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Herman & Wallace Blog

Sexual Health at Menopause

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

Menopause is often euphemistically referred to as ‘The Change’. Historically it was treated with everything from hysterectomy to hormones, and even hospitalization (often in psychiatric institutions). Dr Christiane Northrup writes “Perimenopause is a normal process, not a disease.” But she also writes “It’s no secret that women experience a decrease in their sex drive during perimenopause.”

But according to a study presented by Gavrilov in 2007, American women aged fifty five and older enjoy sex more than women a decade ago who were the same age. Today’s menopausal women, they report, consider a healthy sex life to be part of a healthy lifestyle.

Although it has been reported that genital sexual responsiveness of premenopausal and post menopausal women doesn’t differ significantly (Van Lunsen 2004), many women report painful intercourse possibly because of vaginal dryness or vulvar-vaginal atrophy caused by decreased levels of estrogen. Symptoms of vulvar and vaginal atrophy (VVA), including dyspareunia and vaginal dryness, have a distinct negative impact on a woman's quality of life. The REVIVE survey (Freedman 2014) highlighted the lack of awareness of VVA symptoms among postmenopausal women with vaginal symptoms, with many women reluctant to initiate discussions with their healthcare professionals despite the presence of vaginal symptoms.

The vast majority of postmenopausal women will develop VVA at some point in their lives (Freedman 2008) and up to 50% will experience physical symptoms of vaginal atrophy, particularly dyspareunia (pain with intercourse), vaginal dryness, and vaginal irritation (Santoro 2009). Furthermore, the prevalence of VVA in postmenopausal women is likely to increase, secondary to factors such as the aging population, increased longevity, and a decline in the use of systemic hormone therapy (Gass et al 2011) Despite the increased prevalence of VVA, many women report that their healthcare professional (HCP) did not inquire about specific conditions such as dyspareunia during routine examinations.

Sexual function is a complex, integrated phenomenon that reflects the health and balance not only of the ovaries and hormones but also of the cardiovascular system, the brain, the spinal cord and the peripheral nerves. In addition, every factor that affects sexual function has underlying psychological, sociocultural, interpersonal and biological influences of its own. (Northrup 2012). And then of course there is pelvic health! Pelvic therapists are in a unique position when it comes to dealing with sexual health – we may be the only health care professional capable of integrating interviewing about sexual health with an external and internal pelvic floor muscle exam, as well as our advanced skills in merging and interpreting the relationship between the spine, hips, pelvic girdle and the pelvic floor. We can combine our skills in assessing and addressing any pelvic floor muscle dysfunctions along with advising about sexual ergonomics secondary to orthopedic issues in the lumbo-pelvic-hip complex.

Interested in learning more about Menopausal health? Join me in Orlando in February for my new course ‘Menopause: A Rehabilitation Approach’

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Meditation and Its Scientific Benefits

This post was written by H&W instructor Nari Clemons. Nari instructs her Meditation for Patients and Providers course.

Nari Clemons

Meditation is persistently making its way into mainstream culture. Research continues to emerge regarding the benefits of meditation, and not just for those who are seeking enlightenment. Traditionally, meditation was thought of and taught as a pathway to transcend the suffering in life, but increasingly there is evidence that meditation practice, even in small amounts, has far reaching benefits.

Last month, in an article titled, “Meditation is even more powerful than we thought” via the Huffington Post online, author Alena Hall states, “Consistent (meditation) practice can help alleviate symptoms of anxiety and depression in people who often need it most.” Hall describes two recent studies. The first, a recent study from Harvard University and the University of Sienna found that the powers of meditation move beyond the cultivation of self-awareness, improvement of concentration and protection of the heart and immune system-- it can actually alter the physiology of the human brain. “Cognition seems to be preserved in meditators," says Sara Lazar, a researcher at Harvard University. Lazar continues in the article to say that “meditators also have more gray matter – literally, more brain cells.” Certainly, more brain cells are something that any of us can use.

She also describes that mediators have longer telomeres. What is a telomere? According to Wikipedia, Telomeres are essentially buffers at the end of genes. When genes replicate, the replication does not occur to the end of the gene, so the chromosomes essentially shorten over time. The portion of the gene where this shortening occurs over time is the telomere. This protects the gene from having the genetic code itself truncated. So the length of the telomere is essentially a marker of biologic aging, versus chronologic aging. Shortened telomeres are associated with biological aging. So, there are even anti-aging associations.

People have said that if the benefits of exercise could be put into a pill, it would be the most prescribed medication. The benefits of meditation are far reaching, including mental health, improved blood pressure and heart rate, brain changes, genetic preservation, not to mention improved pain perception. As physical therapists, we have the ability to teach our patients to use meditation to improve their lives, health, and pain perception. What medication could offer all of that?

In the Herman Wallace course, Meditation for Patients and Providers, we prepare health care providers to integrate these skills into their own practice, how to choose the right techniques to use with different patient populations, and how to use meditation and mindfulness to benefit their own lives and practices.

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Extra-articular Hip Impingement: A New Discovery for Hip Preservation

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

There are two accepted forms of hip impingement currently documented in the literature. The two types are 1) CAM type FAI (femoracetabular impingement) and 2) Pincer type FAI. These two types are found inside the joint, meaning they are considered intra-articular bony anomalies.

FAI is a common comorbidity found with hip labral injury (HLI); and in fact, FAI is a risk factor for HLI. Specifically, FAI is a bony impingement that arises in the femoral head-neck function and the rim of the acetabulum (see photo at right). The two types of FAI also generally occur together more than they do in isolation. However, it is possible that, combined with other issues like acetabular undercoverage or hip instability, CAM or Pincer-type FAI can be found a singular diagnosis.

Surgical Intervention

However, the arena of impingement in the hip is now evolving to consider other locations. In the past 5 years there has been buzz about other types of FAI. They aren’t classically considered FAI issues since this new type of identified impingement occurs outside (extra-articular) the joint. One type newly identified is known as anterior inferior iliac spine/subspinal hip impingement (AIIS). In a 2011 study of 3 case reports, AIIS was found and treated with arthroscopic AIIS decompression with positive results. A more recent 2012 study found excellent results at short-term follow up for surgical decompression of AIIS.

Identification & Diagnosis of AIIS

Both personal and professional experience in the area of AIIS has shown that AIIS is not always discovered on an AP (anterior-posterior) radiograph. However, it is possible to see a larger AIIS on an AP film. Another helpful (but not always definitive) diagnostic test is a CT scan with MRI 3D reconstruction (and no contrast). Bony contrast is more reliable with CT scan than the typically preferred MRA (which is better for soft tissue contrast).

In addition, the rectus femoris (RF) could be implicated in AIIS pathology because the same area receives the proximal attachment of the RF. The same 2011 study reported that the morphology and role of the RF in extra-articular impingement is “not well reported at this time.”

Likewise, the identification of AIIS as a primary driver of pathology in intra-articular hip injury (FAI and/or HLI) is rare. Some cases of AIIS are being found during hip arthroscopy to correct identified existing deficits such as FAI and/or HLI. This means that AIIS may be missed and should be included as a potential mechanism of injury, especially for anterosuperior labral tears in the 2 to 3 o’clock region.

Patients who have AIIS may present like a typical HLI patient, which means they may have a positive Thomas test, FADDIR test, or mechanical symptoms such as popping, clicking, grinding or giving way. It is important to note these signs and symptoms and work in a team approach with surgeons and physical therapists who specialize in hip preservation and reconstruction.

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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Fatigue and Breast Cancer: More Common than Not

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.

Elizabeth Hampton

According to Schmitz et al, 94% of people experience fatigue as a side effect during breast cancer treatment, and, unfortunately, this condition commonly persists after treatment ends. Fatigue is often described as an unrelenting sense of tiredness that interferes with daily functioning. The symptoms of fatigue, such as generalized weakness, inability to concentrate and impaired short-term memory are often disproportionate to activity levels and unresponsive to sleep (Mitchell, 2010).

The causes of fatigue during cancer treatment are often multi-factorial and may be related to anemia, pain, deconditioning, hormonal and electrolyte imbalances or emotional distress, among other reasons. Physicians may attempt to alleviate the symptoms with pharmaceutical interventions such as pain and sleep medications or iron supplements, however, the only intervention that has been shown to have a significant effect in lowering fatigue levels is exercise. The NNCN states that exercise has been shown to lower fatigue levels by 40-50% (NCCN, 2008).

Radiation, chemotherapy and surgical intervention have been associated with fatigue, however, a Cochrane review by Markes, et al showed that exercise can improve physical function even during cancer treatment (Markes, Barckow & Resch, 2006). Patients who continue exercise within safe parameters during cancer treatment have been shown to reap the following benefits; improved energy, appetite, and psychological states, and even a greater functional capacity.

Furthermore, exercise during and after cancer treatment, has been shown to improve overall treatment outcomes and lower patient’s risk of cancer recurrence, as well as decrease the risk or limit other side effects of breast cancer treatment such as lymphedema, fatigue and osteoporosis. Susannah Haarmann’s course “Rehabilitation for the Breast Cancer Patient,” will explain safe parameters of exercise before and after cancer treatment to improve the health and overall quality of life of cancer patients.

References:

Markes, M., Borkcow, T., & Resch, K., Exercise for women receiving adjuvant therapy for breast cancer. Cochrane Database of Systematic Reviews (4). CD005001.
Mitchell, S., Caner-related fatigue; Clinical practice guidelines in oncolog. J. Natl. Comp. Canc Netw, 2010; 5 (10), 1054-1078.

Schmitz, K, Speck, R., Rye, S., DiSpio, T., Hayes, S., Prevalence of breast cancer treatment sequelae over 6 years of follow-up. Cancer, 2012; 118(8) 2217-2225.

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Gait Patterns and Intra-articular Hip Injury

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

One of the easiest ways to determine if someone is in pain is to watch the way they move. And perhaps the most commonly observed and universal movement pattern is gait. From a subtle loss of trunk rotation or pelvic translation to a gross loss of reciprocal gait, a dynamic assessment of walking is a very valuable tool in the physical therapist’s toolbox.

In evaluation of the hip, gait assessment is a critical element of the physical therapy exam. Pain-free ambulation is an essential part of measuring a person’s quality of life (QOL) and is a clinically significant functional outcome measure. Loss of hip extension and knee hyperextension prior to or at heel strike are part of several self-limiting patterns that arise from intra-articular hip injury. Dynamic gait assessment can give the therapist distinct clues as to hip pathophysiology etiology.

It was previously assumed that surgery to correct intra-articular pathology, such as in CAM-based femoracetabular impingement (FAI), would result in correction of deficiencies in gait patterning. CAM FAI limits and creates pain in the direction of hip osteokinematic flexion, adduction, and internal rotation range of motion and is caused by a lack of sphericity of the femoral head and neck, causing impingement of the labrum and/or chondral contact at the acetabulum.

A recent study published in 2013 in Gait and Posture, shows that previous assumptions about gait are incorrect. The study compared the gait of healthy controls to those with FAI and hypothesized that gait abnormalities would resolve status post surgery.

Gait measures were obtained both preoperatively and postoperatively. Researchers were surprised to find that gait abnormalities found presurgically did not automatically resolve postsurgically. Another pertinent finding is that the surgical patients not only retained their old faulty antalgic gait patterns and habits, they also adopted new abnormalities that resulted from surgical intervention, such as those arising from scar tissue, soft tissue pathology, neuromuscular patterning, or loss of arthrokinematic motion in the hip. These findings underscores the importance of early intervention via physical therapy for both operative and nonoperative patients if we want our patients to enjoy or return to a high quality of life.

Although the patients in the study who underwent FAI surgery did demonstrate decreased pain, nonoptimal preoperative gait patterns that persist postoperatively can put these patients at risk for reinjury (e.g. labral retears) or related cobmorbidities like pelvic pain, back pain, or sacroiliac joint dysfunction.

Further, a separate study published in 2009 established the presence of altered hip and pelvic biomechanics during gait, finding that those with hip FAI had decreased peak hip abduction, attenuated pelvic frontal ROM or translation, and less sagittal ROM than controls. Soft tissue restriction including scar tissue from previous or current surgeries, myofascial restriction, or neuromuscular patterning problems are, again, all important variables which must be differentially diagnosed for their possible contribution to the loss of ROM and function. Other considerations that can alter gait pattern and increase injury or reinjury risk assessment of capsular mobility, ligamentous integrity, and sacroiliac joint contributions to limited hip ROM and excursion.

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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Upcoming Continuing Education Courses

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (RESCHEDULED)

Jul 10, 2020 - Jul 12, 2020
Location: Virginia Hospital Center

Mobilization of Visceral Fascia: The Gastrointestinal System

Jul 10, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Short Form Remote Course

Athletes & Pelvic Rehabilitation - Remote Course

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Bowel Pathology and Function - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

Jul 12, 2020 - Jul 14, 2020
Location: Rutgers University - Doctoral Programs in Physical Therapy

Pregnancy Rehabilitation - Remote Course

Jul 16, 2020 - Jul 17, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

Jul 18, 2020 - Jul 19, 2020
Location: Intercore Physical Therapy

Pelvic Floor Level 1 - Colorado Springs, CO (SOLD OUT)

Jul 18, 2020 - Jul 19, 2020
Location: Manual Edge Physiotherapy

Postpartum Rehabilitation - Remote Course

Jul 18, 2020 - Jul 19, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

Jul 18, 2020 - Jul 19, 2020
Location: Husson University

Pelvic Floor Level 1 - Columbus, OH

Jul 18, 2020 - Jul 19, 2020
Location: Fitness Matters

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 21, 2020 - Jul 22, 2020
Location: Short Form Remote Course

Nutrition Perspectives for the Pelvic Rehab Therapist - Columbia, MO (Rescheduled)

Jul 24, 2020 - Jul 26, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Advocate Illinois Masonic Medical Center

Pelvic Floor Level 1 - Fayetteville, NC (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Methodist University School of Health Sciences

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jul 25, 2020 - Jul 26, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Glenwood Springs, CO (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Valley View Hospital

Pudendal Neuralgia and Nerve Entrapment - Maywood, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Loyola University Health System

Pelvic Floor Level 2B - Los Angeles, CA (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Mount Saint Mary’s University

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Jul 31, 2020 - Aug 1, 2020
Location: Short Form Remote Course

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

Jul 31, 2020 - Aug 2, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Restorative Yoga for Physical Therapists - Remote Course

Aug 1, 2020 - Aug 2, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Chicago, IL (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: Midwestern Regional Medical Center

Pelvic Floor Level 2A - Washington, DC (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: The George Washington University

Pelvic Floor Level 1 - New York City, NY (RESCHEDULED)

Aug 2, 2020 - Aug 3, 2020
Location: Touro College

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Aug 8, 2020 - Aug 9, 2020
Location: Shelby Baptist Medical Center