griffin Hospital