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Apr 21, 2015

With words like jumping, diving, spiking, hitting, and blocking making up the game's activities, volleyball is clearly a sport that requires a healthy pelvic floor. We know that athletes are at risk for pelvic dysfunction, with symptoms ranging from tension to leakage, but what happens when the pelvic floor is reeducated? In a study addressing volleyball players, researchers assess the effectiveness of a pelvic muscle rehabilitation program on symptoms of urinary incontinence. 32 female athletes were divided evenly between a control group and an experimental group. Inclusions criteria for the sample was nulliparity, symptoms of stress urinary incontinence, age between 13 and 30, and leakage amount more than 1 gram on the pad weight test. Exclusion criteria is as follows: treatment time of less than six months, sport practice for less than two years, urinary tract infections (either current or repeated prior infections), intervention adherence less than 50%, or body mass index outside of the range of 18-25.

 

Before and after intervention, the athletes were given a baseline questionnaire, a pad test (in the first 15 minutes of volleyball practice), and they completed seven days of a bladder diary to track leakage. The treatment group were instructed in anatomy and physiology of the lower urinary tract, about urinary incontinence (UI) and UI in athletes, and in leakage prevention strategies. A 3-day bladder diary was completed to improve awareness of fluid intake and bladder habits. Pelvic muscle awareness and correct contractions, doing protective pre-contractions of the pelvic floor, and a home exercise program of quick and endurance pelvic muscle contractions in different positions were also instructed.

 

The results of the intervention include a significant decrease in urinary leakage in the treatment group. The education provided also allowed for prevention of negative coping strategies that were reported in the subjects: the athletes would conceal leakage by wearing a menstrual pad, decreased their fluid intake, or empty their bladder more frequently. This study contributes to the growing body of evidence linking sport to pelvic dysfunction, and more importantly, rehabilitation efforts to improvement. If you want to learn more about pelvic dysfunction in athletes, come to The Athlete and the Pelvic Floor with Michelle Lyons. This 2-day continuing education course took place recently in New York City and your next opportunity to take the class is in Denver in October!


Apr 17, 2015

Blog by Holly Tanner

In the treatment of pelvic dysfunction, collaboration among physicians and pelvic rehabilitation providers creates an optimal care situation for the patient. In a research article that will be published in the July issue of Journal of Lower Genital Tract Disease, physical therapist and Herman & Wallace Institute faculty member Stacey Futterman demonstrates how a partnership between disciplines provides information valuable to the field of pelvic rehabilitation. Stacey and physicians Deborah Coady, Dena Harris, and Straun Coleman hypothesized that persistent vulvar pain may be generated by femoroactebular impingement (FIA) and the resultant effects on pelvic floor muscles. Through the research, the authors attempted to determine if hip arthroscopy was a beneficial intervention for vulvar pain, and if so, which patient characteristics influenced improvements.

 

Twenty six patients diagnosed with generalized, unprovoked vulvodynia or clitorodynia underwent arthroscopy for femoroacetabular impingement. For 3-6 months following hip repair, patients were treated with physical therapy that included surgical postoperative rehabilitation combined with rehabilitation for vulvodynia. Time period for follow-up data collection ranged from 36-58 months. Six patients reported improvements in vulvar pain following surgery and did not require further treatment, and it is noted that these patients were all in the youngest age bracket (22-29). Among the patients who did not report sustained relief, relatively older ages (33-74) were noted, along with a tendency to have vulvar pain for 5 years or longer.

 

The relationship between hip and pelvic pain may come from the bony structures, hip muscles including but not limited to the obturator internus, and nerves such as the pudendal. The authors conclude that "All women with vulvodynia need to be routinely assessed for pelvic floor and hip disorders…" and if needed, treatment should be implemented to address the appropriate tissue dysfunctions. If you are interested in learning more about hip dysfunction so you can better screen for dysfunction such as femoroacetabular impingement, check out faculty member Steve Dischiavi's continuing education course. Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System takes place next in Durham, North Carolina in May.


Apr 16, 2015

Patients diagnosed with colorectal cancer may undergo a procedure called mesorectal excision as part of their oncology management. In this procedure, a significant portion of the bowel is removed along with the tumor. Total mesorectal excision refers to the entire rectum and mesorectum (peritoneum that connects the upper rectum.) The rectum is removed up to the level of the levator muscles, and this procedure is indicated for tumors of the middle and lower rectum. In a study published in the World Journal of Oncology, the authors report on female urogenital dysfunction following total mesorectal excision (TME).

 

Questionnaires were returned by 18 women (age range 34-86) who had undergone TME for rectal cancer. Results of the study are summarized in the chart below. (All patients had reported vaginal childbirth, and five had undergone total abdominal hysterectomy and oophrectomy.)

 

Presurgical
Postsurgical

Sexual function

5/18 (28%) were sexually active (with no complaints of dyspareunia) Sexually active patients remained active but all reported discomfort with penetration
2 patients reported decreased libido due to stoma

Urinary function

3/18 (17%) reported urinary urgency and frequency Of patients with urinary symptoms, 80% persisted longer than 3 months post-surgery
7/18 (39%) reported stress urinary incontinence
New onset symptoms: 61% developed nocturia, 20% developed stress urinary incontinence, 1 patient required permanent catheter

 


Apr 10, 2015

Blog by Holly Tanner

Among the challenges in research for chronic pelvic pain is the lack of consensus about diagnosis and intervention. Prominent researchers and physicians J. Curtis Nickel and Daniel Shoskes describe a methodology for classification of male chronic pelvic pain using phenotyping, which can be simply described as “a set of observable characteristics.” The authors point out in this article that men with complaints of pelvic pain have historically been treated with antibiotics, even though now it is known that most cases of “prostatitis” are not true infections. With most patients having chronic pelvic pain presenting with varied causes, symptoms, and responses to treatment, Nickel and Shoskes acknowledge that traditional medical approaches have not been successful.

 

In an attempt to improve classification of patients and subsequent treatment approaches, the UPOINT system was developed. The domains of the system include urinary, psychosocial, organ specific, infection, neurological/systemic conditions, and tenderness of skeletal muscles, and are listed below. Within each domain, the clinical description has been adapted from the original study (which can be accessed full text at the link above.)

 

UPOINT Domains

 


Apr 09, 2015

Prolapse Bladder

You know how some women report that they have a mild prolapse that feels better if they wear a tampon during strenuous activity, or that a tampon worn (temporarily) helps avoid urinary leakage? Using a tampon instead of a pessary seems like a great fix, with one problem: tampons are not designed to be used as a pessary. They are designed to be absorptive and to expand to fill the vaginal canal as they expand. Some women can even suffer from toxic shock syndrome - a condition related to bacterial infection and associated with super-absorbent tampon use, contraceptives, and diaphragm use. What if an item could be used that is similar to a tampon, but not absorptive, and that provided more support than a cylindrical-shaped tampon? That must have been what Kimberly Clark, the manufacturer of a new product, created to fit this need.

 

The Impressa is marketed as a device for urinary incontinence that a patient can buy over-the-counter. The product comes in an applicator and can be inserted similarly to the way a tampon is, but the Impressa is not made to absorb leaks. Once inserted, the product has an interesting shape that is designed to help support the urethra. The device comes in 3 sizes labeled 1, 2, and 3, and the product has a "sizing kit" with 2 of each size in a box that can be trialed for finding the best fit. It will be interesting to see how valuable this product is and we will only know as we begin to hear feedback from their use. Pessary fit is a tough process in that providers and patients often have to go through a period of trial and error for best fit, and also because providers are poorly reimbursed for management of pessary fit and use. (Click here to read more on the blog about prolapse and pessaries.)

 

It appears that the product is not yet widely available, but it will be interesting to hear women's' experiences about the product. Having an option for an affordable, disposable pessary-like device that is available over-the-counter could be a very helpful option to know about. Health professionals can go to the website impressapro.com to send an email requesting a sample or more information. And thank you to certified Pelvic Rehabilitation Practitioner Joyce Steele for sharing information about the Impressa as this may be something your patients start asking more about. To learn more about prolapse management and female pelvic floor dysfunction, come to one of our intermediate-level continuing education courses, PF2B. The next opportunities to take this class (that aren't sold out!) are in Connecticut, North Carolina, and Missouri this year.


Apr 03, 2015

Blog by Holly Tanner

In a case report published within the past year by physical therapist Karen Litos, a detailed and thorough case study describes the therapeutic progression and outcomes for a woman with significant functional limitation due to a separation of her diastasis recti muscles. The patient in the case is described as a 32-year-old G2P2 African-American woman referred to PT at 7 weeks postpartum. Delivery occurred vaginally with epidural, no perineal tearing, and pushing time of less than an hour. Primary concerns of the patient included burning or sharp abdominal pain when lifting, standing, and walking. Uterine contractions that naturally occurred during breastfeeding also worsened the abdominal pain and caused the patient to discontinue breastfeeding. The patient furthermore reported sensations that her insides felt like they would fall out, and abdominal muscle weakness and fatigue with activity.

 

Although many other significant details related to history, examination and evaluation were included in the case report, I will focus on the signs, interventions, and outcomes recorded in the paper. Diastasis was measured using finger width assessment and a tape measure. (Although ultrasound is more accurate and valid, palpation of diastasis has been demonstrated to have good intra-rater reliability as used in this study. Measures for interrecti distance (IRD) at time of evaluation were 11.5 cm at the umbilicus, 8 cm above the umbilicus, and 5 cm below the umbilicus. The patient also reported pain on the visual analog scale (VAS) of 3-8/10.

 

Interventions in rehabilitation included, but were not limited to: instruction in wearing an abdominal binder, appropriate abdominal and trunk strengthening (promotion of efficient load transfer and avoidance of exercises that may worsen separation), biomechanics training with functional tasks such as transfers, self-bracing of abdominals, avoiding Valsalva, postural alignment and symmetrical weight-bearing strategies. Plan of care was developed as 2-3x/week for 2-3 weeks, the patient was seen for 18 visits over a four month period. Therapeutic exercise was progressed to include general hip and trunk muscle strengthening towards a goal of stability during movement. Cardiovascular training progressed to light treadmill jogging and use of an elliptical.

 


Mar 31, 2015

support

Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, score on the PERFECT scheme, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.

 

Intervention
sEMG biofeedback PFMT: Use of intravaginal sensor and 30 slow, maximal-effort contractions followed by 3 minutes of fast, maximal-effort contractions in supine.
Sham NMES: sacral surface electrodes with pulse width of 50 ms at 2 Hz, on/off 2/60 seconds for 30 minutes
Intravaginal NMES: 200 ms at 10 Hz for 30 minutes using vaginal sensor.
TTNS: surface electrodes in the left lower leg with pulse width at 200 ms at 10 Hz for 30 minutes.
Group 1, n = 6 X X
Group 2, n = 7 X X
Group 3, n = 7 X     X

 

The following factors made up some of the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, 4 month history of stable symptoms, currently participating in a sexually active relationship, and able to contract the pelvic floor muscles. Participants were excluded if they had delivered within the prior 6 months, had pelvic organ prolapse (POP) greater than stage I on the POP-Q, were perimenopausal or menopausal. Neurologic function symptoms were also monitored so that subjects could be evaluated for any potential flare-up. Home program instruction in PFMT included 30 slow and 30 fast PFM contractions to be completed in varied postures 3x/day.

 

Results included that all groups improved via the PERFECT scheme evaluation. Other specific indicators of improvement were noted for each group, and the use of the FSFI provided measures of sexual function. The authors conclude that pelvic floor muscle training (with or without electrostimulation) can produce positive changes in sexual arousal, vaginal lubrication, sexual satisfaction and sexual lives. The use of PFMT with intravaginal NMES "…appears to be a better treatment option than PFMT alone or in combination with PTNS in the management of the orgasm, desire and pain domains of [the FSFI]." You can find the abstract of the article by clicking here.


Mar 27, 2015

abdominal pain

A research article published last year i BioMed Research international aims to identify premenopausal and postmenopausal factors influencing endometriosis. The authors cite medical literature in stating that 10-15% of all women of reproductive age have endometriosis, with common symptoms of abdominopelvic pain, activity limitations, and decreased sexual function. Thirty-five postmenopausal women (in whom endometriosis was diagnosed premenopausally) completed questionnaires containing 147 questions. The questions referred to the patient’s general medical history, premenopausal symptoms and complaints, and postmenopausal complaints.

 

The good news is that endometriosis symptoms overall improved in the postmenopausal period. General physical activity limitations were less attributed to endometriosis in the postmenopausal period. Following are some of the reported changes in dysfunction and pain intensity reported on 0-10 pain scale.

 

Symptom
Premenopausal
Postmenopausal
Abdominal pain 94% (pain average: 8) 63% (pain average: 3)
Dyspareunia 71% (pain: 5) 54% (pain: 2)
Sexual dysfunction 80% (pain: 5) 54% (pain: 1)
Psychological dysfunction 51% 20%
Restriction of social activity 63% 17%
Work activity limitations 80% 20%

 

While the authors found that postmenopausal variables in large part were improved, the rather high incidence of dysfunction should still alert pelvic rehabilitation providers to the importance of working with women in the postmenopausal period. The analyses did not demonstrate a significant relationship between medications, pregnancy and parity, family history, comorbid diseases, and the postmenopausal variables studied. Surgical history also did not appear to have a negative impact on the postmenopausal symptoms, except for hysterectomy with the adnexa or bilateral adnexectomy.


Mar 25, 2015

Professionals

In order to refer patients to needed care, it is vital that health care providers understand the roles that each provider plays. Within pelvic rehabilitation, this issue presents barriers and opportunities, as many providers do not know about pelvic rehabilitation, and about the wide scope of care that we can provide towards bowel, bladder, sexual dysfunction, and pelvic pain in men, women, and children. An article written by a physiotherapist and published in the British Journal of Midwifery highlights the issues such barriers can cause. Utilizing a focus group of seven 3rd year midwifery students, a researchers asked questions about student midwives' perceptions of the physiotherapist's role in obstetrics. Five distinct themes were proposed as a result of the focus group interviews:

 

1. Role recognition: in order to enable services for patients, understanding other professional roles is valuable.
2. Lack of knowledge: participants expressed a lack of knowledge about the physiotherapy role, and the students wondered if they should be seeking out that knowledge, or if the physiotherapists should be educating the midwives about their role. Prior inter professional education opportunities, which provides the students with potential for understanding other professions, were not viewed as positive by the students.
3. Perceived views existed: Although participants did not have a clear view of what a physiotherapist's role is in obstetrics, they had developed ideas (accurate or not) about the role. 4. Utilization of physiotherapy: Numerous barriers to utilization of physiotherapy in obstetrics rehabilitation were identified, and variations in referrals and utilization of PT were noted. 5. Benefits of physiotherapy: Participants' lack of knowledge, lack of feedback from patients, and issues such as waiting periods prior to getting care limited the stated benefits of physiotherapy care in obstetrics.

 

In order to avoid working independently of each other, physical therapists and midwives, along with other care providers for women, must understand the complementary roles we play. One of the best ways that we can create a shared understanding is through spending time in each other's educational or clinical environments. Each of us can take responsibility for providing some level of education towards teaching other providers what we do, what we know, and how we can collaborate. One of the ways that the Institute attempts to make this task easier is to provide you with presentations that are already created for this purpose. Our "What is Pelvic Rehab?" powerpoint presentation allows you to edit the slides created for referring providers. Within the presentation, basic information about pelvic therapy and specific research about pelvic rehabilitation for various conditions is combined. To check out the "What is Pelvic Rehab?" presentation and other patient and provider education materials, head to the Products and Resources page and see what information may help you (and your patients) share information about the role of the pelvic rehabilitation provider in collaboration with other health professionals.


Mar 24, 2015

Researchers using a community-based sample in the upper Midwest cities of Minneapolis/St. Paul surveyed 138 women between the ages of 18-49 with diagnosed vulvodynia. Vulvodynia was classified as primary (pain started with first tampon use or sexual penetration) or secondary pain started following a period of intercourse that was not painful. The authors aimed to determine the rates of remission of vulvar pain versus pain-free time periods. Remission was defined in this study as having at least one period of time that was pain-free for at least 3 months. Generalized vulvodynia categorization was made after clinical exam and was determined by the subject having pain at each point on the perineal “clock” with cotton swab provocation.

 

The authors reported that women diagnosed with primary vulvodynia were 43% less likely to report vulvar pain remission that women with a diagnosis of secondary vulvodynia. They also found that obesity and having generalized versus localized vestibulodynia was associated with reduced rates of remission. The theory was discussed that women who have different types of vulvodynia may have varied underlying mechanisms of pain that lead to differences in symptoms. Specifically, the paper reports on recent brain imaging work that suggests women who have primary vulvodynia demonstrate more characteristics of central pain processing.

 

In relation to health behaviors (such as seeking pain therapy), the authors state that the data may not be sufficiently powered to determine the influence of therapy on remission. They do agree that “…understanding of both spontaneous remission and improvement owing to therapy will ultimately provide guidance in developing more effective interventions.” Because a significant portion of women do not seek care for vulvar pain (for unknown reasons), a bias is created in the research through the lack of representation of those women who are not being studied through healthcare access.

 

The research concludes with a few familiar themes including the need for more research studying the clinical courses of primary versus secondary vulvodynia. We are also left with questions about which women seek care and why, how their clinical outcomes and remission history may differ based on intervention and other intrinsic variables such as body mass index, and how central pain processing affects pain duration and remission. If you are interested in learning more about vulvodynia, come to one of our newer courses offered by faculty member Dee Hartmann, Assessing and Treating Women with Vulvodynia. Two entire days are spent discussing vulvodynia theory and clinical skills for helping women optimize their health and function. You still have a few weeks to sign up for this course that takes place next in April in Minneapolis!


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Upcoming Continuing Education Courses

Finding the Driver in Pelvic Pain - Milwaukee, WI
Apr 23, 2015 - Apr 25, 2015
Location: Marquette University

Pelvic Floor Level 1 - Durham, NC (SOLD OUT!)
Apr 24, 2015 - Apr 26, 2015
Location: Duke University Medical Center

Sexual Medicine for Men and Women - Fairlawn, NJ
Apr 24, 2015 - Apr 26, 2015
Location: Bella Physical Therapy

Bowel Pathology and Function - Kansas City, MO
Apr 25, 2015 - Apr 26, 2015
Location: Saint Luke\'s Health System

Pelvic Floor Level 1 - Los Angeles, CA (SOLD OUT)
May 01, 2015 - May 03, 2015
Location: Mount Saint Mary’s University

Pelvic Floor Level 2A - Seattle, WA (Sold Out!)
May 01, 2015 - May 03, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Oncology and the Female Pelvic Floor - Torrance, CA
May 02, 2015 - May 03, 2015
Location: HealthCare Partners - Torrance

Care of the Postpartum Patient - Boston, MA
May 02, 2015 - May 03, 2015
Location: Marathon Physical Therapy

Pediatric Incontinence - Minneapolis, MN
May 16, 2015 - May 17, 2015
Location: Mercy Hospital

Biomechanical Assessment of The Hip & Pelvis - Durham, NC
May 16, 2015 - May 17, 2015
Location: Duke University Medical Center

Special Topics in Women's Health - Maywood, IL
May 30, 2015 - May 31, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Middletown, CT
May 30, 2015 - May 31, 2015
Location: Middlesex Hospital

Pelvic Floor Level 2B - Seattle, WA (Sold Out!)
Jun 05, 2015 - Jun 07, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Pelvic Floor Level 3 - Atlanta, GA
Jun 05, 2015 - Jun 07, 2015
Location: One on One Physical Therapy

Visceral Mobilization of the Urologic System - Madison, WI
Jun 05, 2015 - Jun 07, 2015
Location: Meriter Hospital