During labor, I had no problem breathing out. My hang up came when I had to inhale - actually oxygenate my blood and maintain a healthy heart rate for my almost newborn baby. When extra staff filled the delivery room, and an oxygen mask was placed over my face, my husband remained calm but later told me how freaked out he was. He was watching the monitors that showed a drop in my vitals as well as our baby’s. In retrospect, I wonder if practicing yoga, particularly the breathing techniques involved with pranayama practice, could have prevented that moment.
A research article by Critchley et al., (2015) broke down breathing to a very scientific level, determining the consequences of slow breathing (6 breaths/minute) versus induced hypoxic challenges (13% inspired O2) on the cardiac and respiratory systems and their central neural substrates. Functional magnetic resonance imaging measured the 20 healthy subjects’ specific brain activity during the slow and normal rate breathing. The authors mentioned the controlled slow breathing of 6 breaths/minute is the rate encouraged during yoga practice. This rate decreases sympathetic activity, lessening vasoconstriction associated with hypertension, and it prevents physiological stress from affecting the cardiovascular system. Each part of the brain showed responses to the 2 conditions, and the general conclusion was modifying breathing rate impacted autonomic activity and improved both cardiovascular and psychological health.
Vinay, Venkatesh, and Ambarish (2016) presented a study on the effect of 1 month of yoga practice on heart rate variability in 32 males who completed the protocol. The authors reported yoga is supposed to alter the autonomic system and promote improvements in cardiovascular health. Not just the breathing but also the movements and meditation positively affect mental health and general well-being. The subjects participated in 1 hour of yoga daily for 1 month, and at the end of the study, the 1 bpm improvement in heart rate was not statistically significant. However, heart rate variability measures indicated a positive shift of the autonomic system from sympathetic activity to parasympathetic, which reduces cortisol levels, improves blood pressure, and increases circulation to the intestines.
Bershadsky et al., (2014) studied the effect of prenatal Hatha yoga on cortisol levels, affect and depression in the 34 women who completed pre, mid, and post pregnancy saliva tests and questionnaires. While levels of cortisol increase naturally with pregnancy, yoga was found to minimize the mean levels compared to the days the subjects did not participate in yoga. After a single 90-minute yoga session, during which breathing was emphasized throughout the session, women had higher positive affect; but, the cortisol level was not significantly different from the control group. Overall, the authors concluded yoga had potential to minimize depression and cortisol levels in pregnancy.
Considering the positive effect of slow breathing practiced in yoga, the positive shift in the autonomic nervous system function and the decrease in cortisol levels, yoga is gaining credibility as an effective adjunct to treatment during pregnancy. If a woman enters the delivery room with a solid practice of slow breathing under her belt, she may be equipped to handle the intensity of contractions and the pain of pushing a little better. Yoga may help a woman breathe for her life and her baby’s as well.
If you're interested in learning more about yoga for pregnant patients, consider attending Yoga as Medicine for Pregnancy with Ginger Garner, PT, DPT, ATC/LAT, PYT. The next opportunity is in Fort Lauderdale, FL on January 28th and 29th, 2017. Don't miss out!
Critchley, H. D., Nicotra, A., Chiesa, P. A., Nagai, Y., Gray, M. A., Minati, L., & Bernardi, L. (2015). Slow Breathing and Hypoxic Challenge: Cardiorespiratory Consequences and Their Central Neural Substrates. PLoS ONE, 10(5), e0127082.
Vinay, A., Venkatesh, D., & Ambarish, V. (2016). Impact of short-term practice of yoga on heart rate variability. International Journal of Yoga, 9(1), 62–66.
Bershadsky, S., Trumpfheller, L., Kimble, H. B., Pipaloff, D., & Yim, I. S. (2014). The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms. Complementary Therapies in Clinical Practice, 20(2), 106–113.
Myofascial release (MFR) can be one of your greatest treatment tools as a pelvic rehabilitation practitioner. Just in case you don’t think about fascia often here are a couple helpful things to remember. Fascia is the irregular connective tissue that covers the entire body, and it is the largest sensory system in the body, making it highly innervated. The mobilizing effect of MFR techniques occurs by stimulating various mechanoreceptors within the fascia (not by the actual force applied). MFR techniques can help to reduce tissue tension, relax hypertonic muscles, decrease pain, reduce localized edema, and improve circulation just to name a few physiological effects.
An interesting case report published in 2015 by the Journal of Women’s Health Physical Therapy1 offers a wonderful example of how a physical therapist used specific MFR techniques for a patient with clitoral phimosis and dyspareunia. The specific MFR techniques used helped to provide relief and restore mobility to the pelvic tissues for this patient.
Clitoral phimosis is adherence between the clitoral prepuce (also known as the clitoral hood) and the glans. This condition can be the result of blunt trauma, chronic infection, inflammatory dermatoses, and poor hygiene. In this case report, the 41-year-old female patient had sustained a blunt trauma injury to the vulva (when her toddler son charged, contacting his head forcibly into her pubic region). She presented to physical therapy with complaints of dyspareunia, low back pain, a bruised sensation of her pubic region, vulvar pain provoked by sexual arousal, decreased clitoral sensitivity, and anorgasmia. The physical therapist completed an orthopedic assessment for the lower quarter (including spine and extremities), as well as a thorough pelvic floor muscle assessment.
Treatment for this patient addressed not only the pelvic complaints, but the lower quarter complaints as well. A detailed treatment summary for each visit is outlined in the case report. The clitoral MFR and stretching was performed by applying a small amount of topical lubricant to the clitoral prepuce. Then, a gloved finger or a cotton swab was used to stabilize the clitoris, a prolonged MFR or sustained stretch was applied in the direction away from the fixated clitoris by the therapist’s other finger. The therapist applied this technique along the entire length of the prepuce. The other physical therapy interventions this patient was treated with were stretching, joint mobilization, muscle energy techniques, transvaginal pelvic floor muscle massage, clitoral prepuce MFR techniques, biofeedback, Integrative Manual Therapy (IMT) techniques, nerve mobilization, and therapeutic and motor control exercises. Additionally, between the physical therapy evaluation and the second visit the patient did use topical Clobetasol 0.05% cream (commonly prescribed for vulvar dermatitis issues such as Lichen Sclerosis) for 30 days with no change to her clitoral phimosis.
After 11 sessions, the patient had resolution of dyspareunia, vulvar pain, pubic pain, and reduced low back pain. Also, the patient had 100% restored mobility of the clitoral prepuce, as well as normalized clitoral sensitivity and clitoral orgasm. The patient felt these improvements were still present at her 6-month follow-up interview over the phone. Current medical management for clitoral phimosis is surgical release or topical/injectable corticosteroids. Having a conservative treatment option, such as MFR, for this condition can be helpful for patients. As with most evolving treatment techniques, more research and studies are appropriate.
Not one health care professional had ever assessed the fascial mobility of the clitoris until this physical therapist did. This case report is an example of how MFR techniques can be effective treatment tools for your patients with pelvic disorders and a good reminder to check the fascial mobility of the pelvic tissues.
Morrison, P., Spadt, S. K., & Goldstein, A. (2015). The Use of Specific Myofascial Release Techniques by a Physical Therapist to Treat Clitoral Phimosis and Dyspareunia. Journal of Women’s Health Physical Therapy, 39(1), 17-28.
One of my dear patients was recently diagnosed with Ehlers-Danlos sydrome (EDS). The diagnosis brought a sense of relief for sweet Katie who for years struggled with numerous health problems and was often misunderstood and under cared for by the medical community. Katie was referred to me 2 years ago at 28 for pelvic pain, endometriosis and IC. Upon exam we also discovered a significant elimination disorder and paradoxical elimination. Katie regularly timed her elimination and was spending at times up to 2 hours trying to empty her bowels. As we worked together we uncovered bilateral hip dysplasia, left hip labral tear, ilioinguinal and pudendal neruralgia and POTS (Postural Orthostatic Hypotension Syndrome). Katie already had a history of anxiety and depression but managed well with good family and friend support. When the diagnosis of EDS came, she finally felt like she had an explanation for why her body is like it is. This brought great relief as well as the knowledge that her condition was genetic and her conditions needed to be managed as best as possible to give her the most function, but would likely never be fully resolved.
In her book "A Guide to Living with Ehler's Danlos Syndrome" Isobel Knight does a beautiful job outlining the various genetic subtypes of Ehlers Danlos but also highlighting the fact that EDS hypermobility type (Type III) does not just affect the connective tissue in the musculoskeletal sytem leading to joint instability and hypermoblity, muscle tears, dislocations, subluxations, hip dysplasia and flat feet. EDS can also affect the body's systemic collagen leading to increased risk for endometriosis, POTS, Renauds, bladder problems, fibromyalgia, headaches, restless legs, ashtma, consitpation, bloatedness, prolapse, IBS symptoms, anxiety, depression and learning difficulties. She notes that some people have only a few of these systemic symptoms while others may be more affected. Per Isobel: "it is important that all symptoms are treated seriously and not ridiculed and that the appropriate medical support is given to them when necessary."
It seems that EDS is becoming more widely recognized. As rehabilitation specialists we should be alert to problems stemming from joint hypermobility when we notice how our patients position themselves. Often legs are curled up or double crossed. Upon questioning we might find that the patient has a history of being "double jointed" or was able to do "party tricks" with their bodies. The Bighton scale is a test of joint hypermobility which we should all be familiar with. It is also important to note that a patient may have hypermobility without having EDS, and that EDS is usually associated with pain. A rheumatologist, or in Katie's case a geneticist, can help confirm a suspected EDS diagnosis.
If you have a patient with hypermobliiy or with EDS, know that their ability to know where their body is in space is limited as their joints have much more range of motion than normal. The proprioceptors do not fire well at mid range and the patient will have to be trained to become accustomed to neutral joint positions. This was really painful for Katie and it took a huge mental and physical effort. She is getting stronger now and it is becoming easier to achieve. Stretching and soft tissue massage can feel really good when your muscles have to work so hard to maintain your joints in healthy positions. Patients should be instructed to not stretch into end range and also not "hang out" on their ligaments. Some patients may have to begin just with isometrics. I used Sara Meeks' program for safe and effective floor exercise with Katie. The floor gave her support while she strengthened her core muscles. Then she was able to progress to seated and seated on a ball as well as standing exercises. She loves the body blade! Yoga, Pilates, exercise in water can be effective for strength, propriception and movement reeducation. Mirrors are helpful for increasing position sense.
It is also helpful to note that even patients with EDS may be hypermobile in some joints and hypomobile in others. Isobel reports that her SI joints were extremely unstable while her thoracic spine was very rigid to the point that her lung capacity was affected. Having her therapist work on the hypomobility and doing breath work was life changing.
As pelvic health therapists and rehabilitation providers we may be the first professional to suspect EDS in a patient. There is a great deal that we and the greater medical and holistic community can do to help patients with EDS lead lives with less pain and dysfunction.
In the 80’s, I would stand in my older sister’s bedroom wearing a button-down, collared shirt under a sweater and beg her to “fix me.” I felt stuck and wanted to cry until she twisted the shirt and loosened the snags of the knitted covering and made the outfit lay properly together. The myofascial system can often make us feel the same way if what’s lying underneath the intricately woven network of tissue has trigger points and inflammatory mediators rearing their ugly heads. When myofascial restrictions strike the pelvic region, every move a person makes can tug at the affected fascia and magnify the pain.
How do we know if someone has myofascial pain syndrome? Itza et al., (2015) published a study on turns-amplitude analysis (TAA) efficacy for diagnosing the syndrome in patients with chronic pelvic pain. The 128 subjects (64 with chronic pelvic pain and 64 healthy controls) underwent electromyogram (EMG) tests conducted in the levator ani muscle and the external anal sphincter. The mean TAA data was analyzed automatically, and an increase in the score was considered to be positive, while a decrease was negative. An increased TAA was found in 86% of the patients (no difference between men and women), and 100% of the control subjects displayed no increase in TAA. This study showed TAA to be an effective means by which to diagnose myofascial pain syndrome of the pelvic floor.
What are some treatments being researched? Anderson et al., (2016) conducted a study on using a multi-modal protocol with an internal myofascial trigger point wand to treat men and women with chronic pelvic pain syndrome (CPPS). After 6 days of training, male and female subjects with CPPS engaged in 6 months of pelvic floor trigger point release with an internal trigger point device that was self-administered in combination with paradoxical relaxation training. In the end, women and men subjects experienced similar reduction of symptoms as trigger point sensitivity decreased significantly.
Adelowo et al., (2013) explored the efficacy of botulinum toxin type A (Botox) for treatment of myofascial pelvic pain via a retrospective cohort study. Trigger points and pelvic floor hypertonicity were identified and confirmed with digital palpation. Twenty-nine women were assessed after intralevator injection with Botox A, and 79.3% reported reduction of pain. Botox A was deemed an effective and safe intervention with only mild, spontaneously resolving side effects occurring in 8 of the patients.
In 2012, Fitzgerald et al. studied the difference in outcomes between myofascial physical therapy (MPT) versus global therapeutic massage (GTM) for patients with interstitial cystitis/painful bladder syndrome. Of the 81 women randomly allocated to the two treatment groups, the MPT group had the greater response with 59% reporting moderate or marked improvement in symptoms (compared to 26% in the GTM group). Ultimately, myofascial physical therapy was considered beneficial for pelvic disorders.
Being able to adjust an outward snag such as a twisted sweater or stocking is much less complicated than deciphering and untangling the internal myofascial dysfunctions in the pelvis. When you are without an EMG, high-tech internal wands, or Botox, it is up to your hands and keen sensibility to detect the presence of the trigger points and release the restrictions. Thankfully, courses like “Mobilization of the Myofascial Layer: Pelvis and Lower Extremity” can guide you towards greater efficacy in this endeavor.
Itza, F., Zarza, D., Salinas, J., Teba, F., & Ximenez, C. (2015). Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain. Pain Research & Management : The Journal of the Canadian Pain Society, 20(2), 96–100.
Anderson, R.U., Wise, D., Sawyer, T. et al. (2016). Equal Improvement in Men and Women in the Treatment of Urologic Chronic Pelvic Pain Syndrome Using a Multi-modal Protocol with an Internal Myofascial Trigger Point Wand. Applied Psychophysiology Biofeedback. 41:215.
ADELOWO, A., HACKER, M. R., SHAPIRO, A., Modest, A. M., & ELKADRY, E. (2013). Botulinum Toxin Type A (BOTOX) for Refractory Myofascial Pelvic Pain. Female Pelvic Medicine & Reconstructive Surgery, 19(5), 288–292.
FitzGerald, M., Payne, C., Lukacz, E., Yang, C., Peters, K., Chai, T., … Nyberg, *LM. (2012). Randomized Multicenter Clinical Trial of Myofascial Physical Therapy in Women with Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) and Pelvic Floor Tenderness. The Journal of Urology, 187(6), 2113–2118.
Faculty member Jennafer Vande Vegte, MSPT, BCB-PMD, PRPC has written in to encourage us all to practice kindness and patience. A positive attitude can affect more than just your friends and family; your patients will benefit in so many ways as well!
First a little personal story. Several years ago my daughter was going through a tough time and we worked with a child psychologist. He was a wonderful man who taught my husband and I so much about how to raise a challenging kiddo. The foundation of what we needed to learn was the power of positive. People need nine (or so) positive interactions to override a negative one. Poor kid was definitely at a deficit! So if she did something that needed correcting, we were to give her a chance at a "do over" where sometimes we had to coach her to choose a better action. After she got it right, we lavished praise on our little pumpkin. And would you believe, not only did all that positiveness make a difference for her, it made a difference for her parents too!
Now back to the clinical. Just about two years ago I had the privilege of teaching with Nari Clemons. We taught PF2B together. Nari said something during one of her lectures that revolutionized my PT practice. She challenged us in lab to find three positive things about our lab partner and share those things before recognizing any deficits. How many times do we get finished with an evaluation and sit down with a patient and list all the things we found that need correction or help, perhaps drawing on our Netter images to fully illustrate the parts of their body that are broken or need fixing.
So I changed things up a bit and started remarking about the positive things I found on exam. "Wow, your hips are really strong and stable." "You've got a really coordinated breathing pattern, that is going to work in your favor." "You're pelvic muscles are really strong." and then later drawing on those positives outline how we could use the patient's strengths to help them overcome their challenges. "Because you have a great breathing strategy we are going to use that to help your whole nervous system to relax which with help your pelvic floor relax," for example.
The results were shocking. Person after person told me how much it meant to them to leave feeling positive and hopeful. One delightful woman who I saw for a diastasis had amazing leg muscles and I told her so. When she returned she said, "I've felt so self conscious about my flabby belly, but this week all I could think about were my strong leg muscles. Thanks for telling me that."
We do know is that our attitudes and beliefs as providers influence not only our clinical management but patient outcomes as well. Darlow et. al. performed a comprehensive literature review looking at how attitudes and beliefs among health care providers affected outcomes in patients with low back pain and discovered, "There is strong evidence that health care provider beliefs about back pain are associated with the beliefs of their patients."
Why not use that truth to our advantage and be positive? Would love to hear about your experiences!
Join Jennafer at one of her upcoming courses, Pelvic Floor Level 2B - Trenton, NJ - February 24-26, 2017, Pelvic Floor Series Capstone - Arlington, VA - May 5-7, 2017, Pelvic Floor Series Capstone - Columbus, OH - August 18-20, 2017, and Pelvic Floor Series Capstone - Tampa, FL - December 2-4, 2016.
With menopause and the hormonal shifts that take place, some women suffer more than others with symptoms such as hot flashes. If you have ever been near someone during a hot flash, you know that this curious condition is more than feeling a little hot under the collar. During a hot flash, women will suddenly disrobe, wake from a deep sleep covered in sweat (so much so that they have to change the sheets!), or otherwise appear distressed and oftentimes suffer interference in whatever activity in which they were engaging. As we reported in an earlier post, women on average may have hot flashes for 5 years after the date of her last period. Some women (up to 1/3 in the referenced study) will report hot flashes for 10 or more years after menopause.
Hot flashes and night sweats also significantly disrupt sleep, according to research by Baker and colleagues. Menopausal women with insomnia may also have higher levels of psychologic, somatic, vasomotor symptoms, and score lower on the Beck Depression Inventory, and sleep efficiency and duration scores. Poor sleep can be associated with morbidity such as hypertension, stroke, diabetes and depression, so interrupted sleep is more than an inconvenience, but potentially a serious health issue.
A more recent study linked anxiety as a potential risk factor for menopausal hot flashes. In 233 women who are premenopausal at baseline and who were followed for at least a year after their final menstrual cycle, anxiety symptoms, hormone levels, hot flashes and other psychosocial variables were assessed. During the 14 year follow-up 72% of the women reported having moderate to severe hot flashes, and the researchers correlated somatic anxiety as a potential predictive association with anxiety. Somatic anxiety refers to the physical symptoms of anxiety, such as stomach ache, increased heart rate, sweating, muscle aches.
In order to help a woman support her wellness during menopausal transitions, being able to address somatic anxiety and conditions like hot flashes is imperative. Teaching skills such as breathing, relaxation training, meditation, or mindfulness may positively impact the anxiety, and therefore have the potential to reduce hot flashes and other adverse symptoms. Herman & Wallace's Menopause Rehabilitation and Symptom Management course is an excellent opportunity to learn some of these valuable skills.
Baker, F. C., Willoughby, A. R., Sassoon, S. A., Colrain, I. M., & de Zambotti, M. (2015). Insomnia in women approaching menopause: beyond perception. Psychoneuroendocrinology, 60, 96-104.
Freeman, E. W., & Sammel, M. D. (2016). Anxiety as a risk factor for menopausal hot flashes: evidence from the Penn Ovarian Aging cohort. Menopause, 23(9), 942-949.
Freeman, E. W., Sammel, M. D., & Sanders, R. J. (2014). Risk of long term hot flashes after natural menopause: Evidence from the Penn Ovarian Aging Cohort. Menopause (New York, NY), 21(9), 924.
My little boy has a t-shirt with a potato telling french fries, “I am your father,” to which the french fries cry, “NO!!!!” The Star Wars spoof makes me laugh, but sometimes the struggle is real. Testicular cancer and the toxic remedies for it can potentially prevent young men from having a successful reproductive life. Survivors of the cancer may one day have to tell their children they are adopted or came from a sperm donor. With the advances in technology and research, however, testicular cancer survivors have a greater chance for their own sperm to be spared or even produced naturally years later to create their offspring.
Vakalopoulos et al. (2015) discussed the impact cancer and the related treatments have on fertility of males. Better survival rates for oncology patients have made preservation of reproductive means more imperative for men. Testicular cancer represents 5% of male urologic cancers, disturbing spermatogenesis and impairing fertility. Chemotherapy, radiotherapy, and surgery can all have gonadotoxic effects in men. Thankfully, only 1 in 5000 men die from testicular cancer now with advanced treatments, but fertility does become a long term factor for survivors. This paper showed chemotherapy combined with radiotherapy was most detrimental to sperm than either treatment alone. Gonadal shielding and moving the testes out of the way to target the malignant cells can help decrease the deleterious effects of cancer treatments. Radiotherapy, however, has been shown to damage sperm up to 2 years after recovery of spermatogenesis. Regarding surgery, radical unilateral orchiectomy is the standard for testicular tumors, and within the first few months, a 50% decrease in sperm concentration occurs, and 10% of patients become azoospermic. On a more encouraging note, after receiving Hematopoietic Stem Cell Transplantation, recovery of sperm in the ejaculate was noted in 33% of patients after 1 year and 80% of patients after 7 years.
Regardless of advancements in decreasing toxicity of cancer treatments and being minimally invasive with surgery, the best guarantee for preservation of sperm is cryopreservation.
A study collecting baseline data for semen quality of cancer patients prior to any gonadotoxic treatment was performed by Auger et al. (2016). Less than 60% of the testicular cancer patients had normal sperm production prior to treatment. The study also looked at patients with Hodgkin’s disease, non-Hodgkin’s Lymphoma, Leukemia, sarcoma, Behcet’s disease, brain tumor, and Multiple Sclerosis. The motility of sperm after freezing (cryopreservation) of the cancer patients was less than half of the healthy sperm donor control group. Intra Cytoplasmic Sperm Injection (ICSI) was shown to provide the best chance of paternity for men, and the authors conclude this as a necessary step in case men do not regain any spermatogenesis after cancer treatment.
There is no perfect circumstance when it comes to cancer. Survival is the primary goal, and then quality of life becomes the “problem,” particularly when it comes to fulfilling dreams of having a family. The toxic cancer treatments are improving but cannot guarantee return of spermatogenesis. Depending on the sperm integrity prior to getting treatment, cryopreservation success can vary but is the most highly recommended step to preserving fertility. In the end, a fresh or frozen spud can still make french fries.
Herman & Wallace has two great courses which can give you the tools needed to help assess and treat male patients who suffer from cancer-related dysfunctions. Consider Oncology and the Male Pelvic Floor: Male Reproductive, Bladder, and Colorectal Cancers or Post-Prostatectomy Patient Rehabilitation for your next continuing education courses.
Vakalopoulos, I., Dimou, P., Anagnostou, I., Zeginiadou T. (2015). Impact of cancer and cancer treatment on male fertility. Hormones. 14(4):579-89. DOI: 10.14310/horm.2002.1620
Auger, J., Sermondade, N., & Eustache, F. (2016). Semen quality of 4480 young cancer and systemic disease patients: baseline data and clinical considerations. Basic and Clinical Andrology, 26, 3. http://doi.org/10.1186/s12610-016-0031-x
My job as a pelvic floor therapist is rewarding and challenging in so many ways. I have to say that one of my favorite "job duties" is differential diagnosis. Some days I feel like a detective, hunting down and piecing together important clues that join like the pieces of a puzzle and reveal the mystery of the root of a particular patient's problem. When I can accurately pinpoint the cause of someone's pain, then I can both offer hope and plan a road to healing.
Recently a lovely young woman came into my office with the diagnosis of dyspareunia. As you may know dyspareunia means painful penetration and is somewhat akin to getting a script that says "lower back pain." As a therapist you still have to use your skills to determine the cause of the pain and develop an appropriate treatment plan.
My patient relayed that she was 6 months post partum with her first child. She was nursing. Her labor and delivery were unremarkable but she tore a bit during the delivery. She had tried to have intercourse with her husband a few times. It was painful and she thought she needed more time to heal but the pain was not changing. She was a 0 on the Marinoff scare. She was convinced that her scar was restricted. "Oh Goodie," I thought. "I love working with scars!" But I said to her, "Well, we will certainly check your scar mobility but we will also look at the nerves and muscles and skin in that area and test each as a potential pain source, while also completing a musculoskeletal assessment of the rest of you."
Her "external" exam was unremarkable except for adductor and abdominal muscle overactivity. Her internal exam actually revealed excellent scar healing and mobility. There was significant erythemia around the vestibule and a cotton swab test was positive for pain in several areas. There was also significant muscle overactivity in the bulbospongiosis, urethrovaginal sphincter and pubococcygeus muscles. Also her vaginal pH was a 7 (it should normally be a 4, this could indicate low vaginal estrogen). I gave her the diagnosis of provoked vestibulodynia with vaginismus. Her scar was not the problem after all.
Initially for homework she removed all vulvar irritants, talked to her doctor about trying a small amount of vaginal estrogen cream, and worked on awareness of her tendency to clench her abdominal, adductor, and pelvic floor muscles followed by focused relaxation and deep breathing. In the clinic I performed biofeedback for down training, manual therapy to the involved muscles, and instructed her in a dilator program for home. This particular patient did beautifully and her symptoms resolved quite quickly. She sent me a very satisfied email from a weekend holiday with her husband and daughter.
Although this case was fairly straightforward, it is a great example of how differential diagnosis is imperative to deciding and implementing an effective treatment plan for our patients. In Herman & Wallace courses you will gain confidence in your evaluation skills and learn evidence based treatment processes that will enable you to be more confident in your care of both straightforward and complex pelvic pain cases. Hope to see you in class!
We are all familiar with the old saying, “You are what you eat.” A functional medicine lecture I attended recently at the Cleveland Clinic explained how chronic pain can be a result of how the body fails to process the foods we eat. Patients who just don’t seem to get better despite our skilled intervention make us wonder if something systemic is fueling inflammation. Even symptoms of vulvodynia, an idiopathic dysfunction affecting 4-16% of women, have been shown to correlate to diet.
In a single case study of a 28 year old female athlete in Integrative Medicine (Drummond et al., 2016), vulvodynia and irritable bowel syndrome (IBS) were addressed with an elimination diet. After being treated by a pelvic floor specialist for 7 months for vulvodynia, the patient was referred out for a nutrition consultation. Physical therapy was continued during the vegetarian elimination diet. In the patient’s first follow up 2 weeks after starting eliminating meat, dairy, soy, grains, peanuts, corn, sugar/artificial sweeteners, she no longer had vulvodynia. The nutrition specialist had her add specific foods every 2 weeks and watched for symptoms. Soy, goat dairy, and gluten all caused flare ups of her vulvodynia throughout the process. Eliminating those items and supplementing with magnesium, vitamin D3, probiotics, vitamin B12, and omega-3 allowed the patient to be symptom free of both vulvodynia and IBS for 6 months post-treatment.
On the more scientific end of research, Vicki Ratner published a commentary called “Mast cell activitation syndrome” in 2015. She described how mast cells appear close to blood vessels and nerves, and they release inflammatory mediators when degranulated; however, mast cell activation syndrome (MCAS) involves mast cells that do not get degranulated properly and affect specific organs like the bladder. She proposed measuring the number of mast cells and inflammatory mediators in urine for more expedient diagnosis of interstitial cystisis and bladder pain syndrome.
Sigrid Regauer’s correspondence to Ratner’s article followed in 2016 relating MCAS to bladder pain syndrome (BPS), interstitial cystitis (IC), and vulvodynia. He described vulvodynia as a pain syndrome with excessive mast cells and sensory nerve hyperinnervation, often found with BPS and IC. The vulvodynia patients had mast cell hyperplasia, most of which were degranulated, and 70% of the patients had comorbidities due to mast cell activation such as food allergies, histamine intolerance, infections, and fibromyalgia.
Considering the association between mast cells and acute inflammatory responses and how mast cells release proinflammatory mediators, it makes sense that dysfunctions such as vulvodynia as well as IC and BPS can result from an excessive amount and dysfunctional granulation of mast cells. Enhanced activation of mast cells causes histamine release, stimulating peripheral pain neurotransmitters (Fariello & Moldwin 2015). If medication and therapy do not solve a patient’s pain, perhaps eliminating the consumption of inflammatory foods could positively affect the body on a cellular level and relieve irritating symptoms of vulvodynia. Pardon the parody, but patients on the brink of being “insane in the brain” from vulvodynia will likely try anything to resolve being “inflamed in the membrane.”
Drummond, J., Ford, D., Daniel, S., & Meyerink, T. (2016). Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report.Integrative Medicine: A Clinician’s Journal, 15(4), 42–47.
Ratner, V. (2015). Mast cell activation syndrome. Translational Andrology and Urology, 4(5), 587–588. http://doi.org/10.3978/j.issn.2223-4683.2015.09.03
Regauer, S. (2016). Mast cell activation syndrome in pain syndromes bladder pain syndrome/interstitial cystitis and vulvodynia. Translational Andrology and Urology, 5(3), 396–397. http://doi.org/10.21037/tau.2016.03.12
Fariello, J. Y., & Moldwin, R. M. (2015). Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management. Translational Andrology and Urology, 4(6), 643–652. http://doi.org/10.3978/j.issn.2223-4683.2015.10.09
As pelvic rehabilitation practitioners, we have all been there, looking ahead to see what patients are on our schedules and recognizing that several will require immense energy from us… all afternoon! Then we prepare ourselves, hoping we have enough stamina to get through, and do a good job to help meet the needs of these patients. Then we still have to go home, spend time with our families, do chores, run errands, and have endless endurance. This can happen day after day. Naturally, as rehabilitation practitioners, we are helpers and problems solvers. However, this requires that we work in emotionally demanding situations. Often in healthcare, we experience burnout. We endure prolonged stress and/or frustration resulting in exhaustion of physical and/or emotional strength and lack of motivation. Do we have any vitality left for ourselves and our loved ones? How can we help ourselves do a good job with our patients, but to also honor our own needs for our energy?
How do we as health care practitioners’ prevent burnout?
Ever hear of “mindfulness” ... I am being facetious. The last several years we have been hearing a lot about “mindfulness” (behavioral therapy or mindfulness-based stress reduction) and its positive effects in helping patients cope with chronic pain conditions. Mindfulness is defined as “the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis,” according to Merriam-Webster’s Dictionary. One can practice mindfulness in many forms. Examples of mindfulness-based practice include, body scans, progressive relaxation, meditation, or mindful movement. Many of us pelvic rehabilitation providers teach our patients with pelvic pain some form of mindfulness in clinic, at home, or both, to help them holistically manage their pain. Whether it is as simple as diaphragmatic breathing, awareness of toileting schedules/behavior, or actual guided practices for their home exercise program, we are teaching mindfulness behavioral therapy daily.
Why don’t we practice what we preach?
As working professionals, we are stressed, tired, our schedules too full, and we feel pain too, right? Mindfulness behavioral therapy interventions are often used in health care to manage pain, reduce stress, and control anxiety. Isn’t the goal of using such interventions to improve health, wellness, and quality of life? Mindfulness training for healthcare providers can reduce burnout by decreasing emotional exhaustion, depersonalization, and increasing sense of personal accomplishment. Additionally, it can improve mood, empathy for patients, and communication.1 All of these improvements, leads to improved patient satisfaction.
Let’s take what we teach our patients every day and start applying it to ourselves. An informal way to integrate mindfulness is by building it into your day. Such as when washing hands in between patients, or before you walk into the room to greet the patient. However, sometimes we have a need for a tangible strategy to combat stress and the desire to be guided by an expert with this strategy.2 I think one of the easiest ways to begin practicing mindfulness is to try a meditation application (app) on a smart phone or home computer. Meditation is one of the most common or popular ways to practice mindfulness and is often a nice starting point to try meditation for yourself or to suggest to a motivated patient. Many popular guided meditation apps include Headspace, Insight Timer, and Calm, just to name a few. Generally, these guided meditation apps have free versions and paid upgrades. Challenge yourself to complete a 10-minute guided meditation app, daily, for three weeks, and see how you feel. It takes three weeks to make a new habit. Hopefully, guided meditation will be a new habit to help you be present with your patients and improve your awareness and energy. After all, how can we help others heal, if we can’t help ourselves?
To learn more about ways, you as a professional can help yourself or your patients with meditation, consider attending Meditation for Patients and Providers.
1)Krasner, M.S., Epstein, R.M., Beckman, H., Suchman, A.L., Chapman, B., Mooney C.J., et al. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 302(12):1284–93.
2)Willgens, A. M., Craig, S., DeLuca, M., DeSanto, C., Forenza, A., Kenton, T., ... & Yakimec, G. (2016). Physical Therapists' Perceptions of Mindfulness for Stress Reduction: An Exploratory Study. Journal of Physical Therapy Education, 30(2).