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Herman & Wallace Blog

Differential Diagnosis: A Case Study

My job as a pelvic floor therapist is rewarding and challenging in so many ways. I have to say that one of my favorite "job duties" is differential diagnosis. Some days I feel like a detective, hunting down and piecing together important clues that join like the pieces of a puzzle and reveal the mystery of the root of a particular patient's problem. When I can accurately pinpoint the cause of someone's pain, then I can both offer hope and plan a road to healing.

Recently a lovely young woman came into my office with the diagnosis of dyspareunia. As you may know dyspareunia means painful penetration and is somewhat akin to getting a script that says "lower back pain." As a therapist you still have to use your skills to determine the cause of the pain and develop an appropriate treatment plan.

My patient relayed that she was 6 months post partum with her first child. She was nursing. Her labor and delivery were unremarkable but she tore a bit during the delivery. She had tried to have intercourse with her husband a few times. It was painful and she thought she needed more time to heal but the pain was not changing. She was a 0 on the Marinoff scare. She was convinced that her scar was restricted. "Oh Goodie," I thought. "I love working with scars!" But I said to her, "Well, we will certainly check your scar mobility but we will also look at the nerves and muscles and skin in that area and test each as a potential pain source, while also completing a musculoskeletal assessment of the rest of you."

Her "external" exam was unremarkable except for adductor and abdominal muscle overactivity. Her internal exam actually revealed excellent scar healing and mobility. There was significant erythemia around the vestibule and a cotton swab test was positive for pain in several areas. There was also significant muscle overactivity in the bulbospongiosis, urethrovaginal sphincter and pubococcygeus muscles. Also her vaginal pH was a 7 (it should normally be a 4, this could indicate low vaginal estrogen). I gave her the diagnosis of provoked vestibulodynia with vaginismus. Her scar was not the problem after all.

Initially for homework she removed all vulvar irritants, talked to her doctor about trying a small amount of vaginal estrogen cream, and worked on awareness of her tendency to clench her abdominal, adductor, and pelvic floor muscles followed by focused relaxation and deep breathing. In the clinic I performed biofeedback for down training, manual therapy to the involved muscles, and instructed her in a dilator program for home. This particular patient did beautifully and her symptoms resolved quite quickly. She sent me a very satisfied email from a weekend holiday with her husband and daughter.

Although this case was fairly straightforward, it is a great example of how differential diagnosis is imperative to deciding and implementing an effective treatment plan for our patients. In Herman & Wallace courses you will gain confidence in your evaluation skills and learn evidence based treatment processes that will enable you to be more confident in your care of both straightforward and complex pelvic pain cases. Hope to see you in class!

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Helping Our Patients Take One Step Forward

Jennafer Vande Vegte, PT, BCB-PMD, PRPC is a H&W faculty member and one of the developers of the advanced Pelvic Floor Capstone course. In this guest post, she reflects on her own clinical and personal experience that informed her work on this advanced course, and her approach with patients.

Rodel Studios Herman Wallace 004Most days I feel like I am on a journey. Some days I make big strides forward, other days I might fall back. But I am always learning, and eventually I hope to grow. I think it is much the same for our patients. And also for ourselves.

My youngest daughter was diagnosed with eczema, allergies (food and others) and asthma at an early age. In my hubris I felt if I could learn all I could about what was going on in her body I could "fix" her. So began a journey that took me outside the realm of traditional medicine into holistic care. I learned so much! My daughter got a lot healthier. The rest of my family got a lot healthier. I got healthier too. And I began to recognize patients in my practice that needed more holistic care. Guess what, they got healthier too.

When she was in first grade she was diagnosed with ADHD. I retraced the steps of my previous journey that had helped her so much with her allergies, eczema and asthma. But ADHD proved to be resistant to diet , supplements, and homeopathy. We visited an OT and got some good suggestions. A family therapist helped us a ton as parents, but I'm not sure how much he helped my daughter. We tried Ritalin to no avail. Energy therapy and essential oils followed before I finally made an appointment with a ADHD child specialist MD. We will see where that step leads. Why

Why am I telling you all this you may ask? Because I realized that my journey with my daughter is very much like our journey walking next to our patients with chronic pain. They/we may try so many things trying to find the "fix" to make their pain go away. As we grow on our own life journeys and experiences and we add quality clinical tools to our toolboxes we very well may be able to help more people experience freedom from pain, improvements in function, and meeting their goals. But there will be always still be those that we feel like we didn't help. Don't despair dear friends. Every person we have come in contact with in the quest to better equip and understand my daughter's mental and physical health has been a wealth of information, inspiration, and resources. Some things I learned some years ago (essential oils for example) and only now am putting into practice. I wasn't ready before but I am now! I realized that there is a similar dynamic for our patients. We may help them take just one step forward. We may walk a whole journey to healing beside them, or we may never know what the impact of our treatment had on them. But in the end we both end up exactly where we needed to be.

Insignia Health developed the PAM (Patient Activation Measure) Survey (http://www.insigniahealth.com/products/pam-survey) to help heath care providers determine where along the pathway of activation of self care a patient falls. What is interesting about the tool is that a single point increase correlates to a 2% decrease in hospitalization and a 2% increase in medication adherence. The science behind the PAM shows that helping our patients to move forward just one step can have a profound influence on their health. The trick is meeting them where they are at.

Pelvic Floor Capstone was a joy to develop with Nari Clemons and Allison Arial. Our goal was to equip you to take one more step in your learning journey in pelvic health. We delve into intense topics like endocrine disorders, pelvic surgery, gynecological cancer, nutrition and pharmacology. Labs are focused on evaluating and treating myofascial restrictions utilizing a gentle, indirect three dimensional system that invites the brain to reconnect with connective tissue in a safe way for powerful change. We would love to see you at Capstone and hear your stories later on how our time together empowered you to help your patients take one more step.

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Mesh Complications

This post was written by Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC. You can catch Jennafer teaching the Pelvic Floor Level 2B course this weekend in Columbus.

mesh complications

"I hate my vagina and my vagina hates me. We have a hate- hate relationship'" said my patient Sandy (name has been changed) to me after treatment. Sandy's harsh words settled between us. I understood perfectly why she might feel this way. I have been treating Sandy on and off for four years. She has had over fifteen pelvic surgeries. Her journey started with a hysterectomy and mesh implantation to treat her prolapsed bladder. She did well for several months and then her pain began. Her physician refused to believe that her pain was coming from the mesh. This pattern was repeated for several years as Sandy tried in vain to explain her pain to her medical providers. She was told her pain was all in her head and put on psych meds. Finally, five years later, Sandy found her way to an experienced urogynecologist who recognized that Sandy was having a reaction to the mesh from her prolapse surgery. It turns out that Sandy's body rejected the mesh like an allergen. Her tissues had built up fibrotic nodules to protect itself from exposure to the mesh. It has taken years and multiple operations to remove all the mesh and all the nodules. Of course then Sandy's prolapse recurred as well as her stress incontinence and she recently had surgery to try to give her some support. In PT we attempted to manage her pain, normalize her pelvic floor function, strengthen her supportive muscles and fascia. Due to years of chronic pain, her pelvic floor would spasm so completely internal work was not possible. Sandy began to also get Botox injections to her pelvic floor and pudendal nerve blocks. She uses Flexeril, Lidocaine and Valium vaginally three times a day to manage her chronic pelvic pain. She is on disability because she cannot work. Later this month Sandy will have her 16th surgery to remove a hematoma caused by her previous surgery and another nodule that we found in her left vulva. Sandy is the most complicated case of mesh complication that I have seen in my practice, however I regularly see women who have had problems with mesh that we manage through PT and also women that have had mesh removal. No one expects to have complications with their surgery and when they do it can be life altering.

In a recent review of the literature surrounding mesh complications Barski and Deng cite that over 300,000 women in the US will undergo surgical correction for stress incontinence (SUI) or pelvic organ prolapse (POP). Mesh related complications have been reported at rates of 15-25%. Mesh removal occurs at a rate of 1-2%. Mesh erosion will occur in 10% of women. There are over 30,000 cases in US courts today related to pain and disability due to mesh complications. The authors looked at mesh complication statistics from studies concerning three surgical procedures: mid urethral slings, transvaginal mesh and abdominal colposacropexy .

The authors note there are sometimes reasons why mesh goes wrong: it is used for the wrong indication, there could be faulty surgical technique, and the material properties of mesh are inherently problematic for some women. Risk factors in patient selection are previous pelvic surgery, obesity and estrogen status. There are several types of complications described: trauma of insertion, inflammation from a foreign body reaction, infection, rejection, and compromised stability of the prosthesis over time. With mid urethral slings there were also several other complications listed such as over active bladder (52%), urinary obstruction (45%), SUI (26%) mesh exposure (18%) chronic pelvic pain (18%). For transvaginal mesh, reported rate of erosion was 21%, dysparunia 11%, mesh shrinkage, abscess and fistula totaled less than 10%. Transvaginal obturator tape was noted to be traumatic for the pelvic floor. Infections that might occur in the obturator fossa require careful and through treatment. Of women who have complications 60% will end up requiring surgical removal. It is imperative to find a surgeon who is experienced and skilled with this procedure as complete excision can be difficult and there are risks of bleeding, fistula, neuropathy and recurrence of prolapse and SUI. After recovery, 10-50% of women who have had excision will have another surgery to correct POP or SUI.

As pelvic health physical therapists we are strategically poised to both help women manage SUI and POP conservatively. We also have the skills needed to help rehabilitate women dealing with complications from mesh, either to avoid removal or after removal. Our job goes beyond the physical too, often helping women cope with the emotional toll that can parallel her medical journey. At PF2B we will discuss conservative prolape management and give you tools to help patients cope with chronic pain. Would love to see you there.

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