Senior faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC sat down with the Pelvic Rehab Report to talk about the role pelvic therapists play on the oncology team that will work with the patient throughout treatment and into survivorship and the impact pelvic health has on quality of life for people with cancer.

Alison is part of the HW faculty team that wrote and instructs the Oncology course series, the next course is Oncology and the Pelvic Floor Level 1 on January 27-28, 2024.

Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. She worked with breast cancer, lymphedema patients, head and neck cancer patients, and the overall oncology team to work with the whole patient to help them get better. When writing these courses, Allison was part of a knowledgeable team that included Amy Sides and Nicole Dugan among others.

September is Ovarian Cancer Awareness Month. According to the American Cancer Society, in 2023 about 19,710 individuals with ovaries will receive a new diagnosis of ovarian cancer. About 13,270 individuals will lose their battle with the disease (1). Ovarian cancer is the deadliest of all gynecological cancers. However, the incidence rates have decreased by 1 to 2% each year from 1990 to the mid 2010s; and by 3% per year from 2015 to 2019 (1).

This is partially due to increased usage of oral contraceptives in the last half century, and the decreased usage of hormonal therapy in menopausal individuals (1). Researchers are continually looking to find ways to help fight ovarian cancer. From the use of new targeted therapies, to hormonal therapies, to surgeries; doctors and researchers are doing what
they can to try to prolong the lives of individuals who have this diagnosis.

Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series as well as created the Rehabilitative Ultraosund courses.. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. You can join Allison in her upcoming two-day course September 29-30  (Rehabilitative Ultrasound: Orthodedic Topics) or the extended three-day course Rehabilitative Ultrasound: Women's Health and Orthodedic Topics that is through October 1st. You can also see Allison at HWConnect in the vendor hall  where she will be doing ultrasound demonstrations. HWConnect is being held in Seattle, Washington this October 6-8, 2023.

“The widespread use of imaging has the potential to change the management of pelvic floor morbidity, such as urinary and anal incontinence, pelvic organ prolapse and related conditions ………. the insights provided by real-time imaging will enhance diagnostic and therapeutic capabilities.”¹ This is a quote from an opinion article in Obstetrics and Gynecology by Hans Peter Dietz.  Dietz has been researching the use of ultrasound and how it can assist in the diagnosis and treatment of pelvic floor disorders for years.  I couldn’t agree more with this quote!  Over the last 20 years that I have been using US imaging in my practice, I have seen more and more clinicians embrace ultrasound and let it change how they treat patients. 

Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. She worked with breast cancer, lymphedema patients, head and neck cancer patients, and the overall oncology team to work with the whole patient to help them get better. When writing these courses, Allison was part of a knowledgeable team that included Amy Sides and Nicole Dugan among others.

As pelvic rehab professionals, we know the importance of the microbiome of the digestive tract and how this can influence issues our bowel patients may experience. You also may know that the GI microbiome can influence immune function as well as mental health. Did you know that the urinary bladder has its own microbiome? Recent developments in next-generation sequencing and bioinformatic platforms have allowed for the detection of microbial DNA in the urinary tract.(1) This could be a game changer for those who suffer from chronic urinary tract infections. However, it could be even more important as a way to prevent bladder cancer. May is Bladder Cancer Awareness Month. In honor of this month, let’s further discuss how the urinary microbiome may influence the development of bladder cancer.

Dysbiosis of the urinary microbiome could be related to bladder cancer through chronic inflammation in the urothelial microenvironment. Chronic inflammation is a hallmark of genomic instability and the development of cancer. A study in 2021 compared the urinary microbiome of patients with muscle-invasive and non-muscle-invasive bladder cancer. They found the microbial profiles differed in patients with cancer compared to healthy individuals. They also found that there were different microbial profiles from the less invasive non-muscle invasive versus the more invasive types of bladder cancer.(2)

Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. She worked with breast cancer, lymphedema patients, head and neck cancer patients, and the overall oncology team to work with the whole patient to help them get better. When writing these courses, Allison was part of a knowledgeable team that included Amy Sides and Nicole Dugan among others.

When diagnosed early, testicular cancer can be very curable and have more favorable outcomes. However, the US Preventative Services Task Force recommends against regular screening for testicular cancer. It is classified as a Grade D recommendation. This means they do not recommend clinical screening in asymptomatic individuals, or teaching patients to perform self-exams because they do not have certainty that screening has a benefit. However, recently several authors are asking for reconsideration to change the rating to a Grade B. A grade B classification is recommended when there is a benefit from doing the screening. These researchers are arguing that new studies support the benefits of regular screening by patients and their physicians. They further argue that not only will earlier diagnosis help with more favorable outcomes but that the current grade confuses individuals about the importance of self-care and wellness and reinforces negative cultural attitudes about wellness and screening. 

We have several self-screens that we should be doing regularly; dermatological skin checks, vulvar skin checks, and self-breast exams. It makes sense to me to include a quick check of the testicles as well. 

Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. She worked with breast cancer, lymphedema patients, head and neck cancer patients, and the overall oncology team to work with the whole patient to help them get better. When writing these courses, Allison was part of a knowledgeable team that included Amy Sides and Nicole Dugan among others.

March is Colorectal Cancer Awareness Month. Did you know that the incidence rate of colorectal cancers is increasing? According to the International Agency for Research on Cancer, 1.9 million new cases of colorectal cancer were identified worldwide in 2020. This number is expected to grow even more. It is predicted that by 2040 the number of new cases of colorectal cancer will rise to 3.2 million new cases a year, and 1.6 million annual deaths worldwide. Additionally, did you know due to the fact that the incidence rate is increasing and it is being diagnosed in younger individuals, the age for screening for colorectal cancer has lowered to 45? At age 45 individuals should begin regular screening for colorectal cancer either via stool-based testing or visual-based screening via a colonoscopy. If someone has risk factors they may need to begin screening at a younger age. 

Colorectal cancer can often be preventable through modifiable risk factors. Changing some of these risk factors, alongside the detection and removal of precancerous lesions can lower someone's risks.  However, if a diagnosis is made, treatment can help to prolong the life of the patient. The treatment can include various surgeries, chemotherapy, and radiation. All of these treatments can cause changes to a patient's body. A rehab professional that has knowledge about both the body and how the medical treatment of cancer causes changes, can make all the difference in the world for that patient returning to activities that they enjoy and love after treatment.

If you work with orthopedic patients, I am sure that you have had a back-pain patient that you have discharged, only for them to return a year later suffering from another episode of pain. We all know that once someone suffers from a back injury, they are more likely to develop a chronic issue. Even patients with insidious back pain and no specific injury often develop chronic issues and can have pain that waxes and wanes after the initial episode.

What happens in the body to cause this? Most of us have learned that the pelvic floor, transverse abdominus, and the deep fibers of the lumbar multifidus play an important role in stabilization. With injury, these muscles can become less effective in stabilizing the spine and pelvis. Studies have shown that muscle atrophy in the lumbar multifidus has been shown to occur with injuries and persist after resolution of the pain.¹

I recently did additional research to find out other reasons that cause these local stabilizing muscles to not function optimally. I found that these muscles also can suffer from arthrogenic muscle inhibition after an episode of low back pain.² Arthogenic inhibition is a deficit in neural activation to a muscle. It is thought to occur due to a change in the discharge of articular sensory receptors due to swelling, inflammation, joint laxity, and damage to afferent nerves.² EMG studies have shown reduced neural activity in the deeper fibers of the multifidus in patients with back pain.³

Ultrasound imaging is being used more frequently in the physical therapy clinical setting. Physical therapists are using ultrasound (US) imaging in varying ways. Some are using it as a training tool for the patient to learn neuromuscular control. Others are using it to guide needle placement while performing dry needling. In a recent article authored by several well-known physiotherapists, the various uses of US imaging were defined, as well as discussions regarding the scope of practice, and training for physiotherapists using ultrasound imaging.

Four uses of US imaging have been reported by physical therapists. The first and most common use of US imaging is the evaluation of muscle structure and function to aid in neuromuscular control. Essentially, the US images are being used as a source of biofeedback. This has been coined Rehabilitative Ultrasound Imaging (RUSI). Additional uses have emerged in recent years including Diagnostic US imaging which is the diagnosis and monitoring of pathology; and interventional US imaging which is using the US images to guide percutaneous procedures involving dry or wet needling. These three categories are performed during clinical care and fall under the umbrella term “point of care ultrasound.” The last category of US imaging use in physical therapy is paired with performing research.

In this article, some thoughts and areas for improvement were brought to light regarding each type of US imaging as well as the scope of practice and training for each type of US use. It was mentioned that RUSI sits almost entirely within the scope of the physical therapy profession, however, it can be difficult for therapists to receive training for this use. Therapists interested in learning diagnostic or interventional US imaging have more options for training because these uses of US have established criteria for training, competence, and regulation outlined by the World Health Organization (WHO), as well as oversight from the World Federation for Ultrasound in Medicine and Biology. These programs often are intended for other healthcare practitioners (radiologists, and sonographers), but physical therapists are able to take the courses. However, it was stated that both diagnostic and interventional US imaging do not fall within the scope of practice for a majority of physical therapists around the world. So, although training may be more available for these types of US use; therapists taking these courses gain increased experience with non-physical therapy applications, and therefore are at risk for operating outside the scope of their practice.

Rehabilitative ultrasound imaging has been used in clinical practice for well over a decade now. It has been used for core stabilization, as well as with female incontinence patients. In recent years, transperineal ultrasound imaging has emerged as a useful tool for assessing prolapses and identifying other women’s health issues in the anterior compartment.

Like other things in men’s pelvic health, the use of ultrasound imaging for rehabilitation has lagged behind that in women’s pelvic health. Ryan Stafford is a researcher that is working to change that. In 2012, Stafford began looking at the normal responses to pelvic floor contractions and what is seen on ultrasound in men. He has since taken his research further to examine differences in men that present with post-prostatectomy incontinence. Stafford, van den Hoorn, Coughlin, and Hodges performed a study looking at the dynamic features of activation of specific pelvic floor muscles, and anatomical parameters of the urethra. The study included forty-two men who had undergone prostatectomy. Some of these men were incontinent and others remained continent. Transperineal ultrasound imaging was used to obtain images of the pelvic structures during a cough, and a sustained maximal contraction. The research team calculated displacements of pelvic floor landmarks with contraction, as well as anatomical features including urethral length, and resting position of the ano-rectal and urethra-vesical junctions.

The data was analyzed and combinations of variables that best distinguished men with and without incontinence were reported. Several important components were identified in the study. Striated urethral sphincter activation, as well as bulbocavernosus and puborectalis muscle activation were significantly different between men with and without incontinence. When these two parameters were examined together, they were able to correctly identify 88.1% of incontinent men. They further reported that poor function of the puborectalis and bulbocavernosus could be compensated for if the man had good striated urethral sphincter function. However, the puborectalis and bulbocavernosus had less potential to compensate for poor striated urethral sphincter function. This is important for a therapist that works with post prostatectomy patients to know. This can explain part of why some men improve and do so well after a prostatectomy and others don’t, even with therapy to help. If the striated urethra sphincter is damaged and its normal responses are changed during surgery, then incontinence after prostatectomy may be more likely.

Several weeks ago, I evaluated a patient who was referred to me from a fellow physical therapist. The patient was suffering from sacroiliac joint and low back pain. The patient is a 34-year-old nulliparous woman who is physically fit and participates in several outdoor activities. The therapist had fully evaluated the patient and did not find any articular issues within her spine or pelvis. What she did find was weakness in her local stabilizing muscles and tightness in her global stabilizing muscles. The therapist  has an ample amount of clinical experience at treating low back and pelvic pain issues. She is adept at using different verbal cues, positions, and tactile cueing in order to help encourage proper activation of the local core muscles. However, the therapist knew the patient was not getting her local core muscles to fire properly. She didn’t know what else to do with this patient in order to get her to properly activate these muscles. She had tried numerous positions, verbal and tactile cueing without success.

Do you ever have patients where you feel stuck, who are not progressing as you would like them to in treatment? We all do! It is frustrating, isn’t it? The physical therapist called me and asked me to evaluate the patient using real-time ultrasound imaging. The therapist said “If the patient can just see what she is doing, she will then be able to learn how to work the muscles correctly.” She referred the patient to me so I could use ultrasound imaging within the treatment to better assess her activation strategies and use the imaging for biofeedback for with the patient. The patient was amazed with the ability to see what the different layers of muscles were doing. We found she was contracting her TA but only on her left side, and her deep multifidus was not firing at all. Using the ultrasound images, the patient was able to learn the proper way to activate her muscles. She is now working on a strengthening program for her local core muscles including her TA, pelvic floor, and multifidus. Within two treatments, the patient was able to fire her muscles in a different way and reports her back has felt better than it has in years!

^{The Pathway Ultrasound Imaging System, available from The Prometheus Group, is a portable ultrasound solution for pelvic rehab}