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Herman & Wallace Blog

The Pudendal Nerve and Order of Movement

Pudendal nerve dysfunction, when severe, is truly one of the most difficult conditions treated by pelvic rehabilitation providers. While peripheral nerve dysfunction anywhere in the body can be challenging to treat, access to the nerve along its many potential sites of irritation is limited when compared to other peripheral nerves. Many research studies have been completed that investigate how structures like the median nerve move in the body, and to what extent the nerve movement changes in cases of dysfunction, yet we still have very little to work with regarding the pudendal nerve. Little, that is, except anatomical knowledge, nerve and tissue mapping and palpation skills, expert listening and evaluation skills, and an abundance of existing and emerging methodology directed to treatment of chronic pain conditions.

The Neuro Orthopaedic Institute (also known as the NOI group)has led the physiotherapy world in seeking and sharing knowledge about the evaluation and treatment of conditions involving the nervous system. In a prior posting within the "noinotes" available as a newsletter from the NOI group, the following is stated: "…for the best clinical exposure of a peripheral nerve problem, take up the part that you think holds the problem first and then progressively add tension to the nerve via the limbs." Let's say, for example, that you gently tension the pudendal nerve by completing an inferior compression of the right levator ani muscle group (towards the lateral portion of the muscle belly versus at the midline). At this point, what limb movement should be performed to increase tension to the nerve? Does a straight leg raise tension the nerve, or hip rotation, hip adduction? What evidence do we have that this nerve tension increases in terms of elongation of the peripheral nerve, and by what connective tissue attachments is this tension proposed to occur? And for using order of movement in the clinic, do we start with a pelvic muscle bearing down or contraction, then add trunk or limb movements?

The "Ordering nerves" post describes listening "…to the patient about the sequence of movements which aggravate them.." so that with clinical reasoning, for evaluation or treatment, the nerve symptoms can be reproduced to an appropriate extent. For example, if a pelvic muscle contraction significantly aggravates a patient's nerve-like symptoms, why should a patient be instructed, or allowed even, to do Kegel muscle exercises to a degree that causes significant pain? If a patient has low grade, annoying symptoms that are only reproduced with posterior pelvic floor stretch combined with an anterior pelvic tilt and passive straight leg raise with internal rotation of the hip, then that position should be incorporated into a clinical and a home program if able.

Just because we don't yet know how patients with true pudendal nerve dysfunction present clinically in terms of nerve gliding ability, and what movements typically engage particular portions of the nerve (such as the proximal portion in the posterior pelvis, the portion that lives along the obturator internus, the portion housed by the Alcock's canal, or even the longest portion of the nerve that extends to the genitals), that does not mean we should default to a one-size-fits-all pelvic muscle strengthening or stretching approach. Each patient must be met with curiosity, and with keen knowledge of anatomy, nerve evaluation principles, and pain-brain centered skills so that an individual approach is designed. As is concluded in this post from the NOI group, we must "Keep playing with order of movement."

If you would love to fill up your toolbox with concepts and techniques for treating pudendal nerve dysfunction, sign up quickly for the last chance this year to take Pudendal Neuralgia and Treatment in San Diego this August.

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Scientists Discover Protein for Diagnosing Crohn's Disease

Scientists at the National University of Ireland in Maynooth reported the detection of a protein, Pellino3 that may stop Crohn's disease from developing. The Irish Times article, University breakthrough in fight against Crohn's disease, described the benefit as diagnostic: [Researchers] will now use the protein as a basis for new diagnostic for Crohn's and as a target in designing drugs to treat the illness.

Researchers noticed that levels of Pellino3 are dramatically reduced in Crohn's disease patients. Prof. Paul Moynagh, who led the researchers, believes that identifying Pellino3s role in Crohn's disease may lead to better treatments for other inflammatory bowel diseases.

In the United States, more than a half-million people suffer from Crohn's disease and more than a million suffer from some type of inflammatory bowel disease. Symptoms often include abdominal pain and diarrhea. These symptoms are often debilitating and even life-threatening. There is neither a known cause nor cure for Crohn's disease.

Therapy has been known as one of the few treatments that can reduce symptoms and even lead to remission.

Hopefully, this discovery will lead to further advancements in treating Crohn's disease: The findings by Prof Moynagh and his team have the potential to impact positively on many lives.

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Pelvic Floor Muscles: to Strengthen or Not to Strengthen?

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images. 

 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

 

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."  If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted. 

 

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels." 

 

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

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Endometriosis and adolescence

Recent research in The Journal of Pediatric and Adolescent Gynecology points to the alarming number of young women who present with pelvic pain who in fact also have endometriosis. Dr. Opoku-Anane and Dr. Laufer report that prevalence rates of endometriosis in an adolescent gynecology population have likely been underestimated (reported range of 25-47%) and that with advanced surgical methods the rates have been estimated to be as high as 73% in those who have pelvic pain. In their retrospective study, 117 subjects ages 12-21 completed laparoscopic examination for endometriosis. These subjects did not previously respond to non-steroidal anti-inflammatories or to oral contraceptives, and they were all referred for evaluation of chronic pelvic pain. In addition to collecting data about patient symptoms, the stage and descriptions of any endometrial lesions were documented.

A remarkable 115 of the 117 subjects (98%) presented with Stage I or II endometriosis as defined by the American Society for Reproductive Medicine guidelines. (Click here for the link to a detailed patient education document from the ASRM that describes endometriosis as well as staging.) The median age for onset of menarche in this population was 12 years old, and the median age of first symptoms reported occurred at age 13. Nearly 16% of the subjects also reported gastrointestinal complaints, menstrual irregularity in nearly 8%, and 76% of the participants reported a family history that included endometriosis, severe dysmenorrhea, and/or infertility. The authors of this research point out that advances made in surgical technique, both from a technological standpoint and a physician skill level, may be contributing factors in the increased rates of diagnosis of endometriosis.The authors also point out that it is yet unknown if early diagnosis and treatment will lead to improved outcomes in this population.

If you are interested in learning more about endometriosis in general, click here to follow the link to a free, full text article in PubMed Central. The article was first published in 2008, and even though advances in surgical diagnosis have been made, most of the information related to symptoms, medical treatment, and related risks remain significantly unchanged. In relation to etiology of endometriosis, one study that has set forth an environmental risk for endometriosis can be accessed here. Dr. C. Matthew Peterson, one of the researchers involved with the ENDO study, presented at the 2011 International Pelvic Pain Society meeting, and he encouraged all present to consider implementing strategies to minimize risks from chemicals in our daily lives. The Environmental Protection Agency offers advice towards protecting our health that can be accessed here. If environmental hazards are influencing the onset or progression of conditions such as endometriosis, it is in our best interest to reduce these risks. Consider not only the product exposure at home, but also at the workplace, and request less toxic products including cleaners when able.

In relation to pelvic rehabilitation, patients who present with pelvic pain or other pelvic health issues due to endometriosis often find relief when working with pelvic rehab providers. While surgery may be critical in reducing severe adhesions, maximizing tissue health and patient mobility and function is a job in which we can all actively participate. The evaluation and treatment of pelvic pain is instructed at various levels of depth in all of the main series courses as well as in many other courses offered at the Herman & Wallace Pelvic Rehabilitation Institute.

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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

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

Pregnancy Rehabilitation - Remote Course

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

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

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

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

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

Postpartum Rehabilitation - Remote Course (SOLD OUT)

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

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

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

Pelvic Floor Level 1 - Columbus, OH

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

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

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

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

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

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

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

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

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

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

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

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

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

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

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

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

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

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

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

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

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

Restorative Yoga for Physical Therapists - Remote Course

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

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

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

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

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

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

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

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

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

Trauma Awareness for the Pelvic Therapist - Remote Course

Aug 8, 2020 - Aug 9, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Boston, MA (RESCHEDULED)

Aug 8, 2020 - Aug 9, 2020
Location: Marathon Physical Therapy

Pediatric Functional Gastrointestinal Disorders - Pullman, WA (RESCHEDULED)

Aug 14, 2020 - Aug 16, 2020
Location: Pullman Regional Hospital

Pregnancy Rehabilitation - Remote Course

Aug 15, 2020 - Aug 16, 2020
Location: Replacement Remote Course

Pediatric Functional Gastrointestinal Disorders - Remote Course

Aug 15, 2020 - Aug 16, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Jonesboro, AR (Rescheduled)

Aug 15, 2020 - Aug 16, 2020
Location: Arkansas State University