Appropriate sun exposure and/or daily supplements provide our bodies with sufficient amounts of Vitamin D. I would venture to guess almost every one of the patients I treated in Seattle had a deficiency of Vitamin D if they were not taking a supplement. Running outside year round has always kept my skin slightly tan and my levels of Vitamin D healthy; however, when I was pregnant in the Pacific Northwest, I had to supplement my diet with Vitamin D, which was a first for this East Coast beach girl. The benefit of Vitamin D has spread beyond just bone health, with studies showing its impact on pelvic floor function.

Parker-Autry et al., (2012) published a study discerning the Vitamin D levels in women who already presented with pelvic floor dysfunction versus “normal” gynecological patients. The retrospective study involved a chart review of 394 women who completed the Colorectal Anal Distress Inventory (CRADI)-8 and the Incontinence Impact Questionnaire (IIQ-7). These women all had a total serum 25-hydroxy Vitamin D [25(OH)D] drawn within one year of their gynecological visit. The authors defined a serum 25(OH)D of <15ng/ml as Vitamin D deficient, between 15-29ng/ml as Vitamin D insufficient, and >30ng/ml as Vitamin D sufficient. In the pelvic floor disorder group comprised of 268 women, 51% were found Vitamin D insufficient, 13% of whom were deficient. The CRADI-8 and IIQ-7 scores were noted as higher among the Vitamin D insufficient women. Overall, the mean 25(OH)D levels in the women without pelvic floor issues were higher than those who presented with pelvic floor disorder symptoms.

Another case-control study in 2014 by Parker-Autry et al., focused on the association between Vitamin D deficiency and fecal incontinence. They considered 31 women with fecal incontinence versus a control group of 81 women without any pelvic floor symptoms, looking at serum Vitamin D levels. The women with fecal incontinence had a mean serum Vitamin D level of 29.2±12.3 ng/ml (insufficient/deficient), while the control group had a higher mean level of 35±14.1 ng/ml (sufficient). The women completed the Modified Manchester Health Questionnaire and the Fecal Incontinence Severity Index, and women with deficient Vitamin D scored higher on the questionnaire, indicating fecal incontinence as a burden on quality of life. The severity scores were higher for Vitamin D deficient women, but there was not a statistically significant difference between the groups.  Once again, the pelvic floor disorder and Vitamin D deficiency correlation prevailed in this study.

When a 472 pound gentleman recently arrived for an evaluation for low back pain, he came to the clinic for me to help him, not deride him about his weight (which he complained all his doctors have already done). He claimed he had lost 120 pounds but gained back 50, and his low back was extremely painful with transitional movements and daily function. Undoubtedly, this man’s body was a battlefield for inflammation, and no matter how much manual therapy or exercise I implemented, nutrition education seemed vital. Instead of just chatting about baseball or the weather, competently sharing what we’ve studied and learned in continuing education courses is warranted in our practice.

In a 2016 review Klek reveals the most current evidence regarding Omega-3 Fatty Acids in nutrition delivered intravenously. Although physical therapists do not decide the ingredients for patients’ parenteral nutrition, the article thoroughly explains the essential benefits of fatty acids. Aside from being important structural components of cell membranes and precursors of prostaglandins and cholesterol, fatty acids regulate gene expression and adjust pathways of cells regarding inflammation and cell-mediated immune responses. Ultimately, fatty acids modulate metabolic processes in the body, whether locally, in a particular region, or at remote sites. Omega-3 fatty acids have been shown to inhibit synthesis of triglycerides by the liver, prevent cardiovascular disease, reduce cancerous cell growth, and even affect the development of rheumatoid arthritis and Chrohn’s disease. This article not only sheds light on parenteral nutrition for post-surgical, oncology, critically ill, and even pediatric patients but also educates the healthcare professional on the impact fatty acids have on the patients we treat.

In 2015, Haghiac et al. performed a randomized double-blind controlled clinical trial to determine if Omega-3 fatty acid supplementation could reduce inflammation in pregnant woman who are obese. Although the study began with 36 subjects in each group, only 24 women in the experimental group receiving 4 capsules a day of Omega-3 fatty acid (total of 2000mg) and 25 of the women taking 4 placebo capsules a day completed the supplementation over the 25 weeks up until delivery. The authors referenced the findings that low grade inflammation becomes exacerbated in obese pregnant women. While an excess of Omega-6 fatty acids practically promotes inflammation via eicosanoid (hormone) production, a healthy balance of Omega-3 fatty acids lessens inflammatory and immunosuppressive eicosanoid production. This study demonstrated an improvement in inflammation in the women who took the Omega-3 fatty acid as evidenced by a decrease in the expression of inflammatory genes in adipose tissue and placenta as well as reduced plasma C-reactive protein (CRP) at delivery.

If an infomercial played in pre-op waiting rooms explaining all the possible side effects or problems a patient may encounter after surgery, I wonder how many people would abort their scheduled mission. As if having an abdominal or pelvic surgery were not enough for a patient to handle, some unfortunate folks wind up with small bowel obstruction as a consequence of scar tissue forming after the procedure. Instead of having yet another surgery to get rid of the obstruction, which, in turn, could cause more scar tissue issues, studies are showing manual therapy, including visceral manipulation, to be effective in treating adhesion-induced small bowel obstruction.

Amanda Rice and colleagues published a paper in 2013 on the non-surgical, manual therapy approach to resolve small bowel obstruction (SBO) caused by adhesions as evidenced in two case reports. One patient was a 69 year old male who had 3 hernia repairs and a laparotomy for SBO with resultant abdominal scarring and 10/10 pain on the visual analog scale. The other patient was a 49 year old female who endured 7 abdominopelvic surgeries for various issues over the course of 30 months and presented with 7/10 pain and did not want more surgical intervention for SBO. Both patients received 20 hours of intensive manual physical therapy over a period of 5 days. The primary focus was to reduce adhesions in the bowel and abdominal wall for improved visceral mobility, but treatment also addressed range of motion, flexibility, and postural strength. The female patient reported 90% improvement in symptoms, with significant decreases in pain during bowel movements or sexual intercourse, and the therapist noted increased visceral and myofascial mobility. Both patients were able to avoid further abdominopelvic surgery for SBO, and both patients were still doing well at a one year follow up.

I lived in Seattle during my pregnancies, where practicing yoga is almost as common as drinking coffee. I never accepted my friends’ invitations to partake in a perinatal yoga classes, mostly because I do not know how to do it, and I simply ran instead. My friends reaped the benefits of the meditation and strengthening involved when it came to delivering their babies. Researchers have been trying to measure the physical benefits from performing yoga during pregnancy, both for the mother and the fetus, and scientifically support the efficacy of participating in peripartum yoga.

In a systematic review of studies regarding yoga for pregnant women, Curtis, Weinrib, and Katz (2012) explored the literature on yoga for pregnancy. Six studies were included in the review, only 3 of which were randomized controlled trials. The aspects of yoga included in the trials were postures, breathing practices, meditation, deep relaxation, counseling on lifestyle change, and chanting and anatomy information. The programs in the trials began either between 18-20 weeks gestation or between 26-28 weeks. The yoga was practiced either 3 times per week for 30-60 minutes or 60 minutes daily. Control groups included walking, standard prenatal exercise, or general nursing care. The literature review suggested improvements were noted regarding quality of life and self-efficacy, discomfort and pain during labor, and birth weight and preterm births. Due to the limited number of trials, only a general positive commendation of yoga during pregnancy could be made from this research.

In 2015, Jiang et al. looked at 10 randomized controlled trials from 2004 to 2014 regarding yoga and pregnancy. The authors found consistent evidence showing a positive correlation between yoga intervention and lower incidence of prenatal disorders and small gestational age. Lower levels of stress and pain as well as higher relationship scores were noted with yoga. The studies showed yoga to be a safe and effective means of exercise during pregnancy, but the authors agreed further randomized controlled studies still need to be performed.

As a child, I remember my grandmother rubbing my lower back to help me pass my stubborn stool, a problem which landed me in the hospital twice before I turned 10. Decades later, after the birth of my first baby, I had a grade III perineal tear that made me afraid I would never be able to control my stool from passing. At the time of each situation, I had no idea how many people of all ages experience the two extremes of bowel dysfunction. Thankfully, for patients struggling with either issue, whether it is chronic constipation or fecal incontinence, healthcare practitioners are becoming knowledgeable in how to treat both effectively through classes such as the Herman & Wallace course, “Bowel Pathology, Function, Dysfunction & the Pelvic Floor.”

In 2014, Kelly Scott, MD, authored an article entitled, “Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence.” She reviews the current literature and notes this area of study lacks high quality randomized controlled trials, and further research is needed to provide evidence on the efficacy of different treatment protocols. Up to 24% of the adult population has been shown to experience fecal incontinence. Under the umbrella of pelvic floor rehabilitation lies pelvic floor muscle training, biofeedback, rectal balloon catheters for volumetric training, external electrical stimulation, and behavioral bowel retraining. The goals of various biofeedback methods include the following: provide endurance training specifically for the anal sphincter and pelvic floor; improve rectal sensitivity and compliance; and, increase coordination and sensory discrimination of the anal sphincter. Overall, the success rate of pelvic floor rehabilitation for fecal incontinence in most of the studies is 50% to 80%, and it is considered safe as well as effective.

On the other end of the spectrum, Vazquez Roque and Bouras (2015) published an article regarding management of chronic constipation. Chronic constipation (CC) in the general population has a prevalence of 20%, and the elderly population has a higher rate than the younger population. Chronic constipation is commonly treated with stool softeners, fiber supplements, laxatives, and secretagogues. However, as in all areas of healthcare, a thorough examination needs to be performed to assess the source of the problem. Determining whether a patient exhibits slow transit constipation or a true pelvic floor dysfunction (PFD) via blood work, rectal exam, and appropriate PFD tests is essential to provide the appropriate treatment. When the CC culprit is dysfunction of the pelvic floor, clinical trials have proven the efficacy of pelvic floor rehabilitation and biofeedback, making them optimal treatments.

Rarely does a patient with sacroiliac joint dysfunction come to see us with a goal of having surgery. Sometimes surgery winds up being the last resort for relief if our efforts and the patient’s commitment to physical therapy and prescribed exercises fail. Some of the most recent research shows positive results from minimally invasive surgery; however, the bottom line is to make sure the most educated, clinically accurate diagnosis has been made in implicating the SI joint as the source of pain.

Capobianco et al (2015) performed a prospective multi-center trial regarding SI joint fusion using a minimally invasive technique in women with post-partum pain in the pelvic girdle. Eligibility for the study required subjects to have 3 out of 5 positive SI joint stress tests and at least 50% relief with image-guided intra-articular SI joint block with a local anesthetic. Of the 172 subjects in the study, 20 of the 100 females had post-partum pelvic girdle pain, and 52 subjects were male. Significant improvements in pain, quality of life, and function were found for not only the post-partum group but all groups 12 months after surgery. Worth noting is one to three weeks after surgery, the subjects engaged in physical therapy, two times per week for six weeks.

Whang et al (2015) assessed the 6-month outcomes of SI joint fusion using triangular titanium implants versus non-surgical management in a prospective randomized controlled trial. Of the 148 subjects chosen based on similar diagnostic criteria as the study mentioned above, 102 underwent surgery, and 46 had non-surgical management. Non-surgical management involved appropriate pain medication administration, physical therapy, intra-articular SI joint steroid injections, and radiofrequency ablation of sacral nerve roots, all based on individual needs. The surgical group subjects in this study were also asked to have physical therapy two times per week for six weeks anywhere from one to three weeks post-op. The results in a six month follow up showed “clinical success” of >80% in the surgical group and <25% in the non-surgical management group.

A few years ago, I was convinced my left hip pain was due to osteoarthritis. When my hip locked up after a 14 mile run, my manual therapist husband differentially diagnosed the pain as discogenic. Partly in denial and partly wanting to know the extent of the “damage,” I got an x-ray of my left hip, which was completely normal, and a lumbar MRI, which wasn't pretty. The source of my hip pain was a disc bulge at L3-4 and L4-5 with a Schmorl's node at L5-S1 to boot. Instead of riding the train of thought that we treat what hurts, therapists need to disembark and look further for the source, as suggested in the course, “Finding the Driver in Pelvic Pain.”

A case report published in the International Journal of Sports Physical Therapy by Livingston, Deprey, and Hensley (2015) documents the discovery of a deeper problem than the referring diagnosis of greater trochanteric pain syndrome. A 29 year old female had to stop running because of lateral hip pain that began 3 months after increasing the intensity and frequency of her running and low impact plyometrics. She had pain in sitting and while running. During the evaluation, she demonstrated a positive Trendelenburg, weak and painless hip abductors, and a positive single leg hop test on concrete. When the pain was not elicited with single leg hop on a foam surface, the patient was referred back to the physician for magnetic resonance imaging. The patient was later diagnosed with an acetabular stress fracture. The therapist’s thorough examination helped prevent possible avascular necrosis or a more traumatic fracture of the pelvis.

In a 2013 issue of the same journal, Podschum et al. presents a case report on deciphering the diagnosis in a female runner with deep gluteal pain with pelvic involvement. A 45 year old female marathon runner reported pulling her hamstring and complained of left ischial tuberosity pain with aching into the gluteal and pubic ramus regions that eventually forced her to stop running. She had pain in sitting and could not tolerate speed work. She had a history of low back and pelvic floor pain, with an MRI showing osteitis pubis, a lateral L3-4 bulge, and facet hypertrophy at L4-5. The physical therapist ruled out lumbar disc lesion, radiculopathy, sacroiliac joint dysfunction, and hip labral tear with special tests. Initial treatment focused on the differential diagnoses of hamstring syndrome and ischiogluteal bursitis based on subjective complaints and objective findings. After 4 visits, her deep ache shifted to the inferior pubic ramus in sitting as the ischial tuberosity pain diminished. A trained therapist then conducted a thorough pelvic floor exam. Pelvic floor hypertonic dysfunction was diagnosed and took over the “driver’s seat” as the focus for the rest of the treatment of this patient. Symptoms resolved and the patient returned to running marathons without any of her initial presenting symptoms.

While working with a 71 year old lady one day, I asked her about her sleep habits, thinking she would describe her neck position, since that it was I was treating. She quickly commented she gets up one to two times every night to use the bathroom. Without any hesitation, she then declared her sister and her friends all do the same thing. No one she knows who is close to her age can sleep through the night without having to pee. Realizing this was more of an issue for my patient than her neck at night, I proceeded to look into the research behind these nighttime escapades of the elderly.

In the Journal of Clinical Sleep Medicine in 2013, Zeitzer et al. performed research regarding insomnia and nocturia in older adults. The introduction explains how 40-70% of older adults experience insomnia, and the greatest cause for sleep disturbance is the need to urinate in the middle of the night (nocturia). In epidemiological studies, between two-thirds and three-quarters older adults report disrupted sleep due to nocturia. The study performed by these authors involved men (average age of 64.3) and women (average age of 62.5) recording their sleep and toileting habits over the course of 2 weeks. The results showed over half the reported awakenings at night were secondary to nocturia. They had worse restfulness and efficiency of sleep associated with the log-reported need to get up to use the bathroom.

In a 2014 study by Tyagi, et al., the effect of nocturia on the behavioral treatment for insomnia in older adults was explored. The authors noted how nocturia being the primary reason for waking up at night increased proportionately with age with results ranging from 39.9% in people 18-44 years of age to 77.1% in the 65 years old or above population. The 79 participants in this study underwent brief behavioral treatment for their chronic insomnia or only received information. People with and without nocturia both demonstrated significant improvements in quality of sleep after receiving brief behavioral treatment versus the control group; however, the effect size was larger in the participants without nocturia. The authors concluded nocturia needs to be addressed first in order to experience the full benefit of behavior treatment for insomnia.

My first experience treating a patient with shoulder pain and limitations post-mastectomy just happened to be a local doctor’s sister. Luckily, I did not know this until a few sessions into her therapy. Ultimately, even more than normal, this patient’s outcome was a make or break situation for a future referral source. Her incredible spirit and optimism made the prognosis an inevitably positive one. Whether or not I had manual therapy training was a moot point, according to current research; however, from my perspective, I would not have been as competent in treating her without it.

In June 2015, De Groef et al. performed a review of literature to investigate the efficacy of physical therapy for upper extremity impairments after surgical intervention for breast cancer. Eighteen randomized controlled studies were chosen for review regarding the efficacy of passive mobilization, myofascial therapy, manual stretching, and/or exercise therapy after breast cancer treatment. In the studies reviewed, physical therapy began at least 6 weeks post-surgical intervention. Combining general exercise with stretching was confirmed effective on range of motion (ROM) by 2 studies. One study showed the effect of passive mobilization with massage was null for pain or impaired ROM. No study showed any effect of myofascial therapy, one poor quality study supported the use of passive mobilization alone, and one study showed no effect of stretching alone. Active exercises were found more effective than no therapy or simply education in five studies. Early intervention was found to be beneficial for shoulder ROM in 3 studies, but 4 other studies supported delayed exercise to promote wound healing longer. Ultimately, pain and impaired shoulder ROM after operative treatment for breast cancer have been treated effectively by a multifactorial approach of stretching and active exercise. The efficacy of passive mobilization, stretching, and myofascial therapy needs to be investigated with higher quality research in the future.

Another review of literature in 2010 by McNeely et al. used 24 studies to analyze the effectiveness of exercise intervention for upper extremity impairments after breast cancer surgical intervention. Ten of the studies focused on early versus late intervention, and all supported the earlier implementation of post-surgical exercises for ROM; however, wound drain volume and duration were increased in the subjects engaged in earlier exercises. Fourteen studies showed structured exercise intervention improved shoulder ROM significantly in the post-op period, and a 6-month follow up continued to show improved upper extremity function. No lymphedema risk was noted in any of the studies.

The day my son was born, my daughter had not defecated for 5 days, and her pain was getting pretty intense. My husband and his mom took her to Seattle Children’s Hospital for help, and they suggested using Miralax and sent them away. When they got back to my hospital room, my daughter was straining so hard it looked like she was about to give birth! Being physical therapists, my husband and I massaged her little muscles and told her to take deep breaths, and eventually she did the deed, yet not without a heart-breaking struggle. Little did I know then there is actually research to back up our emergency, instinctual technique.

Zivkovic et al (2012) performed a study regarding the use of diaphragmatic breathing exercises and retraining of the pelvic floor in children with dysfunctional voiding. They defined dysfunctional voiding as urinary incontinence, straining, weakened stream, feeling the bladder has not emptied, and increased EMG activity during the discharge of urine. Although this study focuses primarily on urinary issues, it also includes constipation in the treatment and outcomes. Forty-three patients between the ages of 5 and 13 with no neurological disorders were included in the study. The subjects underwent standard urotherapy (education on normal voiding habits, appropriate fluid intake, keeping a voiding chart, and posture while voiding) in addition to pelvic floor muscle retraining and diaphragmatic breathing exercises. The results showed 100% of patients were cured of their constipation, 83% were cured of urinary incontinence, and 66% were cured of nocturnal enuresis.

More recently, Farahmand et al (2015) researched the effect of pelvic floor muscle exercise for functional constipation in the pediatric population. Stool withholding and delayed colonic transit are most often the causes for children having difficulty with bowel movements. Behavioral modifications combined with laxatives still left 30% of children symptomatic. Forty children between the ages of 4 and 18 performed pelvic floor muscle exercise sessions at home, two times per day for 8 weeks. The children walked for 5 minutes in a semi-sitting (squatting) position while being supervised by parents. The patients increased the exercise duration 5 minutes per week for the first two weeks and stayed the same over the next six weeks. The results showed 90% of patients reported overall improvement of symptoms. Defecation frequency, fecal consistency and decrease in fecal diameter were all found to be significantly improved. Although not statistically significant, the number of patients with stool withholding, fecal impaction, fecal incontinence, and painful defecation decreased as well.