In my mid 20’s I had a sudden onset of severe, persistent pain at the bottom of my spine. I had fallen while running on trails and thought maybe I had fractured my coccyx. It hurt terribly to sit, especially on hard surfaces. When I finally succumbed to seeing a doctor, he diagnosed me with a pilonidal cyst and performed a simple excision of the infection right there in the office. I recall passing out on the table and waking up with an open wound stuffed with gauze. What I thought was “just” coccydynia turned out to be something completely different, requiring a specific and immediately effective treatment.
Differential diagnosis is essential in all medical professions. Blocker, Hill, and Woodacre2011 presented a case report on persistent coccydynia and the necessity of differential diagnosis. A 59-year old female reported constant coccyx pain after falling at a wedding. Her initial x-rays were normal, as was an MRI a year later, despite continued pain. Neither an ultrasound nor abdominal CT scan was performed until 16 months after the onset of pain, which was 2 months after she started having bladder symptoms. A CT scan then showed a tumor stemming from her sacrum and coccyx, and an MRI confirmed the sacrum as the tumor location. Chordomas are primary bone tumors generally found at the sacrum and coccyx or the base of the skull. They are relatively rare; however, they do exist in males and females and can present as low back pain, a soft tissue mass, or bladder/bowel obstruction. Clinicians need to listen for red flags of night pain and severe, unrelenting pain and ensure proper examination is performed for accurate diagnosis and expedient treatment.
In a more recent case study by Gavriilidid & Kyriakou 2013, a 73 year old male presented with 6 months of tailbone pain, worse with sitting and rising from sitting. The physician initially referred him to a surgeon for a pilonidal cyst he diagnosed upon palpation. The surgeon found an unusual mass and performed a biopsy, which turned out to be a sacrococcygeal chordoma. The tumor was excised surgically along with the gluteal musculature, coccyx, and the fifth sacral vertebra, as well as a 2cm border of healthy tissue to minimize risk of recurrence of the chordoma. These authors reported coccygodynia is most often caused by pilonidal disease, clinically confirmed by abscess/sinus, fluid drainage, and midline skin pits. They concluded from this case study if one or more of those characteristic findings are absent, differential diagnoses of chordoma, perineural cyst, giant cell tumour, intra-osseous lipoma, or intradural Schwannoma should be investigated.
Honestly, if I were not a physical therapy tech when my coccyx started killing me 20 years ago, I am not sure I would have gone to the doctor right away. My boss called me out when I winced every time I sat down, and he sent me off to get an exam. The majority of patients are not blurting out specific details about buttock pain when they come for evaluation. Modesty prevails but does not always benefit a patient with persistent coccydynia. Thankfully I did not have a chordoma, but the pain was intense enough to bring me to tears, and it could have required surgery if I had not been diagnosed early enough. Providing a comfortable environment for our patients during their initial encounter can help them feel less vulnerable and discuss the root of their pain. If we can decipher between chordoma and other causes of coccydynia, we may strike a chord that saves a patient from a poor outcome.
The Herman & Wallace course "Coccyx Pain Evaluation & Treatment" is an excellent opportunity to learn new differential diagnosis techniques for coccyx pain patients. The next opportunity to attend this course is March 25-26 in Tampa, Florida.
Blocker, O., Hill, S., & Woodacre, T. (2011). Persistent coccydynia – the importance of a differential diagnosis. BMJ Case Reports, 2011, bcr0620114408. http://doi.org/10.1136/bcr.06.2011.4408
Gavriilidis, P., & Kyriakou, D. (2013). Sacrococcygeal chordoma, a rare cause of coccygodynia. The American Journal of Case Reports, 14, 548–550. http://doi.org/10.12659/AJCR.889688
Lymphedema with regards to women’s health is most commonly associated with breast cancer. Upper extremity lymphedema can be limiting and painful without a doubt, and I have seen women suffering from irritating edema and limited shoulder range of motion and function after radical mastectomy. However, we may not always consider lower extremity lymphedema which can occur as a result of urogenital cancers and their treatments. Our knowledge and skilled hands can impact the quality of life of these patients who may seek treatment for their post-cancer complications.
Mitra et al., published a 2016 retrospective study on lymphedema risk post radiation therapy in endometrial cancer. They considered 212 endometrial cancer survivors, and 7.1% who received adjuvant pelvic radiation therapy developed lower extremity lymphedema after treatment, whether they had chemotherapy or not. Finding at least 1 positive pathological lymph node was directly correlated with an increased risk of lymphedema, regardless of attempts to control pelvic lymph-node dissection. These statistics encourage finding prophylactic measures to take for stage III endometrial cancer patients to minimize the risk for long-term lymphedema. Regarding treatment for lower extremity lymphedema, this paper discussed compression stocking use, pneumatic compression stockings, and complex decongestive therapy, an intensive regimen of physical therapy and massage that is unfortunately not easily accessible for a majority of patients. The authors encouraged future research on the efficacy of exercise and compression for lymph node positive patients.
Shaitelman et al. presented a review of the progress made in the treatment and prevention of cancer-related lymphedema (2015). They stated gynecologic cancer treatment is associated with 25% incidence of lymphedema. Endometrial cancer had 1%, cervical cancer had 27%, and vulvar cancer had 30% incidence specifically. Sentinel lymph node biopsy (SLNB) can be an important part of cancer treatment, as lymphedema incidence was shown to average 9%. With treatment of genitourinary cancers, lymphedema occurred in 4% patients with prostate cancer, 16% patients with bladder cancer, and 21% patients with penile cancer. Shown to decrease limb volume and improve quality of life, the current standard of care is complete decongestive therapy (CDT). These authors state CDT involves the use of manual lymphatic drainage (MLD), bandaging on a daily basis, skin care, exercise, and a 3-phase protocol of compression. The use of SLNB helps identify the risk of lymphedema post cancer treatment; however, clinicians need to be aware of the signs and symptoms of lymphedema so the affected patient can be recognized early and referred to the appropriate specialist for treatment.
We may be referred patients with the confirmed diagnosis of lymphedema, but often we see post-cancer patients for rehab who develop lymphedema months after radiation or chemotherapy. Any healthcare professional involved with regular treatment of a cancer-surviving patient needs to have a keen sense for diagnosing and properly taking care of lymphedema. Courses such as “Lymphatics and Pelvic Pain: New Strategies” can open a whole new avenue for understanding what patients may need from us following urogenital and genitourinary cancers. Why not be prepared to face with knowledge and skill whatever pathology our patients present?
Mitra, D., Catalano, P.J., Cimbak, N., Damato, A.L., Muto, M.G., & Viswanathan, A.N. (2016). The Risk of Lymphedema After Postoperative Radiation Therapy in Endometrial Cancer. Journal of Gynecologic Oncology, 27(1), e4.
Shaitelman, S.F., Cromwell, K.D., Rasmussen, J.C., Stout, N.L., Armer, J.M., Lasinski, B.B., & Cormier, J.N. (2015). Recent Progress in Cancer-Related Lymphedema Treatment and Prevention. CA: A Cancer Journal for Clinicians, 65(1), 55-81.
During labor, I had no problem breathing out. My hang up came when I had to inhale - actually oxygenate my blood and maintain a healthy heart rate for my almost newborn baby. When extra staff filled the delivery room, and an oxygen mask was placed over my face, my husband remained calm but later told me how freaked out he was. He was watching the monitors that showed a drop in my vitals as well as our baby’s. In retrospect, I wonder if practicing yoga, particularly the breathing techniques involved with pranayama practice, could have prevented that moment.
A research article by Critchley et al., (2015) broke down breathing to a very scientific level, determining the consequences of slow breathing (6 breaths/minute) versus induced hypoxic challenges (13% inspired O2) on the cardiac and respiratory systems and their central neural substrates. Functional magnetic resonance imaging measured the 20 healthy subjects’ specific brain activity during the slow and normal rate breathing. The authors mentioned the controlled slow breathing of 6 breaths/minute is the rate encouraged during yoga practice. This rate decreases sympathetic activity, lessening vasoconstriction associated with hypertension, and it prevents physiological stress from affecting the cardiovascular system. Each part of the brain showed responses to the 2 conditions, and the general conclusion was modifying breathing rate impacted autonomic activity and improved both cardiovascular and psychological health.
Vinay, Venkatesh, and Ambarish (2016) presented a study on the effect of 1 month of yoga practice on heart rate variability in 32 males who completed the protocol. The authors reported yoga is supposed to alter the autonomic system and promote improvements in cardiovascular health. Not just the breathing but also the movements and meditation positively affect mental health and general well-being. The subjects participated in 1 hour of yoga daily for 1 month, and at the end of the study, the 1 bpm improvement in heart rate was not statistically significant. However, heart rate variability measures indicated a positive shift of the autonomic system from sympathetic activity to parasympathetic, which reduces cortisol levels, improves blood pressure, and increases circulation to the intestines.
Bershadsky et al., (2014) studied the effect of prenatal Hatha yoga on cortisol levels, affect and depression in the 34 women who completed pre, mid, and post pregnancy saliva tests and questionnaires. While levels of cortisol increase naturally with pregnancy, yoga was found to minimize the mean levels compared to the days the subjects did not participate in yoga. After a single 90-minute yoga session, during which breathing was emphasized throughout the session, women had higher positive affect; but, the cortisol level was not significantly different from the control group. Overall, the authors concluded yoga had potential to minimize depression and cortisol levels in pregnancy.
Considering the positive effect of slow breathing practiced in yoga, the positive shift in the autonomic nervous system function and the decrease in cortisol levels, yoga is gaining credibility as an effective adjunct to treatment during pregnancy. If a woman enters the delivery room with a solid practice of slow breathing under her belt, she may be equipped to handle the intensity of contractions and the pain of pushing a little better. Yoga may help a woman breathe for her life and her baby’s as well.
If you're interested in learning more about yoga for pregnant patients, consider attending Yoga as Medicine for Pregnancy with Ginger Garner, PT, DPT, ATC/LAT, PYT. The next opportunity is in Fort Lauderdale, FL on January 28th and 29th, 2017. Don't miss out!
Critchley, H. D., Nicotra, A., Chiesa, P. A., Nagai, Y., Gray, M. A., Minati, L., & Bernardi, L. (2015). Slow Breathing and Hypoxic Challenge: Cardiorespiratory Consequences and Their Central Neural Substrates. PLoS ONE, 10(5), e0127082.
Vinay, A., Venkatesh, D., & Ambarish, V. (2016). Impact of short-term practice of yoga on heart rate variability. International Journal of Yoga, 9(1), 62–66.
Bershadsky, S., Trumpfheller, L., Kimble, H. B., Pipaloff, D., & Yim, I. S. (2014). The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms. Complementary Therapies in Clinical Practice, 20(2), 106–113.
In the 80’s, I would stand in my older sister’s bedroom wearing a button-down, collared shirt under a sweater and beg her to “fix me.” I felt stuck and wanted to cry until she twisted the shirt and loosened the snags of the knitted covering and made the outfit lay properly together. The myofascial system can often make us feel the same way if what’s lying underneath the intricately woven network of tissue has trigger points and inflammatory mediators rearing their ugly heads. When myofascial restrictions strike the pelvic region, every move a person makes can tug at the affected fascia and magnify the pain.
How do we know if someone has myofascial pain syndrome? Itza et al., (2015) published a study on turns-amplitude analysis (TAA) efficacy for diagnosing the syndrome in patients with chronic pelvic pain. The 128 subjects (64 with chronic pelvic pain and 64 healthy controls) underwent electromyogram (EMG) tests conducted in the levator ani muscle and the external anal sphincter. The mean TAA data was analyzed automatically, and an increase in the score was considered to be positive, while a decrease was negative. An increased TAA was found in 86% of the patients (no difference between men and women), and 100% of the control subjects displayed no increase in TAA. This study showed TAA to be an effective means by which to diagnose myofascial pain syndrome of the pelvic floor.
What are some treatments being researched? Anderson et al., (2016) conducted a study on using a multi-modal protocol with an internal myofascial trigger point wand to treat men and women with chronic pelvic pain syndrome (CPPS). After 6 days of training, male and female subjects with CPPS engaged in 6 months of pelvic floor trigger point release with an internal trigger point device that was self-administered in combination with paradoxical relaxation training. In the end, women and men subjects experienced similar reduction of symptoms as trigger point sensitivity decreased significantly.
Adelowo et al., (2013) explored the efficacy of botulinum toxin type A (Botox) for treatment of myofascial pelvic pain via a retrospective cohort study. Trigger points and pelvic floor hypertonicity were identified and confirmed with digital palpation. Twenty-nine women were assessed after intralevator injection with Botox A, and 79.3% reported reduction of pain. Botox A was deemed an effective and safe intervention with only mild, spontaneously resolving side effects occurring in 8 of the patients.
In 2012, Fitzgerald et al. studied the difference in outcomes between myofascial physical therapy (MPT) versus global therapeutic massage (GTM) for patients with interstitial cystitis/painful bladder syndrome. Of the 81 women randomly allocated to the two treatment groups, the MPT group had the greater response with 59% reporting moderate or marked improvement in symptoms (compared to 26% in the GTM group). Ultimately, myofascial physical therapy was considered beneficial for pelvic disorders.
Being able to adjust an outward snag such as a twisted sweater or stocking is much less complicated than deciphering and untangling the internal myofascial dysfunctions in the pelvis. When you are without an EMG, high-tech internal wands, or Botox, it is up to your hands and keen sensibility to detect the presence of the trigger points and release the restrictions. Thankfully, courses like “Mobilization of the Myofascial Layer: Pelvis and Lower Extremity” can guide you towards greater efficacy in this endeavor.
Itza, F., Zarza, D., Salinas, J., Teba, F., & Ximenez, C. (2015). Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain. Pain Research & Management : The Journal of the Canadian Pain Society, 20(2), 96–100.
Anderson, R.U., Wise, D., Sawyer, T. et al. (2016). Equal Improvement in Men and Women in the Treatment of Urologic Chronic Pelvic Pain Syndrome Using a Multi-modal Protocol with an Internal Myofascial Trigger Point Wand. Applied Psychophysiology Biofeedback. 41:215.
ADELOWO, A., HACKER, M. R., SHAPIRO, A., Modest, A. M., & ELKADRY, E. (2013). Botulinum Toxin Type A (BOTOX) for Refractory Myofascial Pelvic Pain. Female Pelvic Medicine & Reconstructive Surgery, 19(5), 288–292.
FitzGerald, M., Payne, C., Lukacz, E., Yang, C., Peters, K., Chai, T., … Nyberg, *LM. (2012). Randomized Multicenter Clinical Trial of Myofascial Physical Therapy in Women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and Pelvic Floor Tenderness. The Journal of Urology, 187(6), 2113–2118.
My little boy has a t-shirt with a potato telling french fries, “I am your father,” to which the french fries cry, “NO!!!!” The Star Wars spoof makes me laugh, but sometimes the struggle is real. Testicular cancer and the toxic remedies for it can potentially prevent young men from having a successful reproductive life. Survivors of the cancer may one day have to tell their children they are adopted or came from a sperm donor. With the advances in technology and research, however, testicular cancer survivors have a greater chance for their own sperm to be spared or even produced naturally years later to create their offspring.
Vakalopoulos et al. (2015) discussed the impact cancer and the related treatments have on fertility of males. Better survival rates for oncology patients have made preservation of reproductive means more imperative for men. Testicular cancer represents 5% of male urologic cancers, disturbing spermatogenesis and impairing fertility. Chemotherapy, radiotherapy, and surgery can all have gonadotoxic effects in men. Thankfully, only 1 in 5000 men die from testicular cancer now with advanced treatments, but fertility does become a long term factor for survivors. This paper showed chemotherapy combined with radiotherapy was most detrimental to sperm than either treatment alone. Gonadal shielding and moving the testes out of the way to target the malignant cells can help decrease the deleterious effects of cancer treatments. Radiotherapy, however, has been shown to damage sperm up to 2 years after recovery of spermatogenesis. Regarding surgery, radical unilateral orchiectomy is the standard for testicular tumors, and within the first few months, a 50% decrease in sperm concentration occurs, and 10% of patients become azoospermic. On a more encouraging note, after receiving Hematopoietic Stem Cell Transplantation, recovery of sperm in the ejaculate was noted in 33% of patients after 1 year and 80% of patients after 7 years.
Regardless of advancements in decreasing toxicity of cancer treatments and being minimally invasive with surgery, the best guarantee for preservation of sperm is cryopreservation.
A study collecting baseline data for semen quality of cancer patients prior to any gonadotoxic treatment was performed by Auger et al. (2016). Less than 60% of the testicular cancer patients had normal sperm production prior to treatment. The study also looked at patients with Hodgkin’s disease, non-Hodgkin’s Lymphoma, Leukemia, sarcoma, Behcet’s disease, brain tumor, and Multiple Sclerosis. The motility of sperm after freezing (cryopreservation) of the cancer patients was less than half of the healthy sperm donor control group. Intra Cytoplasmic Sperm Injection (ICSI) was shown to provide the best chance of paternity for men, and the authors conclude this as a necessary step in case men do not regain any spermatogenesis after cancer treatment.
There is no perfect circumstance when it comes to cancer. Survival is the primary goal, and then quality of life becomes the “problem,” particularly when it comes to fulfilling dreams of having a family. The toxic cancer treatments are improving but cannot guarantee return of spermatogenesis. Depending on the sperm integrity prior to getting treatment, cryopreservation success can vary but is the most highly recommended step to preserving fertility. In the end, a fresh or frozen spud can still make french fries.
Herman & Wallace has two great courses which can give you the tools needed to help assess and treat male patients who suffer from cancer-related dysfunctions. Consider Oncology and the Male Pelvic Floor: Male Reproductive, Bladder, and Colorectal Cancers or Post-Prostatectomy Patient Rehabilitation for your next continuing education courses.
Vakalopoulos, I., Dimou, P., Anagnostou, I., Zeginiadou T. (2015). Impact of cancer and cancer treatment on male fertility. Hormones. 14(4):579-89. DOI: 10.14310/horm.2002.1620
Auger, J., Sermondade, N., & Eustache, F. (2016). Semen quality of 4480 young cancer and systemic disease patients: baseline data and clinical considerations. Basic and Clinical Andrology, 26, 3. http://doi.org/10.1186/s12610-016-0031-x
We are all familiar with the old saying, “You are what you eat.” A functional medicine lecture I attended recently at the Cleveland Clinic explained how chronic pain can be a result of how the body fails to process the foods we eat. Patients who just don’t seem to get better despite our skilled intervention make us wonder if something systemic is fueling inflammation. Even symptoms of vulvodynia, an idiopathic dysfunction affecting 4-16% of women, have been shown to correlate to diet.
In a single case study of a 28 year old female athlete in Integrative Medicine (Drummond et al., 2016), vulvodynia and irritable bowel syndrome (IBS) were addressed with an elimination diet. After being treated by a pelvic floor specialist for 7 months for vulvodynia, the patient was referred out for a nutrition consultation. Physical therapy was continued during the vegetarian elimination diet. In the patient’s first follow up 2 weeks after starting eliminating meat, dairy, soy, grains, peanuts, corn, sugar/artificial sweeteners, she no longer had vulvodynia. The nutrition specialist had her add specific foods every 2 weeks and watched for symptoms. Soy, goat dairy, and gluten all caused flare ups of her vulvodynia throughout the process. Eliminating those items and supplementing with magnesium, vitamin D3, probiotics, vitamin B12, and omega-3 allowed the patient to be symptom free of both vulvodynia and IBS for 6 months post-treatment.
On the more scientific end of research, Vicki Ratner published a commentary called “Mast cell activitation syndrome” in 2015. She described how mast cells appear close to blood vessels and nerves, and they release inflammatory mediators when degranulated; however, mast cell activation syndrome (MCAS) involves mast cells that do not get degranulated properly and affect specific organs like the bladder. She proposed measuring the number of mast cells and inflammatory mediators in urine for more expedient diagnosis of interstitial cystisis and bladder pain syndrome.
Sigrid Regauer’s correspondence to Ratner’s article followed in 2016 relating MCAS to bladder pain syndrome (BPS), interstitial cystitis (IC), and vulvodynia. He described vulvodynia as a pain syndrome with excessive mast cells and sensory nerve hyperinnervation, often found with BPS and IC. The vulvodynia patients had mast cell hyperplasia, most of which were degranulated, and 70% of the patients had comorbidities due to mast cell activation such as food allergies, histamine intolerance, infections, and fibromyalgia.
Considering the association between mast cells and acute inflammatory responses and how mast cells release proinflammatory mediators, it makes sense that dysfunctions such as vulvodynia as well as IC and BPS can result from an excessive amount and dysfunctional granulation of mast cells. Enhanced activation of mast cells causes histamine release, stimulating peripheral pain neurotransmitters (Fariello & Moldwin 2015). If medication and therapy do not solve a patient’s pain, perhaps eliminating the consumption of inflammatory foods could positively affect the body on a cellular level and relieve irritating symptoms of vulvodynia. Pardon the parody, but patients on the brink of being “insane in the brain” from vulvodynia will likely try anything to resolve being “inflamed in the membrane.”
Drummond, J., Ford, D., Daniel, S., & Meyerink, T. (2016). Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report.Integrative Medicine: A Clinician’s Journal, 15(4), 42–47.
Ratner, V. (2015). Mast cell activation syndrome. Translational Andrology and Urology, 4(5), 587–588. http://doi.org/10.3978/j.issn.2223-4683.2015.09.03
Regauer, S. (2016). Mast cell activation syndrome in pain syndromes bladder pain syndrome/interstitial cystitis and vulvodynia. Translational Andrology and Urology, 5(3), 396–397. http://doi.org/10.21037/tau.2016.03.12
Fariello, J. Y., & Moldwin, R. M. (2015). Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management. Translational Andrology and Urology, 4(6), 643–652. http://doi.org/10.3978/j.issn.2223-4683.2015.10.09
You wouldn't place a newborn in a crib without knowing the legs were firmly attached at the right angle to the base. You wouldn't jump on a hammock if the poles or trees were not firmly intact and upright to support the sling. Why would you treat a pregnant woman without checking if her hips were working optimally in proper alignment to support the pelvis, inside which a new life is developing? Let's hope higher level clinicians spend the extra effort to learn about the surrounding areas that affect our specialty, whether it is pelvic floor or spine or sports medicine.
In 2015, Branco et al., published a study entitled, “Three-Dimensional Kinetic Adaptations of Gait throughout Pregnancy and Postpartum.” Eleven pregnant women voluntarily participated in this descriptive longitudinal study. Ground reaction forces (GRF), joint moments of force in the sagittal, frontal, and transverse planes, and joint power in those same 3 planes were measured and assessed during gait over the course of the first, second, and third trimesters as well as 6 months post-partum. The authors found pregnancy does influence the kinetic variables of all the lower extremity joints; however, the hip joint experiences the most notable changes. As pregnancy progressed, a decrease in the mechanical load was found, with a decrease in the GRF and sagittal plane joint moments and joint powers. The vertical GRF showed the peaks of braking propulsion decreases from late pregnancy to the postpartum period. A significant reduction of hip extensor activity during loading response was detected in the sagittal plane. Ultimately, throughout pregnancy, physical activity needs to be performed in order to develop or maintain stability of the body via the lower quarter, particularly the hips.
The same authors, in 2013, studied gait analysis in the second and third trimesters of pregnancy. Branco et al., performed a 3-dimensional gait analysis of 22 pregnant women and 12 non-pregnant women to discern kinetic differences in the groups. Nineteen dependent variables were measured, and no change was noted between 2nd and 3rd trimesters or the control group for walking speed, stride width, right-/left-step time, cycle time and time of support, or flight phases. Comparing the 2nd versus 3rd trimester, a decrease in stride and right-/left-step lengths decreased. The 2nd and 3rd trimesters both showed a significant decrease in right hip extension and adduction during the stance phase when compared to the control group. In this study, the authors also noted increased left knee flexion and decreased right ankle plantar flexion during gait from the 2nd to the 3rd trimester. The bottom line in this study, just as the more recent one suggests, pregnant women need a higher degree of lower quarter stability to ambulate efficiently throughout pregnancy.
Physical therapists are movement specialists with a unique opportunity to analyze how humans function, whether athletes or pregnant women (or even a pregnant athlete). How the hips move and whether or not proper muscles are firing can affect anyone’s gait. The extra demands on the pregnant body require more specific analysis of kinetics by therapists, thus directing the protocols for rehabilitation of this population. It should behoove every pelvic floor specialist, in particular, to attend a course like “Biomechanical Assessment of the Hip and Pelvis" or "Care of the Pregnant Patient" in order to provide patients with the optimal support for the natural “crib” women provide during pregnancy.
Branco, M., Santos-Rocha, R., Vieira, F., Aguiar, L., & Veloso, A. P. (2015). Three-Dimensional Kinetic Adaptations of Gait throughout Pregnancy and Postpartum. Scientifica, 2015, 580374. http://doi.org/10.1155/2015/580374
Branco, M., Santos-Rocha, R., Aguiar, L., Vieira, F., & Veloso, A. (2013). Kinematic Analysis of Gait in the Second and Third Trimesters of Pregnancy.Journal of Pregnancy, 2013, 718095. http://doi.org/10.1155/2013/718095
Assuring patients with chronic pain they are not crazy by explaining the neurophysiology behind what is happening in their brain and body can be life changing. Increasing our patients’ knowledge about physical conditions can reduce anxiety and provide hope. As a healthcare provider, being confident in your differential diagnosis skills can help narrow down the physical source of pain, weed out the psychological components, and connect the dots to the neurological influence on the patient’s persistent symptoms.
A 2015 article in Pain Medicine (Gurian et al) found a direct association between pain sensitivity and treatment of chronic pelvic pain. The study involved 58 women with at least 6 months of pelvic pain, and they were evaluated on pain threshold using transcutaneous electrical nerve stimulation before treatment and 6 months after a multidisciplinary approach to treatment of the pelvic pain. Pain intensity was also evaluated using the visual analog scale and the McGill questionnaire. Depending on the specific condition, treatment included manual therapy, physical therapy, pain medications, laparoscopy, oral contraceptives, nutrition intervention, or psychological support. After receiving treatment for 6 months, the pain threshold mean improved from 14.2 to 17.4. The effect sizes of 0.86 in the group with pain reduction and 0.53 in the group not achieving pain reduction were both within the 95% confidence interval. The authors concluded in this study that central sensitization does occur in patients with chronic pelvic pain, and treatment can reduce the general pain sensitivity of the patient.
Kutch et al., (2015) performed a study regarding the change in men’s resting state of neuromotor connectivity as affected by chronic prostatitis or chronic pelvic pain syndrome (CP/CPPS), showing men are also subject to central sensitization. Fifty-five men (28 males with pelvic pain for at least 3 months and 27 healthy males) completed the study, with resting state functional magnetic resonance imaging detecting the functional connectivity of the pelvis with the motor cortex (pelvic-motor). The right posterior insula and pelvic-motor functional connectivity was found to be significantly different in men with chronic pelvic pain and prostatitis versus the healthy control group. Contraction of the pelvic floor corresponded with activation of the medial aspect of the motor cortex, while the left motor cortex was more associated with contraction of the right hand. The authors concluded this relationship may explain the viscerosensory and motor processing changes that occur in men with CP/CPPS and could be the most important marker of brain function alteration in this group of patients.
As more research is being done on the neurophysiological level of pain, more truth can support the “it’s all in your head” accusation. However, it is a positive light to shed for a patient. The brain is powerful and controls how pain is perceived globally. Proper treatment of a chronic pelvic floor condition, for women and men, can help reduce stress on the brain and lessen pain sensitivity and perception in our patients. Never let a patient pursue the self-perception that they are crazy. Explain central sensitization and how sometimes the brain wins in the war of “mind over matter”; however, give them hope, explaining how the proper treatment can lessen the intensity of the battle wounds.
Maria Beatriz Ferreira Gurian, Omero Benedicto Poli Neto, Julio Cesar Rosa e Silva, Antonio Alberto Nogueira, Francisco Jose Candido dos Reis. (2015). Reduction of Pain Sensitivity is Associated with the Response to Treatment in Women with Chronic Pelvic Pain. Pain Medicine. 16 (5) 849-854; DOI: 10.1111/pme.12625
Kutch, J. J., Yani, M. S., Asavasopon, S., Kirages, D. J., Rana, M., Cosand, L., … Mayer, E. A. (2015). Altered resting state neuromotor connectivity in men with chronic prostatitis/chronic pelvic pain syndrome: A MAPP: Research Network Neuroimaging Study. NeuroImage : Clinical, 8, 493–502. http://doi.org/10.1016/j.nicl.2015.05.013
In manual therapy training, we do not learn just one position to mobilize a joint, so why should pelvic floor muscle training be limited by the standard training methods? There is almost always at least one patient in the clinic that fails to respond to the “normal” treatment and requires a twist on conventional therapy to get over a dysfunction. Thankfully, classes like “Integrative Techniques for Pelvic Floor and Core Function” provide clinicians with the extra tools that might help even just one patient with lingering symptoms.
In 2014, Tenfelde and Janusek considered yoga as a treatment for urge urinary incontinence in women, referring to it as a “biobehavioral approach.” The article reviews the benefits of yoga as it relates to improving the quality of life of women with urge urinary incontinence. Yoga may improve sympatho-vagal balance, which would lower inflammation and possibly psychological stress; therefore, the authors suggested yoga can reduce the severity and distress of urge UI symptoms and their effect on daily living. Since patho-physiologic inflammation within the bladder is commonly found, being able to minimize that inflammation through yoga techniques that activate the efferent vagus nerve (which releases acetylcholine) could help decrease urge UI symptoms. The breathing aspect of yoga can reduce UI symptoms as it modulates neuro-endocrine stress response symptoms, thus reducing activation of psychological and physiologic stress and inflammation associated with stress. The authors concluded the mind-body approach of yoga still requires systematic evaluation regarding its effect on pelvic floor dysfunction but offers a promising method for affecting inflammatory pathways.
Pang and Ali (2015) focused on complementary and alternative medicine (CAM) treatments for interstitial cystitis (IC) and bladder pain syndrome (BPS). Since conventional therapy has not been definitely determined for the IC/BPS population, CAM has been increasingly used as an optional treatment. Two of the treatments under the CAM umbrella include yoga (mind-body therapy) and Qigong (an energy therapy). Yoga can contribute to IC/BPS symptom relief via mechanisms that relax the pelvic floor muscle. Actual yoga poses of benefit include frog pose, fish pose, half-shoulder stand and alternate nostril breathing. According to a systematic review, Qigong and Tai Chi can improve function, immunity, stress, and quality of life. Qigong has been effective in managing chronic pain, although not specifically evidenced with IC/BPS groups. Qigong has also been shown to reduce stress and anxiety and activate the brain region that suppresses pain. The CAM gives a multimodal approach for treating IC/BPS, and this has been recommended by the International Consultation on Incontinence Research Society.
Evidence is emerging in every area of treatment these days, so it is only a matter of time before randomized controlled trials regarding alternative treatment methods for the pelvic floor begin to fill pages of our professional journals. Yoga, Qigong, Tai Chi, biologically based therapies, manipulative and body-based approaches, and whole medical systems all offer safe, effective treatment options for the IC/BPS and urinary incontinence patient populations. The more we use these extra treatment tools and document the results, the more likely we will see clinical trials proving their efficacy.
Tenfelde, S and Janusek, L. (2014). Yoga: A Biobehavioral Approach to Reduce Symptom Distress in Women with Urge Urinary Incontinence. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE. 20 (10), 737–742. http://doi.org/10.1089/acm.2013.0308
Pang, R., & Ali, A. (2015). The Chinese approach to complementary and alternative medicine treatment for interstitial cystitis/bladder pain syndrome.Translational Andrology and Urology, 4(6), 653–661. http://doi.org/10.3978/j.issn.2223-4683.2015.08.10
Spending the past 5 years watching a lot of Disney Junior and reading Dr. Seuss, professional journal reading is generally reserved for the sanctuary of the bathroom. When patients ask if I’ve heard of certain new procedures or therapies, I try to sound intelligent and make a mental note to run a PubMed search on the topic when I get home. Making the effort to stay on top of research, however, makes you a more confident and competent clinician for the information-hungry patient and encourages physicians to respect you when it comes to discussing their patients.
A 2016 article in Translational Andrology and Urology, Lin et al., explored rehabilitation of men post radical prostatectomy on a deeper level, trying to prove that brain-derived neurotrophic factor (BDNF) promotes nerve regeneration. In many radical prostatectomies, even when the nerve-sparing approach is used, there is injury to the cavernous nerves, which course along the posterolateral portion of the prostate. Cavernous nerve injury can cause erectile dysfunction in 60.8-93% of males postoperatively. The authors discussed Schwann cells as being vital for maintaining integrity and function of peripheral nerves like the cavernous nerve. They hypothesized that BDNF, a member of the neurotrophin family that supports neuron survival and prevents neuronal death, activates the JAK/STAT (Janus kinase /signal transducer and activator of transcription) pathway in Schwann cells, thus facilitating axonal regeneration via secretion of cytokines (IL-6 and OSM-M). Through scientific experiment on a cellular level (please refer to the article for the specific details), the authors were able to confirm their hypothesis. Schwann cells do, in fact, produce cytokines that contribute to the regeneration of cavernous nerves.
From a different cellular perspective, Haahr et al., (2016) performed an open-label clinical trial involving intracavernous injection of “autologous adipose-derived regenerative cells” (ADRCs) in males experiencing erectile dysfunction (ED) after radical prostatectomy. Current treatments with PDE-5 inhibitors do not give satisfactory results, so the authors performed a human phase 1, single-arm trial to further the research behind the use of adipose-derived stem cells for ED. Some limitations included the study was un-blinded and had no control group. Seventeen males who had ED after radical prostatectomy 5-18 months prior to the study were followed for 6 months post intracavernosal transplantation. The primary outcome was safety/tolerance of stem cell treatment, and the secondary was improvement of ED. The single intracavernosal injection of freshly isolated autologous adipose-derived cells resulted in 8 of 17 men regaining erectile function for intercourse; however, the men who were not continent did not regain erectile function. The end results showed the procedure was safe and well-tolerated. There was a significant improvement in scores for the International Index of Erectile Function-5 (IIEF-5), suggesting this therapy may be a promising one for ED after radical prostatectomy.
In the clinic, we need to treat our patients to the best of our ability. Taking the Post-Prostatectomy Patient Rehabilitation course is vital if even just one patient enters your office seeking treatment. Keeping up on research (even that which seems too full of forgotten science) and learning new manual techniques and exercises can help us rise as clinicians prepared to optimize patients’ function.
Lin, G., Zhang, H., Sun, F., Lu, Z., Reed-Maldonado, A., Lee, Y.-C., … Lue, T. F. (2016). Brain-derived neurotrophic factor promotes nerve regeneration by activating the JAK/STAT pathway in Schwann cells. Translational Andrology and Urology, 5(2), 167–175. http://doi.org/10.21037/tau.2016.02.03
Haahr, M. K., Jensen, C. H., Toyserkani, N. M., Andersen, D. C., Damkier, P., Sørensen, J. A., … Sheikh, S. P. (2016). Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial. EBioMedicine, 5, 204–210. http://doi.org/10.1016/j.ebiom.2016.01.024