This week we are proud to feature Christy Ciesla, PT, DPT, PRPC! She just earned her Pelvic Rehabilitation Practitioner Certification, and was kind enough to share some of her thoughts with the Pelvic Rehab Report. You can read the interview below. Congratulations to Christy and all the other PRPC practitioners!
Tell us about your clinical practice:
I am currently coordinating a Women and Men’s Health program at the Miriam Hospital (The Men’s Health Center and The Women’s Medicine Collaborative) in Rhode Island. We are fortunate to be a team of 5 skilled pelvic therapists and to work with the some of the best physicians and surgeons in New England. We work with so many different patients. I am currently most excited about our involvement in a tremendous Cancer Survivorship Program offered here at the Women’s Medicine Collaborative.
How did you get involved in Pelvic Rehab?
I have always been actively involved in women’s issues, even as a college student, helping with programming for the Women’s Resource Center on campus. After I had my first son in 2003, I became very interested in working with pregnant and postpartum women, and the pelvic rehab involvement took off from there. I was sent my first male patient in 2008, and found that I enjoyed working with men just as much as working with women in this area.
What/who inspired you to become involved in pelvic rehabilitation?
I went to Elizabeth Noble’s OB/Gyn and Prenatal Exercise Courses in 2004. During the course, we talked quite a bit about birth and the pelvic floor. I left there fascinated with the field, and took my first pelvic floor course a couple of years later.
What patient population do you find most rewarding in treating and why?
I love treating all of my patients, but perhaps the most rewarding feeling is when I can help a cancer survivor SURVIVE their cancer. All too often, when the treatment ends, the patient is left to feel alone with all of the effects of chemo, radiation and surgical trauma. They have incontinence, pelvic pain, and sexual dysfunction, and feel lost. Being able to offer a light in the darkness to these people is the greatest gift that pelvic rehabilitation has given me.
If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
You will never have more of a rewarding experience than you will when you help your patients pee, poop and have sex without dysfunction. I mean, really….what else is there to life?!
What has been your favorite Herman & Wallace Course and why?
PF 1 has still got to be my favorite. It was the most packed with great info, Holly was my instructor, and I was first introduced to the magical world of pelvic rehabilitation. I will never forget that experience.
What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
One of the things that has been consistently conveyed in all of my courses with H&W is the importance of caring for, respecting, and honoring our patients for having the bravery to address these sensitive issues, and to share them with us. The coursework prepared me with the knowledge I needed to help my patients, but the amazing instructors also helped me be a better provider in other ways.
What motivated you to earn PRPC?
So far, I have taken 7 Herman and Wallace courses (8 including the PF 1 course that Holly did privately for my facility and I was able to assist with). It just seemed right to be certified through this wonderful institute. It is what I do every day, all day, and I felt that I needed these credentials to go further with my career in this field.
Postpartum lower extremity nerve injuries is an important topic that we have previously discussed on the blog. A review article(O'Neal 2015) published in the International Anesthesia Research Society journal discusses maternal neurological complications following childbirth. This article, designed to help anesthesiologists identify the symptoms of a neuropathy, discusses diagnosis, management, and treatment. With the incidence of obstetric neuropathy in the postpartum period estimated at 1%, most of the nerve dysfunction is related to compression injuries. Symptoms may include, but are not limited to, lower extremity pain, weakness, numbness, or bowel and bladder dysfunction. Neuraxial anesthesia can also occur, with issues such as epidural hematoma or an epidural abscess. Risk factors are described in the article as having a prolonged second stage of labor, instrumented delivery, being of short stature and nulliparity (delivering for the first time.)
Clinical pearls listed in the article include the following information that may be helpful in understanding a patient’s condition:
In relation to prevention of neuropathies, the authors suggest that women who have diabetes or who have a preexisting neuropathy should be given extra attention. This may include protective padding during labor and delivery as well as frequent repositioning. Pelvic rehabilitation providers are a key player in the arena of birthing. Caring for women and educating them about peripartum issues is critical to helping women both prevent and heal from challenges encountered in relation to pregnancy and childbirth. If you would like to learn more about the topic of peripartum nerve dysfunctions, as well as many other special topics, please join us for the continuing education course Care of the Postpartum Patient. Your next opportunity to take this course will be in Seattle next March!
O’Neal, M. A., Chang, L. Y., & Salajegheh, M. K. (2015). Postpartum Spinal Cord, Root, Plexus and Peripheral Nerve Injuries Involving the Lower Extremities: A Practical Approach. Anesthesia & Analgesia, 120(1), 141-148.
If you celebrated the Thanksgiving holiday by enjoying food with family or friends, you may be lamenting the sheer amount of food you ate, or the calories that you took in. Did you know that chewing your food well can not only affect how much you eat, but also how much nutrition you derive from food? In a meta-analysis by Miquel-Kergoat et al. on the affects of chewing on several variables, researchers found that chewing affects hunger, caloric intake, and even has an impact on gut hormones. Ten papers that covered thirteen trials were included in the meta-analysis. From these trials, the following data are reported:
Research about eating behavior theories are highlighted in this paper, and include a discussion of the variety of factors, both internal and external, that control eating. Chewing is described as providing “…motor feedback to the brain related to mechanical effort…” that may influence how full a person feels when eating foods that are chewed. On the contrary, foods and beverages that do not require much chewing may be associated with overconsumption due to the lack of chewing required. (This makes sense when considering sugar-laden, high-calorie beverages.) Additionally, chewing food mixes important digestive enzymes and breaks down the food properly in the mouth, making the process of digestion further along the digestive tract more efficient. Another study by Cassady et al. which assessed differences in hunger when chewing almonds 25 versus 40 times reported that increased chewing led to decreased hunger and increased satiety when compared to chewing only 25 times.
The theory presented, yet not concluded, in this paper is that chewing may affect gut hormones and thereby decrease self-reported hunger and decrease food intake. For various reasons, including deriving more nutrition from our food, avoiding overconsumption, or making the process of digestion more efficient, focusing more on the act of chewing our food can have beneficial affects. To learn more about health and nutrition, attend the Institute’s course Nutrition Perspectives for the Pelvic Rehab Therapist (link: https://hermanwallace.com/continuing-education-courses/nutrition-perspectives-for-the-pelvic-rehab-therapist). This continuing education course was written and instructed by Meghan Pribyl, who is not only a physical therapist who practices in pelvic rehabilitation and orthopedics, but who also has a degree in nutrition. Her training and qualifications allow her to share important information that integrates the fields of rehabilitation and nutrition. Your next opportunity to take this course is in March in Kansas City.
Cassady, B. A., Hollis, J. H., Fulford, A. D., Considine, R. V., & Mattes, R. D. (2009). Mastication of almonds: effects of lipid bioaccessibility, appetite, and hormone response. The American journal of clinical nutrition, 89(3), 794-800. Miquel-Kergoat, S., Azais-Braesco, V., Burton-Freeman, B., & Hetherington, M. M. (2015). Effects of chewing on appetite, food intake and gut hormones: A systematic review and meta-analysis. Physiology & behavior, 151, 88-96.
Milk duct blockage is a common condition in breast feeding mother’s that can cause a multitude of problems including painful breasts, mastitis, breast abscess, decreased milk supply, breast feeding cessation, and poor confidence with decreased quality of life. A recent study in 2015 in The Journal of Women’s Health Physical Therapy1, showed that physical therapy (PT) maybe a helpful treatment for the lactating mother experiencing milk duct blockage when conservative measures have failed. Common conservative measures typically recommended are self-massage, heat, and regular feedings. The World Health Association, the American Academy of Pediatrics, and Academy of Breast Feeding Medicine, all recommend breast feeding as the primary source for nutrition for infants. There are many benefits to both the mother, and the infant, when breast feeding is used as the primary source for nutrition in infants. Having blocked milk ducts make it difficult and painful to breast feed and can lead to poor confidence for the mother and a frustrated baby as the milk supply could be reduced or inadequate. The primary health concern for blocked milk ducts is mastitis. Mastitis is defined as an infection of breast tissue leading to pain, redness, swelling, and warmth, possibly fever and chills and can lead to early cessation of breast feeding.
A blocked milk duct is not a typical referral to PT, however, this study outlined a protocol used for 30 patients with one or more blocked milk ducts that were referred to PT by a qualified lactation consultant. This study was a prospective pre/posttest cohort study. As an outcome measure, this study utilized a Visual Analog Scale (VAS) for 3 descriptive areas: pain, difficulty breast feeding, and confidence in independently nursing before and after treatment. The treatment protocol included moist heat, thermal ultrasound, specific manual therapy techniques, and patient education for treatment and prevention of the blockage(s). The thermal ultrasound and moist heating provided the recommend amount of heat to relax tissue around the blockage. Ultrasound also provided a mechanical effect that assists in the breaking up of the clog and increased pain threshold for the patient to improve tolerance to the manual clearing techniques. Next, the specific manual therapy was provided to directly unclog the blockage(s), and lastly the education provided was to help the patient identify and clear future blockages to prevent recurrence. 22 of the 30 patients were seen for 1-2 visits, 6 were seen for 3-4 visits, and none of the mother’s condition progressed to infective mastitis or developed breast abscess’s.
The results of the study showed the protocol used was helpful to ease pain, reduce difficulty with breast feeding, and improve confidence with independent breast feeding for lactating women that participated in the study. Although treatment of blocked milk ducts in lactating mothers is not a common PT referral, this study shows that PT may be one more helpful treatment for a patient experiencing this problem that is not responding to traditional conservative treatment. Since breast feeding is important to both mother and infant and is the primary recommended source for infant nutrition, it is important that a lactating mother receives quick, effective treatment for blocked milk ducts to prevent onset of mastitis and breast abscess that lead to early cessation of breast feeding. The cited study recommends that women who suspect a blocked milk duct or are having problems with breast feeding always seek care from a certified lactation consultant first, and that PT may be a referral that is made.
Cooper, B. B., & Kowalsky, D. S. (2015). Physical Therapy Intervention for Treatment of Blocked Milk Ducts in Lactating Women. Journal of Women’s Health Physical Therapy, 39(3), 115-126.
The day my son was born, my daughter had not defecated for 5 days, and her pain was getting pretty intense. My husband and his mom took her to Seattle Children’s Hospital for help, and they suggested using Miralax and sent them away. When they got back to my hospital room, my daughter was straining so hard it looked like she was about to give birth! Being physical therapists, my husband and I massaged her little muscles and told her to take deep breaths, and eventually she did the deed, yet not without a heart-breaking struggle. Little did I know then there is actually research to back up our emergency, instinctual technique.
Zivkovic et al (2012) performed a study regarding the use of diaphragmatic breathing exercises and retraining of the pelvic floor in children with dysfunctional voiding. They defined dysfunctional voiding as urinary incontinence, straining, weakened stream, feeling the bladder has not emptied, and increased EMG activity during the discharge of urine. Although this study focuses primarily on urinary issues, it also includes constipation in the treatment and outcomes. Forty-three patients between the ages of 5 and 13 with no neurological disorders were included in the study. The subjects underwent standard urotherapy (education on normal voiding habits, appropriate fluid intake, keeping a voiding chart, and posture while voiding) in addition to pelvic floor muscle retraining and diaphragmatic breathing exercises. The results showed 100% of patients were cured of their constipation, 83% were cured of urinary incontinence, and 66% were cured of nocturnal enuresis.
More recently, Farahmand et al (2015) researched the effect of pelvic floor muscle exercise for functional constipation in the pediatric population. Stool withholding and delayed colonic transit are most often the causes for children having difficulty with bowel movements. Behavioral modifications combined with laxatives still left 30% of children symptomatic. Forty children between the ages of 4 and 18 performed pelvic floor muscle exercise sessions at home, two times per day for 8 weeks. The children walked for 5 minutes in a semi-sitting (squatting) position while being supervised by parents. The patients increased the exercise duration 5 minutes per week for the first two weeks and stayed the same over the next six weeks. The results showed 90% of patients reported overall improvement of symptoms. Defecation frequency, fecal consistency and decrease in fecal diameter were all found to be significantly improved. Although not statistically significant, the number of patients with stool withholding, fecal impaction, fecal incontinence, and painful defecation decreased as well.
Parents may not be as aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs. To help prevent issues, keep the basics covered, such as making sure children are exercising regularly or being active, drinking plenty of fluids, and eating a diet that includes plenty of fiber. My daughter was only 26 months old when her constipation became a problem, so the stool softener was ultimately the way to go at that time, and everything worked out naturally over the next year. If she were still experiencing functional constipation, I would be delighted to know teaching her pelvic floor exercises (relaxation being the key aspect) and diaphragmatic breathing could be effective for keeping my crazy little girl regular in at least that area of her life!
Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, Vacic N. (2012). Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European J ournal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.
Farahmand, F., Abedi, A., Esmaeili-dooki, M. R., Jalilian, R., & Tabari, S. M. (2015). Pelvic Floor Muscle Exercise for Paediatric Functional Constipation.Journal of Clinical and Diagnostic Research : JCDR, 9(6), SC16–SC17. http://doi.org/10.7860/JCDR/2015/12726.6036
The 2012 guidelines for the treatment of overactive bladder in adults (updated in 2014) recommends as first line treatment behavioral therapies. These therapies include bladder training, bladder control strategies, pelvic floor muscle training, fluid management- all tools that can be learned in the Institute’s Pelvic Floor Level 1 course. These behavioral therapies may also be combined with medication prescription, according to the guideline.
When medications are prescribed for overactive bladder, oral anti-muscarinics or oral B3-adrenergic agonists may be prescribed. Although these drugs may help to relax smooth muscles in the bladder wall, the side effects are often strong enough to make the medication difficult to tolerate. Side effects of constipation and dry mouth can occur, and when they do, patients should communicate that to their physician so that the medication dosage or class can be evaluated and modified if possible. We know that patients who have constipation tend to have more bladder dysfunction, so patients can get stuck in a vicious cycle.
Although patients and their medications are screened at their prescriber’s office and often at the pharmacy, it is important to remember that therapists are an important part of this safety mechanism. Patients may not be candidates for anti-muscarinics if they have narrow angle glaucoma, impaired gastric emptying, or a history of urinary retention. When patients are taking other medications with anticholinergic properties, or are considered frail, adverse drug reactions can also occur. Our geriatric patients may have some additional considerations, not just in medication screening, but also in evaluation and intervention. If you are interested in learning more about pelvic rehabilitation for those in the geriatric population, check out our new continuing education course, Geriatric Pelvic Floor Rehabilitation with Heather S. Rader, PT, DPT, BCB-PMD. The next opportunity to take the class is January 16-17, 2016 in Tampa.
ACOG (American College of Obstetrics and Gynecology) describes hysterectomy as a treatment of last resort, but studies show that anywhere from 10 to 90% of hysterectomies performed in the United States are not medically necessary, evidenced by the fact that today, approximately 90 percent of hysterectomies are performed electively. Corona et al stated: ‘…that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for AUB, uterine fibroids, endometriosis, or pelvic pain. The rate of unsupportive pathology when hysterectomies were done for these indications was 18%.’
The US has the highest rate of hysterectomy in the industrialized world; it is the second most common surgical procedure carried out on women. 1 in 3 American women have their uterus removed by the age of 60, with the highest rates in women aged 30-54 (according to Corona et al in 2014, one in five women may not need it).
Reasons for hysterectomy include cancer, bleeding with childbirth and severe infection with uterine damage, all of which make up about 10% of cases. The other 90% are made up of medical, non-surgical and other surgical reasons, such as for menstrual cramps, heavy bleeding and fibroids. Unfortunately, too many women are also having hysterectomies as a treatment option for endometriosis (instead of laparoscopic excision, histological confirmation and pelvic rehab follow up)
Numerous women who undergo hysterectomy remain unclear about the details of their surgical procedures or indeed the implication for short and long term recovery. Clinically, I have seen many women who assume that as they have had a ‘Total’ Hysterectomy, that includes removal of their ovaries (Total vs Partial Hysterectomy generally refers to cervical preservation). I have also see many women confused as to why their recovery from what has been a laparoscopic surgery, with small incisions, is taking so long. A surgical colleague described it well in my opinion: ‘A laparoscopic hysterectomy is major abdominal/pelvic surgery with tiny incisions’.
In Part Two of this blog, I will discuss the sequelae of hysterectomy and the key role of pelvic rehab. Interested in learning more about Endometriosis, Fertility and Hysterectomy? Join me in Denver in January!
The Boston Women's Health Book Collective. Our Bodies, Ourselves: A New Edition For A New Era. New York: Touchstone, 2005., Centers for Disease Control and Prevention Online. "Hysterectomy Surveillance" --- United States, 1994,1999, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5105a1.htm
‘Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative’ Corona et al (Presented in oral and poster format at the 4oth Annual Scientific Meeting of the Society of Gynecologic Surgeons, Scottsdale March 24-26 2014)
The eve of my daughter’s 5th birthday has me reminiscing about my first pregnancy. I had recently surrendered my ACL on a ski slope and was contemplating surgery when I got confirmation I was pregnant. A seasoned surgeon had told me if I just wanted to return to running and not ski or do cutting sports (without a brace, anyway), I would probably be fine; so, I chose to forego the surgery and was running again 7 weeks later. Being my first pregnancy, I was not sure how hormones would affect my knee stability without an ACL or if the impact was safe for me and the baby or if my doctor would approve of my exercise choice of running. After all, pending ligamentous laxity from hormonal changes made running without an ACL seem risky while pregnant; but, runners tend to be, well, stubborn, when it comes to being able to run.
Deghan et al (2014) discuss the hormone relaxin and its effect on bone, muscle, tendon, ligaments, and cartilage. Interestingly, relaxin actually plays a role in the healing and remodeling of certain tissues in the body such as muscle and bone. However, the article also emphasizes how relaxin has been shown to reduce the integrity of the ACL and put female athletes at risk for injury. Lucky for me, that hormone couldn’t have its way with my knee since the ACL was already gone!
A study in the British Journal of Sports Medicine just published online October 4, 2015, encourages running and other high-impact sports before pregnancy to decrease the risk of pelvic girdle pain. The patients engaging in such exercises prior to being pregnant showed a 14% lower risk of having pelvic girdle pain during pregnancy. Out of 4069 women, 12.5% of the 10.4% of women who experienced pelvic pain were non-exercisers pre-pregnancy. The women who exercised 3-5 days per week and participated in high-impact aerobic exercise prior to being pregnant had less pelvic pain while pregnant.
Tenforde et al (2015) investigated the habits of competitive runners during pregnancy as well as breastfeeding. Out of 110 female runners, 70% continued to run during their pregnancy; however, only 31% continued into their 3rd trimester. Only 3.9% of the women got injured while running pregnant. In general, the competitive runners reduced their intensity and volume and ran primarily for fitness and health. The 84.1% of the women who ran during breastfeeding reported less postpartum depression and no negative impact on breastfeeding.
Looking back at my running log, I ran 3 miles under 10-minute pace two days before going into labor, and my daughter was even 9 days late. I continued to run because I love it and, quite simply, because I could. Personally, my blood pressure, weight, and glucose levels stayed healthy throughout the pregnancy. Even without an important stabilizing ligament in my knee and some extra pounds, I never experienced joint pain while running. On the trail where I ran, I got mixed responses from people coming the other way - mostly encouragement, but also some looks of disappointment or disgust (I didn’t say it was pretty) and an occasional know-it-all “warning.” Ultimately, any woman who has been running prior to pregnancy should be able to continue some level of running through the trimesters until her own body, the obstetrician, or a hard-kicking baby gives a reason to stop.
Dehghan, F., Haerian, B. S., Muniandy, S., Yusof, A., Dragoo, J. L., & Salleh, N. (2014). The effect of relaxin on the musculoskeletal system. Scandinavian Journal of Medicine & Science in Sports, 24(4), e220–e229. http://doi.org/10.1111/sms.12149
Owe KM, Bjelland EK, Stuge B, Orsini N, Eberhard-Gran M, Vangen S. (4 October 2015). Exercise level before pregnancy and engaging in high-impact sports reduce the risk of pelvic girdle pain: a population-based cohort study of 39,184 women. British Journal of Sports Medicine. pii: bjsports-2015-094921. doi: 10.1136/bjsports-2015-094921. [Epub ahead of print]
Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. (2015 Mar). Running habits of competitive runners during pregnancy and breastfeeding. Sports Health.;7(2):172-6. doi: 10.1177/1941738114549542.
Although awareness of pelvic rehabilitation is growing, patients who are referred for pelvic rehabilitation usually have more questions than the average patient about attending therapy. This can mean that you as a provider are burdened with a lot of phone calls or emails that go something like this: can I come to the clinic if I’m on my period? what are you going to do? are you familiar with my condition? how long will it take to get better? Consider how often these questions occur with patients who have knee pain, or headaches, and you may find that pelvic rehab is perceived by patients as quite unique from other types of rehab. How can you avoid trying to find time in your busy clinical schedule to tackle these additional communications? You can start by educating your front desk to handle patient care questions related to pelvic rehab, such as the following frequently asked questions:
It is likely that the patient will ask to speak directly with the therapist, so you can first encourage your support personnel to politely inquire if there is something he or she could help in answering. Create a list of conditions along with a brief description of its definition, and a few examples of skills that a pelvic rehab provider has to offer. Your support staff can also offer to mail a brochure or flyer that you create which answers some of the frequently asked questions. Providing an “FAQ” section on your website that can be referred to may also decrease some of the stress of trying to play phone tag. Make no mistake that if you DO have the time to follow-up with a patient who has a question, you may create a connection that is really important for that patient in regards to scheduling an appointment. On the other hand, if you don’t have time set aside in your day for such calls or emails, you risk having the patient not get her questions answered. A form (on your site or as a written resource) might have some of the commonly asked questions written out, and you could use the ones below as an example to get you started.
Most patients can attend a physical therapy visit without having a prescription or written referral from a doctor or other referring provider. Insurance companies, however, may insist that you have a referral in order for you or your therapist to receive payment. Even if you do not need a referral from a medical provider, your therapist may require that you have seen a medical provider for your condition. Many conditions involving the pelvis can be medical in nature and require checking for more serious conditions before coming to the clinic. It is also helpful to have a medical provider with whom your therapist can coordinate care and discuss your health as a team.
First, we will talk about what concerns or symptoms you have. Your therapist will also look over any forms you filled out to learn more about your history. The exam will be discussed with you so that you can have any questions answered. Your therapy exam may include general movement like bending forward and backward, seeing how you move your body, and specific tests of your joints, muscles, and nerves. For pelvic rehabilitation, an assessment of your pelvic muscles internally (through the rectum or vaginal canal) may be valuable.
Your therapist may use surface EMG (electromyography), a form of biofeedback. This may involve placing some sticky sensors on your body so you and your therapist can get a better idea of how you are coordinating muscle activity in the abdomen or pelvis. Biofeedback means that you will be able to get information about how your muscles are working, and in therapy this is often displayed as graphs or bars on a screen. An internal sensor for the vaginal or rectal canal may also be used.
It is usually not necessary to reschedule if you are on your cycle, so you are welcome to keep your appointment.