While recently researching the topic of fibromyalgia, I came across literature related to the phrase "emotional disclosure." I thought that the phrase is a perfect way of describing what often happens when we are in the clinic working with patients. I know that all of you, regardless of your caseload in pelvic rehabilitation, have worked with patients who have symptoms of fibromyalgia or chronic fatigue syndrome (I mean them as separate entities although research questions if they are one and the same.) And regardless of the patient having a diagnosis of fibromyalgia, the fact that so many of our patients emotionally break down in our presence once they recognize that first, we believe them, and second, we have some strategies to offer towards healing, makes this an interesting topic.

Back to the research. One article describes the relationship between depression, anxiety, and the tendency to "engage in diminished emotional disclosure." The authors found that in the college students who participated in the study, depression was tied to the tendency to avoid emotional disclosure. From a psychological stance, increased disclosure in a counseling session was found to lead to a "deeper" session. Interestingly, not all patients benefit from emotional disclosure, and there is limited evidence in randomized, controlled trials to know which patients should be encouraged to share.

While most pelvic rehabilitation providers are not licensed psychologists or other mental health and behavioral specialists, disclosure happens. We should not be engaged in trying to get a patient to discuss prior trauma or emotional issues unless he or she initiates the dialog or unless we are screening the patient for adverse events so that we can be sensitive to the patient's needs. As the patient is often discussing intimate and emotionally-charged symptoms with us, it is very typical that trust develops quickly in the therapeutic relationship. It is this trust that may allow the patient to feel safe enough to share information about life stress, prior injuries (emotional or physical), and to share feelings of how their physical symptoms impact other domains in life. 

In the current issue of the journal Physical Therapy, Wang and colleagues describe the characteristics of patients (and their pelvic floor diagnoses) presenting for outpatient physical therapy. 109 outpatient clinics participated in this data collection and included information about 2452 patients. The system used for collecting data is FOTO (Focus On Therapeutic Outcomes), and you may have heard the results of this research presented at the most recent Combined Sections Meeting of the American Physical Therapy Association. The results of the study include that most of the people presenting to the clinics for pelvic floor dysfunction were women (92%), and that many reported a combination of urinary, bowel, or pelvic pain symptoms. The authors found a mean patient age of 50 with a standard deviation of 16. Most patients reported symptoms as chronic (74%). You can see from the following chart that is adapted from the article that subgroups of patient populations were noted, and the categories used for reporting include urinary disorders, bowel disorders, and pain (not all subgroups of combinations of pain are included in the chart below.) In general, 67% of the patients reported urinary dysfunction, 27% reported bowel dysfunction, and  39% reported pelvic pain. 

The National Association for Continence (NAFC) has recently created a press release naming the Women's Pelvic Health & Continence Center and the Woman's Hospital of Texas a "Center of Excellence (COE): Continence Care in Women." The release highlights the fact that this is the first time a community hospital as well as a private group of physicians have been given this award. A healthcare institution that meets the pre-qualification requirements can apply and then independently collected patient satisfaction data, a site visit, and employee interviews make up part of the rigorous process that can, upon award of the COE designation, help patients find centers of care that the NAFC can stand behind and promote. 

Fatima Hakeem, physical therapist and director at Woman's Hospital of Texas, has created the foundation for program development and excellence at her facility which won this prestigious designation. Many of you may know Fatima as an educator, mentor, author, or by the work that she has created for marketing and developing the business of physical therapy. Her advice towards developing a women's health practice was featured in the physical therapy magazine "Advance" in 2005, click here to read the article. She has authored various publications related to the practice of women's health physical therapy, including chapters in Irion and Irion's Women's Health in Physical Therapy. Fatima's accomplishments are many, and you can learn more about the steps on her journey by visiting her website: fatimahakeem.com. 

Fatima, along with Holly Herman, founding faculty of the Institute, made an epic journey to Saudi Arabia where they took on an 11 day comprehensive women's health training of more than 30 women. (Click here to see the blog post about that trip!) Both educators and the Institute were honored by the Princess herself. Their next travels will be to Dubai later this year, keep an eye out for a blog update about the upcoming trip and learn where the Institute and esteemed educators such as Fatima and Holly will be sharing their wealth of knowledge. There are many women who have paved the way for the growing numbers of pelvic rehabilitation providers, and through tremendous efforts and acts of generosity they have and will continue to provide opportunities for therapists in this country and abroad. Opportunities to offer support and skilled care for other women and men who so desperately need to hear that their conditions can be alleviated or improved. Hats off to Fatima for her dedication to the profession and to her facility, which is now celebrating a "Center of Excellence" award!

The prevalence of urinary incontinence in women who have multiple sclerosis (MS) is dramatic, according to research recently published in the International Neurourology Journal. The authors conducted the study within a treatment center that is dedicated to the care of patients with MS. Out of the 143 women surveyed, stress UI occurs in 55.9%, urge symptoms in 70.6%, and 44.8% had both stress and urge symptoms, also known as mixed incontinence. The authors report that the condition of UI significantly impacts quality of life (QOL.) The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) were utilized to collect data about both stress and urge urinary symptoms and QOL impact. Women in the study ranged in age from 20-72 years of age, and the subjects who reported stress urinary incontinence were older and tended towards a higher body mass index (BMI). The women with complaints of stress UI  also scored higher on the Incontinence Impact outcomes survey as it related to physical activity. This article is available for free in full-text format by clicking here. 

One of the challenges for the patients who have MS and for the providers who work with them is the potential fluctuation in symptoms. This chronic neurologic disease is characterized by "flare-ups" that usually require a period of medical intervention followed by a time of recovery in which the patient often has to gradually return to prior levels of function. Neurologic lesions of MS can occur in varied levels of the nervous system, thereby influencing the neurologic control of the urinary system to a varying extent. If a patient is going through a flare-up it may be best to limit the amount of intervention such as strengthening of pelvic muscles until the exacerbation has eased. Some patients are fortunate to experience periods of relative stability in symptoms, even so, fatigue and the risk of increasing fatigue through overactivity is significant. During your subjective history taking, you can inquire of the patient how the disease has tended to manifest for him or her, and then inquire about stability of symptoms and the patient's warning signs for fatigue. It is also important to screen for signs of a urinary tract infection (UTI), as UTI's  frequently occur in this patient population. Regarding objective examination, it is imperative to assess the patient's current level of pelvic muscle awareness, strength, sensation, coordination, and endurance. The patient may return for another bout of care at a different time and present with very significant differences in level of function, therefore it is not safe to assume that the patient has a similar baseline to the last bout of therapy.

As many of you know, the Herman & Wallace Pelvic Rehabilitation Institute is currently developing a Pelvic Therapy Practitioner Certification process (PTPC). As part of the multi-step process involved in the development of a robust certification, the job task analysis survey was completed by more than four hundred providers (403 to be exact.) The Institute was thrilled that so many current, past, or future course participants believe in this process so strongly that even a seemingly endless survey could not deter you from completing the tedious, yet crucial questions that were posed. In another step of the process that occurred after the results of the survey were tallied, I was able to view the tables of responses and I found the information very interesting- I thought that you might also be interested to know a bit more about the answers that we received in the survey.

Keeping in mind that the pelvic rehabilitation specialty is one that is not as well-represented in the clinic as orthopedics, for example, and yet is a specialty that is gaining in popularity, it was interesting to note that nearly 1 in 5 therapists completing the survey had less than one year of experience working in pelvic rehabilitation. Approximately 82% of the more than 400 people completing the questions has been working within pelvic rehabilitation for 10 years or less. In terms of the education of the people represented, the highest degree earned at the time of the survey was a doctorate for 41.4% of people, with 8.4% of those represented by transitional doctorate degrees, and less than 1% by an academic doctorate.

Several people indicated that they had board certifications in either cardiovascular and pulmonary (2), geriatrics (2), neurology (1), pediatrics (1), sports (3), and orthopedics (23), or women's health (17). Other qualifications listed by those completing the survey included LANA certification for lymphedema therapy, manual therapy certifications, yoga, Pilates, and biofeedback certifications, to name a few that appeared frequently.

Hopefully you are enjoying the heat of August, and staying cool while we enjoy record breaking heat in many states. This time of the summer is often when we feel the panic of the season slipping away, preparing to enter into the fall season of back-to-school and changing our wardrobes. It may seem slightly out of season, then, to discuss handwarming at a time when most of our hands are staying pretty toasty, but it is such a simple, tangible, and effective clinical tool that it is worthy of a blog post. Hand warming, also described as temperature biofeedback, is a form of self-regulation that allows a small probe to be heated, or warmed, by the skin temperature. Recall that biofeedback is a broad term that describes an approach in which a subject is given some type of information, perhaps in the form of an audio or visual signal, which is related to the subject's physiologic response to an intervention or experience. 

According to the very thorough textbook "Biofeedback: A Practitioner's Guide" by Mark Schwartz and Frank Andrasik (3rd edition), the measurement of changing skin temperature is meaningful because sympathetic arousal is correlated to vasoconstriction. When the nervous system is calmed, and the blood vessels dilate, more heat is allowed into the local vessels thereby increasing local temperature. I was first introduced to the clinical tool of "handwarming" using a thermistor by Janet Hulme who taught a wonderful course on the topic of fibromyalgia. On her website she offers a device called the PhysioQ for $25. That seems like the going rate for many of the devices on the market, including this "stress thermometer" sold by bio-medical.com. The bio-medical site also has a terrific page explaining the concept of handwarming as well as specific strategies to apply for teaching its use. Click here to access that page.

The instruction in the clinic of handwarming can be billed as part of your home program training. In this time of decreasing reimbursement and emphasis on self-care, a device such as a thermistor could be a perfect training tool for your patient who wants to continue to manage stress, tension, and to use handwarming as a part of his or her rehabilitation program. The great thing about devices that give feedback is the instant gratification and measure of success that a patient can achieve when the ability to monitor and influence physiologic measures is seen. A thermistor typically has a wire that terminates in a sensor that can be attached (with tape or a little piece of velcro) to the underside of a fingerpad. The readout is observed in degrees, and some devices will have the ability to set goals or use tones for audio feedback. The use of a thermistor has been documented in the literature for the treatment of Reynaud's syndrome, migraines, and other conditions that have a stress-related component. 

I have seen several articles talking about the “Grey Effect.” The idea is that the incredibly popular book series beginning with “Fifty Shades of Grey” has created a frenzy of female sexual interest. (When I say “incredibly popular” the series has allegedly outsold the paperback Harry Potter series…) I won't go into detail about the book, or about the various critiques and controversies, let's save that for the people who are well-poised to do so. In a nutshell, the book series contains “explicitly erotic scenes.” Reports suggest that the book series craze is sending women in droves to the sex toy shops and is giving women permission to explore their sexuality. What does that have to do with pelvic rehabilitation? 

The book may be a topic of discussion with our patients and this in itself may encourage us to explore our own comfort zones related to sexual health. How do you respond when a woman says that she has pelvic pain, is using a sex toy to stretch the vaginal opening, but her husband's penis is much bigger than the toy and she still has pain? How do you give advice about masturbation- or do you? What is the correct response to "my partner thinks I should be able to have an orgasm with penetration?" The replies to any of these questions depend on several factors, such as your level of knowledge about sexual health including anatomy and physiology, your own belief systems, the standards and culture at your place of work, as well as your understanding of sexual practices that are different from your own. What are the ethical issues that surface when faced with the above questions? If you are outside of your comfort zone and do not want to talk about sexual function, is it ok to say so, or are you denying your patient access to available information? How much do you share, knowing that these conversations are intimate and potentially confusing if your patient has poor boundaries? What if a patient asks you some questions and you are feeling unclear about the patient's motivations? These are really good topics for discussion, and outside of giving comprehensive answers, I would like to point out some ideas and resources that may be helpful to you. The Herman & Wallace Pelvic Rehabilitation Institute offers several courses that provide education about sexual health and function or dysfunction. All courses in the series discuss sexual function to some extent, and the Level 3 course has quite a bit of detail about sexual health. The Male course discusses rehabilitation of male sexual function, and there is a newer class instructed by Heather Howard, PhD, all about sexual interviewing and counseling. 

PF1 Boston is almost SOLD OUT! Register today to save your spot.

This course is taught by Institute founders Holly Herman, PT, DPT, MS, OCS, WCS,BCB-PMD and Kathe Wallace, PT, BCB-PMD. Pelvic Floor Function, Dysfunction and Treatment 1 is a prerequisite to many of our other courses and is offered two more times in 2012.

If you can't make it to PF1 Boston, try checking out the following courses:

A colleague recently sent an inquiry through the Institute asking if there is new research supporting pelvic floor muscle training after radical prostatectomy. As a matter of fact, I chose not to report on some recent research that I read, because it does not support conservative care for urinary incontinence (UI).  The Cochrane review for postprostatectomy UI was updated this year, and the results of the review indicate that we need more and better research. (If you are unfamiliar with the Cochrane library, one of its 6 databases contains systematic reviews of the literature that are updated periodically.) Although within the abstract of the review the report states that there is a lack of consistency in the interventions, the populations, and in the outcome measures, the value of conservative approaches is deemed "uncertain." The authors do conclude that benefit from one-to-one pelvic floor muscle training is "unlikely" following transurethral resection of the prostate, or TURP. 

The critiques of the research listed in the review include the above mentioned lack of consistency in outcomes and interventions. Most of the studies also did not include a report of pre-surgical outcome status, of adverse effects, and lifestyle changes as an intervention was never identified in any of the research. This leads us to this question: why are we treating men for UI or erectile dysfunction (ED) if this systematic review brings into question the efficacy of what we do? Certainly patients are improving as a result of pelvic rehabilitation, or I doubt that the medical providers would continue to refer patients to the offices who provide rehabilitation to these patients. What we do not know about each of the studies is how much of the male anatomy was affected by the procedure for the prostate. The patient's pre-surgical status and the skill level of the surgeon are both known factors for outcomes following prostatectomy, yet how are those quantified in the literature?

Most importantly, how can we be a part of the solution when it comes to creating research to support the services that we provide. It may be helpful as therapists to be certain that we are maximizing the level of knowledge about the surgeries, the anatomy involved, and about the available treatments. This can mean attending coursework that is specific to or includes discussion of male pelvic floor issues. (Check out the Pelvic Floor Series level 2A course or the Male Pelvic Floor Courses offered by the Institute, especially if more male patients are finding their way to your door.) Speak with referring physicians about surgical techniques, observe some surgeries, or attend a urology conference (maybe there's one near your hometown, or you want to attend with your local referring urology group.) Always document using outcomes studies when you can. Write a case study. You can even purchase a text book that teaches you step-by-step how to write a case study. I know that you don't have time...so, create a weekly lunch meeting at work with a colleague where you each work on and critique each other's project. Getting involved with local university programs can also allow you to be part of the research solution. 

What pelvic symptoms can vitamin D deficiency be causing in our pelvic rehab patients? 

Vitamin D deficiency has been researched heavily in relationship to topics such as autism, fertility, multiple sclerosis, orthopedic health, muscular pain, osteoporosis, as well as pelvic floor health. Deficient levels of the vitamin have been reported as reaching "pandemic" levels, with risk factors including old age, dark skin, obesity, Chrohn's disease, occupations that require indoor activity, or living in cultures that require covering of face and body. The use of sunscreen to prevent UV exposure has also been linked to poor vitamin D levels as the sun is one way that we receive vitamin D. 

Following is a brief list of research that has linked vitamin D to pelvic health issues: