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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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Meet the Instructor of Manual Therapy for the Lumbo-Pelvic-Hip Complex

This post features an interview with Eric Dinkins, PT, MSPT, OCS, MCTA, CMP, Cert. MT, who will be instructing the brand new course, Manual Therapy for the Lumbo-Pelvic-Hip Complex: Mobilization with Movement including Laser-Guided Feedback for Core Stabilization. Pelvic Rehab Report sat down with Eric to learn a little bit more about his course and his clinical approach

Eric Dinkins

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

During this two day lab based course, clinicians will learn anatomy, assessment techniques, and manual therapy techniques that are designed to minimize pain and restore function immediately. As a bonus, clinicians will be introduced to stabilization exercises utilizing the Motion Guidance visual feedback system for these areas. This system allows for immediate feedback for both the clinician and the patient on determining preferred or substituted movement patterns, and enhancing motor learning to quickly address these patterns if desired.

What inspired you to create this course?

Women's and Men's health patients often have concurrent orthopedic problems that contribute to the pain or dysfunction that they are experiencing in the lumbar spine, pelvis, hips and sexual organs. There are few manual therapy courses offered that are able to bridge a gap between these two topics. This makes for a unique opportunity to offer manual therapy techniques that can address these problems and help improve clinic outcomes.

What resources and research were used when writing this course?

The books and resources I pulled from include:

Mulligan Concept of Manual Therapy 2015

Travell and Simmons Volume 2. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities

Principles of Manual Medicine 4th Edition

www.motionguidance.com

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

PT's, PTA, DO's and DC's should take this course to give them knowledge and manual skills of pain free techniques to offer their Women's Health, Men's Health, and pregnancy patients with orthopedic conditions.

 

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Dysmenorrhea

This post was written by Allison Ariail, PT, DPT, CLT-LANA, PRPC, BCB-PMD. You can catch Allison teaching the Pelvic Floor Level 1 course in May in Los Angeles.

Blog by  Allison Ariail

Dysmenorrhea is the medical term used for painful menstruation. Symptoms usually begin 1 or 2 days before or the first day of menstruation and include headache, low back and thigh pain, abdominal pain, nausea and vomiting, diarrhea, and excessive fatigue. Sixty percent of women suffer from dysmenorrhea, with many of these women being incapacitated for up to 3 days each month due to symptoms. There are two types of dysmenorrhea. Primary dysmenorrhea is menstrual pain that is not caused from another disorder or disease. Secondary dysmenorrhea is menstrual pain that is due to a disorder in the pelvic organs including endometriosis, fibroids, adenomyosis, pelvic inflammatory disease, cervical stenosis, or infection. In the past, treatment approaches for primary dysmenorrhea have included the use of non-steroidal anti-inflammatories, hormonal contraceptives, vitamins, and acupuncture. There have not been many studies that look at how physical activity influences the degree of pain for women with primary Dysmenorrhea. However, clinical experience has shown me that some women who begin exercising regularly decrease their dysmenorrhea symptoms compared to what they previously experienced. So I have done a search to find some studies that address this matter.

A Cochrane review found only one study that used a control group. In this study, the experimental group participated in a 12-week walking or jogging program at 70-80% of heart rate range, 3 days a week for 30 minutes. Moos’ Menstrual Distress Inventory was used to measure outcomes. This was given pre-training, post-training, and during the premenstrual and inter-menstrual phases for the three hormonal cycles measured. There were significant lower scores on the Moos’ Menstrual Distress Inventory during the menstrual phase in the group that participated in exercise compared to the control group. Additionally, there was a negative linear trend in scores over the three observed cycles for the training group with no linear trend seen in the control group.1 So the exercise group lessoned the degree of their symptoms over the three months by participating in the walking program!

A study by Maceno de Araujo et al. looked at the severity of primary dysmenorrhea symptoms before and after participating in a two month Pilates exercise regimen 2 times per week for 60 minutes. Outcome measures used included visual analog scale and McGill Pain Questionnaire. Although this study did not use a control group and the number of participants was low (n=10), it did show significant changes in pain scores during menstruation when comparing little to no exercise to a regular exercise program of Pilates. Pain scores due to menstruation prior to the study were 7.89 ± 1.96, and dropped to 2.56 ± .56 with the exercise program!

I found these articles interesting and began to wonder how many women we as therapists could help by knowing this information! I do not think that we as pelvic heath therapists are reaching this population of patient diagnoses. Yes, starting an exercise regimen, especially a walking program, sounds easy to us as physical therapists or occupational therapists. However, it can be daunting to a woman who has not previously participated in any type of exercise program. Meeting with some of these women who suffer from primary dysmenorrhea and evaluating any musculoskeletal dysfunctions that are present, then prescribing an appropriate exercise routine that is individualized for that patient can help the patient stay committed to the program. In finding this information, I am excited to pass it along to my patients and future patients in hopes of improving their life and lessening their discomforts! Join me to discuss this topic as well as others related to the pelvic floor in Los Angeles at PF1!

1. Brown J, Brown S. Exercise for dysmenorrhea. Cochrane Database of Systematic Reviews 2010, Issue 2. Art. No.: CD004142. DOI: 10.1002/14651858.CD004142.pub2.

2. Macêdo de Araújo L; Nunes da Silva JM; Tavares Bastos W; Lima Venutra P. Pain improvement in women with primary dysmenorrhea treated with Pilates. Revista Dor. 2012; 13(2).

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Nerve Entrapments and Pelvic Pain

This post was written by Elizabeth Hampton PT, WCS, BCIA-PMB, who teaches the course Finding the Driver in Pelvic Pain: Musculoskeletal Factors in Pelvic Floor Dysfunction. You can catch Elizabeth teaching this course in April in Milwaukee.

Blog by Elizabeth Hampton

Chronic pelvic pain has multifactorial etiology, which may include urogynecologic, colorectal, gastrointestinal, sexual, neuropsychiatric, neurological and musculoskeletal disorders. (Biasi et al 2014) Herman and Wallace faculty member, Elizabeth Hampton PT, WCS, BCB-PMD has developed an evidence based systematic screen for pelvic pain that she presents in her course “Finding the Driver in Pelvic Pain”. One possible origin of pelvic pain as well as chronic psoas pain and hypertonus may arise from genitofemoral, ilioinguinal or iliohypogastric neuralgia, the screening of which is addressed in the “Finding the Driver” extrapelvic exam.

The iliohypogastric nerve arises from the anterior ramus of the L1 spinal nerve and is contributed to by the subcostal nerve arising from T12. This sensory nerve travels laterally through the psoas major and quadratus lumborum deep to the kidneys, piercing the transverse abdominis and dividing into the lateral and anterior cutaneous branches between the TVA and internal oblique. The anterior cutaneous branch provides suprapubic sensation and the lateral cutaneous branch provides sensation to the superiolateral gluteal area, lateral to the area innervated by the superior cluneal nerve. (10)

The ilioinguinal nerve arises from the L1 spinal levels, passes through the psoas major inferior to the iliohypogastric nerve, across the quadratus lumborum and iliacus and lastly through the transversus abdominis along with the iliohypogastric nerve between the transverse abdominis and the internal oblique muscle. (7) The ilioinguinal nerve supplies the skin of the medial thigh, upper part of the scrotum/labia as well as penile root (5).

The genitofemoral nerve arises from the L1 and L2 spinal levels and splits into the genital and femoral branches after passing through the psoas muscle. (1). The genital branch (motor and sensory) passes through the inguinal canal and innervates the upper area of the scrotum of men. In women it runs alongside the round ligament and innervates the area of the skin of the mons pubis and labia majora. The motor function of the genital branch is associated with the cremasteric reflex. The femoral (sensory) branch runs alongside the external iliac artery, through the inguinal canal and innervates the skin of the upper anterior thigh. (8)

Differential diagnosis of entrapment of one of the three nerves can be challenging due to their overlapping sensory innervations and anatomic variability. Rab et al found up to 4 different patterns of anatomical variability in these nerve pathways. (9)

Transient or lasting genitofemoral, ilioinguinal and iliohypogastric neuralgia results from compression or irritation of these nerves anywhere along their pathway: from their spinal origin to distal pathways. Cesmebasi at al report that “neuropathy can result in paresthesias, burning pain, and hypoalgesia associated with the nerve distributions. “ (11) These entrapments may be associated with surgery, T12-L2 segmental dysfunction or HNP, constipation and is commonly observed clinically alongside psoas overactivity and pain. Lichtenstein found that up groin pain after hernia surgery ranged from 6-29% with Bischoff et al (2012) (6) denoting the post-operative neuralgia ranging from 5-10%.

Differential diagnosis of nerve entrapments are key skills in the screening of musculoskeletal contributing factors to pelvic pain and physical therapists are uniquely skilled to put all of the puzzle pieces together in these complex clients. Finding the Driver is being offered twice in 2015: April 23-25, 2015 at Marquette University and again in the fall. Check Herman & Wallace's webite for further details.

http://www.gotpaindocs.com/gentfmrl_nurlga.htm
Tubbs et al.Journal of Neurosurgery: Spine. March 2005 / Vol. 2 / No. 3 / Pages 335-338. Anatomical landmarks for the lumbar plexus on the posterior abdominal wall. http://thejns.org/doi/abs/10.3171/spi.2005.2.3.0335
Phillips EH. Surgical Endoscopy. January 1995, Volume 9, Issue 1, pp 16-21. Incidence of complications following laparoscopic hernioplasty
http://link.springer.com/article/10.1007/s00268-012-1657-2
Tsu W et al. World Journal of Surgery. October 2012, Volume 36, Issue 10, pp 2311-2319. Preservation Versus Division of Ilioinguinal Nerve on Open Mesh Repair of Inguinal Hernia: A Meta-analysis of Randomized Controlled Trials
Bischoff JM. Hernia. October 2012, Volume 16, Issue 5, pp 573-577. Does nerve identification during open inguinal herniorrhaphy reduce the risk of nerve damage and persistent pain?
http://en.wikipedia.org/wiki/Ilioinguinal_nerve
http://en.wikipedia.org/wiki/Genitofemoral_nerve
Rab M, Ebmer And J, Dellon AL.. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain.

Plastic and Reconstructive Surgery [2001, 108(6):1618-1623].

http://en.wikipedia.org/wiki/Cutaneous_innervation_of_the_lower_limbs
Cesmebasi et al (2014) Genitofemoral neuralgia: A review. Clinical Anatomy. Volume 28, Issue 1, pages 128–135, January 2015. http://onlinelibrary.wiley.com/doi/10.1002/ca.22481/abstract

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Convalescence and Mitohormesis

This post was written by Megan Pribyl MSPT, who teaches the course Nutrition Perspectives for the Pelvic Rehab Therapist. You can catch Megan teaching this course in June in Seattle.

Blog by Megan Pribyl MSPT Convalescence and mitohormesis…really big words that in a scientific way suggest “BALANCE”. In our modern world, there are many factors that influence the pervasive trend of being “on” or in perpetual “go mode”. We see the effects of this in clinical practice every day. The sympathetic system is in overdrive and the parasympathetic system is in a state of neglect and disrepair. And so we reflect on that word “balance” through the concepts of convalescence and mitohormesis.

 

“In the past, it was taken for granted that any illness would require a decent period of recovery after it had passed, a period of recuperation, of convalescence, without which recurrence was possible or likely.
Convalescence fell out of favor as powerful modern drugs emerged. It appeared that [antibiotics] and the steroid anti-inflammatories produced so dramatic a resolution of the old killer diseases… that all the time spent convalescing was no longer necessary.” (Bone, 2013)

 

How many of us take the time to convalesce after even a minor cold or flu? “Convalescence needs time, one of the hardest commodities now to find.” (Bone, 2013) We live in a culture where getting well FAST typically takes priority over getting well WELL.

 

On the flip-side of convalescence lies mitohormesis, or stress-response hormesis. Simply put, hormesis describes the beneficial effects of a treatment (or stressor) that at a higher intensity is harmful. Without mitohormesis, the driving, adaptive forces of life might lie dormant or find dysfuction. In a recent article (Ristow, 2014) mitohormesis is discussed: “Increasing evidence indicates that reactive oxygen species (ROS) do not only cause oxidative stress, but rather may function as signaling molecules that promote health by preventing or delaying a number of chronic diseases, and ultimately extend lifespan. While high levels of ROS are generally accepted to cause cellular damage and to promote aging, low levels of these may rather improve systemic defense mechanisms by inducing an adaptive response.

 

Relevant to nutritional trends, Tapia (2006) suggests this perspective: “it may be necessary…to engender a more sanguine perspective on organelle level physiology, as… such entities have an evolutionarily orchestrated capacity to self-regulate that may be pathologically disturbed by overzealous use of antioxidants, particularly in the healthy.” Think of mitohormesis as the cellular-level forces that spur change. Motivation….drive….exhilaration. These life-sprurring stressors include physical activity and glucose restriction among other interventions.

 

The natural world is full of contrasts; day and night, winter and summer, land and sea, sun and rain. These contrasts are not only essential in creating rhythm to our existence, but necessary as driving forces of life. But what happens when there is not a balance of activity and rest? What happens when our energy systems go haywire? What nutritional factors play a role in whether a client of yours will have a healing and helpful course of therapy or may struggle with the healing process? How might we frame our understanding of the importance of balance through the lens of nourishment?

 

March is “National Nutrition Month”! It’s a perfect time to register for our brand new continuing education course Nutrition Perspectives for the Pelvic Rehab Therapist to learn more about how nutrition impacts our clinical practice. To register for the course taking place in June in Seattle, click here.

 

References

Bone, K. Mills, S. (2013) Principles and Practice of Phytotherapy; Modern Herbal Medicine. Second Edition. Churchill Livingstone Elsevier.

Gems, D., & Partridge, L. (2008). Stress-response hormesis and aging: "that which does not kill us makes us stronger". Cell Metab, 7(3), 200-203. doi: 10.1016/j.cmet.2008.01.001

Ristow, M., & Schmeisser, K. (2014). Mitohormesis: Promoting Health and Lifespan by Increased Levels of Reactive Oxygen Species (ROS). Dose Response, 12(2), 288-341. doi: 10.2203/dose-response.13-035.Ristow

Tapia, P. C. (2006). Sublethal mitochondrial stress with an attendant stoichiometric augmentation of reactive oxygen species may precipitate many of the beneficial alterations in cellular physiology produced by caloric restriction, intermittent fasting, exercise and dietary phytonutrients: "Mitohormesis" for health and vitality. Med Hypotheses, 66(4), 832-843. doi: 10.1016/j.mehy.2005.09.009

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Lymphedema Management in Women’s Health Physical Therapy

This post was written by Debora Chassé DPT, WCS, CLT-LANA, who teaches the course Lymphatic Drainage for Pelvic Pain. You can catch Debbie teaching this course in April in Arizona.

Deborah Hickman

Lymphedema Management in Women’s Health Physical Therapy is a home study module developed for the physical therapist who would like to learn more about lymphedema as well as prepare for the lymphedema portion of Women’s Health Clinical Specialist exam. Complete Decongestive Therapy (CDT) has been used universally to treat lymphedema since the 1800’s. The well-known Foldi Clinic is located in Germany and in the 1990’s CDT was brought to America to train practitioners. You will learn about the anatomy and physiology of the lymphatic system, lymphedema diagnoses, differential diagnoses and the phases and steps involved in CDT. The course manual takes you through the physical therapy initial evaluation for lymphedema following the guidelines for specialty practice. It also contains many case studies designed to enhance your application of CDT. CDT has many concepts and procedures that will additionally help patients with inflammation, autoimmune disorders and pain. It is a must for all physical therapist.

Do you need another tool for treating pelvic pain and pelvic congestion? Manual lymph drainage for Pelvic Pain is a two-day intermediate course that covers the lymphatic system, lymphedema, pelvic pain, manual lymphatic drainage (MLD), and how this procedure is used to reduce inflammation and pelvic pain. The course will reveal the relationship between lymph flow and pelvic pain. Research shows that manual lymph drainage increases venous flow. In one case study, researchers found that using MLD on a patient with pelvic congestion decreased the patient’s symptoms, impairments and pain by 50% following 5 consecutive days of MLD. Another case study reported that a chronic pelvic pain patient had both an increase in energy level and a 50% decrease in abdominal inflammation and pelvic pain. Manual Lymphatic Drainage for Pelvic Pain is a procedure developed by Debora Chassé using MLD techniques on the vulva and in the vaginal vault to stimulate the lymphatics in the vagina to return lymph fluid to the circulatory system. This is a low risk treatment with outstanding outcomes for all pelvic pain diagnoses. This course is an excellent adjunct for clinicians interested in learning how to evaluate the lymphatic function, design an MLD treatment plan and master MLD treatment strokes for pelvic pain patients.

Join Debbie this April!

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The Hip & Pelvis: The Cornerstone of Movement Analysis

Lila

This post was written by Steven Dischiavi, MPT, DPT, ATC, COMT, CSCS, who teaches the course Biomechanical Assessment of the Hip and Pelvis. You can catch Steve teaching this course in May at Duke University in Durham, NC.

 

One thing that jumps out at me when treating a professional athlete, is that they have “a guy or gal” for everything! Most high profile athletes have a physical therapist, athletic trainer, acupuncturist, nutritionist, massage therapist, personal trainers for speed, power, cross fit, and pretty much “a guy or gal” for anything that has something to do with athletic performance or injury prevention. In most recent years I have been hearing more and more that athletes use someone that can analyze their movement and develop corrective exercises for them. These professionals are not just physical therapists, but some are personal trainers, exercise physiologists, chiropractors, and so on…

This has clearly been leading to a paradigm shift in not only evaluation of the athlete, but more specifically how we treat our athletes and clients. The Functional Movement Assessment is a tool that is gaining more and more popularity. It identifies “movement dysfunction” and then sets out to manage these movement patterns. I am a firm believer in functional movement assessment, and I believe it does need a larger role in our profession…I believe this so strongly I have recently changed gears professionally and have accepted an assistant professor position on the Physical Therapy faculty at High Point University. I want to affect change from within!

That said this is a very slippery slope right now in our profession. There are many people that believe that functional assessment is necessary. These same people cannot agree on the best way to do this and the there is a paucity of evidence to support a specific method at this time. This has driven me to continue to push the envelope in how to assess human movement and what is the cornerstone of this philosophy. I think the cornerstone is the hip and pelvis. I know this is somewhat broad, but after working professional hockey for 10 years I saw first hand what the hip and pelvis brings to the table. This led me to integrate this cornerstone into all facets of my treatments with all types of clients, young, old, big, small, athletic human, non-athletic humans! It was a quantum leap when the evidence caught up to practice and we stopped taping the patella because we were able to wrap our heads around the fact that it’s the track moving under the train! This momentum continues, because I am in a state of the art biomechanics lab everyday watching and learning how we can extrapolate these concepts and continue to move forward and advance movement theory. This has also allowed me to see that there is still a need about how we treat movement dysfunction. Which has led me to continue to work on the concept of the Dynamic Integration of the Myofascial Sling Systems!

If you attend this course I think you will look at human movement a little differently. I think you’ll enjoy the creative ways we can activate particular muscle chains to integrate and coordinate complex movements with more efficiency.

Yes, Herman & Wallace traditionally focuses on the women’s health practitioner. This course gives women’s health practitioners more treatment options to go with their unbelievable manual therapy skill set. This course offers many therapeutic exercise options that can help control the neurologic changes they are creating with their clients. Past course participants from the women’s health arena have continuously commented that they have gained a new tool in their toolbox to address movement imbalances and a way to integrate more function into their exercise programs. The sports and ortho PT will really enjoy this course. It will challenge some of their current paradigms and stir up some lively conversation on functional movement assessment and how to treat movement dysfunction when identified. Sports/ortho PTs consistently report how refreshing it is to consider new things in the profession. These PTs will leave this course challenging some of the traditional approaches they have taken. The reports back to me are usually that the sports/ortho PTs have had fun at this course and look forward to trying what they have learned and performed in lab sessions and applying it with their clients. I look forward to having you in class and having some fun and trying a lot of new exercises and discussing how the assessment of human movement and how identifying movement dysfunction is the direction things are going. William Blake once said “what is now proven, was once only imagined!” I don’t think movement analysis is quite proven yet, but we’re definitely applying science to the art of practice!

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Musculoskeletal Screening Model for Pelvic Pain

This post was written by H&W instructor Elizabeth Hampton. Elizabeth will be presenting her Finding the Driver course in Milwaukee in April!

ms or pfm exam

One of the most consistent questions that we hear at the Pelvic Floor 2B course is, “How do you choose between a pelvic floor and a musculoskeletal exam during your first visit with a pelvic pain client?” The answer depends on a number of factors, which include your clinical reasoning, toolbox, the client’s presentation, the clinical specialty, and expectations of the referring provider as well as the expectations of the client. It can be stressful to imagine gathering a detailed history, testing, client education and a home program within the first visit! Now that we have less time and total visits to evaluate and treat these complex issues, it can be overwhelming to know where to start.

Chronic pelvic pain has multifactorial etiology, which may include urogynecologic, colorectal, gastrointestinal, sexual, neuropsychiatric, neurological and musculoskeletal disorders. (Biasi et al 2014) Herman and Wallace faculty member, Elizabeth Hampton PT, WCS, BCB-PMD has developed an evidence based systematic screen for pelvic pain that she presents in her course “Finding the Driver in Pelvic Pain”. “There are a number of extraordinary models that exist for treatment of pelvic pain including Diane Lee’s Integrated System of Function, Postural Restoration Institute, Institute of Physical Art and more,” states Hampton. “However, regardless of the treatment style and expertise of the clinician, each clinician should be able to perform fundamental tissue specific screening. If a client has L45 discogenic LBP with segmental hypermobility into extension, femoral acetabular impingement, urinary frequency > 12/day as well as constipation contributed to by puborectalis functional and structural shortness, all clinicians should be able to arrive at the same fundamental findings during their screening exam. The driver of the PFM overactivity(3) needs to be explored further as local treatment alone (biofeedback and downtraining) will not resolve until the condition causing the hypertonus is found and treated.” Finding the Driver in Pelvic Pain is a course that models a comprehensive intrapelvic and extrapelvic screening exam with evidence based validated testing to rule out red flags, understand key factors in the client’s case as well as develop clinical reasoning for prioritizing treatment and plan of care. The screening exam complements any treatment model as it identifies tissue specific pain generators and structural condition, which will lead the clinician to follow their clinical reasoning and treatment model. Once the fundamentals are established, the clinician can move beyond screening and drill down into treatment of key factors which may include specific muscle gripping patterns, arthokinematic assessment and respiratory evaluation and retraining, among others.

Co-morbidities are common in pelvic pain are well documented (1, 2) and clinically these multiple factors are the reason pelvic pain is complex to evaluate and treat. Intrapelvic (urogynecologic, colorectal, sexual) as well as extrapelvic (orthopedic, neurologic, psychological and biomechanical clinical expertise) are required for skilled evaluation and treatment of this population. It is precisely this complexity, which makes working with pelvic pain clients challenging and extraordinarily rewarding. Physical therapists are uniquely skilled to put all of the puzzle pieces together in these complex clients. Finding the Driver is being offered twice in 2015: April 23-25, 2015 at Marquette University and again in the fall. Check Herman Wallace.com for further details.

1. Chronic pelvic pain: comorbidity between chronic musculoskeletal pain and vulvodynia. Reumatismo: 2014 6;66(1):87-91. Epub 2014 Jun 6. G Biasi, V Di Sabatino, A Ghizzani, M Galeazzi
2. http://www.jhasim.net/files/articlefiles/pdf/XASIM_Master_5_6_p306_315.pdf
3. IUGA/ICS Terminology for Female Pelvic Floor Dysfunction. http://c.ymcdn.com/sites/www.iuga.org/resource/resmgr/iuga_documents/iugaics_termdysfunction.pdf

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Resurfacing after Hip Labral Surgery

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in March!

Ginger Garner

Lots of you have reached out with questions about “best care” practices after hip surgery. There isn’t a whole lot in scientific literature written about rehab, and over many months of fielding questions on my closed HIP LABRAL PHYSIOTHERAPY FB page, I am finally ready to share what Best Care Practices after Hip Labral Surgery may look like.

Today is Post 1 of this series, which will follow me day-by-day, week-by-week, through the highs and lows of my recovery and rehabilitation. Here we go!

First, “What IS Hip Labral Surgery?”

A relatively new term, the surgery is presently called “Hip Preservation.” However I like to call a spade a spade – this surgery is a bona fide hip reconstruction.

This surgery is a major undertaking for surgeon and patient and is constantly charting new territory in surgical techniques and discoveries. A brilliant way to preserve the hip joint, a surgeon is charged with essentially piecing the hip back together and reshaping it to work better than before surgery. It comes with risks AND benefits, many of which I will address in posts to come. It requires serious dedication and a wicked good physical therapist to get you back to fighting shape after surgery. But success begins with choosing a good surgeon who is a specialist in this type of surgery (more on that later).

Not a hip replacement, hip labral surgery rarely ONLY consists of repair of the labrum. Most of the time, a torn hip labrum is an issue secondary to a whole slew of hip disorders that make up a quagmire of highly technical and complex systems that converge during hip reconstruction. Whew, that was a mouthful.

A few of those technical things include hip dysplasia, impingement syndromes (and oh are there lots of different kinds we will be discussing), tendinosis, bursitis, pelvic pain, sexual dysfunction, snapping hip phenomenon (internal and external), anteversion, retroversion, and well, that’s enough to get us started.

Passion for Hip Labral Rehab

Let me tell you that this surgery was everything I thought it was going to be, and a hell (there’s just no other way to put it) of a lot more. I would have LOVED to avoid surgery, and heck, to avoid the injury that led to surgery – because I don’t know a single person who would prefer to gain clinical expertise by actually suffering through the injury or surgery. But alas, adversity is often what makes us better.

As you may guess, I did experience a single traumatic injury – which then proceeded to give birth to a perpetually poorly behaved, havoc-wreaking monster of a chronic condition. The funny thing was before the injury, my area of clinical expertise was ALREADY orthopaedics and women’s health. You can see I was kind of in for a colossal butt-kicking lesson from the universe. Oh the irony…

I did try to prepare myself for the road to recovery though. Read my post on Shutting Down to Move Forward: The Therapist Becomes the Patient.

But trust me, I would rather NOT have gleaned clinical expertise on hip labral and pelvic injury through personal tragedy.

Nonetheless, I knew that my journey from hip reconstructive surgery back to health, was going to help more than just me. I could use it to help so many others who wrestle with that same monster.

But yea, there are a few challenges to recovery:

  • I am mother. Of three boys. Ranging in age from 3-9.
  • I was/still am trying to finish my doctorate.
  • I completed a book chapter for a colleague’s new text on Fostering Creativity in Rehabilitation and a research manuscript during early post-op.
  • I had to maintain a full teaching schedule that required walking and stair climbing (which I couldn’t do) and lots of standing (which I also could not do).
  • The final straw was, midway through rehab, my oldest son received a special needs diagnosis.

Nevermind having clean laundry and healthy meals to foster healing (and maintain sanity). I mean, a human can only do so much. The point is – I didn’t live tweet or post about my recovery in real time.

The Bright Side

The good side though – is my delay in posting has given me much needed time to reflect on what variables are most critical to the recovery process.

If you are considering hip labral surgery, please read Top Five Must Have Hip Labral Surgery Tips to help you prepare.

Other colleagues I know have released blog series in real time, a chronicle to their injury and recovery. Shelly Prosko and her traumatic Achilles Tendon rupture, is one of those colleagues. Also a physioyogi, I highly recommend Shelly’s series on her recovery. Read here or cut and paste: http://www.gingergarner.com/2014/10/28/medical-therapeutic-yoga-achilles-tendon-rupture-missing-link-rehabilitation/

Now onward and forward, I am (finally) sitting down to write, 5 and a half months AFTER my surgery.

I hope you’ll join me on my journey through Hip Preservation, er, Reconstruction Surgery and that, most of all, you’ll find something that will inspire you to more complete healing and recovery.

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The Format of Sexual Medicine for Men and Women

This post was written by H&W founder and instructor Hollis Herman, DPT OCS WCS BCB-PMD IF AASECT PRPC, who authored and instructs the course, Sexual Medicine for Men and Women. She will be presenting this course this April in New Jersey!

Hollis Herman

This course is perfect to help you, the healthcare professional, feel comfortable and knowledgeable about all sorts of sexual issues. The course is fun, interesting and unlike any other you have taken.It has three parts.

Part 1: The first part is designed to help you get in touch with your attitudes, beliefs, values and biases regarding sexual function. There are questionnaires to fill out and bring with you to the course, movies to watch, and books to read. These questionnaires, movies, videos and books will bring up sexual subject matter, questions, images and ideas that may be controversial to you. You will be exposed to many variations in sexual activity and asked about your reactions, sexual development, upbringing, feelings and worries you may carry around.

In other words, the preparation for this course is designed to bring up issues that are potentially keeping you from being as helpful as possible to your patients, yourself and your own relationship. It sounds scary, but it is not at all because you share only what you want. Therefore, Please be as open and honest as possible when filling out all of the questionnaires and reaction summaries to the movies, videos and books. There are no right or wrong answers and it is for your own self-awareness.

Part 2: The second part of the course is designed to provide you with a solid knowledge foundation regarding the different phases of the female and male sexual response cycles, erectile dysfunction, premature ejaculation, Peyronie’s disease, postnatal body changes, post prostatectomy issues, oral, anal, vaginal sexual practices, LGBT issues, aging and sexual issues, toys, lubricants, sexual, verbal and physical abuse, female and male genital surgeries, psychological practices of Cognitive Behavioral Therapy (CBT) and Eye Movement Disassociate Readjustment (EMDR) . The information will help you confidently answer questions and concerns you and your patients have.

Part 3: The third part of the course contains lab activities to learn clinical manual skills. External manual techniques for the pelvis only.

The underlying premise of this course is that healthy active sexual practices are a vital human right however they play out. As a healthcare professional you can provide education, specific hands on evaluation, treatment techniques and bio-mechanical instruction that no other professional can.

The Goal: Leave with self-awareness, knowledge and tools to promote healthy active sexual function in your patients’ lives and in your own life.

Join Holly in New Jersey this April!

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Upcoming Continuing Education Courses

Oct 11, 2019 - Oct 13, 2019
Location: Houston Methodist

Oct 11, 2019 - Oct 13, 2019
Location: Physical Therapy Services of Lansing

Oct 11, 2019 - Oct 13, 2019
Location: Northwestern Medicine

Oct 11, 2019 - Oct 13, 2019
Location: Florida Hospital - Wesley Chapel

Oct 12, 2019 - Oct 13, 2019
Location: Evolution Physical Therapy

Oct 18, 2019 - Oct 20, 2019
Location: The George Washington University

Oct 18, 2019 - Oct 20, 2019
Location: University Hospitals

Oct 19, 2019 - Oct 21, 2019
Location: Lee Memorial Health System

Oct 25, 2019 - Oct 27, 2019
Location: Core 3 Physical Therapy

Oct 26, 2019 - Oct 27, 2019
Location: Texas Children’s Hospital

Nov 1, 2019 - Nov 3, 2019
Location: Adena Rehabilitation and Wellness Center

Nov 1, 2019 - Nov 3, 2019
Location: Asante Rogue Valley Medical Center

Nov 1, 2019 - Nov 3, 2019
Location: Cancer Treatment Centers of America - Chicago, IL

Nov 1, 2019 - Nov 3, 2019
Location: Upper Chesapeake Health

Nov 2, 2019 - Nov 3, 2019
Location: University Hospitals

Nov 2, 2019 - Nov 3, 2019
Location: Griffin Hospital

Nov 3, 2019 - Nov 5, 2019
Location: Touro College: Bayshore

Nov 8, 2019 - Nov 10, 2019
Location: Washington Regional Medical Center

Nov 9, 2019 - Nov 11, 2019
Location: Comprehensive Therapy Services

Nov 9, 2019 - Nov 10, 2019
Location: Summa Health Center

Nov 9, 2019 - Nov 10, 2019
Location: STI PT and Rehab

Nov 9, 2019 - Nov 10, 2019
Location: Providence Holy Cross Medical Center of Mission Hills

Nov 15, 2019 - Nov 17, 2019
Location: Banner Physical Therapy and Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Ability Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Huntington Hospital

Nov 16, 2019 - Nov 17, 2019
Location: Princeton Healthcare System

Dec 6, 2019 - Dec 7, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Franklin Pierce University

Dec 6, 2019 - Dec 8, 2019
Location: Florida Hospital - Wesley Chapel