So many physiological changes occur to a woman’s body during pregnancy, it is no wonder that pregnant women have back and lower extremity aches and pains. These women experience hormonal changes, weight gain, reduced abdominal strength, and their center of mass shifts anteriorly. These physiological changes result in altered spinal and pelvic alignment, and increased joint laxity. Also, many women report increases in size of their feet and a tendency to have flatter arches during and after pregnancy. Alignment changes may influence pain. Altered alignment could change the physical stresses placed upon different tissues of the body, which that specific tissue was not adapted to, therefore, causing pain or injury to that tissue.
A recent study published in 2016, in the Journal of Women’s Health Physical Therapy1, investigated if there may be a relationship between anthropometric changes of the foot that occur with pregnancy, and pregnancy related musculoskeletal pain of the lower extremity. The study included 15 primigravid women and 14 weight matched controls. This study was a repeated-measurements design study, where the investigators measured foot length, foot width, arch height index, arch rigidity index (ARI), arch drop (AD), rear foot angle, and pelvic obliquity during the second and third trimesters and post-partum. The subjects were surveyed on pain in the low back, hips/buttocks, and foot/ankle.
The author’s findings were that measures of arch flexibility (ARI and AD) correlated with pain at the low back and the foot and ankle. They concluded that medial longitudinal arch flexibility may be related to pain in the low back and foot. The more flexible arches were associated with more pain in the study participants. They reported the participants in their study did not have very high pain levels in general, and recommend further studies to compare pregnant women who experience severe pain with women who do not while comparing their alignment factors. This article is a good reminder for physical therapists to consider the changes that occur to the foot including changes in arch height, arch flexibility, and foot size and how that influences the pelvis and lower extremity for prevention and treatment of musculoskeletal pain during pregnancy.
Educating our pregnant patients on shoe wear seems even more important now. Making recommendations, unique to each individual patient based on their objective data, foot type, and arch flexibility status seems like an appropriate addition to a well-rounded treatment plan. Doesn’t it seem prudent to wear shoes that provide some arch support to hopefully reduce musculoskeletal pain associated with pregnancy changes? I have observed some patients who are pregnant arrive to physical therapy wearing unsupportive flip flops and other poor shoe wear choices. I understand there are barriers for pregnant patients, I remember from when I was pregnant that reaching your feet to put shoes on can be very difficult, and sometimes your feet are swelling so it may be near impossible to physically get shoes on your feet. You might even need a new pair of shoes, as your shoes may no longer fit. However, an article such as this one, seems like something I could easily share with a patient to help persuade them of the importance of good shoe wear or at least proper arch support. Being able to discuss a recent scientific study with a patient can be powerful and motivating to a patient. Additionally, an article such as this reminds a practitioner of specific objective data to monitor such as arch height and flexibility as it changes throughout the patient’s pregnancy. How does the patient’s changing arch height and flexibility influence their specific pelvic, hip, knee, and ankle alignment? How does swelling play a part in the patients’ foot anthropometrics day to day, trimester to trimester? Ask more questions about their daily activities, are they ‘barefoot and pregnant’? Could something as simple as having them wear appropriate, arch supportive shoes while in the home reduce their lower extremity or back pain?"
Harrison, K. D., Mancinelli, C., Thomas, K., Meszaros, P., & McCrory, J. L. (2016). The Relationship Between Lower Extremity Alignment and Low Back, Hip, and Foot Pain During Pregnancy: A Longitudinal Study of Primigravid Women Versus Nulliparous Controls. Journal of Women’s Health Physical Therapy, 40(3), 139-146.
Have you ever tried to teach a patient how to isolate their transversus abdominis (TA) contraction or a pelvic floor muscle (PFM) contraction and the patient had difficulty or you weren’t sure how well they were isolating it? Did you ever wish you had the ability to use real-time ultrasound (US) to confirm which abdominal layers they were isolating or use it for visual feedback to assist in your patient’s learning? Could it be helpful to be able to use real-time US to identify if they were isolating the pelvic floor muscles and give your patient visual feedback? Of course!
Real- time US has been used as an assessment and teaching tool to directly visualize abdominal and PFMs. PFM function can be assessed by observing movement at the bladder base and bladder neck. Various studies have used US on women with and without urinary incontinence (UI). These studies usually use transabdominal (TAUS) and transperineal (TPUS) ultrasound to measure if PFM isometrics or exercises are performed correctly or incorrectly, or how the muscles are functioning.
A 2015 study in the International Urogynecology Journal utilized TAUS to identify the ability to perform a correct elevating PFM contraction and assess bladder base movement during an abdominal curl up exercise. Abdominal curl ups are cited to increase intra-abdominal pressure. Activities that increase intra-abdominal pressure have been cited to provoke stress urinary incontinence (SUI). Abdominal curl ups are often completed in group exercise classes and have been found to provoke SUI in up to 16% of women.
Use of PFM exercises and of “the knack” (performing an isometric pelvic contraction before an exertional activity where intra-abdominal pressure increases, such as before lifting or coughing) has been shown to help manage stress urinary incontinence.
The theory is that elevation of the PFMs during activities that increase intraabdominal pressure (like a curl up) assist in urethral closure and counter act the downward movement, therefore stabilizing the urethra and bladder neck. When using TAUS, while performing a correct PFM contraction, one might expect to see an elevating PFM contraction. In the study, TAUS was used on 90 women participating in a variety of group exercise classes. The participants completed a survey and then three attempts of an abdominal curl up exercise in hooklying. During the curl ups, bladder base displacement was measured to determine correct or incorrect activation patterns. It was found that 25% of the women were unable to demonstrate an elevating PFM contraction, and all women displayed bladder base depression on the abdominal curl exercise. It was also found that parous women displayed more bladder base depression than nulliparous women, and overall 60% of the participants reported SUI. Lastly, this study found there was no association between SUI and the inability to perform an elevating PFM contraction or the amount of bladder base depression.
What interesting information. Using real time US in the clinic could help us identify if our patients were completing “the knack” correctly with specific activities. This study is a great example of how we can use real time US to help collect evidence to provide us with more information that can help us answer our own questions, patient questions, and improve our instructional methods to patients when teaching core or PFM exercises.
1) Barton, A., Serrao, C., Thompson, J., & Briffa, K. (2015). Transabdominal ultrasound to assess pelvic floor muscle performance during abdominal curl in exercising women. International urogynecology journal, 26(12), 1789-1795.
The Center for Disease Control reports that prostate cancer is the most common form of male cancer in the United States (just ahead of lung cancer and colorectal cancer), and the American Cancer Society estimates that 1 in 7 men will be diagnosed with prostate cancer at some point in their lifetime. With prostate cancer being so common, it is likely that a male with symptoms of urinary incontinence following a prostatectomy may show up at your clinic’s door for treatment. What do you do? Whether you have extensive training for male pelvic floor disorders or are just starting your initial training for pelvic floor dysfunctions, you likely have some intervention skills to help this population.
A recent case report in the Journal of Women’s Health Physical Therapy, outlines management of a 76-year-old male patient with mixed urinary incontinence postprostatectomy 10 years. This case report does a nice job describing not just physical therapy (PT) interventions, but also multifaceted management of a typical patient post radical prostatectomy. The case report describes a thorough history, systems review, pelvic floor muscle (PFM) examination, tests &measures, and outcome assessment. Our discussion will focus on interventions as you may already possess the skills for several of the treatments included in this patient’s plan of care.
The patient’s complaints were mixed urinary incontinence (UI) symptoms including 3-4 pads per day and 1 pad at night. He reported nocturia 3-4 times per night. 2-3 times per week he had large UI episodes that soaked his outwear. Also, he complained of inability to delay voiding, and UI with walking to the bathroom, sit to stand, lifting, coughing, and sneezing.
For the patients’ urge UI symptoms, behavioral interventions were utilized. The patient completed PFM contractions to inhibit detrusor contractions and suppress urgency (urge control technique). Educating the patient on correct PFM contraction isolation was a very important component of this patients’ treatment. Verbal, digital, and surface electromyography (sEMG) techniques were used to ensure correct PFM contraction and to reduce Valsalva. Clinical decision making for home exercise program utilized dominant PFM fiber types and the patients’ performance on the PERFECT PFM strength testing system described by Laycock. (External Urethral Sphincter is predominantly Type II fast twitch muscle fiber in males and Levator Ani is predominantly Type I slow twitch.) For the home program, the patient completed progressive reps and sets of 10” (targets slow twitch) and 2” (targets fast twitch) PFM isometrics in supine progressing to standing. (There is a chart with additional details on PFM home program for each visit in the case report.) Additionally, instruct and use of “the knack” (volitional PFM contraction before and during cough or other physical exertions to prevent UI) for activities that the patient usually had UI with including sit to stand transfer, lifting, coughing, and sneezing was essential for the patients’ symptoms. PFM coordination training with sEMG helped reduce his accessory muscle recruitment patterns and Valsalva. Bladder retraining and lifestyle recommendation were important (per his 3-day bladder diary) as he was consuming 3 cups of coffee and 4 cups or more of tea a day, likely contributing to urgency and urge UI symptoms. Also, he was informed regarding the effect of obesity on UI (as his BMI was 35.9 placing him in the obese range) and that modest amounts of weight loss maybe sufficient for UI reduction. Abdominal exercises targeting Transversus Abdominus were also prescribed for their role in core support with PFM’s. Lastly, electrical stimulation was not included in this patients’ plan of care due to the patients’ cardiac history and pacemaker, as well as, he could initiate PFM contraction and utilize urge control techniques appropriately.
The outcome for this patient was positive. He attended 5 PT sessions over a 3-month period. He did have to cancel two appointments between the 4th and 5th visits due to an emergency surgery to place two cardiac stents. He had reduced urinary leakage indicated by reduced undergarment changes and reduced pad usage per day. His pads were less saturated and he no longer had leakage that spread to his outwear. He had a 50% reduction in UI episodes reported on his bladder diary and a 50% reduction in nocturia from 4 times to 2 times per night. He reported reduced daily urinary frequency from 7 to 5 times per day with no instances of severe urgency. He demonstrated improved PERFECT score of 4, 10, 8, 10 (initially his score was 2, 5, 3, 5) indicating improved PFM strength and endurance. Also, he had improved PFM coordination as he could isolate PFM contraction without Valsalva or accessory muscle activation. He also had one strength grade improvement with abdominal strength. All that being said, most importantly, this patient had improved rating on the outcome questionnaire (International Continence Society male Short Form (ICSmaleSF)) at discharge indicating improved quality of life. At initial evaluation, this patient rated “a lot” (3 on ICSmaleSF) when asked how much the urinary symptoms interfered with his life, at discharge he reported “not at all” (0 on ICSmaleSF).
One component to this case that I found fascinating was the duration of time that had passed since this patients’ prostatectomy. It had been 10 years since this patient had his surgical procedures. He had never been offered physical therapy or knew about it as a possible treatment for his symptoms. Additionally, that he could have such success with improvements in voiding and incontinence function, as well as improved quality of life as long as 10 years’ post-prostatectomy.
This case report is a comprehensive glimpse of what physical therapy assessment and treatment may look like for a patient with urinary dysfunction following radical prostatectomy. This patient had great improvements with positive changes enhancing his quality of life. So, if you are considering adding treatment of this population to your practice consider attending Post-Prostatectomy Patient Rehabilitation, available this July in Annapolis, MD or September in Seattle, WA.
"Cancer Among Men", Centers for Disease Control and Prevention
Roscow, A. S., & Borello-France, D. (2016). Treatment of Male Urinary Incontinence Post–Radical Prostatectomy Using Physical Therapy Interventions. Journal of Women’s Health Physical Therapy, 40(3), 129-138.
Myofascial release (MFR) can be one of your greatest treatment tools as a pelvic rehabilitation practitioner. Just in case you don’t think about fascia often here are a couple helpful things to remember. Fascia is the irregular connective tissue that covers the entire body, and it is the largest sensory system in the body, making it highly innervated. The mobilizing effect of MFR techniques occurs by stimulating various mechanoreceptors within the fascia (not by the actual force applied). MFR techniques can help to reduce tissue tension, relax hypertonic muscles, decrease pain, reduce localized edema, and improve circulation just to name a few physiological effects.
An interesting case report published in 2015 by the Journal of Women’s Health Physical Therapy1 offers a wonderful example of how a physical therapist used specific MFR techniques for a patient with clitoral phimosis and dyspareunia. The specific MFR techniques used helped to provide relief and restore mobility to the pelvic tissues for this patient.
Clitoral phimosis is adherence between the clitoral prepuce (also known as the clitoral hood) and the glans. This condition can be the result of blunt trauma, chronic infection, inflammatory dermatoses, and poor hygiene. In this case report, the 41-year-old female patient had sustained a blunt trauma injury to the vulva (when her toddler son charged, contacting his head forcibly into her pubic region). She presented to physical therapy with complaints of dyspareunia, low back pain, a bruised sensation of her pubic region, vulvar pain provoked by sexual arousal, decreased clitoral sensitivity, and anorgasmia. The physical therapist completed an orthopedic assessment for the lower quarter (including spine and extremities), as well as a thorough pelvic floor muscle assessment.
Treatment for this patient addressed not only the pelvic complaints, but the lower quarter complaints as well. A detailed treatment summary for each visit is outlined in the case report. The clitoral MFR and stretching was performed by applying a small amount of topical lubricant to the clitoral prepuce. Then, a gloved finger or a cotton swab was used to stabilize the clitoris, a prolonged MFR or sustained stretch was applied in the direction away from the fixated clitoris by the therapist’s other finger. The therapist applied this technique along the entire length of the prepuce. The other physical therapy interventions this patient was treated with were stretching, joint mobilization, muscle energy techniques, transvaginal pelvic floor muscle massage, clitoral prepuce MFR techniques, biofeedback, Integrative Manual Therapy (IMT) techniques, nerve mobilization, and therapeutic and motor control exercises. Additionally, between the physical therapy evaluation and the second visit the patient did use topical Clobetasol 0.05% cream (commonly prescribed for vulvar dermatitis issues such as Lichen Sclerosis) for 30 days with no change to her clitoral phimosis.
After 11 sessions, the patient had resolution of dyspareunia, vulvar pain, pubic pain, and reduced low back pain. Also, the patient had 100% restored mobility of the clitoral prepuce, as well as normalized clitoral sensitivity and clitoral orgasm. The patient felt these improvements were still present at her 6-month follow-up interview over the phone. Current medical management for clitoral phimosis is surgical release or topical/injectable corticosteroids. Having a conservative treatment option, such as MFR, for this condition can be helpful for patients. As with most evolving treatment techniques, more research and studies are appropriate.
Not one health care professional had ever assessed the fascial mobility of the clitoris until this physical therapist did. This case report is an example of how MFR techniques can be effective treatment tools for your patients with pelvic disorders and a good reminder to check the fascial mobility of the pelvic tissues.
Morrison, P., Spadt, S. K., & Goldstein, A. (2015). The Use of Specific Myofascial Release Techniques by a Physical Therapist to Treat Clitoral Phimosis and Dyspareunia. Journal of Women’s Health Physical Therapy, 39(1), 17-28.
As pelvic rehabilitation practitioners, we have all been there, looking ahead to see what patients are on our schedules and recognizing that several will require immense energy from us… all afternoon! Then we prepare ourselves, hoping we have enough stamina to get through, and do a good job to help meet the needs of these patients. Then we still have to go home, spend time with our families, do chores, run errands, and have endless endurance. This can happen day after day. Naturally, as rehabilitation practitioners, we are helpers and problems solvers. However, this requires that we work in emotionally demanding situations. Often in healthcare, we experience burnout. We endure prolonged stress and/or frustration resulting in exhaustion of physical and/or emotional strength and lack of motivation. Do we have any vitality left for ourselves and our loved ones? How can we help ourselves do a good job with our patients, but to also honor our own needs for our energy?
How do we as health care practitioners’ prevent burnout?
Ever hear of “mindfulness” ... I am being facetious. The last several years we have been hearing a lot about “mindfulness” (behavioral therapy or mindfulness-based stress reduction) and its positive effects in helping patients cope with chronic pain conditions. Mindfulness is defined as “the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis,” according to Merriam-Webster’s Dictionary. One can practice mindfulness in many forms. Examples of mindfulness-based practice include, body scans, progressive relaxation, meditation, or mindful movement. Many of us pelvic rehabilitation providers teach our patients with pelvic pain some form of mindfulness in clinic, at home, or both, to help them holistically manage their pain. Whether it is as simple as diaphragmatic breathing, awareness of toileting schedules/behavior, or actual guided practices for their home exercise program, we are teaching mindfulness behavioral therapy daily.
Why don’t we practice what we preach?
As working professionals, we are stressed, tired, our schedules too full, and we feel pain too, right? Mindfulness behavioral therapy interventions are often used in health care to manage pain, reduce stress, and control anxiety. Isn’t the goal of using such interventions to improve health, wellness, and quality of life? Mindfulness training for healthcare providers can reduce burnout by decreasing emotional exhaustion, depersonalization, and increasing sense of personal accomplishment. Additionally, it can improve mood, empathy for patients, and communication.1 All of these improvements, leads to improved patient satisfaction.
Let’s take what we teach our patients every day and start applying it to ourselves. An informal way to integrate mindfulness is by building it into your day. Such as when washing hands in between patients, or before you walk into the room to greet the patient. However, sometimes we have a need for a tangible strategy to combat stress and the desire to be guided by an expert with this strategy.2 I think one of the easiest ways to begin practicing mindfulness is to try a meditation application (app) on a smart phone or home computer. Meditation is one of the most common or popular ways to practice mindfulness and is often a nice starting point to try meditation for yourself or to suggest to a motivated patient. Many popular guided meditation apps include Headspace, Insight Timer, and Calm, just to name a few. Generally, these guided meditation apps have free versions and paid upgrades. Challenge yourself to complete a 10-minute guided meditation app, daily, for three weeks, and see how you feel. It takes three weeks to make a new habit. Hopefully, guided meditation will be a new habit to help you be present with your patients and improve your awareness and energy. After all, how can we help others heal, if we can’t help ourselves?
To learn more about ways, you as a professional can help yourself or your patients with meditation, consider attending Meditation for Patients and Providers.
1)Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney C.J., et al. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302(12):1284–93.
2)Willgens, A. M., Craig, S., DeLuca, M., DeSanto, C., Forenza, A., Kenton, T., ... & Yakimec, G. (2016). Physical Therapists' Perceptions of Mindfulness for Stress Reduction: An Exploratory Study. Journal of Physical Therapy Education, 30(2).
Urinary incontinence (UI) can be problematic for both men and women, however, is more prevalent in women. Incontinence can contribute to poor quality of life for multiple reasons including psychological distress from stigma, isolation, and failure to seek treatment. Patients enduring incontinence often have chronic fear of leakage in public and anxiety about their condition. There are two main types of urinary leakage, stress urinary incontinence (SUI) and urge urinary incontinence (UUI).
SUI is involuntary loss of urine with physical exertion such as coughing, sneezing, and laughing. UUI is a form of incontinence in which there is a sudden and strong need to urinate, and leakage occurs, commonly referred to as “overactive bladder”. Currently, SUI is treated effectively with physical therapy and/or surgery. Due to underlying etiology, UUI however, can be more difficult to treat than SUI. Often, physical therapy consisting of pelvic floor muscle training can help, however, women with UUI may require behavioral retraining and techniques to relax and suppress bladder urgency symptoms. Commonly, UUI is treated with medication. Unfortunately, medications can have multiple adverse effects and tend to have decreasing efficacy over time. Therefore, there is a need for additional modes of treatment for patients suffering from UUI other than mainstream medications.
An interesting article published in The Journal of Alternative and Complimentary Medicine reviews the potential benefits of yoga to improve the quality of life in women with UUI. The article details proposed concepts to support yoga as a biobehavioral approach for self-management and stress reduction for patients suffering with UUI. The article proposes that inflammation contributes to UUI symptoms and that yoga can help to reduce inflammation.
Surfacing evidence indicates that inflammation localized to the bladder, as well as low-grade systemic inflammation, can contribute to symptoms of UUI. Research shows that women with UUI have higher levels of serum C-reactive protein (a marker of inflammation), as well as increased levels of inflammatory biomarkers (such as interleukin-6). Additionally, when compared to asymptomatic women and women with urgency without incontinence, patients with UUI have low-grade systemic inflammation. It is hypothesized that the inflammation sensitizes bladder afferent nerves through recruitment of lower threshold and typically silent C fiber afferents (instead of normally recruited, higher threshold A-delta fibers, that respond to stretch of the bladder wall and mediate bladder fullness and normal micturition reflexes). Therefore, reducing activation threshold for bladder sensory afferents and a lower volume threshold for voiding, leading to the UUI.
How can yoga help?
Yoga can reduce levels of inflammatory mediators. According to the article, recent research has shown that yoga can reduce inflammatory biomarkers (such as interleukin -6) and C-reactive protein. Decreasing inflammatory mediators within the bladder may reduce sensitivity of C fiber afferents and restore a more normalized bladder sensory nerve threshold.
Studies suggest that women with UUI have an imbalance of their autonomic nervous system. The posture, breathing, and meditation completed with yoga practice may improve autonomic nervous system balance by reducing sympathetic activity (“fight or flight”) and increasing parasympathetic activity (“rest and digest”).
The discussed article highlights yoga as a logical, self-management treatment option for women with UUI symptoms. Yoga can help to manage inflammatory symptoms that directly contribute to UUI by reducing inflammation and restoring autonomic nervous system balance. Additionally, regular yoga practice can improve general well-being, breathing patterns, and positive thinking, which can reduce overall stress. Yoga provides general physical exercise that improves muscle tone, flexibility, and proprioception. Yoga can also help improve pelvic floor muscle coordination and strength which can be helpful for UUI. Yoga seems to provide many benefits that could be helpful for a patient with UUI.
In summary, UI remains a common medical problem, in particular, in women. While SUI is effectively treated with both conservative physical therapy and surgery, long-term prescribed medication remains the treatment modality of choice for UUI. However, increasing evidence, including that described in this article, suggests that alternative conservative approaches, such as yoga and exercise, may serve as a valuable adjunct to traditional medical therapy.
Tenfelde, S., & Janusek, L. W. (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.
A diagnosis of breast cancer means many different things to many different people. Regardless, receiving this diagnosis means some sort of treatment will likely follow. The types of treatment and outcomes are largely dependent on individual patient scenarios, however, one thing is for certain: A patient’s life will be forever changed after having received this diagnosis.
Historically, comprehensive care for a patient with breast cancer has focused on treatment and prevention. However, more and more women are surviving breast cancer every year. Therefore, more attention needs to be paid to survivorship. Once someone has survived cancer, comprehensive, quality care should obviously focus on preventing recurrence, however, it may also include guidance and counseling on maintaining a healthy lifestyle and addressing physical and psychosocial changes.
A very recent 2016 article published in the Annals of Surgical Oncology discusses the subject of survivorship in breast cancer patients. This article suggests that the key to achieving successful outcomes for management of a breast cancer survivor is a multidisciplinary approach to help these survivors deal with the physical and psychosocial sequela resulting from their diagnosis.
As a pelvic rehabilitation provider, this is a very thought-provoking article as it outlines several areas in which I feel breast cancer survivors could benefit from physical therapy. A pelvic rehabilitation provider can be a valuable part of the multidisciplinary team that helps manage a breast cancer survivor towards positive and meaningful outcomes, ultimately enhancing their quality of life. The following are some areas addressed in the article in which a breast cancer survivor may need assistance to improve and support a meaningful quality of life.
Sexuality: According to this article, studies show treatment for breast cancer is associated with significant decrease in sexual interest, desire, arousal, and difficulty achieving orgasm and/or lack of sexual pleasure. Additionally, patients can also report pain with intercourse (dyspareunia) and/or vaginal dryness, which can lead to sexual dysfunction. Physical therapy can help by providing education on normal sexual response and lubricants, as well as help with tissue healing. Therapeutic techniques include exercise and manual treatments to areas that may be damaged from surgery, radiation, and chemotherapy. Additionally, exercise has been shown to improve self-image. Poor body image has been linked to sexual dysfunction following breast surgery (depending on the type “breast sparing techniques” versus mastectomy). This includes only some of the ways a physical therapist can help improve sexual dysfunction.
Lymphedema: According to the article, 30-70% of breast cancer patients experience lymphedema after treatment. Physical therapy can play an important role in the control and/or reduction of lymphedema. A physical therapist can provide helpful education, exercise, weight control, and, if needed, manual techniques and compression garments and bandaging.
Teachable moments after cancer diagnosis: A teachable moment is when you identify and seize an opportunity to educate your patient. After a life altering event or illness, people are more accepting of advice and change of lifestyle. As healthcare providers, we can utilize this time to help our patients improve outcomes by modifying their behavior. The cited article states there is clear evidence that physical activity decreases incidence and recurrence.There is additional evidence to show controlling weight and maintaining a normal body mass index (BMI) improves breast cancer survivor outcomes. A physical therapist can help a breast cancer survivor to develop a guided and progressive home exercise program to help them maintain normal BMI and participate in regular physical activity safely and regularly.
The discussed article, “Breast Cancer Survivorship: Why, What and When?”, sheds light on many areas of physical and psychosocial challenges that patients surviving breast cancer may deal with. This article also advocates that a multidisciplinary approach yields the greatest outcomes. I suggest that physical therapy can be a valuable part of the team when creating patient care plans for breast cancer survivors.
To learn more about breast cancer and outcomes based treatments, consider attending "Physical Therapy Treatment for the Breast Oncology Patient! The next course is taking place in Stockton, CA this September 24-25.
Gass, J., Dupree, B., Pruthi, S., Radford, D., Wapnir, I., Antoszewska, R., ... & Johnson, N. (2016). Breast Cancer Survivorship: Why, What and When?. Annals of Surgical Oncology, 1-6.
The care I received from the doctors, nurses, and hospital staff during labor, delivery, and postpartum period was excellent. I felt all the staff members explained all procedures for myself and the baby. The labor and delivery nurses were helpful and compassionate. They showed me how to breastfeed the baby, assisted me with skin to skin contact, and taught my husband and I how to care for the baby when we took her home. The birth center site at the hospital was amazing. I had an individual birthing suite with a bathroom, a television, a bathtub and a place for my husband to sleep. Health care for the baby and I following delivery continued to be excellent. I had a surgical follow up one week later with my doctor and another postpartum visit at 6 weeks. At each visit I was given The Edinburgh Postnatal Depression Scale (a scale to help identify postpartum depression) as well as educational pamphlets on self-care following a cesarean delivery. The only complaints I had that required assistance from a health care provider was with getting baby to latch with breast feeding and neck and shoulder pain from breast feeding the baby. I took it upon myself to work on core and hip exercises I would give a postpartum patient who had undergone a cesarean delivery and was working on my scar tissue to prevent problems with bladder, bowel, abdomen, and uterus. I sought some massage for my neck and shoulders and did my physical therapy exercises for my neck and shoulders. I sought a lactation consultant for the latching issues with breast feeding. Seeking care helped resolve these issues which reduced my neck and shoulder pain and helping me enjoy breastfeeding my baby.
Before having my daughter, I had preconceived notions about postpartum care. For the last ten years since I started working with women’s health patients I have heard repeatedly from my patients that they felt they did not receive comprehensive postpartum care. Many of these women hopped from health care provider to health care provider, sometimes taking years to resolve orthopedic or pelvic floor problems from their pregnancy or labor and delivery experience. Quality postpartum care was my soap box issue and still is. That being said, I was very satisfied with my postpartum health care experience. My experience revealed that support and education about postpartum problems as well as proactive healthcare for theses challenges is becoming mainstream. I have always felt that women in our country need better post-partum care and I am happy to see improvements being made. We may forget between the constant baby changing, soothing, and feedings that mom needs some care too. I am not sure that we always remember that there have been 9 months of physiologic changes occurring to a woman’s body. Additionally, physical trauma that occurs with caesarean or vaginal delivery. A mother may need physical therapy for exercises to strength abdominals or back, help for bowel or bladder problems, manual therapy for painful intercourse, or scar tissue work for abdominals or pelvic floor.
I think as a society we are getting more aware of the influence of hormones, crying babies, sleep deprivation, and a heavy work load can overwhelm a postpartum mother. Based on my experience only, I think we are doing a better job of monitoring postpartum depression, pain management, and pelvic floor problems. I was so pleased at the availability of information and counseling opportunities presented to me during my birthing and postpartum experience. I received so much encouragement and permission to seek help from others during my postpartum healing.
Now that patients are being routinely counseled on postpartum self-care for mind and body we need to help them achieve successful outcomes. As health care providers, we should help postpartum patients decide how to include self-care with their new routine with baby. Caring for a baby takes a lot of time! My postpartum experience was likely similar to other women, where I had very little time to do all the “things I should be doing.” (For me this included neck, shoulder, abdominal, back, and pelvic exercises. As well as attending pediatrician, massage therapy, and lactation appointments.) The baby needs to feed constantly. By the time you feed, change, and soothe the baby (and pump if needed) it is almost time to do it again. You may never have more than an hour to get things done or get some sleep. As a mother there are many novel challenges to face, skills to learn, and emotional stress from fatigue and hormones. On top of all that, oh yeah, you should exercise, eat healthy, and if you are lucky shower and sleep! The point is, being a mother is challenging and we are all doing the best job we can. It is difficult to care for your baby while taking care of yourself. Reflecting back on my “birth story” has helped me empathize with my patients but also helped me to see that as health care providers, we should continue to provide education to our patients on self-care and continue to encourage them to seek care for their problems. However, to really help our patients successfully heal, we need to help them figure out how postpartum self-care blends into their new life with baby.
Towards the end of my pregnancy, my doctor ordered an ultrasound to make sure the baby was growing appropriately. This was precautionary as the baby had measured small the last couple appointments. The ultrasound gave us some important information. Baby K was growing appropriately, however, she was breech. At this point, she should have already flipped into the cephalic (head down) position, and it was unlikely that she would turn further along in my pregnancy. I knew what this meant… “C-section” (cesarean). Like so many women before me, this was not what I wanted for my birth plan. Having a planned cesarean had not really crossed my mind. I figured it would only be some kind of emergency that would result in this outcome. Instantly I thought of all the patients I have treated over the years who had cesarean delivery. I thought of abdominal adhesions and scar tissue mobility work that would need to be done postpartum. Naturally, as a physical therapist, I also thought of all the mobility challenges this would bring after baby. Having a cesarean would change my post-partum recovery; I would need more help with lifting, carrying, and we have so many stairs in our house! I know this may sound crazy… but what saddened me the most about cesarean delivery was that I was not going to experience what labor felt like. I felt cheated, in a weird way, I was looking forward to it, almost like a rite of passage. I wanted to analyze labor and delivery from a patient’s standpoint, not just as a therapist. I thought it would help me relate to patients and friends who have experienced labor. All that being said, a scheduled C-section was happening unless that baby miraculously flipped.
My doctor suggested a version, which is a procedure where your doctor tries to manually turn your baby using an external technique. I had heard it is painful, but I pride myself on being a pretty tough woman who has dealt with some pain, I can do this! Needless to say, the version was painful… Very painful! As a matter of fact, the most painful procedure I have ever encountered. After trying about four times to turn the baby, my doctor asked me if we should try one more time. Although I was miserable, I asked if they thought the baby was close to being in the right position. The looks on my husband’s and doctor’s faces told me that she hadn’t moved at all. We gave it one more try, but that stubborn baby really liked the spot she was in. The plan was to proceed with the scheduled C-section at 39 weeks, unless I went into labor first, then it would be an emergency cesarean delivery.
At 39 weeks, I woke up the morning of the planned cesarean and thought, “it’s a good day to have a baby”. I was excited to finally meet this little princess, but a little nervous about the cesarean delivery. I was trying not to think about what was going to happen to my abdomen and uterus. I was hoping Baby K would handle all of this safely, and she would be well. My plan for the procedure was distraction, not to think about what was happening, as I knew too much. Sometimes ignorance is bliss. I did not want to think of every unfortunate story I had heard about “spinals”, and “cesareans gone wrong”, so I kept telling myself to trust my doctors and relax. After all, this is what they do every day, and they are good at it. I wasn’t the biggest fan of the numbness and tingling I felt in my legs, as well as the lack of motor control in the lower half of my body once they administered the spinal, but it did the trick.
All I felt during the caesarean was just some tugging on my abdomen as the doctor worked to get baby out and complete the procedure. Luckily, it was all happening behind a partition while my husband held my hand and we told jokes to relieve our nerves. All of a sudden, there was a loud cry, and I felt instant relief. It was my baby, and she had healthy lungs! My doctor popped around the screen and showed me my beautiful brown-haired baby. Next, my husband and the nurses cut the cord and took care of baby. Once she was cleared and safe, they plopped her on my chest. Like a moth to a flame, that baby wriggled herself right onto my breast. It was the purest form of instinct I have ever witnessed. How did that little baby that just entered this world have the innate knowledge to nourish, and the strength to find her food source. It was amazing! Overall, no matter how much you research and plan for labor and delivery, it likely won’t turn out how you plan it. The positive is that our bodies have been delivering babies forever, so trust in your body, and trust in those around you helping with the delivery. The labor and delivery experience is innate.
The following is the first in a three-part blog series which chronicles the peripartum journey of Rachel Kilgore.
In April, I had my first child, a sweet and healthy baby girl. Reflecting on the last year, what a ride! I have had many of my friends, family members, patients, and acquaintances discuss the journey and challenges of motherhood with me, however, experiencing it first hand was a memorable voyage. I thought I was very prepared and knew what I was getting into, but as usual, nothing compares to first-hand knowledge and experience. From an academic standpoint, I had done my research on everything from conception, what to expect each trimester of pregnancy, and reviewed the many options for labor and delivery. I even was lucky enough to assist in the Herman and Wallace Care for the Post-Partum Patient course with Holly Tanner while I was pregnant! As a practitioner, I love treating pregnant and post-partum patients, it is one of my favorite populations to treat. I love helping these strong, motivated women with pain relief and to teach them management skills to adapt to a new lifestyle and a changed body that has unique musculoskeletal needs.
I had always had a preconceived notion that I would exercise diligently and eat super healthy through my pregnancy. After all, that was how my lifestyle was before pregnancy, why should it change? That lasted about 6 weeks, until 24-hour episodes of nausea and vomiting overwhelmed me, which continued until the start of the second trimester. I basically just tried to make it through the day without vomiting at work, and would go straight to bed whenever I had the chance. I even had to miss several days of work! I thought it was termed “morning sickness” implying that it went away after morning, but apparently it should be renamed to “forever nausea” as that is what it felt like at the time. Because of the nausea, I wanted nothing to do with food, which in turn lead to constant concern about the baby not getting enough nourishment. Of course, my regular activity levels plummeted. In addition to nausea was constant fear of miscarriage and whether my regular activities were somehow harmful to my baby. Instead of ice cream and pickles, I craved information. What should I be doing, and what should I not be doing?
When the first day of the second trimester hit, the nausea just went away. I was ecstatic! I got my energy back and was finally enjoying the pregnancy again! I was able to exercise regularly and eat healthy, two of my favorite things. Everything was going well, and it was time to start figuring out this whole baby thing. Luckily, most of my friends are mothers themselves, and they helped guide me. They directed me to great resources to satisfy my quest for knowledge about everything I needed to know for pregnancy, labor delivery, and the baby itself. They helped me decipher what all these baby products were, and what do you actually need. All the fun stuff was happening! We painted the baby’s room, ordered furniture, and planned a baby shower.
Everything that happens to my patients happens to me. Third trimester was when I started to really “feel pregnant”. Daily mobility became challenging. I never realized how many times in a workday I show patients correct lifting mechanics or how often I set things on the ground or pick up weights. I started to dread every time I had to pick up something. At work, I would drop my pen on the ground so many times, and why had I never noticed that I did it so often? Luckily, I used my “physical therapy knowledge and skills” and did things I tell my pregnant patients to do; the results were minimal problems with musculoskeletal pain. Techniques such as: Using proper mechanics throughout my day, pulling in my core, and wearing a maternity support if my back was hurting a little. I never really developed severe back pain as is the case for many pregnant women. I completed hip and trunk exercises I usually give my pregnant patients and found they were easy to do and made me feel better... shocking right? Of course I was doing my kegels too! While my musculoskeletal system was doing well, my gastrointestinal system was not. I had never really had heart burn before, but now had it constantly, and found it to be very frustrating and depressing. I love cooking and eating but neither are enjoyable when you have heartburn. The heartburn was so bad it would wake me up every night coughing and chocking on my own acid reflux. Between lack of sleep, heartburn, and reduced mobility, I was getting pretty excited to be done with pregnancy and to finally meet “Baby K” as we had begun calling her. Overall, being pregnant was a very informative experience for me as a person and as a clinician. I often hear my patients tell me of their uncomfortable symptoms during pregnancy involving their musculoskeletal and gastrointestinal systems, however, now I empathize on another level.