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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.

Pedersini et al., (2017) evaluated the functional and cosmetic outcomes of “trident” preputial plasty using a modified-triple incision for surgically managing phimosis in children ages 3-15. All patients seen in a 1 year period who were unable to retract the foreskin and had posthitis or balanoposthitis or ballooning of the foreskin during urination were included and treated initially with a two-month trial of topic corticosteroids. Only the patients unresponsive to corticosteroids were treated with the "trident" preputial plasty. At 12 months post-surgery, 97.6% (all but one of the 41 subjects) of patients were able to retract the prepuce, and cosmetics and function were satisfactorily restored.

Phimosis is apparently not a highlight in medical school curriculum, and parents often seek attention for other issues that lead to the diagnosis of phimosis. Like the tight material lining the neck of a shirt, the prepuce can be given a prolonged static stretch, and, over time, may retract appropriately. Or, cutting the shirt material may be necessary for long term success. Similarly, surgical intervention such as circumcision or the newer “trident” preputial plasty may be required.


Chan, Ivy HY and Wong, Kenneth KY. (2016). Common urological problems in children: prepuce, phimosis, and buried penis. Hong Kong Medical Journal. 22(3):263–9. DOI: 10.12809/hkmj154645
Pedersini, P, Parolini, F, Bulotta, AL, Alberti, D. (2017). "Trident" preputial plasty for phimosis in childhood. Journal of Pediatric Urology. 13(3):278.e1-278.e4. doi:10.1016/j.jpurol.2017.01.024

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Fractures for Females: Pregnancy-Associated 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.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.

Other treatment approaches for similar case presentations have been published. One gave credit to denosumab injections giving pain relief and improved BMD to 2 women, ages 35 and 33, after postpartum vertebral fractures (Sanchez, Zanchetta, & Danilowicz2016). Guardio and Fiore2016 reported success using the amino-bisphosphonates, neridronate, in a 38-year-old with PAO T4 fracture.

Thankfully for these women experiencing PAO vertebral fractures, supplements boosted their BMD and prevented further fractures. However, they all had to prematurely stop breastfeeding to reduce their pain as well. This rare condition can be used as a warning for women to proactively increase their BMD. The course, Meeks Method for Osteoporosis, can help therapists implement safe, effective, and active ways to promote bone health for all - especially the pregnant population in serious need of support.


Krishnakumar, R., Kumar, A. T., & Kuzhimattam, M. J. (2016). Spinal compression fractures due to pregnancy-associated osteoporosis. Journal of Craniovertebral Junction & Spine, 7(4), 224–227. http://doi.org/10.4103/0974-8237.193263
Nakamura, Y., Kamimura, M., Ikegami, S., Mukaiyama, K., Komatsu, M., Uchiyama, S., & Kato, H. (2015). A case series of pregnancy- and lactation-associated osteoporosis and a review of the literature. Therapeutics and Clinical Risk Management, 11, 1361–1365. http://doi.org/10.2147/TCRM.S87274
Sánchez, A., Zanchetta, M. B., & Danilowicz, K. (2016). Two cases of pregnancy- and lactation- associated osteoporosis successfully treated with denosumab. Clinical Cases in Mineral and Bone Metabolism, 13(3), 244–246. http://doi.org/10.11138/ccmbm/2016.13.3.244
Gaudio, A., & Fiore, C. E. (2016). Successful neridronate therapy in pregnancy-associated osteoporosis. Clinical Cases in Mineral and Bone Metabolism, 13(3), 241–243. http://doi.org/10.11138/ccmbm/2016.13.3.241

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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.

Interestingly, Leitner et al. (2017) explored pelvic floor muscle activation for continent and incontinent females during running. For 10 seconds, EMG tripolar vaginal probe recorded activity at 7, 11, and 15km/h. No statistically significant differences between continent or incontinent subjects were found for the EMG values. Pre-activity and reflex activity mean EMG increased significantly with speed; mean pelvic floor muscle EMG activity during running was significantly above onset activation value; and, maximum voluntary contraction was exceeded 100% for all time intervals at 15km/h in women with UI. These authors suggested the stimulus of running could actually be beneficial in pelvic floor muscle training considering the reflex activity of the muscles.

At races now, I still silently survey my competition, but now I am more curious as to how many women are actually able to complete the run without leakage. The prevalence of UI among athletes continues and is becoming more of an open topic of conversation. The research as to how much and which kind of exercise correlates with UI or what activity and level of participation may be preventative for UI is growing. The need for pelvic floor therapists to treat athletes who are fit to be dry is ever increasing.


Brennand, E., Ruiz-Mirazo, E., Tang, S., Kim-Fine, S., Calgary Women’s Pelvic Health Research Group. (2017). Urinary leakage during exercise: problematic activities, adaptive behaviors, and interest in treatment for physically active Canadian women. International Urogynecology Journal. http://www.doi:10.1007/s00192-017-3409-1
Nygaard, I. E., & Shaw, J. M. (2016). Physical Activity and the Pelvic Floor. American Journal of Obstetrics and Gynecology, 214(2), 164–171. http://doi.org/10.1016/j.ajog.2015.08.067
Leitner M, Moser H, Eichelberger P, Kuhn A, Radlinger L. (2017). Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurourology and Urodynamics. 36:1570–1576. https://doi.org/10.1002/nau.23151

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Breast Oncology: Not “One-Size-Fits-All” Rehab

Summer can make women cringe at the thought of baring most of their bodies yet finding just the right coverage for their breasts. Some scrounge for padded tops to pump up their actual A cup. Some seek the greatest amount of coverage to support every ounce of skin. And still others search for flattering tops to accentuate cleavage and minimize tan lines. Just like one swimsuit does not fit every woman, only one aspect of post-breast cancer rehab is not generally sufficient. A combination of exercise, mindfulness, and myofascial release may need to be implemented for optimal recovery.

Ibrahim et al., (2017) produced a pilot randomized controlled trial considering the effects of specific exercise on upper limb function and ability to return to work after radiotherapy for breast oncology. The study involved 59 young women divided into an exercise group or a control group that received standard care. The Disability of Arm, Shoulder, and Hand (DASH), the Metabolic Equivalent of Task-hours per week (MET-hours/week), and a post hoc questionnaire on return to work were all used and recorded over 6 time periods after the 12-week post-radiation targeted exercise program. Women who had a total mastectomy still had upper limb dysfunction, but no there was no statistically significant difference in DASH scores between groups. Both groups at 18 months had returned to their pre-illness activity levels, and 86% returned to work (at just 8.5 fewer hours/week). The authors concluded exercise alone does not change the long-term outcome of upper limb function post-radiation.

Mindfulness-based cognitive therapy (MBCT) for persistent pain in women after treatment for primary breast cancer was explored by Johannsen et al., in two 2017 articles, one concerned with clinical and psychological mediators and the other focused on cost-effectiveness. Each study included 129 women with persistent pain from breast cancer, placed in a MBCT group or a wait-list control group. The first study showed attachment avoidance was a statistically significant moderator, with subjects who had a higher attachment avoidance having lower pain intensity after MBCT. In the subjects undergoing radiotherapy, MBCT had a smaller effect on pain than those not having radiotherapy. The authors’ next study focused on the minimal clinically important difference (MCID) on pain intensity. Baseline and 6 months post-treatment data on healthcare utilization and pain medication were analyzed from national registries. The average total cost of the MBCT group was 730 euros less than the control group, and more women in the MBCT group had a MCID in pain than those in the control group.

DeGroef et al., (2017) performed a randomized controlled trial to assess the efficacy of myofascial techniques for breast cancer survivors who experienced upper limb dysfunctions. Fifty women post-unilateral breast cancer received either 12 sessions of standard physical therapy with myofascial therapy or 12 sessions of standard physical therapy plus a sham intervention during a 3-month period. After intervention, no significant differences between groups were found for active shoulder range of motion, lymphedema, handheld dynamometer strength, scapular statics and dynamics, shoulder function, or quality of life. The authors concluded shoulder ROM and function in both groups showed positive effects up to 1 year follow-up, but myofascial therapy provided no additional benefit in breast cancer patients.

Treatment for any patient should be individualized, based on deficits found clinically, whether they are physiological, anatomical, or psychological. Having a beach bag overflowing with techniques and tools, each ready to be used when the appropriate time comes, makes for a more competent therapist and a better rehabilitation outcome for patients. There simply is no “one size fits all” in breast oncology rehab.

YOU can be a major contributor to a breast cancer patients medical care team. Learn new skills by attending Physical Therapy Treatment for the Breast Oncology Patient this September in Boston, MA.


Ibrahim, M, Muanza, T, Smirnow, N, Sateren, W, Fournier, B, Kavan, P, Palumbo, M, Dalfen, R, Dalzell, MA. (2017). Time course of upper limb function and return-to-work post-radiotherapy in young adults with breast cancer: a pilot randomized control trial on effects of targeted exercise program. Journal of Cancer Survivorship: research and practice. http://doi:10.1007/s11764-017-0617-0
Johannsen, M, O'Toole, MS, O'Connor, M, Jensen, AB, Zachariae, R. (2017). Clinical and psychological moderators of the effect of mindfulness-based cognitive therapy on persistent pain in women treated for primary breast cancer - explorative analyses from a randomized controlled trial. Acta Oncology. 56(2):321-328. http://doi:10.1080/0284186X.2016.1268713
Johannsen, M, Sørensen, J, O'Connor, M, Jensen, AB, Zachariae, R. (2017). Mindfulness-based cognitive therapy (MBCT) is cost-effective compared to a wait-list control for persistent pain in women treated for primary breast cancer-Results from a randomized controlled trial. Psychooncology. http://doi:10.1002/pon.4450
De Groef,A, Van Kampen, M, Verlvoesem N, Dieltjens, E, Vos, L, De Vrieze, T, Christiaen, MR, Neven, P, Geraerts, I, Devoogdt, N. (2017). Effect of myofascial techniques for treatment of upper limb dysfunctions in breast cancer survivors: randomized controlled trial. Support Care Cancer. 25(7):2119-2127. http://doi:10.1007/s00520-017-3616-9

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Post-Prostatectomy: Calling Attention to Erectile Dysfunction

At a hair salon, I once saw a plaque that declared, “I’m a beautician, not a magician.” This crossed my mind while reading research on radical prostatectomy, as knowing the baseline penile function of men before surgery seemed challenging. Restoring something that may have been subpar prior to surgery can be a daunting task, and it can cause discrepancies in results of clinical trials. Despite this, two recent studies reviewed the current and future penile rehabilitation approaches post-radical prostatectomy.

Bratu et al.2017 published a review referring to post-radical prostatectomy (RP) erectile dysfunction (ED) as a challenge for patients as well as physicians. They emphasized the use of the International Index of Erectile Function (IIEF) Questionnaire to establish a man’s baseline erectile function, which can be affected by factors such as age, diabetes, alcohol use, smoking habits, heart and kidney diseases, and neurological disorders. The higher the IIEF score preoperatively, the higher the probability of recovering erectile function post-surgery. The experience of the surgeon and the technique used were also factors involved in ED. Radical prostatectomy is a trauma to the pelvis that negatively affects oxygenation of the corpora cavernosum, resulting in apoptosis and fibrotic changes in the tissue, leading to ED. Minimally invasive surgery allows a significantly lower rate of post-RP ED with robot assisted radical prostatectomy (RARP) versus open surgery. The cavernous neurovascular bundles get hypoxic and ischemic regardless of the technique used; therefore, the authors emphasized early post-op penile rehabilitation to prevent fibrosis of smooth muscle and to improve cavernous oxygenation for the potential return of satisfactory sexual function within 12-24 months.

Clavell-Hernandez and Wang2017 [and Bratu et al., (2017)] reported on various aspects of penile rehabilitation after radical prostatectomy. The treatment with the most research to support its efficacy and safety was oral phosphodiesterase type-5 inhibitors (PDE5Is), which help relax smooth muscle and promote erection on a cellular level. Sildenafil, vardenafil, avanafil, and tadalafil have been studied, either used on demand or nightly. Tadalafil had the longer half-life and was considered to have the greatest efficacy. Nightly versus on-demand for any PDE5I was variable in its results. Intracavernosal injection (ICI) and intraurethral therapy using alprostadil for vasodilation improved erectile function, but it caused urethral burning and penile pain. Vacuum erection devices (VED) promoted penile erection via negative pressure around the penis, bringing blood into the corpus cavernosum. There was no need for intact corporal nerve or nitric oxide pathways for proper function, and it allowed for multiple erections in a day. Intracavernous stem cell injections provided a promising approach for ED, and they may be combined with PDE5Is or low-energy shockwave therapy. Ultimately, the authors concluded early penile rehabilitation should involve a combination of available therapies.

Restoring vascularity to healing tissue is a primary goal in rehabilitation, and the sooner the better. Disruption of cavernous nerves and penile tissue post-RP demands rehabilitation, and some methods have more supporting clinical evidence than others. Newer approaches require more exposure and clinical trials for efficacy and long term outcomes. Clinicians should pay attention to updated research and consider taking continuing education courses such as Post-Prostatectomy Patient Rehabilitation or Oncology and the Male Pelvic Floor.


Bratu, O., Oprea, I., Marcu, D., Spinu, D., Niculae, A., Geavlete, B., & Mischianu, D. (2017). Erectile dysfunction post-radical prostatectomy – a challenge for both patient and physician. Journal of Medicine and Life, 10(1), 13–18.
Clavell-Hernández, J., & Wang, R. (2017). The controversy surrounding penile rehabilitation after radical prostatectomy. Translational Andrology and Urology, 6(1), 2–11. http://doi.org/10.21037/tau.2016.08.14

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Pelvic Pain, Sexual Function, and Yoga

Speaking with a runner friend the other day, I mentioned I was writing a blog on yoga for pelvic pain. She had the same reaction many runners do, stating she has doesn’t care for yoga, she never feels like she is tight, and she would hate being in one position for so long. Ironically, neither of us has taken a yoga class, so any preconceived ideas about it are null and void. I told her yoga is being researched for beneficial health effects, and one day we just might find ourselves in a class together!

Saxena et al.2017 published a study on the effects of yoga on pain and quality of life in women with chronic pelvic pain.  The randomized case controlled study involved 60 female patients, ages 18-45, who presented with chronic pelvic pain. They were randomly divided into two groups of 30 women. Group I received 8 weeks of treatment only with nonsteroidal anti-inflammatory medication (NSAIDS). Group II received 1 hour, 5 days per week, for 8 weeks of yoga therapy (asanas, pranayama, and relaxation) in addition to NSAIDS (as needed). Table 1 in the article outlines the exact protocol of yoga in which Group II participated. The subjects were assessed pre- and post-treatment with pain scores via visual analog scale score and quality of life with the World Health Organization quality of life-BREF questionnaire. In the final analysis, Group II showed a statistically significant positive difference pre and post treatment as well as in comparison to Group I in both categories. The authors concluded yoga to be an effective adjunct therapy for patients with chronic pelvic pain and an effective option over NSAIDS for pain.

In the Pain Medicine journal, Huang et al.2017 presented a single-arm trial attempting to study the effects of a group-based therapeutic yoga program for women with chronic pelvic pain (CPP), focusing on severity of pain, sexual function, and overall well-being. The comprehensive program was created by a group of women’s health researchers, gynecological and obstetrical medical practitioners, yoga consultants, and integrative medicine clinicians. Sixteen women with severe pelvic pain of at least 6 months’ duration were recruited. The group yoga classes focused on lyengar-based techniques, and the subjects participated in group classes twice a week and home practice 1 hour per week for 6 weeks. The Impact of Pelvic Pain (IPP) questionnaire assessed how the participants’ pain affected their daily life activities, emotional well-being, and sexual function. Sexual Health Outcomes in Women Questionairre (SHOW-Q) offered insight to sexual function. Daily logs recorded the women’s self-rated pelvic pain severity. The results showed the average pain severity improved 32% after the 6 weeks, and IPP scores improved for daily living (from 1.8 to 0.9), emotional well-being (from 1.7 to 0.9), and sexual function (from 1.9 to 1.0). The SHOW-Q "pelvic problem interference" scale also improved from 53 to 23. The multidisciplinary panel concluded they found preliminary evidence that teaching yoga to women with CPP is feasible for pain management and improvement of quality of life and sexual function.

Whatever treatment we provide for our patients, we need to consider the individual and their often biased opinions or perceptions. Providing research and educating each patient on the efficacy behind the proposed therapy will likely impact their outcome. The Yoga for Pelvic Pain course can enhance a clinician’s understanding and allow them to better implement a potentially life-changing therapy for their clients.


Saxena, R., Gupta, M., Shankar, N., Jain, S., & Saxena, A. (2017). Effects of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. International Journal of Yoga10(1), 9–15. http://doi.org/10.4103/0973-6131.186155
Huang, AJ, Rowen, TS, Abercrombie, P, Subak, LL, Schembri, M, Plaut, T, & Chao, MT. (2017). Development and Feasibility of a Group-Based Therapeutic Yoga Program for Women with Chronic Pelvic Pain. Pain Medicine. http://doi.org/10.1093/pm/pnw306

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Manual Therapy – Use your Head to Guide your Hands

What if we were only taught treatment techniques during our healthcare training with no theory or explanation as to why or on whom or under what circumstances they should be used? Focusing on “how to” but ignoring the “discernment as to why” would make for a weak clinician. Manual therapy for the pelvic floor is a treatment approach to implement once we have used our heads and palpation skills to reveal the underlying source of dysfunction.

Pastore and Katzman (2012) published a thorough article describing the process of recognizing when myofascial pain is the source of chronic pelvic pain in females. They discuss active versus latent myofascial trigger points (MTrPs), which are painful nodules or lumps in muscle tissue, with the latter only being symptomatic when triggered by physical (compression or stretching) or emotional stress. Hyperalgesia and allodynia are generally present in patients with MTrPs, and muscles with MTrPs are weaker and limit range of motion in surrounding joints. In pelvic floor muscles, MTrPs refer pain to the perineum, vagina, urethra, and rectum but also the abdomen, back, thorax, hip/buttocks, and lower leg. The authors suggest detecting a trigger point by palpating perpendicular to the muscle fiber to sense a taut band and tender nodule and advise using the finger pads with a flat approach in the abdomen, pelvis and perineum. They emphasize a multidisciplinary approach to finding and treating MTrPs and making sure urological, gynecological, and/or colorectal pathologies are addressed. A thorough subjective and physical exam that leads to proper diagnosis of MTrPs should be followed by manual physical therapy techniques and appropriate medical intervention for any corresponding pathology.

Halder et al. (2017) investigated the efficacy of myofascial release physical therapy with the addition of Botox in a retrospective case series for women with myofascial pelvic pain. Fifty of the 160 women who had Botox and physical therapy met the inclusion/exclusion criteria, and the primary complaint in all those subjects was dyspareunia. The Botox was administered under general anesthesia, and then the same physician performed soft tissue myofascial release transvaginally for 10-15 minutes, with 10-15 additional minutes performed if rectus muscles had trigger points. The patients were seen 2 weeks and 8 weeks posttreatment. Average pelvic pain scores decreased significantly pre- and posttreatment, with 58% of subjects reporting improvements. Significantly fewer patients (44% versus 100%) presented with trigger points on pelvic exam after the treatment. The patients who did not show improvement tended to have inflammatory or irritable bowel diseases or diverticulosis. Blocking acetylcholine receptors via Botox in combination with pelvic floor physical therapy could possibly provide longer symptom-free periods. Although the nature of the study could not determine a specific interval of relief, the authors were encouraged as an average of 15 months passed before 5 of the patients sought more treatment.

The need for the specific treatment for myofascial pelvic pain is determined by a clinician competent in palpation of the pelvic floor musculature finding trigger points and restrictions in the tissue. Listening to a patient’s symptoms and understanding pelvic pathology allow for better treatment planning. Manual Therapy Techniques for the Pelvic Rehab Therapist is a comprehensive course to enhance knowledge in your head to lead your hands in the right direction for assessing/treating patients with pelvic pain.


Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN / NAACOG, 41(5), 680–691. http://doi.org/10.1111/j.1552-6909.2012.01404.x
Halder, G. E., Scott, L., Wyman, A., Mora, N., Miladinovic, B., Bassaly, R., & Hoyte, L. (2017). Botox combined with myofascial release physical therapy as a treatment for myofascial pelvic pain. Investigative and Clinical Urology, 58(2), 134–139. http://doi.org/10.4111/icu.2017.58.2.134

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Leaking Athletes Take Their Training to the Floor

While running on my treadmill, I watched a commercial advertising specially designed pads as “the solution” for women athletes who “leak” during their sport. Before my introduction to Herman and Wallace Rehabilitation Institute, I would have rushed to the nearest store to buy a case of them. When we don’t know how to fix a problem, we tend to cling to bandages to cover them, allowing us to ignore them. With 29 years of running and racing and 2 natural childbirths under my belt, leaks have happened, and it is common. However, leaks due to urinary stress incontinence are not normal and do not stop simply because you place a contoured, sporty, sanitary pad in the lining of your shorts.

A 2016 cross-sectional study by Ameida et al. investigated urinary incontinence (UI) and pelvic floor dysfunctions (PFD) such as constipation, anal incontinence, pelvic organ prolapse, vaginal laxity, and dyspareunia in female athletes who participate in high-impact sports. The 67 amateur athletes and 96 non-athletes completed an ad hoc survey to determine PFD symptoms. Artistic gymnasts, trampolinists, swimmers, and judo participants were among the athletes with the highest risk of urinary incontinence. Although the athletes had a higher risk of UI, they reported less constipation, less straining to relieve themselves, and less manual assistance for defecation than the non-athletes. The authors were able to conclude that high impact sports or sports requiring a strong effort put athletes at risk for UI, uncontrolled gas expulsion, and even sexual dysfunction. They emphasize a need for attention to be given to pelvic floor training for rehabilitation as well as preventative strategies and education for high risk yet asymptomatic athletes.

In 2015, DaRoza et al. performed a cross-sectional cohort study to determine the urinary leakage in 22 young female trampolinists based on the volume of their training and level of ranking. Leakage was assessed by the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-UI-SF), and another questionnaire determined each athlete’s championship ranking and training volume. An astounding 72.7% of girls reported urine leakage since starting to perform on the trampoline, and the greatest severity was significantly associated with the highest training volume. The impact of UI on the athlete’s quality of life was greatest in this 3rd tertile. The authors recommended these athletes with a high frequency of UI be educated on the impact of their sport on their pelvic floor muscles and proposed they get treated by pelvic health professionals to minimize or resolve the incontinence.

Thankfully, none of the above researchers or medical professionals advises the study participants to just use a pad and carry on with their sport. Urinary incontinence is a real problem in athletes, and its prevalence is appalling. Even young girls without any birthing of babies to blame are leaking. Making females (and males) aware of the impact sports can have on their pelvic floor and educating them that urinary leakage is not normal are essential missions for healthcare professionals. “The Athlete and the Pelvic Floor” course can help integrate pivotal aspects of pelvic rehabilitation into sports medicine, as some conditions just may require training to move down to the pelvic floor for complete recovery.


Almeida, MB, Barra, AA, Saltiel, F, Silva-Filho, AL, Fonseca, AM, Figueiredo, EM. (2016). Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scandinavian Journal of Medicine & Science in Sports. 26(9):1109-16. http://doi:10.1111/sms.12546
Da Roza, T, Brandão, S, Mascarenhas, T, Jorge, RN, Duarte JA. (2015). Volume of training and the ranking level are associated with the leakage of urine in young female trampolinists. Clinical Journal of Sport Medicine. 25(3):270-5. http://DOI:10.1097/JSM.0000000000000129

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Fecal Incontinence May Surrender to Stem Cells

While recently visiting Seattle with my daughter, we had the pleasure of talking with Dr. Ghislaine Robert, owner of Sparclaine Regenerative Medicine. She is a highly respected sports medicine doctor who has steered much of her practice towards regenerative medicine, with a focus on stem cell and platelet enriched plasma (PRP) injections. She brought to my attention the use of stem cells for pelvic floor disorders. And, like any successful practitioner, she encouraged me to research it for myself.

In 2015, Cestaro et al. reported early results of 3 patients with fecal incontinence receiving intersphincteric anal groove injections of fat tissue. They aspirated about 150ml of the fat tissue and used the Lipogem system technology lipofilling technique to provide micro-fragmented and transplantable clusters of lipoaspirate. The intersphincteric space was then injected with the lipoaspirate. A proctology exam was performed at 1 week, 1 month, and 6 months following the procedure. All 3 patients all had reduced Wexner incontinence scores 1 month post-treatment and a significant improvement in quality of life 6 months post-procedure. Resting pressure of the internal anal sphincter increased after 6 months, and the internal anal sphincter showed increased thickness.

A 2016 study by Mazzanti et al., used rats to explore whether unexpanded bone marrow-derived mononuclear mesynchymal cells (MNC) could effectively repair anal sphincter healing since expanded ones (MSC) had already been shown to enhance healing after injury in a rat model. They divided 32 rats into 4 groups: sphincterotomy and repair (SR) with primary suture of anal sphincters and a saline intrasphincteric injection (CTR); SR of anal sphincter with in-vitro expanded MSC; SR of anal sphincter with minimally manipulated MNC; and, a sham operation with saline injection. Muscle regeneration as well as contractile function was observed in the MSC and MNC groups, while the control surgical group demonstrated development of scar tissue, inflammatory cells and mast cells between the ends of the interrupted muscle layer 30 days post-surgery. Ultimately, the authors found no significant difference between expanded or unexpanded bone marrow stem cell types used. Post-sphincter repair can be enhanced by stem cell therapy for anal incontinence, even when the cells are minimally manipulated.

Finally, in 2017, Sarveazad et al. performed a double-blind clinical trial in humans using human adipose-derived stromal/stem cells (hADSCs) from adipose tissue for fecal incontinence. The hADSCs secrete growth factor and can potentially differentiate into muscle cells, which make them worth testing for improvement of anal sphincter incontinence. They used 18 subjects with sphincter defects, 9 undergoing sphincter repair with injection of hADSCs and 9 having surgery with a phosphate buffer saline injection. After 2 months, there was a 7.91% increase in the muscle mass in the area of the lesion for the cell group compared to the control. Fibrous tissue replacement with muscle tissue, allowing contractile function, may be a key in the long term for treatment of fecal incontinence.

As long as accessing human-derived stem cells is a viable option for patients, the preliminary studies show promise for success. With fecal incontinence being such a debilitating problem for people, especially socially, stem cells are definitely an up and coming treatment, and we should all keep up on this research. After all, who wouldn’t spare some adipose tissue for life-changing, functional gains?


Cestaro, G., De Rosa, M., Massa, S., Amato, B., & Gentile, M. (2015). Intersphincteric anal lipofilling with micro-fragmented fat tissue for the treatment of faecal incontinence: preliminary results of three patients. Videosurgery and Other Miniinvasive Techniques, 10(2), 337–341. http://doi.org/10.5114/wiitm.2014.47435
Mazzanti, B., Lorenzi, B., Borghini, A., Boieri, M., Ballerini, L., Saccardi, R., … Pessina, F. (2016). Local injection of bone marrow progenitor cells for the treatment of anal sphincter injury: in-vitro expanded versus minimally-manipulated cells. Stem Cell Research & Therapy, 7, 85. http://doi.org/10.1186/s13287-016-0344-x
Sarveazad, A., Newstead, G. L., Mirzaei, R., Joghataei, M. T., Bakhtiari, M., Babahajian, A., & Mahjoubi, B. (2017). A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial. Stem Cell Research & Therapy, 8, 40. http://doi.org/10.1186/s13287-017-0489-2

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Accepting Stress with Mindfulness

After my Dad’s 3rd trip to the emergency room not being able to breathe because of his sleep apnea and congestive heart failure, his cardiologist recommended he ”just relax” when his suffocating feelings occurred. Of course, not being able to catch his breath would always heighten anxiety, which made it even more difficult to inhale and exhale. Ultimately, what my Dad needed to learn was mindfulness to deal with his relatively benign inability to breathe, since the focus of mindfulness is acceptance of rather than control over your circumstances.

The concept of mindfulness has been studied in adults, but it is gaining popularity among the pediatric population. Ruskin et al., (2017) used a prospective pre-post interventional study to assess how children with chronic pain respond to mindfulness-based interventions (MBI’s). For 8 weeks, 21 adolescents engaged in group sessions of MBI. Before, after, and 3 months post-treatment, the authors collected self-report measurements for a variety of factors such as disability, anxiety, pain quality, acceptance, catastrophizing, and social support. Subjects were highly satisfied with the treatment, and all would recommend the group intervention to friends. From baseline to 3-month follow-up, pain acceptance, body awareness, and ability to cope with stress all improved in the subjects. Further randomized controlled studies are needed, but the initial conclusion was MBI’s were received well by adolescents.

A feasibility study performed by Anclair, Hjärthag, and Hiltunen in 2017 considered the effect of mindfulness and cognitive behavioral therapy for the parents of children with chronic conditions, looking at Health-Related Quality of Life (HRQOL), measured with Short Form-36 (SF-36), and life satisfaction. Ten parents received group-based cognitive behavioral therapy (CBT), and 9 participated in a group-based mindfulness program (MF). Treatment was implemented for 2-hour weekly sessions over the course of 8 weeks. The CBT treatment was based on the Acceptance and Commitment Therapy, focusing on changing thoughts and emotions about stressful issues as well as behaviors. They avoided the acceptance aspect, as it would overlap the MF intervention. The MF therapy used the Here and Now Version 2.0 (including daily themes on knowing your body, observing breathing, acceptance, meditation, coping, understanding thoughts versus facts, and self-care reinforcement). The parents in each group significantly improved their Mental Component Summary (MCS), Vitality, Social functioning, and Mental health scores. The MF group even showed notable improvement in Role emotional and some of the physical subscales (Bodily pain, General health, and Role physical). The CBT group showed improved satisfaction with Spare time and Relation to partner, and CBT and MF groups improved life satisfaction Relation to child. The authors conclude CBT and MF may positively affect HRQOL and life satisfaction of parents with chronically ill children.

Whether young or old or in between, how we perceive stressful situations and chronic pain can impact our health. The neurodevelopmental aspect of mindfulness is still being studied. The “Mindfulness Based Pain Treatment” course applies the concept to treating chronic pain patients. This approach brings to mind the Serenity Prayer by Reinhold Niebuhr: “Lord grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.”


Ruskin ,DA, Gagnon, MM, Kohut SA, Stinson JN, Walker KS. (2017). A Mindfulness Program Adapted for Adolescents With Chronic Pain: Feasibility, Acceptability, and Initial Outcomes. The Clinical Journal of Pain. http://www.doi:10.1097/AJP.0000000000000490
Anclair, M., Hjärthag, F., & Hiltunen, A. J. (2017). Cognitive Behavioural Therapy and Mindfulness for Health-Related Quality of Life: Comparing Treatments for Parents of Children with Chronic Conditions - A Pilot Feasibility Study. Clinical Practice and Epidemiology in Mental Health : CP & EMH, 13, 1–9. http://doi.org/10.2174/1745017901713010001

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