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Herman & Wallace Blog

Using Yoga for Post-traumatic Stress Disorder


When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.

Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).

This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.

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Pudendal Nerve: Caught in the Space Between


My 6 year old girl (going on 13) asks “Alexa” to play the Descendants II soundtrack over and over again. So the song, “Space Between,” was lingering in my head while reading the most recent articles on pudendal neuralgia, particularly when pudendal entrapment is to blame. After all, entrapment, by medical standards, describes a peripheral nerve basically being caught in between two surrounding anatomical structures.

Ploteau et al., (2016) presented 2 case studies highlighting the warning signs when pudendal nerve entrapment does not follow the Nantes criteria. A brief summary of those 5 criteria follows:

Pain in the region of the pudendal nerve innervation from anus to penis or clitoris.Pain most predominant while sitting.The patient does not wake at night from the pain.No sensory impairment can be objectively identified.Diagnostic pudendal nerve block relieves the pain.

The case studies of a 31 and a 68 year old female revealed endometrial stromal sarcoma and adenoid cystic carcinoma in the ischiorectal fossa, with night pain was noted in both patients, as well as no pain with sitting or defecation, respectively. Clinicians must always be mindful to resolve red flags in patients.

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Flaxseed: Improving Prostate Health


I love adding flax seed to my recipes when I bake. I even hide it in yogurt with crushed graham crackers for my kids. It is a powerful nutrient that can be consumed without knowing it! Although the specific mechanism for its efficacy on prostate health continues to be researched, studies over the last several years applaud flax seed for its benefits and encourage me to keep sneaking it in my family’s diet.

In 2008, Denmark-Wahnefried et al. performed a study to see if flax seed supplementation alone (rather than in combination with restricting dietary fat) could decrease the proliferation rate of prostate cancer prior to surgery. Basically, flax seed is a potent source of lignan, which is a phytoestrogen that acts like an antioxidant and can reduce testosterone and its conversion to dihydrotestosterone. It is also rich in plant-based omega-3 fatty acids. In this study, 161 prostate cancer patients, at least 3 weeks prior to prostatectomy, were divided into 4 groups: 1) normal diet (control); 2) 30g/day of flax seed supplementation; 3) low-fat diet; and 4) flax seed supplementation combined with low-fat diet. Results showed the rate of tumor proliferation was significantly lower in the flax seed supplemented group. The low-fat diet was proven to reduce serum lipids, consistent with previous research for cardiovascular health. The authors concluded, considering limitations in their study, flax seed is at least safe and cost-effective and warrants further research on its protective role in prostate cancer.

In 2017, de Amorim et al. investigated the effect of flax seed on epithelial proliferation in rats with induced benign prostatic hyperplasia (BPH). The 4 experimental groups consisting of 10 Wistar (outbred albino rats) rats each were as follows: 1) control group of healthy rats fed a casein-based diet (protein in milk); 2) healthy rats fed a flax seed-based diet; 3) hyperplasia-induced rats fed a casein diet; and 4) hyperplasia-induced rats fed a flax seed diet. Silicone pellets full of testosterone propionate were implanted subcutaneously in the rats to induce hyperplasia. Once euthanized at 20 weeks, the prostate tissue was examined for thickness and area of epithelium, individual luminal area, and total prostatic alveoli area. Results showed the hyperplasia induced rats fed a flax seed-based diet had smaller epithelial thickness as well as a reduced proportion of papillary projections found in the prostatic alveoli. These authors determined flax seed exhibits a protective role for the epithelium of the prostate in animals induced with BPH.

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Colorectal Cancer: Complications after the Cure


Curing cancer but not addressing life-altering complications can be compared to feeding the homeless on Thanksgiving but turning your back on them the rest of the year. We love hearing positive outcomes of a surgery, but we are not always aware of what happens beyond that. Colorectal cancer is often treated by colectomy, and sometimes the survivor of cancer is left with urological or sexual dysfunction, small bowel obstruction, or pelvic lymphedema.

Panteleimonitis et al., (2017) recognized the prevalence of urological and sexual dysfunction after rectal cancer surgery and compared robotic versus laparoscopic approaches to see how each impacted urogenital function. In this study, 49 males and 29 females underwent laparoscopic surgery, and 35 males and 13 females underwent robotic surgery. Prior to surgery, 36 men and 9 women were sexually active in the first group and 13 men and 4 women were sexually active in the latter group. Focusing on the male results, male urological function (MUF) scores were worse pre-operatively in the robotic group for frequency, nocturia, and urgency compared to the laparoscopic group. Post-operatively, urological function scores improved in all areas except initiation/straining for the robotic group; however, the MUF median scores declined in the laparoscopic group. Regarding male sexual function (MSF) scores for libido, erection, stiffness for penetration and orgasm/ ejaculation, the mean scores worsened in all areas for the laparoscopic group but showed positive outcomes for the robotic group. In spite of limitations of the study, the authors concluded robotic rectal cancer surgery may afford males and females more promising urological and sexual outcomes as robotic.

Husarić et al., (2016) considered the risk factors for adhesive small bowel obstruction (SBO) after colorectal cancer colectomy, as SBO is a common morbidity that causes a decrease in quality of life. They performed a retrospective study of 248 patients who underwent colon cancer surgery, and 13.7% of all the patients had SBO. Thirty (14%) of the 213 males and 9 (12.7%) of the 71 females had SBO; consequently, they found patients being >60 years old was a more significant risk factor than sex regarding occurrence of SBO. The authors concluded a Tumor-Node Metastasis stage of >3 and immediate postoperative complications were found to be the greatest risk factors for SBO.

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Gynecological Cancers Challenge the Pelvic Floor


When I work prn in inpatient rehabilitation, I have access to each patient’s chart and can really focus on the systems review and past medical history, which often gives me ample reasons to ask about pelvic floor dysfunction. So, of course, I do. I have yet to find a gynecological cancer survivor who does not report an ongoing struggle with urinary incontinence. And sadly, they all report that they just deal with it.

Bretschneider et al.2016 researched the presence of pelvic floor disorders in females with presumed gynecological malignancy prior to surgical intervention. Baseline assessments were completed by 152 of the 186 women scheduled for surgery. The rate of urinary incontinence (UI) at baseline was 40.9% for the subjects, all of whom had uterine, ovarian, or cervical cancer. Stress urinary incontinence (SUI) was reported by 33.3% of the women, urge incontinence (UI) by 25%, fecal incontinence (FI) by 3.9%, abdominal pain by 47.4%, constipation by 37.7%, and diarrhea by 20.1%. The authors concluded pelvic floor disorders are prevalent among women with suspected gynecologic cancer and should be noted prior to surgery in order to provide more thorough rehabilitation for these women post-operatively.

Ramaseshan et al.2017 performed a systematic review of 31 articles to study pelvic floor disorder prevalence among women with gynecologic malignant cancers. Before treatment of cervical cancer, the prevalence of SUI was 24-29% (4-76% post-treatment), UI was 8-18% (4-59% post-treatment), and FI was 6% (2-34% post- treatment). Cervical cancer treatment also caused urinary retention (0.4-39%), fecal urge (3-49%), dyspareunia (12-58%), and vaginal dryness (15-47%). Uterine cancer showed a pre-treatment prevalence of SUI (29-36%), UUI (15-25%), and FI (3%) and post-treatment prevalence of UI (2-44%) and dyspareunia (7-39%). Vulvar cancer survivors had post-treatment prevalence of UI (4-32%), SUI (6-20%), and FI (1-20%). Ovarian cancer survivors had prevalence of SUI (32-42%), UUI (15-39%), prolapse (17%) and sexual dysfunction (62-75%). The authors concluded pelvic floor dysfunction is prevalent among gynecologic cancer survivors and needs to be addressed.

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To Abduct or Adduct Hips: Does the Pelvic Floor Care?


When reading published research on a subject matter directly relating to what we do in our career, we may need to remember the expression, “Don’t throw the baby out with the bathwater.” Sometimes the test results for a promising hypothesis are not statistically significant, and we can close our minds to the concept entirely. If we skim the abstract and hone in on the “results” or “conclusion” rather than reading the whole article, particularly a study’s limitations, we may drop a sound clinical pearl down the drain.

A research article published in May 2017 by Amorim et al., looked at the force generation and maintenance of the pelvic floor muscles when combined with hip adduction or abduction contractions. They hypothesized that pelvic floor muscle (PFM) contraction combined with hip abduction contraction (rather than adduction) should produce a greater PFM contraction because of the myofascial connection of the obturator internus to the levator ani muscle. The study included 20 nulliparous women without pelvic floor dysfunction. The pelvic floor muscle contraction was measured in isolation, with 30% and 50% maximum hip adduction contraction, and with 30% and 50% maximum hip abduction contraction. The forces were measured with a cylindrical, intravaginal strain-gauge for PFM and another strain-gauge around the hips for adduction/abduction force generation. The women were given visual feedback to help them obtain the required hip contraction force. An average of 3 contractions (10 seconds each with a 1 minute rest) was used for each condition. This was all performed again 4 weeks later.

The results of this study by Amorim et al.2017 did not support the hypothesis. No statistically significant difference was found among any of the conditions measured. The intravaginal PFM force generation was not different when combined with hip abduction versus hip adduction contraction. Neither hip adduction nor abduction made a significant change in force of the PFM contraction compared to isolated PFM contraction. The authors had to conclude there is no evidence to support the efficacy of combining PFM training with contraction of the hip abductors or adductors.

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Cardiovascular Health in Menopause: Move it or Lose It


One of my greatest nemeses when I was racing at 30 years of age was a woman in her 50’s. Although I hated losing to her, I was always inspired by her speed at her age. She motivated me to continue training hard, realizing my fastest days could be yet to come. As I now race in the “master’s” category in my 40’s, I still find myself crossing the line behind an older competitor occasionally. Research shows I should take heart and keep in step with females who continue to move their bodies beyond menopause.

Mazurek et al., (2017) studied how organized physical activity among post-menopausal women could reduce cardiovascular risk. The study included 35 sedentary women aged 64.7 ± 7.7 years who had no serious health issues. They all participated in the Active Leisure Time Programme (ALTP) 3 times per day for 40–75 minute sessions for 2 weeks, including 39 physical activities. Exercise intensity stayed within 40–60% of maximal HR, and ratings of perceived exertion (RPE) on the Borg scale stayed between 8 and 15 points. This exercise training was followed by 3 months of the Prevent Falls in the Elderly Programme (PFEP), which is a general fitness exercise program to prevent falls in the elderly. Health status was measured at baseline, 2 weeks into the program, and after 3 months. The results showed significant reductions in central obesity, which increased the exercise and aerobic capacity of the subjects and improved lipid profiles. A significant reduction also occurred in the absolute 10-year risk of death from cardiac complications. The authors concluded these exercise programs could be effective in preventing primary and secondary cardiovascular disease in the >55 years old female population.

Nyberg et al., (2016) took a physiological look at exercise training on the vascular function of pre- and postmenopausal women, studying the prostanoid system. Prostanoids are vasoconstrictors, and prostacyclins are vasodilators. The loss of estrogen in menopause affects the ability of the vasodilators to function properly or even be produced, thus contributing to vascular decline. The authors checked the vasodilator response to an intra-arterial fusion of a prostacyclin analog epoprostenol as well as acetylocholine in 20 premenopausal and 16 early postmenopausal women before and after a 12-week exercise program. Pre-exercise, the postmenopausal women had a reduced vasodilator response. The women also received infusion of ketorolac (an inhibitor of cyclooxygenase) along with acetylcholine, creating a vasoconstriction effect, and the vascular response was reduced in both groups. The infusions and analyses were performed again after 12 weeks of exercise training, and the exercise training increased the vasodilator response to epoprostenol and acetylcholine in the postmenopausal group. The reduced vasodilator response to epoprostenol prior to exercise in early postmenopausal women suggests hormonal changes affect the capacity of prostacyclin signaling; however, the prostanoid balance for pre and postmenopausal women was unchanged. Ultimately, the study showed exercise training can still have a positive effect on the vascularity of newly postmenopausal women.

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Male Phimosis: Not a Fraction of Retraction


As I read about male phimosis, I thought about a shirt that just won’t go over my son’s big noggin. I tug and pull, and he screams as his blond locks stick up from static electricity. Ultimately, if I want this shirt to be worn, I either have to cut it or provide a prolonged stretch to the material, or my child will suffocate in a polyester sheath. This is remotely similar to the male with physiological phimosis.

In a review article, Chan and Wong (2016) described urological problems among children, including phimosis. They reported “physiological phimosis” is when the prepuce cannot be retracted because of a natural adhesion to the glans. Almost all normal male babies are born with a foreskin that does not retract, and it becomes retractable in 90% of boys once they are 3 years old. A biological process occurs, and the prepuce becomes retractable. In “pathological phimosis” or balanitis xerotica obliterans, the prepuce, glans, and sometimes even the urethra experience a progressive inflammatory condition involving inflammation of the glans penis, an unusually dry lesion, and occasional endarteritis. Etiology is unknown, but males by their 15th birthday report a 0.6% incidence, and the clinical characteristics include a white tip of the foreskin with a ring of hard tissue, white patches covering the glans, sclerotic changes around the meatus, meatal stenosis, and sometimes urethral narrowing and urine retention.

This review article continues to discuss the appropriate treatment for phimosis (Chan & Wong 2016). Once phimosis is diagnosed, the parents of the young male need to be educated on keeping the prepuce clean. This involves retracting the prepuce gently and rinsing it with warm water daily to prevent infection. Parents are warned against forcibly retracting the prepuce. A study has shown complete resolution of the phimosis occurred in 76% of boys by simply stretching the prepuce daily for 3 months. Topical steroids have also been used effectively, resolving phimosis 68.2% to 95%. Circumcision is a surgical procedure removing foreskin to allow a non-covered glans. Jewish and Muslim boys undergo this procedure routinely, and >50% of US boys get circumcised at birth. Medical indications are penile malignancy, traumatic foreskin injury, recurrent attacks of severe balanoposthitis (inflammation of the glans and foreskin), and recurrent urinary tract infections.

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Fractures for Females: Pregnancy-Associated Osteoporosis

Osteoporosis

On my son’s due date, I ran 5 miles (as I often did during my pregnancy), hoping he would be a New Year’s baby. The thought of low bone density never crossed my mind, even living in Seattle where the sun only intermittently showers people with Vitamin D. However, bone mineral density changes do occur over the course of carrying a fetus through the finish line of birth. And sometimes women experience a relatively rare condition referred to as pregnancy-related osteoporosis.

Krishnakumar, Kumar, and Kuzhimattam2016 explored vertebral compression fracture due to pregnancy-related osteoporosis (PAO). The condition was first described over 60 years ago, and risk factors include low body mass index, physical inactivity, low calcium intake, family history, and poor nutrition. Of 535 osteoporotic fractures considered, 2 were secondary to PAO. A 27-year-old woman complained of back pain during her 8th month of pregnancy, and 3 months postpartum, she was found to have a T10 compression fracture. A 31-year-old with scoliosis had back pain at 1 month postpartum but did not seek treatment until 5 months after giving birth, and she had T12, L1, and L2 compression fractures. The women were treated with the following interventions: cessation of breastfeeding, oral calcium 100 mg/day, Vitamin D 800 IU/day, alendronate 70 mg/week, and thoracolumbar orthosis. Bone density improved significantly, and no new fractures developed during the 2-year follow up period.

Nakamura et al.2015 reviewed literature on pregnancy-and-lactation-associated osteoporosis, focusing on 2 studies. The authors explained symptoms of severe low back, hip, and lower extremity joint pain that occur postpartum or in the 3rd trimester of pregnancy can be secondary to this disorder, but it is often not considered immediately. A 30-year-old woman with such debilitating pain in her spine with movement 2 months postpartum had to stop breastfeeding, and 10 months later, she was found to have 12 vertebral fractures. She had low bone mineral density (BMD) in her lumbar spine, and she was given 0.5mg/day alfacalcidol (ALF), an active vitamin D3 analog, as well as Vitamin K. No more fractures developed over the next 6 years. A 37-year-old female had severe back pain 2 months postpartum, and at 7 months was found to have 8 vertebral fractures due to PAO. Her pain subsided after stopping breastfeeding, using a lumbar brace, and supplementing with 0.5mg/day ALF and Vitamin K. The authors concluded goals for treating PAO include preventing vertebral fractures and increasing BMD and overall fracture resistance with Vitamins D and K.

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Female Athletes: Fit to be Dry


At the peak of my racing career I won awards in all my races from 5k to marathon. While warming up I would scope out my competition, intimidated by muscular females wearing outfits to accentuate their physiques. Many times, appearance out-weighed running capacity. In a similar manner, one strong pelvic floor contraction produced by a female athlete does not always mean she has the endurance to stay dry in the long run.

Brennand et al. (2017) researched urinary leakage during exercise in Canadian women. A summary of their findings concluded that skipping, trampoline, jumping jacks, and running/jogging were most likely to cause leakage. To combat the problem, 93.2% emptied their bladder just before exercise, 62.7% required voiding breaks during exercise, and 37.3% actually restricted their fluid intake to minimize leakage. While 90.3% of women who reported leakage impacted their activity just decreased their intensity, 80.7% avoided the activity entirely. Many women used pads (49.2%). Interest in pelvic floor physiotherapy to improve their UI was high (84.6%), but 63.5% of women still sought pessary or surgical management. Unfortunately, 35.6% of the women had no idea treatment was even an option.

Nygaard & Shaw (2016) reviewed and summarized the cross-sectional studies regarding the association between physical activity and pelvic floor disorders. Trampolinists, especially those in the 3rd tertile of competition, even those who were nulliparous, experienced greater leakage. Competitive athletes in the highest quartile of time exercising were found to have 2.5 times the amount of urinary incontinence (UI) as the lowest inactive quartile; however, 2nd and 3rd quartile recreational athletes had no difference in UI compared to inactive women. Type and dosage of exercise were both factors in UI risk. Various studies showed habitual walking decreased UI in older women, moderate exercise decreased the risk of UI, and no exercise increased the risk of UI. The incidence of UI being related to having performed strenuous exercise early in life has been limited and variable, with one study of Norwegian athletes and US Olympians not having any greater UI later in life, while another showed middle-aged women who used to exercise 7.5 hours per week had a higher incidence of UI. This review also reported athletes had a 20% greater cross sectional area of the levator ani muscle and a greater pubovisceral muscle mean diameter; however, the pelvic floor strength recorded was lower than non-athletes.

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