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Sep 30, 2014

This post was written by H&W instructor Megan Pribyl. Megan will be teaching Nutrition Perspectives for the Pelvic Rehab Therapist in June 2015!

 

Megan Pribyl

Curiosity and innovation: the spark and the journey towards a broad understanding of conditions of complex etiology. These words are the driving force behind the creation of a new Herman & Wallace course entitled “Nutrition Perspectives for the Pelvic Rehab Therapist”.

 

The connection between nutrition and rehabilitation outcomes is at the beginnings of elucidation. An Italian article published in September / October 2014 entitled “What about OMT and Nutrition for Managing the Irritable Bowel Syndrome? An Overview and Treatment Plan” is an example of this emerging integration. The article describes in detail one of the common diagnoses encountered by the pelvic rehab therapist and artfully describes an integrated approach for treatment using both manual therapy techniques (termed osteopathic manipulative treatment) and nutritional guidance. The critical components of the "microbiota-brain-gut" axis are addressed. The conclusion drawn is that combining OMT with appropriate nutrition appears to be an optimal approach in IBS and might represent a promising strategy. Research is emerging en-masse about “microbiota-brain-gut” connections and how it relates to far-reaching aspects of health. Not surprisingly, one of the most influential factors on the status of gut health is nutrition.

 


Sep 29, 2014

Consider how many times we have worked with a patient who refuses to participate in rehabilitation or cancels an appointment because of constipation. Also recall the high number of patients we treat who are in chronic pain and who are also likely taking an opioid medication for pain management. A well-known side effect of opioids is constipation, which can create a viscous cycle: taking the medication can mean having to strain to pass stool, or being bloated which can aggravate an already painful state. Not taking pain medications can increase pain levels, potentially decreasing physical activity levels, another cause for poor bowel function. A recent research article sheds light on this problem, pointing out that, despite a failure of medications in positively treating their constipation, patients are willing to continue on the current course of treatment.

 

The on-going longitudinal study in the USA, Canada, Germany, and the UK aims to assess the burden of opioid-induced constipation (OIC) in patients who have chronic pain that is not cancer-related. Patients were using at least 30 mg of opioids per day for more than four weeks and had self-reported opioid-induced constipation. For the 493 patients who met the inclusion criteria, retrospective chart reviews, on-line patient surveys, and physician surveys were utilized. Outcomes tools included the Patient Assessment of Constipation-Symptoms, Work Productivity and Activity Impairment Questionnaire-Specific Health Problem, EuroQOL 5 Dimensions, and Global Assessment of Treatment Benefit, Satisfaction, and Willingness to Continue. 62% of the patients were female, mean age in males and females was 52.6.

 

Patients complained of bowel dysfunction including abdominal pain and bloating, painful straining to defecate and having flatulence, rectal pain and bleeding, headaches, and having hard stools that were difficult to pass. Most of the patients (83%) wanted to have at least one bowel movement (BM) per day, yet the mean reported BM was 1.4 per week without use of laxatives, and 3.7 BM with use of laxatives. Natural or behavioral therapies were used by 84%, and 60% of the patients used at least 1 over-the-counter (OTC) laxative, 24% used 2 or more OTC laxatives, and 19% used one or more prescription laxatives. Unfortunately, 94% of the patients reported inadequate response to laxative use.

 

Current employment rates for the sample population was 27%, and of these patients, the average reports of missed work due to constipation issues was 4.6±11.9 hours of work over the past 7 days. Even worse, from a pain-management perspective, 49% of the patients reported "…moderate to complete interference with pain management resulting from their constipation." The authors conclude the following: "The prevalence of these symptoms suggests that patients may be undertreating their OIC and/or that the currently utilized therapies for the treatment of OIC may be lacking in efficacy and tolerability." Can we conclude that the under-treatment applies to a lack of pelvic rehabilitation intervention? Granted, opioid-induced constipation by nature of its effects on the gut will in turn affect peristalsis and hydration of stool. However, if a patient learns techniques to stimulate bowel activity, how to manage abdominal bloating and pain, and how to affect the nervous system in a positive way, perhaps less work (and leisure) time would be lost.


Sep 25, 2014

pregnant yoga

An article this year in Canadian Family Physician concludes that "…pregnant women should avoid practicing hot yoga during pregnancy." Have you ever had a pregnant patient ask you if she should use hot tubs, warm pools, use hot packs, exercise in the heat, or participate in hot yoga? As always, the answer to some of the questions may be "it depends," as many factors must be considered including the woman's age, fitness status, pre-pregnancy exercise routines, general health, level of risk, what part of the body she wants to expose to heat, and ability to modify the requested activity. And, most importantly, the biggest driving factors behind our response to our patients is this: is there any known risk for the mother and her baby, and what does her physician say? If there is any known risk to the mother and to the viability of her pregnancy, then we always want to err on the side of caution.

 

What about yoga? Can participating in a hot yoga class increase core temperature and put the growing fetus at risk? The linked clinical reference article above cites some of the following factors as potential reasons why a person should not participate in hot yoga during pregnancy.

•Elevated core temperatures can occur with fever, extreme exercise, saunas, and hot tubs

•First trimester hyperthermia may lead to neural tube defects, gastroschisis, esophageal atresia, omphalocele, and encephaly in the developing fetus

•Heat decreases time to exhaustion, potentially leading to over stretching, muscle and joint injuries

•High temperatures may increase the risk of dizziness or fainting due to effects on blood pressure

 

I can imagine the arguments from all sides of the story, and we know that, especially in a highly litigious society, a medical provider will always suggest the most conservative approach. When the stakes are inclusive of both a healthcare license and the maternal/fetal health of our clients, rehabilitation professionals must also be medically conservative and mindful of the most safe, and effective health practices. Several prior posts have discussed the benefits of yoga during pregnancy, and the article by Chan and colleagues acknowledges that for pregnant women participating in yoga the benefits can include increased quality of life, decreased stress and anxiety, decreased pain, and improved sleep. Is it reasonable, then, to suggest that a woman avoid hot yoga during pregnancy?

 








Sep 24, 2014

This post was written by H&W instructor Michelle Lyons, PT, MISCP. Michelle will be instructing her course "Menopause: A Rehabilitation Approach" in Florida this February.

 

Michelle Lyons

The physiological effects of the decline in circulating estrogen, combined with the aging process, put postmenopausal women at risk of urogynecological dysfunction (Lee 2009). Incontinence, prolapse and sexual dysfunction are common problems, and their symptoms can greatly affect quality of life. Pelvic therapy can offer effective, conservative, and cost effective treatments for these issues.

 

The most significant aetiological factors for the development of prolapse are advancing age and parity (MacLennan et al, 2000). Several studies have investigated tissue metabolism and properties in postmenopausal women with symptoms of prolapse and/or stress urinary incontinence. Links have been identified between these symptoms and alterations in connective tissue and estrogen levels.

 


Sep 23, 2014

male sling

Surgery for prostate cancer can impair urinary function, and in the case of persistent urinary incontinence, patients may progress to surgical interventions. In order for physicians to conduct optimal patient counseling and surgical candidate selection for post-prostatectomy urinary incontinence (UI), the records of 95 patients were reviewed in this study. The patients were retrospectively placed into "ideal", n = 72, or "non-ideal", n = 23, categories based on chosen characteristics, and the results of their outcomes and satisfaction were consolidated. Men in the "ideal" group had the following characteristics: mild to moderate UI, external urethral sphincter that appeared intact on cystoscopy, no prior history of pelvic radiation or cryotherapy, no previous UI surgeries, volitional detrusor contraction with emptying of the bladder, and a post-void residual of < 100 mL. Patients who did not meet all listed criteria for the "ideal" group were placed into the "non-ideal" classification.

 

A cure for the surgery was considered total resolution of post-prostatectomy incontinence with the sling. Of the patients fitting into the ideal classification, 50% reported cure, and of the non-ideal group, 22% reported a cure. Satisfaction rates within the ideal group for the procedure were 92%, whereas the non-ideal group reported a 30% satisfaction. Although uncommon, complications occurring in both groups included prolonged pelvic pain and worsened urinary incontinence. The authors describe the importance of placing the correct amount of tension through the sling, and of leaving as much of the external urethral sphincter in place as possible. Another complication that occurred more frequently is that of acute urinary retention. In the ideal cohort, the 11 cases of urinary retention resolved within 6 weeks of surgery. Of interest is that 12 of the 23 men in the "non-ideal" category had to undergo further surgery with an artificial urethral sphincter.

 

This information can assist surgeons in guiding and advising patients about operative procedures for post-prostatectomy incontinence. (Ideally, every patient would "fail" a trial of pelvic rehabilitation prior to progressing to a surgery!) If a patient wishes to proceed with a sling surgery despite being in a "non-ideal" category, he could be advised of the known potential outcomes. This article offers support for pre-operative investigation techniques such as urodynamics. Our role as pelvic rehabilitation providers may allow us to discuss such research with patients and providers, and participate in discussions about the role of rehabilitation pre-operatively or post-operatively. If you would like to learn more about working with men who have pelvic floor dysfunctions, you still have time to book a flight to Orlando for the Male Pelvic Floor Function, Dysfunction, & Treatment course, where you can learn about male pelvic pain, incontinence and BPH, and male sexual dysfunction. This is the last opportunity to take this course this year!


Sep 19, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy Robinson, PT, PRPC, CLT.

 

Amy Robinson

What/who inspired you to become involved in the pelvic rehabilitation field?:

I first learned about pelvic rehabilitation while I was a student at the Indiana University Physical Therapy program. The instructor brought in speakers for special topics sessions and I must admit I knew at that moment that pelvic rehab was an area of interest for me. However, I was hesitant to start in the area of pelvic health as I felt I needed to gain experience as a new graduate, and I also wasn’t sure I would feel comfortable performing pelvic examinations. I chose to work in a hospital setting for one year, a long term care setting for 2 years, and then transitioned into outpatient physical therapy. There were numerous times in each of those settings that it was apparent pelvic rehabilitation was the missing link in the patients’ treatment plan. In 1998 we had a physician, Dr. Scott Miles, approach the president of the rehabilitation company that I worked for and request that they train a women’s health physical therapist. This was my opportunity and I took my first course with Kathe Wallace, PT. I remember thinking that she was a wealth of knowledge and her enthusiasm allowed me to get over the trepidation of performing pelvic examinations. She allowed me to focus on the examination process itself, how to apply critical thinking to the patient symptoms and evaluation findings, and how to pick the appropriate treatments. I was hooked! I feel very blessed to have had the opportunity to participate in several continuing education courses all over the country from so many very talented Pelvic Health Practitioners and each and every one of them have inspired me in some way to continue to learn and perfect my skills as a pelvic practitioner.

What patient population do you find most rewarding in treating and why?

I truly enjoy treating patients who have a diagnosis of pelvic pain. There are so many different types of pelvic pain and the complexity of the cases fascinate me. I thrive on working together as a team with my client to identify the issues at the root of their pain. There are no two pelvic pain patients who are alike which allows me to create an individualized plan for each patient. It is always very rewarding when a patient who has been suffering with pain for years meets their therapy goals, has the knowledge to self treat, and can complete ADLs and work functions, all being done without pain limiting them.


Sep 19, 2014

digestive system

 

An interesting study assessed the ability of fluorescence imaging to measure the benefits of manual lymphatic drainage (MLD), a key component of complete decongestive therapy (CDT). Lymphatic dysfunction, often developing into lymphedema, affects a significant population of our patients who undergo treatment for breast cancer or pelvic cancer. Complete decongestive therapy includes manual lymphatic drainage, compression bandaging, therapeutic exercise, and specific skin care techniques. A theory describing the beneficial effects of MLD, as explained in this article, is that MLD stimulates a contractile or "pumping" mechanism within the superficial lymphatic system. 

 

 

Although effects of MLD can be measured by limb volume assessment, this study aimed to investigate if in fact contractile function is improved. The investigators used near-infrared fluorescence, or NIR fluorescence, to measure "…the apparent propulsive lymph velocities..and…the period or time of arrival between successive propulsive events." Twelve subjects diagnosed with Grade I or II unilateral lymphedema and 10 controls were included in this research and were treated by a certified lymphedema therapist. The manual lymphatic drainage preparatory protocol for an involved upper extremity included lymphatic massage to the cervical lymph nodes x 5 minutes, then the neck, axillary region of the contralateral arm, and the ipsilateral inguinal region. Lower extremity MLD also started at the neck, then treatment was directed to the contralateral inguinal nodes and ipsilateral axillary nodes. The control subjects received massage to the neck for 3 minutes, bilateral axillary region massage x 5 minutes or bilateral inguinal regions, depending on if the upper or lower limb was imaged in the study. The appropriate limb was then treated with MLD massage techniques. 


Sep 18, 2014

A recent on-line survey queried fourty-four Obstetrician-Gynecologists (OB-GYNs) in British Columbia to learn more about the needs of physicians who treat women who have endometriosis and chronic pelvic pain (CPP). Physicians reported that women who present with endometroisis or chronic pelvic pain usually require more visits than other patients, for reasons including medical and pain management, lack of a clear diagnosis, and lack of improvement in condition. Evaluation techniques utilized by the physicians often included laparoscopy and ultrasound, and despite these practices, the OB-GYNS reported challenges in making a diagnosis or successfully treating their patients with CPP. In fact, survey results indicated that 5% of the respondents were able to diagnose a patient for a cause of pelvic pain in > 70% of patients. Most of the physicians reported that less than half of the women treated had a good response to interventions. Although the highest rate of referral for these providers was to another OB-GYN specializing in pelvic pain, nearly 60% of the time a referral to physical therapy was reported. 

 

 

Although some of the narrative comments encountered in this survey were positive, including one physician's report of having "…good success with physiotherapy…", more often the providers expressed frustration and annoyance when faced with not only the challenges of diagnosis and treatment, but also the poor compensation and the longer visits required for counseling and teaching of patients. In addition to wanting more clear guidelines on diagnosis and management of female CPP, physicians expressed interest in having group educational sessions for patients, and more resources such as educational brochures on self-management for patients.

 

 

How can pelvic rehabilitation providers fill in this knowledge gap? I recall asking a referring provider if he was pleased with his patients' rehabilitation outcomes, and he expressed such a relief that I was taking the "dregs of the practice." He meant nothing disparaging about the patients themselves, he explained, just that when these patients walked in the door he felt a sinking feeling because he did not know what to do for them. Now, he reported, these same patients were returning from a pelvic rehabilitation referral and excitedly reporting on progress they had made. So many physicians and other referring providers still do not understand the scope of the patient populations that we can treat in pelvic rehabilitation. We can provide a necessary bridge between the challenge of diagnosing and medically treating chronic pelvic pain and the rehabilitation approach that addresses the chronic pain issues. Differential diagnosis of chronic pelvic pain from a rehabilitation standpoint is a skill set  that every therapist must continually improve upon. If you are interested in learning more about these skills, sign up for faculty member Peter Philip's continuing education course Differential Diagnostics of Chronic Pelvic Pain next month in Connecticut. 


Sep 15, 2014

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal), when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

 

 

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness.  Surface electromyography (sEMG), a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia. 

 

 

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation. 


Sep 15, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy C. Sanderson, PT, OCS, PPRC.

 

Amy Sanderson

Describe your clinical practice.:

I am a co-owner of a private physical therapy practice in the Spokane, Washington area. We currently have 3 clinics and staff 14 providers overall. I have been an Orthopaedic Certified Specialist since 1996, and our clinic is primarily an orthopedic setting. We do, however, provide several specialties, including Pelvic Rehab, Vestibular Program, and Video Gait Analysis for athletes.

How did you get involved in the pelvic rehabilitation field?

I have been practicing since 1993 and began a Women’s Health program in 1994 at a previous place of employment. When I had interviewed for the position of a staff physical therapist for this clinic, I was asked if I would be interested in starting any new programs for the company. The manager had recommended that I develop a Women’s Health program. Truthfully, I had not heard of Women’s Health in the early 90’s, but I really wanted the job, so I said “absolutely!” I figured that I was a woman and I knew some things about health, so how hard could it be. Countless hours of continuing education and several years of marketing to the local physicians and community, we have now built our Pelvic Rehab program up to 3 physical therapists providing treatment to all of our clinics in the Spokane, Washington area.


Upcoming Continuing Education Courses

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College

Pelvic Floor Level 2B - St. Louis, MO (SOLD OUT)
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic

Pelvic Floor Level 3 - Derby, CT
Dec 12, 2014 - Dec 14, 2014
Location: Griffin Hospital

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performace Center

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Menopause: A Rehabilitation Approach - Orlando, FL
Feb 21, 2015 - Feb 22, 2015
Location: Florida Hospital Sports Medicine and Rehabilitation

Breast Oncology - Phoenix, AZ
Feb 21, 2015 - Feb 22, 2015
Location: Spooner Physical Therapy

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center