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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.


Feb 13, 2015

Tarlov Cyst

Some of our patients will present with sacral or coccygeal pain, and the potential causes of this pain are numerous. One potential cause of sacrococcygeal pain is a Tarlov cyst, which occur when the nerve root sheaths are swollen and fill with cerebrospinal fluid. The condition can be very painful and can affect bowel, bladder, and sexual dysfunction due to the location of the nerves that may be compressed from the swelling. To learn more about the possible causes of Tarlov cyst formation, you can find a lot of information on the tarlovcystfoundation.org site. Symptoms might include low back and buttock pain, neurologic symptoms in the lower extremities, pain with sitting, and swelling over the sacral area. Pelvic dysfunction including bowel or bladder changes, rectal or vaginal pain, or painful intercourse can occur. The pain might worsen with forward flexion due to nerve tension, and pressure changes in cerebrospinal fluid can contribute to headaches or vision disturbances.


Unfortunately, most of our patients present with some or all of the above complaints, so how do we participate in the process of determining when the patient needs to return to a medical provider? In addition, these cysts might be discovered as an “incidental” finding on an imaging study, and the medical provider may complete further tests to determine if the cyst is causing the patient’s symptoms. The most important aspect of screening for dysfunction such as a Tarlov cyst, which can progress to significant neurologic impairment if symptomatic and eft untreated, is keeping track of our patient’s symptom progression and neurologic signs. Getting a baseline lower extremity neurologic screen for every patient with pelvic pain or dysfunction is an critical skill so that we can communicate any significant worsening or lack of progress to the medical provider. Such a lower extremity neurologic scan should include sensation testing, deep tendon reflexes, and signs such as Babinski and clonus tests.


Patients will also present to pelvic rehabilitation after having had a Tarlov cyst repair. Surgeries can include drainage of the cyst followed by use of a fibrin glue to occlude the cyst in hopes of preventing recurrence. The American Association of Neurological Surgeons points out on their website that surgery may not eliminate the patient’s symptoms, and care involving supervised pain management may be appropriate. From a rehabilitation standpoint, these patients may or may not be finding their way to a pelvic rehab practitioner. Is there a provider in your area who may be treating these patients and who is not aware that you have skills to offer? Interventions such as pain management strategies, modalities, movement therapy, manual therapy, treatment directed to neurodynamics, and general wellness education may all play a role in helping patients recover from procedures for Tarlov cysts.


Feb 11, 2015

New Updates to the Male Course

Many of us in pelvic rehabilitation started out working exclusively with female patients and within the realm of urinary dysfunction. As our caseload broadened and the recognition that a "simple" case of urinary dysfunction was about as common as a "simple" ankle sprain, our education and clinical skills branched out to meet the needs of our patients. Many therapists had to extrapolate what they knew about women's anatomy and pelvic rehabilitation and apply that knowledge to men. (Even despite some therapists' insistence that their caseload should focus on women, the men who were desperate for care would show up anyway!) So what is different about men, and why is there a need to understand not only the common dysfunctions they face, but also how men tend to approach health care?


To begin with, men have significant barriers to healthcare, including lack of a primary caregiver. (Grant et al., 2012) Although men may have greater social privileges than women, that privilege also comes with social pressures to be more dominant, more in control and to be less emotional. (Fleming et al., 2014) These barriers and pressures may make it difficult for a man to seek the healthcare that can improve his state of well-being. Therapists can familiarize themselves with approaches to communication and providing support that fit within the context of the individual patient, allowing him to learn needed strategies while still maintaining a sense of empowerment.


Men also tend to have different pelvic dysfunctions than women. Anatomically, a longer urethra means that men tend to suffer fewer urinary tract infections. Without the physiologic needs for childbirth, men are designed with a smaller pelvis, larger bony attachments for muscles, and decreased rates of prolapse and abdominal wall separation. Men do, however, tend to have higher rates of dysfunctions such as inguinal hernias, and may be more prone to rectal prolapse than rectocele. Prostate cancer, the most common cancer among men, can also lead to significant urinary and sexual dysfunction following surgery or other treatments. As pelvic rehabilitation providers, we want to be best prepared to answer questions about all domains in men's health, whether the concerns relate to bowel, bladder, sexual dysfunction or pain.


Feb 10, 2015

Prolapse Bladder

Measuring pelvic floor function and dysfunction is an emerging clinical science. Researchers and clinicians including Kari Bo, physiotherapist from Norway, have contributed tremendously to the field of pelvic rehabilitation. In an article by Bo and Sherburn published in the Journal of Physical Therapy, the authors describe methods of evaluating pelvic floor function as being divided into measuring of contraction ability (clinical observation, vaginal palpation, ultrasound, MRI, or electromyography (EMG)), and measuring of strength quantification (manual muscle test via vaginal palpation, manometry, dynamometry, or cones.) The authors state that while each method has their place in rehabilitation, each also has limitations. In addition to understanding the best methods for examining pelvic muscle function, we can also consider the techniques that are most useful in examining pelvic organ prolapse.


In standing, gravity exerts increased force on the tissues of the pelvis and pelvic floor, therefore, prolapse may be more easily and accurately identified in the standing position. Frawley and colleagues have pointed out that because the provocation of prolapse is higher in standing than in sitting for most patients, rehabilitation testing in standing may be more reflective of functional pelvic floor muscle activity. Research has also concluded that digital (using an examining finger) pelvic organ prolapse examination in supine is unreliable. In standing, however, the same article reports that quality of life and symptom impairment do correlate with digital pelvic floor muscle testing.


Although it has been established that physiotherapists can reliably utilize the pelvic organ prolapse quantification (POP-Q) protocol, POP-Q staging and ordinal scale staging (scoring on a 0-4 scale) have been found to be similar in identifying prolapse. This brings us to the question of how to clinically evaluate for pelvic organ prolapse in standing. Therapists use a variety of strategies for assessing a patient in standing, including:

- Ask patient to sit or squat over opening in table (you may or may not have such a table)

Jan 30, 2015

Female Pelvis for Drawing

One of the challenges we see in pelvic rehabilitation is an issue that we can observe across many conditions: an individual who may not appear to have significant objective signs can have significant impairments, while someone who presents with major physical dysfunction has mild or no complaints. Within the gynecologic literature, the question of "what is a significant level of prolapse" has been a frequent question, and usually a question that lacks specific answers. Looking at some of the research helps to highlight the clinical query and to demonstrate some of the research conclusions.


- When the authors Swift et al. (2003) attempted to correlate patient symptoms with level of pelvic organ support in a general population of 477 women, they found that women who presented with Stage II and stage III prolapse have increased symptoms. They suggested that these findings may help define POP levels that are symptomatic. (None presented with stage IV prolapse in the study.)

-Broekhuis et al. (2009) make the point that while pelvic organ prolapse (POP) and pelvic organ dysfunction symptoms can occur at the same time, they can also occur independent of each other. The only symptom in their study (n = 69) that correlated positively with degree of pelvic organ prolapse was having a sensation of or being able to see a vaginal bulge.

-In a similar study correlating the level of perineal descent with pelvic symptoms, the authors found that prolapse symptoms were associated with degree of perineal descent, but urinary incontinence and anorectal symptoms were not associated with level of descent. The study states that " …the clinical …impact of perineal descent in urogynecology is still unclear at this time point." (Broekhuis et al., 2010)


Jan 29, 2015

Relaxation Training for UI

How does pelvic floor muscle function differ in women with symptoms of overactive bladder compared to symptomatic women? A study completed by Knight and colleagues included determining if pelvic floor muscle surface electromyography (EMG) and pelvic floor muscle (PFM) performance were different among these groups. Scores regarding anxiety, life stress, and quality of life were assessed. Symptoms of overactive bladder can include urinary urgency, frequency, nocturia, and leakage of urine. Subjects in this study had "dry" overactive bladder, meaning that the patients did not experience leakage associated with the urgency.


28 women with urinary urges and frequency were age-matched to 28 asymptomatic controls. Participants completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Recent Life Changes Questionnaire. Surface EMG was utilized to assess pelvic floor muscle function. Results of the study included that women with urinary urgency and frequency had significantly more anxiety than women in the control group. Surface EMG measures (pathway vaginal sensor was used with self-placement) were not significantly different for ability to contract or relax the PFM. Scores on the PFIQ and the RLCQ were significantly higher for women with overactive bladder. The authors conclude that, although a causative relationship could not be made between overactive bladder and anxiety, there exists a relationship between the two conditions.


Another interesting study which compared interventions of yoga versus mindfulness for women who have symptoms of urinary urge incontinence found that mindfulness-based stress reduction was effective for reducing urinary incontinence episodes whereas yoga was not. This study followed a pilot directed by the same primary investigator which showed similar positives results of mindfulness training on urinary urge incontinence.


Jan 21, 2015

Are you eligible to become pelvic rehab certified?


The rigorous and psychometrically validated Pelvic Rehabilitation Practitioner Certification (PRPC) will be offered for the third examination this year. You still have time to join the nearly eighty practitioners who have earn their letters! (Keep in mind that, different from a "certificate", this certification allows you to use the designation "PRPC" after your name, helping to distinguish you as an expert in pelvic rehabilitation. In case you are uncertain if you are a candidate to sit for the PRPC examination, check out some commonly-asked questions below.


Types of practitioners: Do I have to be a physical therapist?


You do not need to be a physical therapist in order to apply for the PRPC exam. What is required is that you have a license to practice the skills utilized in pelvic rehabilitation. Such a license may include physician (MD, DO, ND), registered nurse (RN), occupational therapist (OT), advanced registered nurse practitioner (ARNP), or physician assistant (PA-C). Any other provider can apply and will be examined on a case-by-case basis.

Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Seattle, WA (SOLD OUT!)
Apr 03, 2015 - Apr 05, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Myofascial Release for Pelvic Dysfunction - Tampa, FL
Apr 10, 2015 - Apr 12, 2015
Location: Florida Hospital - Wesley Chapel

Lymphatic Drainage for Pelvic Pain - Scottsdale, AZ
Apr 11, 2015 - Apr 12, 2015
Location: Evolution Physical Therapy

Assessing and Treating Vulvodynia - Minneapolis, MN
Apr 11, 2015 - Apr 12, 2015
Location: Park Nicollet Clinic--St. Louis Park

Pelvic Floor Level 2B - Columbus, OH (SOLD OUT)
Apr 17, 2015 - Apr 19, 2015
Location: Ohio Health

Athlete and the Pelvic Floor - New York City, NY
Apr 18, 2015 - Apr 19, 2015
Location: Kima - Center for Physiotherapy & Wellness

Pudendal Neuralgia Assessment and Treatment - Salt Lake City, UT
Apr 18, 2015 - Apr 19, 2015
Location: University of Utah Orthopedic Center

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