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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?

 


Mar 04, 2015

Blog by Holly Tanner

The merriam-webster online dictionary defines reflex as "an action or movement of the body that happens automatically as a reaction to something" or as "something that you do without thinking as a reaction to something." This reflexive action ideally describes what the pelvic floor does when we perform an activity that increases intra-abdominal pressure- and that can help us tighten the pelvic floor protectively so that urine is not expelled from the bladder and out the urethra. A research article by Dietz, Bond, & Shek asked if childbirth interrupted the body's natural reflex of contracting the pelvic floor muscles during a cough.

 

84 women completed the study, which utilized ultrasound measurements to assess reflex contraction of the pelvic floor during a cough. The women were pregnant with their first child (a singleton) and were between 33-37 weeks gestation. Prior to childbirth, 98% of the subjects demonstrated a reflex contraction of the pelvic floor muscles. At a postpartum visit at least 3 months postpartum, the number of women completing a reflex contraction was reduced to 75%. In addition to fewer women demonstrating a shortening contraction during a cough in the postpartum women, the intensity of the contraction was also reduced.

 

To collect the data, the researchers prospectively completed 4D (4-dimensional) ultrasound (US) volume measurement of the pelvic floor during a cough. They used levator hiatus diameter changes to quantify reflex action of the pelvic floor muscles. From prenatal to postnatal visit, the magnitude of the reflex contraction decreased from 4.8 mm to 2.0 mm (the number represents the mean difference in midsaggital diameter between rest and maximal contraction.) In the antenatal visit, 26 of the 84 women complained of stress urinary incontinence, at the postpartum visit, 20 reported stress incontinence. An association was noted between a lower magnitude of reflex contraction and stress urinary incontinence.

 


Mar 03, 2015

Blog by Holly Tanner

Although pelvic rehabilitation therapists are not directly involved in decision-making related to pharmacological pain management, knowledge of procedures and practice patterns related to perioperative pain management may be useful in communicating with the medical team and in understanding a patient's pain experiences related to surgery. A review article published in Female Pelvic Medicine & Reconstructive Surgery highlights the pain management strategies described in the literature that are relevant for urogynecologic surgery. Brief descriptions of the preoperative, intraoperative, and postoperative pain control strategies are discussed in this study, and the following recommendations are made:

 

-Multimodal analgesic approaches should be considered for all procedures because the use of several interventions (with varied mechanisms of action) can reduce postoperative pain, reduce opioid use and opioid-related side effects. Medications for potential use in a multimodal approach include perioperative paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), dexamethasone, and local anesthetics.

 

-For patients having abdominal urogynecologic procedures, bilateral TAP blocks are recommended. A TAP block is short for transversus abdominis plane block, and aims to numb the sensory afferent nerves of the anterior abdominal wall running superficial to the transversus abdominis muscle. For the procedure, a needle is placed into the area created within the margins of the superior iliac crest, the latissimus dorsi muscle, and the external oblique muscle. The needle placement can be done by palpation or with ultrasound guidance.

 


Feb 27, 2015

Blog by Holly Tanner

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.

 

 


 

Examples of Research Cited
Ideas for Addressing Potential for Harm
dropped handlebar position increases pressure on the perineum and can decrease genital sensation encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily
chronic trauma can cause clitoral injury encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able
saddle loading differs between men and women women should consider specific fit for bike saddles
women have greater anterior pelvic tilt motion is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?
lymphatics can be harmed from frequent infections and from groin compression patients should be instructed in positions of relief from compression and in self-lymphatic drainage
pressure in the perineal area is affected by saddle design, shape female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues
unilateral vulvar enlargement can occur from biomechanics factors therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use
genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.

 


Feb 25, 2015

Blog by Holly Tanner

An important survey completed in Australia asked if prenatal pelvic floor function and dysfunction relates to postnatal pelvic floor dysfunction (PFD). Interestingly, the authors propose that "…damage to the pelvic floor is probably made before first pregnancy due to congenital intrinsic weakness of pelvic floor structures." Many of the patients involved in the study had dysfunction in more than one domain of pelvic health, with the authors recommending a comprehensive approach to the evaluation of pelvic floor dysfunction.

 

As part of the large study called the Screening for Pregnancy Endpoints study, or SCOPE, a prospective cohort study called Prevalence and Predictors of Pelvic floor dysfunction in Prenips, or 4P, was also completed. The 4P research (n = 858) contained 2 different studies including a questionnaire-based survey and a detailed clinical assessment. The survey utilized the Australian pelvic floor questionnaire which was administered at 15 weeks gestation and at 1 year postpartum. The Australian questionnaire scores items on domains of urinary dysfunction, fecal dysfunction, pelvic organ prolapse, and sexual dysfunction. When the participants answered the questionnaire the first time, all answers were directed to be answered for symptoms they experienced prior to being pregnant.

 

The results indicated that at 1 year postpartum, 90% of the women in this study reported pelvic floor dysfunction. Regarding the domains of bladder, bowel, prolapse and sexual symptoms, 71% of the participants reported symptoms from more than 1 of these domains, 31% from 2 domains, 24% from 3 sections of the survey, and 8% from all four sections. Other interesting statistics are as follows:

 


Feb 24, 2015

Blog by Holly Tanner

Results from a national survey of surgeons published in 2010 offers insights into the challenges that providers and patients face in addressing the complications caused by post-surgical adhesions. The survey included 55 multiple-choice questions, four open-ended questions, and four optional questions. The questions were posed to Dutch surgeons and trainees and included information about awareness of adhesions, use of anti-adhesive agents in surgery, informed consent, and benefits versus risks of adhesions. The survey also included items with "correct" answers containing data from evidence-based information about post-surgical adhesions including the following:

-postoperative adhesions are the cause of 70% of small-bowel obstructions-there is a 5% readmission rate after colorectal surgery related to postoperative adhesions

-there is approximately a 30% readmission rate following abdominal surgery due to adhesions

-adhesiolysis poses a 20% risk of accidental enterotomy

-a colonic total resection has highest rate of adhesion-related morbidity compared with partial small-bowel resection, appendectomy, or rectal resection

-being older than 60 is associated with less adhesions


Feb 19, 2015

Prolapse Bladder

When considering rehabilitation of prolapse symptoms, therapists often implement an approach that addresses multiple factors related to pelvic health and function. Rehabilitation of prolapse symptoms may include bladder re-training, pelvic muscle strengthening, bowel health management, trunk and pelvic control strategies, avoidance of potential aggravating maneuvers such as bearing down, and education in management tools such as pessaries. As we have established in earlier posts in this 3-part series, each patient must be evaluated and treated with respect to her complaints and clinical findings. This post highlights a few of the many clinical research studies aimed at determining effectiveness of pelvic rehabilitation for prolapse symptoms.

 

In recent research, Hagen and colleagues completed a multi-center, randomized trial using parallel treatment groups to assess recovery from prolapse. Women with a stage I-III prolapse of any type confirmed by a physician using the POP-Q system and complaints of prolapse symptoms were the primary inclusion criteria. Women who had previously been treated by surgery for prolapse were excluded. The control group (n = 222) were given a prolapse lifestyle advice leaflet and no pelvic floor muscle training. The lifestyle advice included information about weight loss, constipation, avoidance of heavy lifting, coughing, and high-impact exercise. No information about pelvic floor muscle exercise was included.

 

The physiotherapy treatment group (n = 225) received up to 5 individualized sessions of pelvic floor muscle training over 16 weeks. The first appointments were scheduled closer together to allow for proper training in muscle education, with the latter appointments being spread further apart. Rehabilitation began with instruction in pelvic muscle anatomy and function. Exercises were instructed based on results of a pelvic muscle assessment, and exercises were progressed with a goal of up to 10, 10-second holds, and up to 50 quick contractions completed three times per day. Women were also instructed in a pre-contraction of the pelvic floor muscles prior to increases in intra-abdominal pressure. (Electromyography, electrical stimulation, or pressure biofeedback were not allowed among the interventions.)

 


Feb 17, 2015

Tai Chi

Tai chi is described in the National Center for Complementary and Integrative Health’s (NCCIH) introduction as a “moving meditation” that originated in China as a martial art. Slow, gentle movements are combined with awareness and breathing. To watch a demonstration of a short form of Tai Chi Chuan click here. The health benefits of Tai Chi have been studied for a variety of conditions, including research funded by the NCCIH. Examples of topics and populations studied in funded research include bone loss in menopause, cancer-related issues such as fatigue, depression, fibromyalgia symptoms, osteoarthritis, cardiovascular function, and other types of arthritis.

 

A systematic review published last year in Complementary Therapies in Medicine discussed the effects of Tai Chi on quality of life for patients with chronic conditions. Included in the review were 21 articles meeting the criteria of being a randomized, controlled trial, including adults with chronic conditions such as arthritis, asthma, cancer, COPD, diabetes, heart disease, or AIDS, with Tai Chi being the primary intervention that was assessed by an outcome measure. Of the seven studies evaluated for the musculoskeletal system, conditions studied related to post-menopausal osteoporosis, osteoarthritis, rheumatoid arthritis, or fibromyalgia. Quality of life questionnaires were completed by the patients using self-assessment forms.

 

Although the limitations in the study included poor recording of length of time of Tai Chi sessions, or lack of documentation of home program use of the exercise, Tai Chi was found to be a safe and simple approach that improved self-reported functions, both physiological and psychological. An additional benefit that is pointed out in this research is that Tai Chi requires no equipment or particular facility in which to practice.

 


Upcoming Continuing Education Courses

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

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