Therapists are increasingly learning about and treating pediatric patients who have pelvic floor dysfunction, yet there are still not enough of them to meet the demand. Many therapists I have spoken to are understandably concerned about how to transfer what they have done for adult patients to a younger population. Here are some of the more common concerns therapists express or questions they ask in relation to the pediatric population:
Although each question deserves a longer answer, we can start with biofeedback, and the answer is a resounding “yes”. There is abundant research affirming the potential benefit of biofeedback training for children with pelvic floor dysfunction. And no, we do not typically complete an internal pelvic muscle assessment on children, as that would not be appropriate. Considering that pediatrics can refer to young adults up to age 18-21, there may be a reasonable clinical goal in mind for utilizing internal assessment or treatment. The words we use when we speak to children become very important. Herman & Wallace faculty member Dawn Sandalcidi (known as “Miss Dawn” to her younger patients) gives ample strategies for adapting our language in her continuing education course Pediatric Incontinence and Pelvic Floor Dysfunction. For example, Dawn emphasizes the importance of describing an episode of incontinence as a “bladder leak” and of pointing out to a child that his or her bladder leaked, rather than the child leaking. She also likes to encourage parents and school personnel to drop the term “accident” from vocabulary. In her 2-day course, Dawn also teaches therapists how to train children to become a “Bladder Boss”, and how to teach young patients about relevant anatomy.
The way we teach anatomy to kids is really important in making sure they “get” it. One study published in 2012Equit 2013 describes the results when children are asked to draw a urinary tract in a body diagram. Only half of the children drew a bladder and other organs, and nearly 43% of the children drew “anatomically incorrect pictures.” The authors point out that older children and the ones who had gone through group training for bowel and bladder were more likely to draw correct images. For the last question about teaching contract/relax exercises to children, I had an opportunity to ask Dawn this question recently when she was filming a pediatrics course for MedBridge Education. Her answer emphasized the importance of getting children to develop awareness of the pelvic muscles, and to improve their coordination as well as strength- concepts that participating in an exercise program can work toward.
If you would like to learn more about working with children, the next opportunity to take Dawn’s course is in Boston later this month.
Equit, Monika et al. "Children's concepts of the urinary tract". Journal of Pediatric Urology , Volume 9 , Issue 5 , 648 - 652
You went through Herman and Wallace’s Pelvic Floor 1 course and were ready to treat your clients with incontinence and prolapse……….then you started getting referrals for clients with pelvic pain.
You have 45-60 minutes (or longer if you are lucky) to create a safe and comfortable environment, skillfully establish trust and rapport and gather objective and subjective data to get to the bottom of their pain. You want to give them the summary of your findings, their rehab road map and something to work on at home. By the end of the visit, you need to have completed their problem list and plan of care. Where do you start?
No pressure, right?
Clinicians are under a huge amount of pressure to get clients better and faster, which can result in rushing treatment before differential diagnosis is complete. A thorough approach enables us to say, with confidence, what the drivers of their condition are or at the very least what they are not. It is safe to say that no one single issue drives pelvic pain: it is a condition that is unique to each individual and requires a right AND left brain toolbox to unravel the ball of yarn that is pelvic pain.
A client with severe groin and labial pain was referred to my office for a second PT course of care. Her previous course of PT (by an outstanding clinician) focused on intrapelvic visceral work and postural corrections. The client’s pain had remained unchanged. Her visceral mobility, posture, joint biomechanics, neural upregulation, core muscle inhibition, myofascial trigger points, dysfunctional voiding and deconditioning were most definitely significant factors. The initial evaluation aligned with severe OA with a labral tear being the primary driver of her pain. I am no guru: it was with evidence-based sensitive and specific testing I was confident that this woman needed a new hip and that no amount of physical therapy could improve her pain as quickly or efficiently as a hip replacement. She DID need a customized PT pre-op course of care to prepare her for a great outcome. When she got a new hip, we incorporated all key factors into her post op rehab and she is back to her goals of hiking and having sex with her husband. (But not at the same time, as far as I know.)
Before you jump to conclusions, I am not a surgery happy PT. I work with orthopedic surgeons and interventional pain docs as frequently as I work with Reiki healers, craniosacral therapists and acupuncturists. I want to fill my toolbox with right as well as left brained tools, from the most subtle of manual interventions and precise movement re-education to dynamic mobilization and strengthening interventions. As a profession we are called to utilize evidence-based treatment as well as innovative interventions that may be researched one day. Every evidence-based practice was once an unresearched clinical intervention based on clinical reasoning and perhaps gut instinct.
As pelvic health therapists, our work requires high EQ as well as IQ to earn client trust as well as differential diagnosis abilities to design their plan of care. Before we can ask for more visits, we need to justify the reasons behind the request based on solid clinical reasoning including objective data. Certainly in 45 minutes it can be difficult if not impossible to perform a comprehensive pelvic health and musculoskeletal evaluation. That being said, we need to address main categories of foundational evaluation testing to capture their data in a thorough manner.
“Finding the Driver in Pelvic Pain” is a course that enables the clinician to perform a foundational comprehensive musculoskeletal and pelvic health exam to find the evidence based factors in the client’s pain. We are called to deliver care that integrates both the art and science of physical therapy and healing. If we just use the ‘art’, or only the ‘science’, we miss key elements in our differential diagnosis which could delay the client getting better.
Research published in a Nursing journal highlights the need for pelvic rehab providers to assess for sexual dysfunction in women before, during, and after pregnancy. 200 women were interviewed about their return to sexual activity after pregnancy and childbirth, and the results demonstrate that women can (and do) have limitations in their sexual function around the entire peripartum period.
The results of the survey concluded that before pregnancy 33.5% of the women reported sexual dysfunction, and this number increased to 76% during pregnancy, and to 43.5% following delivery. The types of sexual dysfunction included dyspareunia, vaginismus, and decreased desire and orgasm. The authors of the study correlated dysfunctions with Catholic religion, vaginal delivery without suture, dyspareunia during pregnancy, vaginismus before pregnancy, and with working more than 8 hours per day.
The information collected in this study raise important points with a variety of topics related to sexual function. How we as providers aim to address these topics with women can have a critical impact on the health of a woman and her family. Let’s look at some action items this research can lead us to:
This type of research can lead to many more questions, such as how religious beliefs impact sexual function during pregnancy, what the effect of physiologic changes versus fatigue can have on libido, or if women who have intervention for dyspareunia prior to pregnancy have decreased sexual dysfunction after pregnancy. Most of us were not instructed in how to dialog about these types of questions, and of course some topics, like religion, are potentially very sensitive to bring up with our patients.
If you would like more practical advice about the clinical implications for sexual medicine across the lifespan and among all genders, consider a trip to San Diego this November to learn from Herman & Wallace co-founder Holly Herman at Sexual Medicine for Men and Women: A Rehabilitation Perspective!
Holanda, J. B. D. L., Abuchaim, E. D. S. V., Coca, K. P., & Abrão, A. C. F. D. V. (2014). Sexual dysfunction and associated factors reported in the postpartum period. Acta Paulista de Enfermagem, 27(6), 573-578.
How often do we hear of patients trying to explain their sexual pain to a partner, only to be doubted, not believed, or guilt tripped into having sex because of the lack of understanding of the condition? I’d say about as often as we hear of the other unfortunate misunderstandings about the nature of painful sexual function, such as people not wanting to be in a relationship for fear of sexual dysfunction limiting their participation, or believing that healthy sex is gone for good. Most of us are familiar with the phrase, “not tonight- I’ve got a headache” yet how often is the truth really that a person has a “pelvic ache?” And do headaches and pelvic pain go together? That is the question posed in research published in the journal Headache.
For 72 women who were being treated for chronic headache, a survey was administered to assess for associations between sexual pain and libido, a history of abuse, and to determine the number of women being treated for sexual pain. Nearly 71% of the women were diagnosed on the International Classification of Headache Disorders (ICHD)-III criteria with chronic migraines, nearly 17% with medication overuse headache, 10% with both chronic overuse headache and migraine. Below are some of the statistics from the survey.
|Symptom||% Respondents who Experienced Symptom|
|Pelvic region pain brought on by sexual activity||44%|
|Pelvic region pain preventing from engaging in sexual activity||18%|
|Among women who had pain:|
|Reported pain for < 1 year||3%|
|Reported pain for 1-5 years||35%|
|Reported pain for 6-10 years||29%|
|Reported pain for > 10 years||32%|
Although the next statistics should not be so surprising based on prior literature and on our work in the clinics, 50% of the women had not discussed their pelvic pain with a provider. Of the women who had discussed their pelvic pain with a provider, 37.5% were currently receiving treatment, 31% had not received any treatment, 31% had received care in the past, and 1% did not provide an answer. Reasons for not receiving treatment included that no treatment was offered, pain was not severe enough to warrant care, or fear of pursuing treatment due to embarrassment. Unfortunately, rehabilitation was not a significant part of the treatment plan, even though all but one of the women said they would want to pursue care if available.
Other interesting associations were made in the article, which is available as full text in the link above, including rates of sexual abuse, and associations between types of headaches and pelvic pain. The bottom line is that headaches and pelvic pain can occur together, and that based on this research, many women are still suffering for long periods of time without accessing care for pelvic pain. When it comes to headaches, there are many types of headaches, and many other conditions that occur and can cause pain in the head, face, and neck. If you would like to sharpen your clinical tools related to headaches, as well as dizziness and vertigo, you still have time to sign up for the Institute’s new continuing education course on Neck Pain, Headaches, Dizziness, and Vertigo that takes place in Rockville in November.
Peyronie’s disease is a condition in which there are fibrotic plaques (sometimes calcified) that can cause a curvature in the penis, most notable during erection. Pain as well as urinary and sexual dysfunction may occur with Peyronie's disease. Increased attention has been given in recent years to the relationship between male hormones, erectile dysfunction, and Peyronie's disease. According to the Mayo Clinic, testosterone, the predominant hormone affecting male physical characteristics, peaks during adolescence and early adulthood. Testosterone gradually decreases about 1% per year once a man reaches age 30-40. Some men experience symptoms from the decline in testosterone and these symptoms can include decreased sexual function, sleep disturbances changes in bone density and muscle bulk, as well as changes in cognition and depression. Because other factors and conditions can cause similar symptoms, patients with any of these changes should talk to their medical provider to rule out diabetes, thyroid dysfunction, depression, sleep apnea, and medication side effects, according to Mayo.
In an article published in 2012, Iacono and colleagues studied the correlation between age, low testosterone, fibrosis of the cavernosal tissues, and erectile dysfunction. 47 patients diagnosed with erectile dysfunction (ED) were included, with 55% of the 47 men being older than age 65. Having increased fibrosis corresponded to having a positive Rigiscan test- meaning that a nocturnal test of penile rigidity demonstrated abnormal nighttime erections. Low levels of testosterone also corresponded to erectile dysfunction. (This is an open access article with full text available) Another published article agreed with the above in that low testosterone is associated with Peyronie’s disease and/or erectile dysfunction. The authors are cautious, however, in describing the association between the variables, as causation towards plaque formation characteristic of Peyronie’s is not known.
The larger question about Peyronie’s disease is what a patient can do to improve the symptoms of the condition. Therapists who treat male patients are increasingly interested in this question, and many are working with their patients to address the known soft tissue dysfunction. Interventions may include teaching patients to perform soft tissue mobilizations and stretches to the restricted tissue, and educating the patient in what the available literature tells us about rehabilitation of this condition. Hopefully, as male pelvic rehabilitation continues to grow in popularity, more therapists will contribute case studies and participate in higher levels of research so that more men can add conservative care of Peyronie’s to their list of treatment options.
To learn more about what the literature tells us about Peyronie’s and other male pelvic rehabilitation conditions, the Male Pelvic Floor continuing education course is taking place in Seattle in November, and you won't want to miss it!
If you are familiar with the work of Diane Lee, you may have noticed the term “driver” used throughout descriptions of patient assessment techniques. One definition of “driver” is “a factor that causes a particular phenomenon to happen or develop.” When it comes to a patient’s pelvic dysfunction, we know that there may be a dramatic number of factors driving the symptom, so what is the value of trying to determine the level of significance of various factors?
Let’s imagine that we meet a female patient who presents with pelvic pain, urinary incontinence, and difficulty holding back gas. In addition to providing a thorough subjective interview, screening for underlying medical conditions requiring attention, examining her neuromusculoskeletal system, and learning more about her daily habits, we need to figure out the best place to start with her care. What if, even though this particular patient has only experienced one major episode of leakage (after which all other symptoms started) you complete the exam to find that she is holding her pelvic muscles tense continuously? Perhaps you share this observation with the patient, only to hear her say that she is “so afraid of leaking again that she keeps her muscles tight to prevent it.” This type of rehabilitation sleuthing can help us get to the heart of the matter with our patients, regardless of the presenting complaints. For example, if we can educate this patient about the potential negative consequences of her fear of having another embarrassing episode (fear leads to muscle guarding which leads to pelvic pain and potentially dysfunctional voiding) then her thoughts can positively contribute to the other therapeutic recommendations we make.
Other examples may include meeting a patient with pelvic dysfunction whose true “driver” is a kyphotic thoracic spine that compresses the abdominal organs, or a habit of wearing pants with a waistband so tight that bowel function is compromised (true story), foot pain that creates increased loading on the now painful side of the pelvis, or even emotions and thoughts such as fear and shame. I’m sure you can think of many other examples based on your own clinical experience. If you are a newer therapist, or perhaps wish to work through further examples of not only how to evaluate but to treat for finding the primary contributors to a patient’s dysfunction, check out Pelvic Rehabilitation Institute faculty member Elizabeth Hampton’s continuing education course that focuses on this Finding the Driver in Pelvic Pain.
Have you ever tried to make a fitted sheet reach all corners of a mattress when there is a small, defective seam stitched into the middle of the fabric? No matter how much you pull or tug, the sheet won’t hug the last corner just right. If you get it to stay, the opposite corner flips off from the extra tension. Unless you release the snag the stitching created, you won’t ever get the sheet to fit smoothly. This is like the myofascial system in the body, where a snag in one area can affect another proximally or distally when normal movement tries to occur.
Even the pelvic floor can get myofascial restrictions and trigger points; however, this area is often ignored and seemingly insignificant when not fully understood. Pelvic floor fascial restrictions and trigger points can have paramount implications for the pelvic, abdominal, hip, and lumbar regions. This why pelvic rehabilitation practitioners should be equipped to evaluate and treat myofascial snags.
Pastore and Katzman (2012) published an article stating that 14%-23% of women with chronic pelvic pain have myofascial pelvic pain, and up to 78% of women with interstitial cystitis have myofascial trigger points. Once a trigger point in pelvic floor musculature is identified through palpation, it can refer pain to the perineum, vagina, urethra, and rectum, which seems obvious; however, pain may also refer to the abdomen, back, trunk, hip, buttocks, and lower leg. If palpation can provoke a referral pattern of pain, stretching and/or contraction of the musculature with that myofascial restriction will surely provoke a cascade of symptoms. How can we as clinicians just let statistics like this slide and figure “someone else should do that examination and fix it?” To demonstrate the efficacy in treating myofascial trigger points in pelvic musculature, consider the following study. Anderson et al (2015) had 374 patients follow a protocol of pelvic floor myofascial release of trigger points with an internal trigger point wand along with paradoxical relaxation therapy for 6 months. The goal was to see if patients with chronic pelvic pain syndrome could reduce their medication after following the protocol. At 6 months, a 36.9% reduction in medication use was noted in a complete case analysis, and a 22.7% reduction was revealed in the modified intention to treat (mITT) analysis. Patients no longer needing to take medication significantly correlated with the reduction of overall symptoms from following the protocol.
Knowing how to find and treat pelvic floor myofascial trigger points can lead to reduction of pain in women (and men) and even help reduce the need for medication for their chronic pelvic pain symptoms. Stop trying to make a bed without discerning if the base layer is free of snags. Learning how to go deeper to feel what’s under the covers can help unveil a source of potentially chronic, disabling pain. You can learn how to skillfully treat the “hidden” dysfunction by attending a Myofascial Release for Pelvic Dysfunction course with Ramona Horton.
Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. Journal of Obstetric, Gynecologic, and Neonatal Nursing : JOGNN / NAACOG, 41(5), 680–691. http://doi.org/10.1111/j.1552-6909.2012.01404.x
Anderson , R., Harvey, R., Wise, D., Smith, J., Nathanson, B., Sawyer, T. (2015 March). Chronic Pelvic Pain Syndrome: Reduction of Medication Use After Pelvic Floor Physical Therapy with an Internal Myofascial Trigger Point Wand. Applied Psychophysiology and Biofeedback. Volume 40, Issue 1, pp 45-52
The concept of patient compliance, or adherence (a more preferred term), has been the subject of many medical studies, and adherence in pelvic rehabilitation is an aspect of rehab of critical interest. Recently published results of a survey questioning providers and the public about adherence in pelvic floor muscle training offers an insightful perspective. Researchers Frawley, Dumoulin, and McClurg conducted a web-based survey which was published in published in Neurourology and Urodynamics. The survey was completed by 515 health professionals and by 51 individuals from the public. Interestingly, but perhaps not surprisingly, health professionals and public respondents placed different value on which factors related to rehabilitation contributed the most to adherence.
Data collected in the study included topics such as barriers to adherence in pelvic floor muscle training (PFMT), perception of potential benefit of PFMT, therapy-related factors including therapeutic relationship, socioeconomic factors, and issues surrounding short-term versus long-term adherence, for example. For the providers, poor motivation was rated high as a barrier to short-term adherence, whereas the patients rated perception of minimal benefit from PFMT as the most important barrier. Facilitators of pelvic muscle training included aspects of access such as having appointments outside of the typical workday, or having childcare available, transportation, and not being bored by the exercise program or feeling that the therapist has adequate training and skills.
As suggested by the authors, perhaps that most important variable agreed upon by both providers and public is that of perceived benefit. In other words, patients need to believe that the exercise program can alleviate symptoms and that what they are doing in their particular program is going to achieve positive results rather than wasting time on a home program that will not be effective. This issue is one that can be easily remedied through appropriate patient education, communication with the patient about whether or not they understand the potential value and expected recovery through program participation, and adequate training of the therapist that allows for proper diagnosis and treatment planning. The study concludes by emphasizing that health providers “need to be aware of the importance of long-term patient perception of PFMT…”
If you are interested in advancing your diagnostic or treatment planning skills, check out the pelvic floor series of continuing education courses and the many specialty courses that the Institute offers.
Oftentimes in the blog we address specific populations, perhaps involving pediatrics, post-prostatectomy patients, or patients who have oncology-related issues. Another population that deserves more focus is the geriatric population. If we consider who and where the women are who may be dealing with the highest level of pelvic dysfunction, we are led to the women in their later decades of life. A major challenge for geriatric women is that many pelvic rehab therapists are not reaching them: outpatient clinics tend to cater to younger patients, and for the women who are in living settings other than their own home, there are few therapists trained to address pelvic floor dysfunction such as incontinence or prolapse. Now seems like a great time to remedy these issues, as the Institute has created a course specific to geriatric patients.
What is different about pelvic floor evaluation and intervention in the geriatric population? This is a broad question with a range of important answers, but we can start with this one: what is different about the pelvic floor exam for women of geriatric age? Following are a few key thoughts. (You can find even more information about recommendations for pelvic exams and the use of speculums in the medical clinic in this article published in the Journal of Women’s Health.
Geriatric patients may require assist for positioning on the examining table, including use of a high-low table or assistive devices for transitions. If a patient cannot tolerate the supine hooklying position for an exam, she may be able to tolerate either a frog-leg position (supine with with bent, heels together, knees abducted) or left sidelying with an assistant holding the top leg in a position for best viewing. Women of older age may have atrophic vaginitis, or thinning of the tissues that creates fragility, and a pelvic muscle assessment may need to be completed externally via observation, palpation, or with external sensors and biofeedback. Age-related changes such as difficulty with vision, hearing, or with complex instructions may require adaptations in exam strategies and sequencing.
Another article which summarized guidelines for pelvic exams and cancer screening in women over age 65 discusses the importance of screening women of all ages. Because, as the authors point out, women over 65 are more likely to develop “late stage diagnoses of cancers, pelvic organ disease, incontinence, and infections…”, practitioners should encourage women to continue to seek expert care for screening of such diseases and conditions. The article also discusses the lack of access to gynecologic care in settings like nursing homes and assisted living, leaving women at risk for not having routine exams and screening.
There is much to learn about the pelvic rehabilitation process for geriatric patients of all genders. Herman & Wallace faculty member Heather Rader has offered her expertise in the field of geriatric pelvic rehab and is prepared to discuss not only the common conditions, modifications to evaluation and intervention, but also nuts and bolts topics like documentation, billing, and all things Medicare! You still have time to schedule a warm, sunny break for the coming winter as the continuing education course will take place in Florida in January!
Coccyx pain is a frequently encountered condition in pelvic rehabilitation practices. Although sitting is one of the primary limitations for patients who present with coccyx pain, or coccygodynia, defecation can be included in the list of functional complaints. This brings to mind the question: what does the coccyx do during defecation?
Coccygeal mobility was examined using MRI in this study by Grassi and colleagues. The authors included 112 subjects for the dynamic MRI research in positions of maximal contraction as well as straining for evacuation. Included in the study were subjects who complained of constipation, sense of incomplete evacuation of bowels, pain (not coccyx pain), organ prolapse, and minor trauma. Although the MRI was completed with the patient in supine (a non-functional defecation position), the authors reported that during a straining maneuver, the coccyx moves into extension, or backwards.
What if the coccyx does not move into extension during a straining maneuver? Is it possible for the coccyx to interfere with defecation? This appears to be true for a patient who appeared as the subject in the Journal of Medical Case Reports. The patient presented with an anteverted coccyx, and complained of “…worsening rectal pain developing an hour before defecation and lasting for several hours afterwards.” Pain was also reported during sitting on a hard surface. (See the linked article for an interesting image of the coccyx position and what is described as “rectal impingement.”) The patient was treated with coccygectomy which appeared to significantly reduce the symptoms (there are no outcomes tools reported in the case study, so progress reported is vague.) Although removal of the coccyx was the treatment in this particular case, the authors state that first-line treatment for coccyx pain includes conservative measures such as seat cushioning, coccygeal massage, stretching and manipulation, and injections, and that the majority of patients will respond favorably to these interventions.
There is more to learn about the coccyx and its role in defecation, sitting, and other daily functions. Faculty member Lila Abbate teaches a great course called Coccyx Pain, Evaluation & Treatment and it is a great opportunity to learn some new evaluation and treatment techniques. Join her this October 25-26 in Bay Shore, NY.