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.
In case you’ve been under a rock (or maybe studying for the Pelvic Rehabilitation Provider Certification (PRPC) exam, the latest Netflix series starring Maria Bamford is out, and it is, as the kids say, amazeballs. We have Maria Bamford and team, and Lady Dynamite, to thank for getting the term vaginismus out in the public as the title of Season 1, Episode 8. The episode is named “A Vaginismus Miracle.” In this episode Maria is answering the question of when she last had sex. She answers that is was a year ago, which reminds her that the annual date of "Vaginismus" must be coming up. Maria further explains that she must have sex once per year because then everything is good "under the hood", and if she doesn't have sex once a year, her "vagina could close up." It's a nail biter of an episode as Maria's assistant has messed up the schedule, and Maria finds out that "Vaginismus" is that very night, and she must find a partner before midnight.
As a pelvic health provider, I knew that neither myself nor my colleagues would be able to sit back and worry about Maria suffering through another year with “Vaginismus” on her calendar, a looming deadline when we all know that with a little bit of rehabilitation, the issue could be much, much better, or maybe resolved altogether. The episode inspired me to write an open letter to Maria. Feel free to share and tag your friends who you think would love to watch a smart, funny show that puts real life issues including mental health in the spotlight.
Dear Lady Dynamite,
I recently saw your Netflix show and I have to say that it is brilliant. I love how you weave humor, the messiness of life, and important topics into an unpredictable series of events. You are clearly one smart cookie, but I’m not convinced that your new agent, Karen Grisham, is such a great influence on you (or anyone for that matter).
I wanted to reach out and let you know that, as a pelvic rehabilitation therapist and faculty member at the Herman & Wallace Pelvic Rehabilitation Institute, I really appreciate that you brought the term vaginismus into the big time. So many women suffer needlessly because there is so much that pelvic rehab can do for women like you! It does seem that you have figured out a system that works for you, but what if things hadn’t worked out with Scott that night? Hanging out in a bar hoping that you can find someone to hook up with is just so 80’s. Your condition of vaginismus, a tightening of the muscles around your Lady Dynamite parts, does often cause pain with sex, and that’s called dyspareunia. This is a condition that we pelvic rehab specialists treat every day with a heck of a lot of success. Your new boyfriend Scott (he is still your boyfriend after Thanksgiving and all, right?) could even help you overcome some tenderness and tightness by learning to help you release your vaginal muscle tension. Now if that doesn’t sound like great fodder for some stand-up I don’t know what does!
It’s hard to know sometimes why vaginismus starts, maybe it was the years of freezing temperatures in Duluth that led to your tight muscles, or sliding down Chester Bowl on the ice. Maybe it was spending too much time sitting in a wheelchair while medicated, or caused by medication itself (that happens too- even birth control pills can cause pelvic pain!) My point is, there’s no need to put so much pressure on yourself and have this horrible deadline of “vaginismus” hanging over your head when you can see a kind, smart health care provider about the issue. If you, dear Lady Dynamite, need a referral for a great pelvic rehab therapist in your neighborhood, let us know! We train hundreds of therapists every year, and can help you find the perfect fit (pun intended!) Ha! (We know you can handle a little “adult humor.”) Wishing you all the best, and thanks again for talking about your vagina!
Yours in Pelvic Health,
P.S. Good luck with the Pussy Noodles representation!
P.P.S Go ‘Toppers!
P.P.P.S Can’t wait for Season 2!
P.P.P.P.S And if you see Mark McGrath around, say “hi” for me!
So, dear readers, if you would like to enjoy a smart and really funny show, check out Lady Dynamite. And if you want to learn more about vaginismus, Herman & Wallace offers several courses which would be up your alley. Consider joining faculty member Dee Hartmann, PT, DPT at Vulvodynia: Assessment and Treatment - Denver, CO this October 15-16.
Brady, P. & Hurwitz, M. (Creators). (2016). Lady Dynamite: Season 1, Episode 8. Retrieved from http://netflix.com
Pain associated with menstruation is known as dysmenorrhea, and more than half of women have pain related to their period for 1-2 days per month, according to The American College of Obstetricians and Gynecologists. Primary dysmenorrhea is related to menstruation, and often begins within a short period of time once menses occurs, whereas secondary dysmenorrhea is often related to a condition within the reproductive tract such as endometriosis or fibroids. In the medical office, a medical history, a pelvic exam, and possibly an ultrasound or laparoscopy will be completed. Treatment may include medications such as NSAIDs which target the prostaglandins that often lead to symptoms of dysmenorrhea, birth control pills, or surgeries.
A recent literature review asked if physiotherapy can help with symptoms of primary dysmenorrhea. Of the articles reviewed, 186 were chosen, and included a range of articles from descriptive, experimental studies to prospective, randomized controlled studies. A variety of interventions and approaches were included in the review, such as TENS, abdominal massage, acupuncture, cryotherapy and thermotherapy, connective tissue, Pilates, and belly dance. All of the approaches demonstrated some therapeutic benefit, either in response to the immediate application of the intervention, or up to a few months after the intervention was applied or instructed.
This literature review echoes a prior systematic review that evaluated the effectiveness and safety of acupressure, acupuncture, aspirin, behavioral interventions, oral contraceptives, and other supplements, procedures, and complementary and alternative medical interventions. Click here to view the full-text article. In that particular review, the authors reported the following:
- high-frequency TENS reduces pain (but less so than ibuprofen)
- acupressure may be as effective as ibuprofen
- topical heat may be as effective as ibuprofen and more effective than paracetamol
The bottom line from this research should be that we as pelvic rehabilitation providers need to help patients address pain and symptoms from dysmenorrhea. Clearly, there are many pathways to achieve symptom reduction, and some, such as TENS or topical heat, are easily carried out on an independent basis. How are you reaching adolescent girls who may develop primary dysmenorrhea? In clinical practice, talking with their parents, or reaching out at the community level to schools, churches, camps, gyms, or coaches may provide an opportunity to provide education and help. If you would like to learn more about myofascial release techniques for the abdomen and pelvis, check out the Myofascial Release for Pelvic Dysfunction continuing education course taking place next month in Illinois!
The American Urological Association issued new guidelines in May of this year for the diagnosis and treatment of Peyronie's. The disorder, which you can read more about at this link, often leads to a curvature in the penis that can be painful, or that can lead to impaired sexual or urinary function. While the exact mechanism leading to Peyronie's is still being researched, what is known is that plaques (sometimes calcified) may form in a deep layer of thick connective tissue called the tunica albuginea that surrounds the penis.
In the clinical guidelines, the authors state that a diagnostic process should include documentation of the signs and symptoms of Peyronie's disease. This can include a careful history (assessing any penile deformity, limitations in sexual function, penile pain, and level of distress). In the medical office, an intracavernosal injection (check here for a Medscape article describing an algorithm) can be completed. The authors also state, in line with expert opinion, that a provider should only evaluate a patient's Peyronie's disease when possessing "…the experience and diagnostic tools to appropriately evaluate, counsel, and treat the condition." In regards to pelvic rehabilitation, understanding the condition and encouraging the patient to visit a medical provider who is appropriately trained to manage Peyronie's is valuable. Establishing a baseline for the amount of dysfunction and curvature aids the patient and physician in determining current and future care planning.
Available treatments include education about possible treatments as well as adverse reactions to medical treatment. Interventions might include oral NSAIDs, intralesional injections (to reduce the amount of scar/thickened tissue or pain), and surgeries. Surgical options include procedures to remove the plaque or scar tissue, remodel the penile tissues after plaque removal, and for more severe cases, to implant a penile prosthesis. (Recommendations for treatments to avoid due to potential for harm or for lack of evidence are also listed in the article.)
The role of pelvic rehabilitation is emerging for men who present with genital pain, deformity, or pelvic dysfunction. There are certainly comorbid dysfunctions that we can address, such as pelvic muscle dysfunction, bowel and bladder issues if present, and we can provide a significant amount of education about pelvic health. Therapists are also teaching patients to perform connective tissue mobilization on the penile tissues, and some therapists are directing manual therapy, dry needling, and other modalities to the tissues. Rehabilitation lacks, at this time, compelling evidence to support direct treatment to the tissues, and hopefully that research will be seen in the near future. The authors of the new guidelines conclude that "…The most effective approach for a particular patient is best determined by the individual clinician and patient in the context of that patient’s history, values, and goals for treatment." This sounds to me like an effective approach for every patient who struggles with a condition that lacks a clear understanding of etiology and best treatments. These guidelines are a step forward in management of patients who deal with the frustrating condition, and the guidelines will be updated, according to the article, as the science advances.
If you would like to learn more about the rehabilitation implications of Peyronie's, and the potential and current roles of therapists in male pelvic health, you have two opportunities this year to attend the Male Pelvic Floor course , August in Denver, and November in Seattle. We expect the Seattle to course to sell out, and it's filling up fast, so check your calendar and come join us at the Male course.
A recent study aimed to determine if an association is present between childhood functional constipation and parental child-rearing attitudes. Of the 133 studied children (ages 4-18), all were diagnosed with functional constipation and participated in a randomized, controlled trial evaluating the effectiveness of behavioral therapy compared with conventional treatment. Outcomes tools included the Amsterdam version of the Parental Attitude Research Assessment (A-PARI). The scale measures parental attitudes in the following domains: autocratic ("the child needs authority, strictness"), autonomy (encouraging independence), over-protection (prevent disappointments for the child), and self-pity (irritation with bringing up child.) (For more information about the methods, results, inclusion or exclusion criteria, you can download the linked article as full, free text.)
The study determined an association between defecation and fecal incontinence and parental child-rearing attitudes. For example, a highly overprotective or a high self-pity attitude both increased fecal incontinence, and that high autonomy and low autonomy attitudes were found to be detrimental to bowel health. The authors conclude that "…child-rearing attitudes are associated with functional constipation in children" and that parenting issues should be addressed when treating constipation in children. Specifically, if parenting issues are limiting the success of the pediatric patient or "when the parent-child relationship is at risk", referral to mental health services may be needed. The research study discusses concepts of education to "demystify" the dysfunction and positively affect parental attitudes.
We know that management of pediatric urinary dysfunction relies in large part on management of bowel dysfunction. In addition to needing to understand how we approach childhood constipation rehabilitation, we may be able to identify concerns in how a parent is dealing with a child's constipation. It is understandable that managing a child's bowel or bladder dysfunction can be frustrating for a patient, yet if the pelvic rehabilitation provider has concerns about a parent's participation in home program carryover, the parent may be appropriate for referral to a mental health provider, as this study suggests. If you would like to have more information about treating children with bowel and bladder dysfunction, you can sign up for Pediatric Incontinence and Pelvic Floor Dysfunction. You have two opportunities still this year to take this course that will prepare you for helping kids with pelvic dysfunction: Houston in July, and Boston in October
Lymphedema following breast cancer treatment, characterized by limb pain, tightness, heaviness, and possible infections, can occur during or even years following treatments for cancer. Determining which patients are at risk for lymphedema after breast cancer may allow clinicians and researchers to provide appropriate follow-up care and education. In a recent study 190 women who underwent breast cancer treatment including level 3 axillary lymph node dissection (ALND) were followed to determine risk factors for development of lymphedema. Level 3 dissection refers to the surgical classification of the axillary lymph nodes into three compartments, defined in relationship to the pectorals minor muscle. Level 3 describes the nodes above and medial to the pectoralis minor. This page includes more information about breast anatomy and the levels of dissection.
To determine the presence of lymphedema, upper limb circumferential measurements were taken. Lymphedema was found to be present in 41.5% of the women. Of these women, 44 had stage 1, 25 had stage 2, and 10 had stage 3 lymphedema. Stage 1 lymphedema is described as pitting edema that is reversible, stage 2 as non-pitting and irreversible, and stage 3 is considered advanced lymphedema with enlarged limb volume and significant skin changes. The distribution of the lymphedema was measured as 15 cm proximal to the elbow in 94.9% of the patients, and in 73.4% it was located 10 cm distal to the elbow.
In this study, the identified risk factors for developing lymphedema included axillary radiotherapy, chemotherapy, the number of metastatic lymph nodes, age and body mass index (BMI). Because of the known increase in lymphedema prevalence in patients who experience axillary lymph node dissection versus sentinel lymph node dissection, the authors recommend that physicians should play a stronger role in identifying high-risk patients and working towards lymphedema prevention. The medical prevention of lymphedema can include more frequent and thorough follow-up after surgery, and education about modifiable risk factors such as obesity. To learn more about additional lymphedema prevention educational strategies, the Institute offers Rehabilitation for the Breast Cancer Patient with instructor Susannah Haarmann. You still have time to sign up for this course that takes place at the end of the month in the Chicago area!
According to the online resource www.celiac.org celiac disease (also called celiac sprue or gluten sensitive enteropathy) is an autoimmune disorder in which the ingestion of gluten can damage the small intestine. It is further described as an autoimmune disorder affecting 1 in 100 people worldwide and a disorder that can occur among "genetically predisposed people." Common signs and symptoms include abdominal bloating and pain, chronic diarrhea, vomiting, constipation, weight loss, fatigue, irritability and behavioral issues, dental enamel defects, delayed growth, failure to thrive, and ADHD. If not treated, long-term consequences may include developing other disorders such as Type I diabetes, multiple sclerosis, dermatitis herpetiformis (itchy rash), anemia, osteoporosis, infertility, epilepsy, migraines, and intestinal cancers.
Last year, in the Journal of Family Practice, an article was published describing "Why celiac disease is so easy to miss" the authors point out that less than half of patients present with GI symptoms. An unexplained symptom, iron deficient anemia, may be a clue that a patient needs to be tested for celiac disease. Other conditions, such If a patient has a 1st degree relative with celiac disease, presents with autoimmune thyroid disease, peripheral neuropathy, recurrent migraine, chronic fatigue, osteopenia/osteoporosis, or elevated liver enzymes. (See the linked article for further considerations for testing.) Blood serum tests can help determine the presence of celiac disease, and other tests such as an intestinal biopsy or response to a gluten-free diet can be used to confirm the condition. Adherence to a gluten free diet is critical for a patient with celiac disease, and if you are currently (or have tried) eating a gluten free diet, you know how challenging that may be because gluten is in so many products including sources such as vitamins, medications, and lipsticks! If your patient has been diagnosed recently with celiac disease, referral to a nutritionist may be an excellent part of the patient's plan.
While we might imagine that a patient who has a genetic susceptibility for celiac disease would be diagnosed long before we first see them in the clinic, patients can have a "triggering event" such as a trauma, infection, or severe stress that triggers an onset of the disease. And because of the common gastrointestinal symptoms that are present, a patient with undiagnosed celiac disease may be found in our clinical practice. If you would like to learn more about how celiac disease can affect our patients, those diagnosed or undiagnosed, check out the Institute's new course on Nutrition Perspectives for the Pelvic Rehab Therapist, instructed by Megan Pribyl who earned degrees in both nutrition and exercise science. The course taking place in Seattle this weekend has a few last-minute spots for you to attend, and if you'd like to host this course, contact us at the Institute!
A few weeks ago, a pelvic course participant shared some sensitive and intimate thoughts about being at a course and being "the biggest girl in class." This week, we will address specific strategies for communicating with your patients and for adapting your exam techniques when appropriate. The following quote is from an educational book for Nurse Practitioners, and echoes a very healthy and realistic sentiment about our role when working with patients in pelvic rehabilitation.
"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit."
Unfortunately, according to the authors, women who are obese are less likely to receive routine gynecologic care due to bias and fear of judgement, or even practical issues like exam tables, gowns, and equipment not being adequate. Another issue is that of mobility: is the exam table too narrow for safety and comfortable positioning? In my own clinical practice, I have had patients ask me: "Is that massage table going to hold me?" In order to answer that question, you need to know what the safe weight limits are for your chairs, walkers, exam tables, and any other equipment your patients may use. You might imagine that if a patient is concerned about falling off of a table, completing an appropriate exam could be difficult due to muscle guarding. Other techniques recommended include the following:
- ask an assistant to gently hold back skin folds if vagina or vulva is obscured
- ask the patient to flex her hips upward if able
- ask patient to help hold back excess skin in lower abdomen if helpful
- ultrasound may be used rather than palpation as needed (this is in reference to a medical gynecologic exam, but how might rehab US contribute to our toolkit?)
- document any difficulty with the examination - placing a small towel or pillow under the patient's hips may also help in viewing the cervix
This "Bias Tool Kit" offers further suggestions to avoid causing harm when evaluating a woman who is obese:
- if you would like to weigh the patient, ask for consent first, using sensitive language, i.e. "would you like to be weighed today?" and maintain privacy
- in addition to considering equipment like tables, think about having a stepstool with a handle, properly sized blood pressure cuffs, sturdy, armless chairs, and a long exam speculum
- use words that patients find more acceptable, such as excess weight or BMI
Advice to the nurse practitioners include the following to counter the fact that obese women are often discriminated against:
"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit." For example, for a medical exam: "Due to the shape and size of your body, I wasn't able to feel your uterus and ovaries." Any similarly needed communications can be shared in a professional and warm tone.
While sensitive topics can require patience, practice, and an abundance of professionalism, everyone wins when difficult subjects are approached with honesty. Thanks again to Erin B. for shining her light on this sensitive and valuable topic.
This question is one that, a decade ago, may have made more sense to ask, as very few male therapists were engaged in the world of pelvic rehabilitation. Most pelvic rehabilitation practices still stem from programs developed in "Women's Health" so it's logical to see more female patients being treated, usually by female therapists. We are at an exciting time in the healing professions, and particularly in pelvic rehabilitation, when choice of provider may come to be based more on experience, personality and qualifications of the treating therapist than on the provider's or patient's gender. At the Institute's most recent entry-level Pelvic Floor 1 (PF1) courses, 2 male therapists were in attendance at 2 different PF1 courses on opposite sides of the nation. This shift (we tend to have an occasional male therapist within the pelvic floor series courses) has been noticed, and at the Institute, we have committed efforts at exploring if and how this shift affects our coursework. For example, are the instructors comfortable, are the female participants cool with it, and do the men feel welcomed? To find out a little more about the subject, I bring your attention to a few of the men who are currently representing the field of pelvic health.
Herman & Wallace Institute faculty member, Peter Philip, has treated both men and women in his practice for years. This treatment involves internal assessment and intervention when needed, and Peter approaches all of his patients with the same matter-of-fact, clearly defined consent. As a private practice owner, it makes sense that Peter is able to retain his patients regardless of the condition for which they are seeking care. Having to refer a patient to another therapist or clinic would negate the ability for a therapist to provide comprehensive care. On his website you will find a listing of women's health issues described next to sports, work, and other lifestyle injuries.
I posed the following question to Jake Bartholomy , physical therapist in Seattle, Washington: "Why is it so important for a male therapist to be involved in pelvic rehab, regardless if the goal is to focus on working with male or female or other gendered patients?" Jake's response reflects the value of offering choices to the patients he serves: "I believe it's important for people to have a choice in their therapist. Many people are shy and nervous to discuss their pelvic issues and if male or transgendered patients are more comfortable working with a male therapist, I'm proud to offer that service in the Seattle area."
I recall meeting Daniel Kirages, physical therapist and clinical instructor at the University of Southern California, at a male pelvic floor course years ago. When he introduced himself to the group, he joked that he was there as the token male "to break up the girl party." While this joke has stuck with me, it also drives home the point that it takes courage to show up at coursework which has previously been dominated by female therapists. Daniel has been involved in research, teaching in the classroom and online, and lecturing nationally about pelvic rehab.
In my experience as an instructor, the male therapists who attend pelvic rehab courses are exceptionally grounded, open-minded, and exude a quiet confidence that seems necessary for working with sensitive issues surrounding pelvic rehabilitation. Just for the record, we absolutely do believe that male therapists belong in pelvic rehabilitation coursework and practice, and we at the Institute are going to continue to explore how we can support all genders working in this much-needed, and good work. If you are interested in learning more about the course series or any specialty topics courses, check out our course listings here.