“My butt hurts.” This is such a common subjective complaint in my practice as a manual therapist, and many patients insist it must be a muscle problem or jump to the conclusion it must be “sciatica.” I often tell patients if they did not get shot or bit directly in the buttocks, the pain is most likely referred from nerves that originate in the spine. Although blunt trauma to the buttocks can certainly be the culprit for pain in the gluteal region, a basic understanding of the neural contribution is essential for providing appropriate treatment and a sensible explanation for patients.
A publication by Lung and Lui (2018) describes the superior gluteal nerve. It comes from the dorsal (posterior) divisions of the L4, L5, and S1 nerve roots of the sacral plexus and innervates the gluteus medius, gluteus minimus, and tensor fasciae latae muscles. When this nerve is damaged or compressed, a Trendelenburg gait results because of paralysis of the gluteus medius muscle. The gluteus minimus and tensor fascia latae muscles are also innervated by the superior gluteal nerve and form the “abductor mechanism” together with the gluteus medius to stabilize the pelvis in midstance as the opposite leg is in swing phase. The superior gluteal nerve courses with the inferior gluteal nerve, sciatic nerve, and coccygeal plexus, but it is the only nerve to exit the greater sciatic foramen above the piriformis muscle.
Iwananga et al., (2018) presents a very recent article regarding the innervation of the piriformis muscle, which has been suspected to be the superior gluteal nerve, by dissecting each side from ten cadavers. Often the piriformis muscle can be compromised through total hip replacements with a posterior approach, hip injuries, or chronic pain disorders. This particular study verifies there is no singular nerve that innervates the piriformis muscle, and the most common innervation sources are the superior gluteal nerve (70% of the time) and the ventral rami of S1 (85% of the time) and S2 (70% of the time). The inferior gluteal nerve and the L5 ventral ramus were each found to be part of the innervation only 5% of the time.
Few patients discuss polycystic ovary syndrome (PCOS) in orthopedic manual therapy, but one lady left a lasting impression. She was adopted and did not know her family’s medical history or her genetics. At 18, she had a baby as a result of rape. At 34, she was married and diagnosed with POCS. She struggled with infertility, anxiety, obesity, and hypertension. Although I saw her for cervicalgia, the exercise aspect of her therapy had potential to impact her overall well-being and possibly improve her PCOS symptoms.
Pericleous & Stephanides (2018) reviewed 10 studies that considered the effects of resistance training on PCOS symptoms. Some of these symptoms include the absence of or a significant decrease in ovulation and menstruation, which can lead to infertility; obesity, which in turn can affect cardiovascular health and increase the risk of diabetes, insulin resistance, and metabolic syndrome; and, mental health problems. Research has shown resistance training benefits include lowering body fat, improving insulin resistance and glucose metabolism, and increasing insulin sensitivity in type II diabetes. Although it has been documented that obesity and insulin resistance can exacerbate PCOS symptoms, resistance training is not a common recommendation in healthcare settings for patients with PCOS . Studies have shown diet and exercise are essential to improve cardiac and respiratory health and body makeup in patients with PCOS, as the combination improves the Follicle-stimulating hormone (FSH), sex hormone-binding globulin (SHBG), ovulation, testosterone levels, and weight loss. One systematic review found that weight loss can improve PCOS symptoms without consideration of diet; however, most other studies find intake of various macronutrients (protein, fat, carbohydrates) may lead to different results, and the effects of resistance training can only be optimized with appropriate dietary changes. These authors concluded caloric consumption and macronutrient habits must be considered in conjunction with resistance training to determine the greatest impact on improving PCOS symptoms.
Benham et al., (2018) also performed a recent systematic review to assess the role exercise can have on PCOS. Fourteen trials involving 617 females of reproductive age with PCOS evaluated the effect of exercise training on reproductive outcomes. The data published did not allow the authors to quantitatively assess the impact of exercise of reproductive in PCOS patients; however, their semi-quantitative analysis allowed them to propose exercise may improve regularity of menstruation, the rate of ovulation, and pregnancy rates in these women. Via meta-analysis, secondary outcomes of body measurement and metabolic parameters significantly improved after women with PCOS underwent exercise training; however, symptoms such as acne and hirsutism (excessive, abnormal body hair growth) were not changed with exercise. The authors concluded exercise does improve the metabolic health (ie, insulin resistance) in women with PCOS, but evidence is insufficient to measure the exact impact on the function of the reproductive system.
The British author, John Donne, wrote, “No man is an island, entire of itself; every man is a piece of the continent.” In a similar idea, no neurological symptom is independent and isolated; every system has potential to impact the whole body. Neurogenic bladder should cue a clinician to check for neurogenic bowel and to assess the pelvic floor in order to get a complete map of what to address in treatment.
Martinez, Neshatian, & Khavari (2016) reviewed literature on neurogenic bowel dysfunction (NBD) and neurogenic bladder in patients with neurological conditions such as multiple sclerosis (MS). Constipation and fecal incontinence can coexist with NBD, and a multifactorial bowel regimen is vital to conservative management in patients with neurological disorders. Nonpharmacological, pharmacological, and surgical approaches were reviewed in the article. Specific results for MS were reported only for transanal irrigation (TAI) and biofeedback. In TAI, fluid is used to stimulate the bowel and clean out stool from the rectum. A study showed 53% of the 30 patients with MS demonstrated a 50% or better improvement in bowel symptoms with TAI. In anorectal biofeedback, operant conditioning retrains motor and sensory responses via exercises guided by manometry. With biofeedback, a study showed 38% of patients had a beneficial impact with the intervention. The list of treatment approaches not specifically researched for MS patients in this review includes: dietary modifications, perianal/anorectal stimulation, abdominal massage, suppositories, oral medications such as stool softeners or prokinetic agents, sacral neuromodulation, antegrade continence enema, and colostomy.
Miletta, Bogliatto, & Bacchio (2017) presented a case study about management of sexual dysfunction, perineal pain, and elimination dysfunction in a 40 year old female with multiple sclerosis. She had been experiencing perineal pain for 5 months and had chronic MS symptoms of lower anourogenital dysfunction, including bladder retention and obstructed defecation syndrome. Physical therapy treatment included pelvic floor muscle training (primarily decreasing overactivity of pelvic muscles in this case), perineal massage, biofeedback, postural correction, global relaxation techniques, and a home self-training program. After 5 months of physical therapy, the woman had improved pelvic floor muscle contraction strength, resolution of pelvic floor muscle overactivity, increased sexual satisfaction (according to the Female Sexual Function Index score), a visual analog scale improvement of vulvar and perineal pain by 4 points, normalization of obstructed defecation syndrome, and decreased bladder retention symptoms. The authors concluded the variety of symptoms in MS require a multimodal approach for treatment, considering all the motor, autonomic, and cognitive impairments as well as side effects of medications that try to improve those symptoms. The quality of life of women with MS has potential to be improved significantly if pelvic floor disorders related to MS are addressed appropriately.
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.
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:
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.
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.
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.
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.
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.
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.