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Herman & Wallace Blog

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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Hyaluronic Acid for Vaginal Dryness

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD, PRPC, who will be presenting Pelvic Floor Level 2B in Houston at the end of February.

Allison Ariail

Dyspareunia, or pain during or after intercourse, can be very upsetting and frustrating to a woman. One cause of dyspareunia is vaginal dryness. As estrogen levels decrease, the vaginal tissues can have less moisture, elasticity, and become thinner. This not only can affect postmenopausal women, but also post-partum women, and women who are on estrogen-blocking medication due to cancer or for treatment of fibroids. One of the common and effective treatments for this vaginal dryness includes estrogen creams, or hormone replacement. However, what does a woman do if she is not able to use an estrogen cream, due to an estrogen receptor positive cancer? One possibility is hyaluronic acid. Hyaluronic acid is a substance naturally found throughout connective, epithelial, and neural tissue. You may be more familiar with hyaluronic acid as the substance injected into joints for osteoarthritis. However, there have been some recent published studies comparing the use of hyaluronic acid to estrogen replacement.

In 2011, Ekin et al. published a study comparing the use of hyaluronic acid vaginal tablets with estradiol vaginal tablets. Two groups of postmenopausal women with atrophic vaginitis were studied. One group used estradiol vaginal tablets (n=21) for 8 weeks, while the other group used hyaluronic acid tablets (n=21) for 8 weeks. Outcomes consisted of the degree of vaginal atrophy, vaginal pH, vaginal maturation index, and a self-assessed 4-point scale. Both groups had relief of vaginal symptoms, improved epithelial atrophy, decreased vaginal pH, and increased maturation of the vaginal epithelium. The group on estradiol did have greater improvements, however, it was determined that the hyaluronic acid vaginal tablets was effective enough to be considered an alternative treatment for those who wanted to avoid the use of a local estrogen treatment.

In 2013, Chen et al. published a study comparing the use of hyaluronic acid gel to estriol cream. Women were randomized into two groups, using the hyaluronic acid vaginal gel, or the use of estriol cream (n=72 each group) for 30 days. Outcome measures included a visual analog scale for vaginal dryness, and three other vaginal symptoms. Also measured were lab tests of the vaginal micro-ecosystem, vaginal pH, vaginal US, and incidence of adverse events. Results showed both groups had improvement without a statistically significant difference between the groups.

These two studies show that hyaluronic acid may be an alternative to hormone replacement. This is good news for women who suffer from vaginal dryness and cannot use hormone replacement therapy, or even localized hormone replacement therapy due to the use of anti-estrogen medications! The improvement of vaginal dryness can significantly improve dyspareunia symptoms for many women. To learn more about dyspareunia, as well as other causes of pelvic pain, join me in Houston for PF2B!

References

Chen, J., Geng, L., Song, X., Li, H., Giordan, N., & Liao, Q. (2013). Evaluation of the Efficacy and Safety of Hyaluronic Acid Vaginal Gel to Ease Vaginal Dryness: A Multicenter, Randomized, Controlled, Open?Label, Parallel?Group, Clinical Trial. The journal of sexual medicine, 10(6), 1575-1584.

Ekin, M., Ya?ar, L., Savan, K., Temur, M., Uhri, M., Gencer, I., & K?vanç, E. (2011). The comparison of hyaluronic acid vaginal tablets with estradiol vaginal tablets in the treatment of atrophic vaginitis: a randomized controlled trial. Archives of gynecology and obstetrics, 283(3), 539-543.

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“Pads and Diapers are like Walkers and Wheelchairs” and other Useful Analogies: Using Traditional Rehab Concepts to Market Pelvic Floor

This post was written by H&W instructor Heather S. Rader, PT, DPT, BCB-PMD, who authored and instructs the course, Geriatric Pelvic Floor Rehab. She will be presenting this course this June in Florida!

Heather Rader

“I have never heard of pelvic floor rehab before.”

This comment poses an added job requirement for us, my fellow pelvic rehab practitioners! You have a responsibility to make this specialty understandable to your patients, referring providers, and the community at large. Therefore, marketing and education become interchangeable.

Use the fact that traditional rehab is well known to the public to your advantage by creating analogies to accepted concepts about injury and rehabilitation to boost your role as an educator.

1. What profession knows a lot about strength, endurance and coordination? Physical Therapy, right?This concept is a quick and easy way to explain why pelvic floor rehab is more complex than doing Kegels. Grab a side view pelvic floor model or picture. Use your fingers to simulate pelvic floor movement as you explain the following:

If your pelvic floor doesn’t have adequate strength, it can’t pinch the urethra tight enough to hold urine inside the bladder. If it has poor endurance, you might have trouble making it to the bathroom on time. If you have poor coordination, your pelvic floor muscle might not squeeze fast enough to counteract that cough or sneeze. Your average Kegel program is too simple to address these muscle complexities. Bladder control is dependent on the pelvic floor muscles and these muscles can have the same kinds of problems as the muscles in your arms and legs. But, what profession knows a lot about strength, endurance and coordination? Physical Therapy, right? That’s why your doctor wanted you to have pelvic floor rehab.

2. Pads and diapers are like walkers and wheelchairs. People use physical devices to compensate for physical difficulties. Walking aids are used for gait disturbances and absorbent padding for incontinence. Thin pads are like canes, thick pads are like walkers, and diapers are like wheelchairs. Rushing to the bathroom and going “just in case” would be analogous to someone hanging onto furniture for balance as they walk.

Use this analogy to link absorbent padding and assistive devices in the memory of a referring provider. “Doc, if they need pads, they need PT.” This can trigger a referral to PT for incontinence when patients complain of dependence on protective padding during their appointments, just as it might if a patient complained about trouble with a cane. You can also use this analogy as a way to share articles linking incontinence, poor balance, and low back pain.

3. Pelvic organ prolapse and herniated disks have a lot in common. I use this analogy a lot during community education talks, especially during Q&A. Being sent to PT for spinal pain and herniated discs is commonplace. But for a cystocele? Link how tissue failure by overuse can cause prolapse, whether it’s the bladder or the nucleus. Link how weak and saggy back muscles can cause the spinal bones to “fall” out of normal posture, just as weak pelvic floor muscles contribute to a fallen bladder.

I highly recommend using analogy as a marketing and teaching tool in pelvic floor rehab. Analogy works by associating what is known to what is unknown. If they are similar in some ways, they are likely similar is other ways, helping the patient, medical professionals, and the community understand the value of your skills.

These are just a few analogies. What others work for you in your practice?

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"Change is part of the world. Until the last moment, anything is possible."

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Menopause: A Rehabilitation Approach. She will be presenting this course this February in Florida!

Michelle Lyons

Compared to subject matter that has traditionally been offered in physical therapy curricula, such as musculo-skeletal and neuromuscular coursework, the concept of wellness is a relatively new addition to our skill-set (Fair 2009). ‘A Normative Model of Physical Therapist Professional Education’ includes educational objectives related to wellness, alongside objectives related to orthopaedics and neurology. As patients become increasingly educated about nutrition, complementary and alternative medicine, we as women’s healthcare providers must be able to assist our patients in seeking out healthy lifestyles. Nowhere has this surge in interest been more apparent than in women entering peri-menopause.

Historically, physical therapy has been associated with restoring physical fitness and wellness using manual therapies, exercise instruction and education about healthy lifestyle. Women’s health as a physical therapy specialty was formally established in the U.S. in the late 1970’s by Elizabeth Noble. Initially there was a focus on the reproductive health issues affecting women, primarily obstetrics and gynaecology but today’s physical therapist specializing in women’s health must be well versed in all aspects of menopausal health and wellness to meet the growing demands of women.

The roles of wellness, nutrition and fitness are becoming increasingly recognised by mainstream medicine – the WHO has recognised health as a triad of physical, mental and social well being. Integrative medicine is being hailed as the future of healthcare: The Consortium of Academic Health Centers for Integrative Medicine defines it as ‘the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing’, which for me, has always epitomised the practice of physical therapy and in particular, pelvic rehab.

Nutrition and exercise, alongside complementary therapies such as herbal medicine have become widely used as solutions to some of the signs and symptoms of menopause, especially since the controversies surrounding hormone therapy arose after the publication of the Women’s Health Initiative study. Many physical therapists, especially those working in women’s health, have added wellness services to their clinics, observing the growing demand from women. Even if these are not services you currently offer, if you work with peri-menopausal women, you can expect questions about the benefits of herbs for hot flashes or yoga for osteoporosis.

Peri-menopausal health concerns vary from the signs and symptoms of hormonal fluctuations such as hot flashes and night sweats to osteoporosis, cardiovascular disease and pelvic health concerns including bladder, bowel and sexual health – concerns that today’s well informed physical therapist specialising in women’s health need to be able to discuss and explore. However, the number one killer of post-menopausal women is still cardiovascular disease, so we must look at exercise prescription (and removing barriers to exercise, such as urinary dysfunction).

In ‘Menopause – a Rehab approach’, we will also explore the influence that changing hormone profiles have throughout the female body, from an orthopaedic, cardiovascular and pelvic health perspective. We will discuss the evidence for complementary and alternative medicine (CAM) and how physical therapists can incorporate nutritional advice into their clinical practice supporting peri-menopausal women. Special attention will be given to the role of yoga as an evidence based addition to the skillset of women’s healthcare professionals. We will of course also address the pelvic health concerns particular to the peri-menopausal women and look at how pelvic rehab has much to offer women presenting with urinary, sexual or bowel dysfunctions, along with pelvic organ prolapse. I am very much looking forward to returning to Orlando to teach this new course and hope to see you there!

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Yoga and Mindfulness as Complementary Therapies for Breast Cancer

This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course, Rehabilitation for the Breast Oncology Patient.

Susannah Haarmann

It is holistic and forward thinking for medical practitioners, such as physical and occupational therapists, to consider the interconnectedness of mind and body when creating an effective treatment plan. Today, it is generally accepted that stress weakens the immune system and, the American Medical Association reports that “80% of all diseases are stress related,” (1). Prolonged physical and emotional distress triggers the neuroendocrine system to secrete stress hormones which affect the immune system, specifically, decreasing T-cell production and lowering basal and interferon augmented NK cell activity (NKCA). Knowing this unlocks huge potential for cancer patients who wish to actively boost their immune system during treatment; one of these proven techniques is called mindfulness-based stress reduction (MBSR). A study performed by Witek-Janusek et al, demonstrated a significant increase in NKCA levels in breast cancer patients after just one month of participating in a MBSR program; this is significant because elevated NKCA levels correlate with a decreased incidence of lymph node metastasis and improved survival rates in women with breast cancer (6).

MBSR may be compared to meditation and in the west we are seeing an increased acceptance of patients and practitioners looking to eastern philosophy as an adjunct treatment to western medicine. In fact, yoga is one of the most commonly sought after complementary treatments for breast-cancer related impairments among survivors today (4). Yoga, as a practice, blends mindfulness and movement. Physical exercise and mindfulness practices have both independently been shown to have a positive effect on cancer outcomes (3,6), therefore, it makes sense that patients are seeking yoga during treatment and supports why yoga is beneficial for physical and occupational therapists to include in their tool box of effective interventions.

In 2012, the first available systematic review on yoga for breast cancer survivors was published which performed a meta-analysis of twelve random control trials (RCTs) (2). The outcomes reported the following short-term effects: moderate improvements in overall well-being, small differences in quality of life (functional, social and spiritual), and large changes in perceived stress, anxiety, depression and psychological distress. At the moment, there is no evidence for longer term effects due to the limited amount of RCTs with long-term follow-up. In summary, the authors of the article stated that “the clearly positive effects of yoga on psychological health in breast cancer patients should warrant its use in this patient population. Yoga might be particularly recommended as an intervention to improve psychological health during active breast cancer treatment.” Although physical and occupational therapists objectives are geared towards improved physical outcomes with objective gains, we as practitioners value the importance of a quality of life measures when determining the effectiveness of treatment and can attest to the correlation between lessened psychological distress and alleviated symptom burden (2).

Susannah Haarmann’s course, “Rehabilitation for the Breast Cancer Patient,” will touch on yoga as a solution for the physical side effects of breast cancer such as peripheral neuropathy, osteoporosis, lymphatic cording and chest mobility after surgery to name a few. Participants may choose to participate in short, didactic yoga sessions interspersed throughout the course to address these topics. Bring your yoga mats and be prepared to breathe!

Resources:

1.Chapman, J. Y, YCat YOGA Therapy: Yoga for People with Cancer and Chronic Illness Teacher Training Manual, Yogaville, Buckingham, VA, 2011. 2.Cramer, H., Lange, S., Klose, P., Paul, A., Dobos, G., Yoga for breast cancer patients and survivors: a systematic review and meta-analysis. BMC Cancer, 2012; 12: 412.
3.Denmark-Wahnefried, W., Campbell, K., Hayes,S. Weight management and its role in breast cancer rehabilitation. Cancer, 118 (8). 2277-2287.
4.Fouladbakhsh, J., Stommel, M., Gender, symptom experience, and use of complementary and alternative medicine practices among cancer survivors in the U.S. cancer population. Oncol Nurs Forum, 2010, 37: E7-E15.
5.Rock, C. et al, Nutrition and Physical activity guidelines for cancer survivors. Clinical Journal of Cancer, 2012.
6.Witek-Janusek, L., Albuquerque, K., Chroniak, K., et al. ‘Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain Behav Immun. 2008. 22(6): 969-981.

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Four “Must Know” Tips for Identifying Hip Labral Injuries

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

1. Early Intervention Is Key

Acetabular labral tears are reported to be a major cause of hip dysfunction in young patients and a primary precursor to hip osteoarthritis. New technology is helping with improved identification of tears, however the time of injury to diagnosis is still on average 2.5 years, making long-term prognosis for hip preservation poor.

Because of the lengthy delay many patients are still experiencing, the importance of early intervention cannot be overemphasized.

2. Getting the Best Outcomes: Patient Stories & Details Matter

Patient stories, the subjective reports of the individual, are incredibly important in aiding diagnosis of a hip labral tear. Knowing the morphological classification and common areas for tears in the hip labrum is also important, especially when it comes to identifying and managing adverse biomechanical stressors, such as anterior joint loading in the hip. Quite often in conservative treatment of hip labral injury, it is more important to change or retrain nonoptimal movement strategies rather than to issue exercise, strengthen, or elongate tissues.

Up to 55% of active people with mechanical hip pain are typically confirmed as having acetabular hip labral (ALT) tears, which is affirmed across several research studies. And since 2003, the most commonly cited area of hip pain for labral tears is anterior, followed by lateral, then posterior.

3. Study History to Affect the Future

Suzuki, in 1986, described the acetabular labral tear arthroscopically for the first time, while Altenburg, in 1977, documented the first report of “nontraumatic tearing of the acetabular labrum,” according to Groh and Herrara 2009, Schmerl 2005, and Altenburg 1977. And yet, it is possible for an ALT to go undiagnosed and pain-free, since up to 96% of cadaver hips with a mean age of 78 years old are found to have ALT in the anterosuperior quadrant.

A paucity of studies existed on hip disorders from 1977-2011, having located approximately 70 during early research on the topic. Plante et al (2011) and Margo et al (2003) confirm these findings, stating “there is no clear consensus on diagnosis or terminology” (concerning ALT).However, the increasing interest in ALT is a welcome phenomenon, and in a a second literature review from 2011 to present I located and reviewed over 100 new studies relating to ALT and its often comorbid sister condition, femoracetabular impingement (FAI).

4. What Matters Most in Symptomology?

There are some moderately reliable tests that have undergone scrutiny as to their sensitivity (SN) and specificity (SP) for clinical utility and validity; however, that is a discussion for another post. For now, what matters most in diagnosing ALT?

The short answer is the patient story. Listen to a patient’s onset of symptoms and mechanism of injury (if there is one, oftentimes there isn’t unless the mechanism is pregnancy or postpartum-related. For more information, read my post on postpartum hip labral injury risk. Listen carefully the most typical (and reliable) symptomology for a suspected ALT. Those symptoms would include:

  • Pain in the groin (reported 95-100% SN)
  • Mechanical symptoms, which can include sharp pain, clicking, locking or catching, or giving way (reported 85-100% SP, SN, respectively)
  • Minor hip ROM (range of motion) limitations (same SP and SN as above)

Could There Be a Future Hip Labral Injury (HLI) Scale?

The last symptom that can be incredibly telling (read: reveal the degree of functional impairment and degree of ALT), is night pain. Similar to the RTC impingement degrees of impairment (Stages l I, II, and III), ALT injury is similar. Once a patient’s sleep is interrupted, and is accompanied by any of the symptoms found above, the risk of their having an ALT or other intra-articular (internal) hip derangement is high. Night pain could then be characterized by the most impaired stage, Stage III, lending itself to the possibility of a future HLI Scale.

The findings reported in this post are supported by more than two dozen references, which are a part of the literature review included in the Hip Labral Injury and Differential Diagnosis course that Ginger authored and teaches for Herman and Wallace Pelvic Rehabilitation Institute.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

 

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Case Study from Peter Philip, PT, ScD, COMT, PRPC

This post was written by H&W instructor Peter Philip, PT, ScD, COMT, PRPC, who authored and instructs the Sacroiliac Joint Evaluation and Treatment course. The next SI Joint course will be taking place this January in Seattle.

Peter Philip

Patient one:

55 year old female with complaints of pelvic pain. States that her pain is noted along the deep inguinal region, involving her pubis and labia majora. States that intercourse is difficult, and that she is quite anxious to initiate or participate. She denies trauma, only that she’d been increasing her fitness activities as she’s going to Florida for a winter get-away. She denies changes in her bowel and bladder function, other than intermittent SUI with ‘heavy exercise’.

Clinical testing:

ALROM is negative. During forward flexion there was no reversal of the lordosis.

Segmental myotomal and dermatomal testing is unremarkable.

ASLR and PSLR are negative.

Gillet’s and forward flexion are apparently negative.

There are palpable “marbles” to palpation along bilateral SIJ, and the sacrum is ~40? of nutation.

FABER, FAIR and McCarthy tests are negative. Iliac compression is modestly provocative for patient’s symptoms, while the sacral thigh thrust was provocative for ipsilateral symptom provocation.

While in prone, the patient demonstrated a positive Dead Butt Syndrome bilaterally and there were significant restrictions to fascial rolling throughout the lumbosacral region.

The clinical question is: What to do next? What would you do?

I chose to provide a local traction to each SIJ, followed by a mobilization with movement directed at S3 to promote counter nutation. After treatment, the patient arose from the plinth and remarked that her pain was significantly reduced. On follow up, her pain was 10% that of her initial pain at evaluation.

My questions to you are:

1. What caused her “pelvic pain”?
2. Why did her pain subside? 3. Would you have done an internal evaluation?

These and other questions will be addressed at Sacroiliac Joint and Pelvic Ring Evaluation & Treatment in Seattle, Washington January 25th to the 26th.

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Female and Male Sexual Medicine: A Rehabilitation Perspective

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

Hollis Herman

The Sexual Medicine 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 3 parts:

Part 1: This 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 your reactions, sexual development, upbringing, feelings and worries you may carry around. In other words, bringing 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 to.

Part 2: 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, LGBTQ issues, aging and sexual issues, toys, lubricants, sexual abuse, female and male genital surgeries, psychological practices of CBT and EMDR. The information will help you confidently answer questions and concerns you and your patients have.

Part 3: This 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.

Register to join me in Houston or San Diego, then start preparing!

Watch movies, clips on you tube, read fiction and non-fiction, look at images, listen to songs and open yourself to your own thoughts, feelings, reactions and memories. Have a great time learning!

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Evidence of the Efficacy of Visceral Mobilization

This post was written by H&W instructor Ramona Horton MPT, who authored and instructs the Visceral Mobilization Series. Visceral Mobilization of The Urologic System & Visceral Mobilization of the Reproductive System will be presented throughout 2015.

Ramona Horton

As the instructor and developer of the curriculum for the visceral mobilization series, I am frequently asked for evidence of the efficacy of VMT. In order to gain an understand of why a physical therapist who has spent their entire career treating the somatic structures would possibly want to “manipulate” the internal organs one needs to understand a few basic facts. First: the visceral structures carry a significant mass within the human body and are subject to the same laws of physics as the locomotor system. Second: VMT is simply a form of soft tissue manual therapy that addresses the connective tissue and ligamentous attachments of the above mentioned visceral structures to the somatic frame.

There are multiple studies that demonstrate positive clinical outcomes from VMT, to mention a few are treatment of postoperative adhesions/ilius (Bove, Chappelle), chronic constipation (Harington, Tarsuslu), dysfunctional voiding (Nemett, Helge), mechanical infertility (Kramp, Wern) and low back pain (Michallet, Tozi, McSweeney.) I could write a multitude of paragraphs reviewing the above listed publications but that would steal all of the thunder for my upcoming lecture on the topic to be presented at CSM 2015 titled “Visceral Manipulation: Fact and Fantasy”. Therefore, the following is a completely un-scientific case study complete with visual demonstration… as the saying goes, a picture is worth a thousand words, besides we all love a good patient story.

CS is a 39 y/o G4 P3 female with complaint of chronic LBP and right flank/anterior hip/gluteal pain greater than 2 years in duration and deep dyspareunia. The flank pain would become constant low level ache when in a supine position, disturbing sleep and interfering with her exercise program.

PMHx: Three full term pregnancies, with two vaginal deliveries and one C-section. She experienced an abdominal pregnancy 1998 which culminated in miscarriage with right salpingectomy and partial small bowel resection. Abdominal hysterectomy in 2007 in which the right ureter was damaged, this resulted in multiple ureteral stent placements which failed and finally ureteral re-implantation 2012.

Previous treatment: monthly spinal manipulation and weekly massage for past 2 years, this provided temporary relief of LBP only.

Evaluation: Loss of trunk ROM all planes, with greatest restriction in trunk extension. Presence of exquisite trigger points in multiple regions bilateral abdominal wall, right iliacus, psoas and R quadratus, loss of mobility to spring testing R sacroiliac articulation and loss of tissue mobility at the R renal fascia, cecum, mesenteric root and peri-vesical fascia. Ultrasound imaging demonstrated asymmetry in dome of detrusor.

RTUS-Bladder 03/24/2014
bladder

Treatment: Following evaluation consisted of five sessions of VMT targeted at improving tissue mobility of the peri-vesical fascia, R renal fascia to include mobility of the kidney and ureter, the cecum, mesenteric root and multiple manual therapy techniques to treat somatic dysfunction in the pelvis. At the beginning of session six, CS reported LBP, anterior hip, flank and gluteal pain were eliminated. She was able to return to her regular exercise program. Attention was turned to improving motor control of core stabilizers and treatment of deep dyspareunia.

RTUS-Bladder 06/17/2014
bladder

Follow up: Five months following symptom abatement patient reported LBP, anterior hip pain continue to be fully resolved, she has returned to a regular exercise program and intercourse is pain free. Because of absence of ureteral valve, she does experience R flank pain secondary to ureteral reflux if her bladder becomes overly full and experiences has minor flank pain with first AM void.

This case by no means should be misconstrued as “evidence” of the efficacy of VMT however it is clear that a measurable change has occurred in the structure of this patient’s bladder. Most importantly, when the restrictions found in the visceral fascia were addressed, the patient experienced a timely resolution of symptoms that had been recalcitrant to prolonged intervention that the literature has shown to be effective in the treatment of LBP. As a musculoskeletal therapist, I cannot possibly understand how one is expected to treat bowel and bladder dysfunction, without addressing the bowel and bladder.

Resources:

Bove G, Chapelle S (2011) Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model. Journal of Bodywork and Movement Therapies doi:10.1016/j.jbmt.2011.02.004

Chapell S, Bove G (2013) Visceral massage reduces postoperative ileus in a rat model. Journal of Bodywork and Movement Therapies 17(1): 83-8.

Harrington K, Haskvitz E (2006) Managing a patients constipation with physical therapy. Physical Therapy 86 (11): 1511-1519.

Helge F, Hoesele K (2013) Osteopathic manipulative therapy OMT for treatment of lower urinary tract symptoms (LUTS) in women. Journal of Bodywork and Movement Therapies. 17: 11-18.
Kramp ME (2012) Combined Manual Therapy Techniques for the Treatment of Women With Infertility: A Case Series. Journal of the American Osteopathic Assn 112:680-684.

McSweeney TP, Thomson OP, Johnston R (2012) The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. Journal of Bodywork and Movement Therapies 16(4):416-23.

Michallet J-M (1986) Thesis for the Diploma in Osteopathy, in Barral J-P, Mercier P (1989) Visceral Manipulation II. Eastland Press, Seattle, WA.

Nemett DR et al. (2008) A Randomized Controlled Trial of the Effectiveness of Osteopathy-Based Manual Physical Therapy in Treating Pediatric Dysfunctional Voiding. Journal of Pediatric Urology 4:100-106.

Tarsuslu T, Bol H, Simsek I, Toylan I, Cam S (2009) The effects of osteopathic treatment on constipation in children with cerebral palsy: a pilot study. Journal of Manipulative Physiologic Therapy 32(8): 648-653.

Tozzi P, Bongiorno D, Vitturini C (2012) Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. Journal of Bodywork and Movement Therapies. 16:381-391.

Wurn B, Wurn L, King R, Heuer M, Roscow A, Schari E, Shuster J (2004) Treating female infertility and improving IVF pregnancy rates with a manual physical therapy technique. Medscape 6(2) [online]. [Accessed Aug 13, 2006].

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