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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!


Mar 20, 2015

Professionals

A report in The Canadian Journal of Human Sexuality describes the level of emphasis placed on particular sexual health topics in Canadian medical schools. Both the level of emphasis and the utilized teaching methods among 51 residency programs for obstetrics and gynecology (OBG), family medicine (FM), and undergraduate medicine (UGM) were evaluated. Program Directors and Associate Deans of the respective programs were electronically surveyed about the following topics: contraception, disease prevention, sexual violence/assault, childhood sexual abuse, sexual dysfunction, childhood and adolescent sexuality, role of sexuality in relationships, aging and sexuality, sexual orientation, gender identity, disability, and social and cultural differences.

 

The topic that received the most emphasis among the 3 program types was “information and skills for contraception.” Disease prevention for sexually-transmitted diseases was also a high-ranking topic.

The authors point out that while it seems understandable that OBG residencies may not include a significant amount of training in male sexual health, there was an absence of evidence on training in child sexual abuse and adolescent female sexuality in the OBG programs. The article notes other omissions of emphasis such as the lack of training among family practice residencies in transgender and gender identity issues, disability and sexuality, and cultural differences.

 

This article gives some insight into potential topics of training in human sexual health, and the lack of education in physicians regarding topics of sexual function and dysfunction. In addition to lacking knowledge of some topics in childhood, adolescent, and men’s and women’s health, we can be certain that most providers are not instructed in the role of pelvic rehabilitation providers for sexual dysfunction. How can we contribute to a provider’s knowledge of rehabilitation of sexual dysfunction?


Mar 13, 2015

Blog by Holly Tanner

Research in the field of sexual dysfunction has taught us several things about patients and healthcare visits. Most medical providers don’t ask about sexual function, most patients don’t bring it up, and women’s sexual health has a history of being undervalued and under-evaluated. Authors Maciel and Lagana describe the common myth that as women age, sexual interest decreases, and review literature to propose improved strategies. The study highlights the fact that there are positive physical health effects for older adults, and that by approaching sexual desire through a biopsychosocial method, further understanding of the issues can be gained.

 

Several factors have been found to be linked to healthy sex in older females. Having a positive attitude towards sex, an interesting an interested partner, good health, and a willingness to experiment sexually can all contribute to an active sex life. Women who are dealing with high stress, anxiety, and depression are known to be less sexually active. In this paper, the authors describe the work of Sobecki and colleagues, who found that older women have just as much interest in talking about sexual health as younger women, but that doctors aren’t usually asking about it. Sobecki et al. found that a patient reported feeling less embarrassed about bringing up sexual dysfunction if the medical provider demonstrated a professional demeanor, comfort with the topic, and a disposition that is kind and empathetic.

 

This last point seems worthy of pause and reflection in relation to the role of the pelvic rehabilitation provider. I would submit that most pelvic rehab therapists are highly capable of presenting a professional, kind, and empathetic demeanor. I wonder how many of us, however, had enough education regarding sexual health to demonstrate to patients a level of “comfort with the topic” that inspires a patient to bring up sexual concerns. The more comfortable we are with our own sexuality and the more knowledgeable we are about sexual health practices that are outside of our own experiences, the more we have to offer to our patients.

 


Mar 11, 2015

Pudendal Nerve

Human anatomy is a challenging, yet fascinating study that truly is a lifelong endeavor. Even if a health care provider has a photographic memory for what she learns in her professional training, the reality is that we are still working to understand all of the intricacies of how our bodies are put together to have all of the amazing capacities that our bodies can offer. Textbooks like Netter's anatomy helps us to memorize anatomy by using bright colors to highlight structures and by separating fascia from muscles and nerves, and yet this is a superficial representation of what is really going on in the body. Even once we memorize many of the structures in the body, we are still tasked with understand the functional interplay among our fascial-musculo-skeletal-attached-to-an-amazing-nervous-system bodies.

 

What does this have to do with pelvic rehabilitation? Most of us did not have an adequate study of pelvic rehabilitation in our initial training, and have benefited from learning pelvic anatomy and function at post-professional coursework. And for most of us, this is an ongoing process. Even when we have learned a lot about anatomy, there's this issue: anomalies and variations. We are not all created the same. Some of our patients have extra structures, some lack. Some people have tissues that grow in areas where we least expect it, others have joints that fuse where others have movement. Within pelvic rehabilitation, we learn some very interesting things by reading case reports or surgical histories, and by listening to our patients' stories.

 

One of the structures in the body that can be faced with some fairly challenging anatomical variations is the pudendal nerve. Many of us are familiar with some of the areas in the pelvis that the pudendal nerve can face challenges, or areas where the nerve can become more daily compressed or irritated such as between the sacrotuberous and sacrospinous ligament. Consider this cadaver study that demonstrates variations in inferior rectal nerve development, with differences in truncation and location, including nerves that travel through the sacrotuberous ligament, making it potentially more susceptible to compression. Or what about this cadaver dissection that revealed a double gluteus maximus with variations in nerve pathway between sides? What are the implications for the patient who has a complete ossification of the sacrotuberous ligament?

 


Upcoming Continuing Education Courses

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

Nutritional Perspectives for the Pelvic Rehab Therapist - Seattle, WA
Jun 06, 2015 - Jun 07, 2015
Location: Pacific Medical Center

Rehabilitative Ultra Sound Imaging: Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 13, 2015
Location: Johns Hopkins Bayview Medical Center

Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics - Baltimore, MD
Jun 12, 2015 - Jun 14, 2015
Location: Johns Hopkins Bayview Medical Center

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Jun 12, 2015 - Jun 14, 2015
Location: Marathon Physical Therapy

Pelvic Floor Level 2B - Derby, CT (SOLD OUT)
Jun 26, 2015 - Jun 28, 2015
Location: Griffin Hospital

Breast Oncology - Maywood, IL
Jun 27, 2015 - Jun 28, 2015
Location: Loyola University Stritch School of Medicine

Chronic Pelvic Pain - Arlington, VA
Jul 10, 2015 - Jul 12, 2015
Location: Virginia Hospital Center

Myofascial Release for Pelvic Dysfunction - Winfield, IL
Jul 17, 2015 - Jul 19, 2015
Location: Central DuPage Hospital Conference Room

Pediatric Incontinence - Houston, TX
Jul 18, 2015 - Jul 19, 2015
Location: Texas Children’s Hospital

Yoga for Pelvic Pain - Cleveland, OH
Jul 18, 2015 - Jul 19, 2015
Location: UH Case Medical Center - University Hospitals