What happens to pelvic floor muscle activation in women who have prolapse and a pessary in place? Kari Bo, an extraordinary contributor to the field of pelvic health, and colleagues in Norway investigated this question. Twenty two women (who acted as their own controls) were measured for vaginal resting pressure and maximal voluntary pelvic muscle contraction with and without a ring pessary in place.The aim of the investigation was to determine if the pelvic floor muscles could improve in activation if the prolapse was repositioned. (The authors take the reader through prior research examples to build this clinical question and theory.) Conclusions of this research indicate that having a pessary in place improved the vaginal resting pressure (VRP) but did not create a statistically significant difference in maximal voluntary contraction (MVC).

For this study, 22 women with grade II-IV prolapse (according to POP-Q) who were able to demonstrate a voluntary pelvic muscle contraction were included. Excluded were women who could not tolerate a ring pessary, those who were breastfeeding or pregnant, women with neurological or musculoskeletal disease that could interfere with ability to contract, and cases in which the prolapse was so severe that measurement with the catheter was prohibited. Maximal contractions and an endurance contraction were measured in supine. No significant difference was noted in MVC or in endurance. A higher vaginal resting pressure, however, was recorded. The authors discuss several theories to explain the increase in resting pressure, but do not provide a conclusion as to the reason for this change. Is there a length change in puborectalis that optimizes the length/tension curve, for example?

Childbirth is one of the leading causes of supportive changes in the pelvic floor, yet women have varied levels of prolapse, and not all prolapses create symptoms or functional limitations. Experienced pelvic rehabilitation therapists will likely concur that there are patients who present with a seemingly severe level of prolapse who have minimal symptoms, and vice versa. While degree of prolapse and levator plate descent has been shown to improve in response to pelvic muscle rehabilitation, women also have reported improved symptoms in the absence of significant objective changes to the level of prolapse. One clinical message that this study adds to the literature is the conclusion that a therapist may not need to have a patient remove her pessary in order to accurately test the muscles. Keeping in mind that the patients were tested in a supine position, there may be clinical relevance for assessing a patient in other positions with and without a pessary in place.

If you enjoy "nerding out" and discussing the potential clinical implications that this type of clinical research provides, you can find more discussions about pessaries in our Pelvic Floor 2B course, next happening in Chicago area in July. This course will sell out, so get your seats soon!

Posttraumatic Stress Syndrome, also known as PTSD, is an unfortunate consequence of many women's birth experiences. While there are known risk factors, there is not currently a standardized screening method for identifying symptoms of PTSD in the postpartum period. One recent meta-analysis of 78 research studies identified a prevalence of postpartum PTSD as 3.1% in community samples and as 15.7% in at-risk or targeted samples. Risk factors for PTSD included current depression, labor experiences (including interactions with medical staff), and a history of psychopathology. In the targeted samples, risk factors included current depression and infant complications. Other authors have explored the relationships between preterm birth and PTSD, preeclampsia or premature rupture of membranes, and infants in the neonatal intensive care unit.

One of the main concerns of failing to identify and treat for PTSD in the postpartum period is the potential negative effect on the family. High levels of anxiety, stress, and depression may impact not only the mother's health, but also may affect her ability to meet her new infant's needs, or complete usual functions in work and home life. One study suggested that "…maternal stress and depression are related to infants’ ability to self-sooth during a stressful situation." Clearly, healthy moms promote healthy families, and each mother deserves the attention that her new infant often receives from the world!

How can we be a part of the solution? We have previously posted on the blog about screening for depression in the postpartum period. The US Department of Veterans Affairs lists multiple screening tools for PTSD as well. Here's another bit of exciting news: yoga has been identified as a method to reduce symptoms of PTSD. In a randomized, controlled clinical trial, the treatment arm was given 10 weeks (1x/week at 1 hour sessions) of "trauma-informed" yoga, whereas the control group was given information about women's health and self-efficacy in various domains. Interestingly, while both groups showed positive effects from intervention in the first half of the treatment, the yoga group maintained the improvements during the latter half of the study, while the control group relapsed.

You can learn about yoga for postpartum mothers, and learn how to integrate strategies to help heal postpartum symptoms of PTSD this summer at Ginger Garner's Yoga as Medicine for Labor & Delivery and Postpartum. The continuing education course takes place in Seattle, and we still have a few spots left! Don't miss this chance to add more amazing tools to your toolbox in support of women of any postpartum age.

What is a hymenectomy, and how does it relate to pelvic rehabilitation? To answer this question, an understanding of hymenal anatomy is useful. The hymen is tissue that lines and sometimes covers the vaginal opening. This layer of tissue can be thick or thin, and can have a variety of presentations based on embryological development such as micro perforations, bands, or septa which create distinct openings into the vaginal canal. During menstruation, having an opening through the hymen is critical so that menstrual discharge does not become blocked, and sexual function is optimized when the hymen does not create any narrowing or blockage. When the hymen completely covers the vaginal opening the condition is known as "imperforate hymen." Sometimes this anatomical variation is noticed during neonatal and early childhood examinations, unfortunately, the condition may also be undiagnosed.

Prior to her first gynecological examination, an adolescent female may be at risk for consequences of an imperforate hymen. Depending on the hymenal variation, a young female may experience urinary dysfunction or vaginal infection, but more typical is recognition of the issue when her menstrual cycle begins. Case reports in the literature describe the condition as presenting clinically as low back pain, or as abdominal pain.Complaints that may increase our suspicion about the condition in an adolescent patient may include amenorrhea, abdominal mass, abdominal pain, urinary retention, or constipation.

While it may be uncommon for us to encounter an adolescent with back or pelvic pain who has not been screened by a medical provider, knowing about the condition adds to our toolbox for medical screening. We may also meet patients who are referred to the clinic following a hymenectomy, a surgical procedure that removes all or part of a woman's hymen. In asymptomatic patients who have an imperforate hymen, a surgical procedure may be delayed until puberty, when estrogen's effects on the tissues may negate the need for a procedure. Click here to view basic images of the procedure, and here to access a Medscape article with further details about epidemiology, pathophysiology, and relevant anatomy.

Unfortunately, we know that patients frequently lack a referral for conservative care for pelvic pain or dysfunction that may arise from hymenal dysfunction or surgeries. One of my most memorable and endearing patients told me her horrifying memory of having a hymenal procedure as a young child without any anesthesia.Is that the reason that she developed severe pelvic muscle dysfunction in adulthood? While we can only speculate about this connection, the more we know about a patient's history and how the reported complaints may link to dysfunction, the better. If you would like to know more about hymenectomies and other special topics, come to California, Illinois, or Connecticut this year for one of our PF3 courses to hear from experts Holly Herman and Lila Abbate.

During the postpartum period, not only is a new mother adjusting to the needs of her infant, she is also recovering mentally, physically, and emotionally. Physical challenges can include fatigue, back pain, and healing abdominal or perineal wounds. Emotionally, women are also at increased risk for depression and anxiety which may negatively impact health of the mother and infant.

Recent research evaluated 6 clinical guidelines from the United Kingdom, Australia, and the United States for the postpartum period. (The authors point out that maternity care in these countries varies.) The guidelines fit into four main themes: maternal health, maternal mental health, infant health, and breastfeeding. Only 1 of the guidelines was deemed to have enough detail to provide data about both the mother and the infant that would guide the provider regarding care. The article states that "…scarcity of comprehensive guidelines for mothers and infants is a concern because of the stress many women experience at this time, the high burden of maternal morbidity postpartum and the significant interplay between the health of the mother and infant."

This information is valuable to the rehabilitation provider as we work with women in the postpartum period. We can initiate conversations about a woman's energy levels, sleep, and nutrition. We can inquire politely about her infant, about breastfeeding and support that she has at home. Our patients can be encouraged to discuss any concerns or anxieties about her healing or about parenting. If we do not know the answer, we can seek resources or recommend that the patient consult her healthcare team. Many women are not sure how they should be feeling, physically or emotionally, and the new mother should be reassured that any concerns she has are valuable issues to discuss. If she knows that you care about her symptoms and questions, she is more likely to express concern or share information that can help guide care, including referrals to appropriate providers.

The Peripartum series is designed to help the therapist learn about prenatal and postpartum care. Join faculty member Allison Ariail at Houston in June.

Postpartum mothers are often juggling intense schedules: infant feeding, mealtimes for other family members, work both in and outside of the home, and there is scarce time for self-care. Throw in the typical postpartum fatigue, potential for postpartum depression, adjustment to parenting or adding another child to a family, risk for weight retention, and the ability of a new mom to resume or begin exercises can be beyond daunting. An additional complication arises when a woman has been on bed rest, as she has lost muscle mass and cardiorespiratory function and endurance. How can we best set up a new mother for success?

Research published in the journal Clinical Sciences reports that regardless of exercise intensity, women receiving postpartum intervention experience health benefits. If a woman is unable to reduce the weight gain that occurs in pregnancy, by 6 months postpartum she will have increased risk factors for developing chronic disease, according to the authors. In the study, 20 women were instructed in nutrition advice and low intensity (30% heart rate reserve (HRR)) and another 20 women women were instructed in nutrition advice and moderate intensity(70% HRR) exercise. A group of controls (n = 20) was included and matched for BMI, age and parity.

The exercise program included supervised walking for 45 minutes, 3-4 times per week for 16 weeks. In order to achieve the target heart rate, some women walked with or without a stroller, or with a double stroller with added weight. The participants attended a supervised exercise session at least one time per week, and the first session was limited to 25 minutes, including a 5 minute warm-up and 5 minute cool down. Sessions were increased by 5 minutes per week up to a 45 minute limit. Pedometers were administered, home exercise logs were used to record distance when not in the clinic. and food intake diaries were completed. Each woman met with a nutritionist to be given a program that met her caloric needs and allowed for weight loss as appropriate. Women were screened for chronic disease at 7-8 weeks postpartum and again at 23-25 weeks postpartum.

Regardless of exercise intensity, both intervention groups lost body mass, had decreases in plasma low-density lipoprotein, and had reduced glucose and adiponectin concentrations, all positive changes for reducing chronic disease risk. As hypothesized, the control group did not experience the same positive changes. Here's the bad news: hanging on to increased BMI and low activity levels in the postpartum period can lead to lack of health. The good news: low-intensity walking programs and nutrition advice can improve risk factors for chronic disease. Many women may think they have to exercise at moderate intensity, 5-7 days per week, and while there may be additional fitness benefits from increased exercise intensity, our first goal for patients can be overall health versus fitness.

How do we get new moms into exercise? Make it reasonable, fun, social! Hold postpartum fitness classes at your clinic or at a local center. Teach the women who are in your care about wellness principles, or offer a community lecture. If you want to learn more about postpartum fitness classes, the topic is discussed in the Care of the Postpartum Patient and in Postpartum Special Topics. The next Postpartum class happens in early April, so check out the website for details!

Within the evaluation process for pelvic muscle health, a woman is often asked to "bear down" so that the examiner can assess muscle coordination. This maneuver is also utilized during assessment for prolapse or pelvic organ descent. Clinically, the patient's ability to perform a lengthening or bearing down is quite varied, depending upon many factors such as levator plate resting position, strength and coordination, childbearing status, and comfort with the maneuver. What are the implications of not being able to bear down? An interesting study published in 2007 concluded that women, when asked to perform a Valsalva maneuver (a forced expiration against a closed glottis), frequently co-contracted the levator ani muscles.

Participants included 50 nulliparous women between 36-38 weeks gestation and they were assessed with translabial 3D/4D ultrasound following emptying of the bladder. In almost half of the subjects, a pelvic floor muscle contraction was noted during the attempted Valsalva. Patients were provided with visual biofeedback to train the levator muscles to avoid a concurrent contraction, and despite the training, 11 of the 50 women were still unable to avoid a co-activation. (Keep in mind that for purposes of assessment, the prolapse would be best imaged or viewed if the levator muscles were not tightening.) For this reason, the study concludes that levator muscle co-activation is a significant confounder of pelvic organ descent. While a contraction of the pelvic floor muscles may be a positive, protective action when thoracic pressure is increased, a woman's degree of prolapse or pelvic organ descent may appear diminished during an examination. The authors of the study conclude that a clinician may have a false-negative finding for prolapse in the presence of strong, intact pubovisceral muscles.

This research highlights the value of being able to coordinate pelvic muscle activity with the trunk and with breathing. What is also very interesting is that the 50 women studied were all in late third trimester of pregnancy when assessed. Does the population studied have carry-over to non-pregnant women, or women who have never been pregnant? Does the co-contraction exist at the same rates for nulliparous, non-pregnant women? How will the lack of coordination for bearing down during increased trunk pressure affect labor and delivery? Is there a role for pelvic rehabilitation providers in assisting women who have difficulty coordinating the muscles of the trunk and pelvis prior to delivery? To the last question, I would answer "yes" when considering the women who have been referred to pelvic rehabilitation prior to labor and delivery. Having the opportunity to lengthen a tight, shortened pelvic floor, strengthen, alleviate pain in tissues from prior scars or from tension, and to improve confidence about the body's ability to perform the function of bearing down for childbirth can be a very positive preparation for a woman's childbirth experience.

For all the other research ideas that this article generates, we can see that many unanswered questions remain. Even when the research points us in valuable directions, having the skills to assess the patient to find out what is needed in her particular case is critical. For further refining of pelvic muscle assessment techniques, including skills for assessing and treating prolapse and pelvic organ descent, the Pelvic Floor Level 2B continuing education course offers lectures and labs. PF2B is next offered in early March in Oregon, and later this year in Illinois, North Carolina, and Missouri.

Psychological distress and cognitive impact are common sequelae of a cancer diagnosis, even once a patient is considered disease-free. Fear of cancer recurrence or progression is a significant issue for many patients, and can have severe impacts on a patient's well-being and function. Research published in August of last year describes predictors of this fear of recurrence, or FOR, in almost 1300 patients who completed a range of validated measures. The study reports that patients within a lower social class, this with skin cancer, colon or blood cancer, palliative treatment intention, pain, an increased number of physical symptoms, depression, and decreased social support were at higher risk of having fear of cancer.

Fear and psychological distress could potentially impact a patient's life in many ways, and also may have an effect on a patient's ability to maximally participate in recommended rehabilitation. If a patient is experiencing anxiety and/or depression, getting out of the house, making it to appointments on time, and participating in health programs may be very difficult. Cognitive impact from treatment or from psychological stress can also make remembering a home program or other instruction from you very challenging. What are things we can do to support a patient who has been impacted by a diagnosis of prior cancer? We can ask some simple questions…

What if we, as rehabilitation experts, acknowledged this research and simply asked the patient if fear of cancer recurrence or progression was creating any struggles for him or her? We already inquire about pain and physical symptoms, so can we link a reduction in physical symptoms to reduced psychological distress? Reducing pain and improving function is a logical way for us to have a positive impact. We can also screen a patient for the FOR risk factors mentioned in the literature, and ask if the patient has noticed some changes in the way information is processed or retained since having treatment for cancer. Knowledge that the patient experiences quick mental fatigue is valuable when designing home programs or when teaching important concepts; a therapist could use brief, repeated instruction rather than one long explanation. If a patient describes significant distress, discussing referral options is another way in which rehabilitation providers can serve our patients.

A Cochrane summary that was updated last in 2012 confirmed that a regular physical examination and annual mammogram are as effective as "more intense methods" of exam in detecting a cancer recurrence. If fear of recurrence prevents a patient from wanting to schedule a medical follow-up, we can encourage a patient to make any recommended medical appointments so that changes in health status are caught as early as possible. For further discussions in caring for patients who have experienced cancer, the Pelvic Rehab Institute offers Rehabilitation for the Breast Oncology Patient as well as Oncology and the Pelvic Floor, Parts A and B. The breast oncology course is taking place next month in San Diego, and the pelvic floor oncology (female) course is scheduled for June in Orlando!

A recent article published in the Evidence Based Women's Health Journal reports on the use of transcutaneous electric nerve stimulation (TENS) for labor pain. The study was carried out in a teaching hospital in Cairo, Egypt, and involved 100 subjects divided into a treatment group (TENS application) and a control group (intramuscular pethidine 50-100 mg.) Pain assessment was completed by a visual analog scale (VAS) and a postpartum satisfaction questionnaire 48 hours after birth. Outcomes included relief of labor pain, duration of first stage of labor, labor augmentation, mode of delivery, fetal outcome, and adverse event reports. Patients were excluded in the following cases: cephalopelvic disproportion, multiple gestations, presence of a cardiac pacemaker, known congenital abnormalities, in the presence of complications such as preeclampsia, antepartum hemorrhage, and fetal asphyxia.

TENS was applied in the paravertebral area, between T10-L1 and S2-S4 at the time in labor when the woman experienced regular, painful contractions. In the control group, a gluteal intramuscular injection of meperidine hydrochloride (opioid analgesic) was applied every 4 hours or more as needed. For more details about the methods and results you can see the full text article by clicking here.

This randomized, controlled trial had groups similar in maternal age, gestational age, and parity. Results included both groups having a significant decrease in pain scores. However, the satisfaction surveys demonstrated a dramatic difference with the TENS group at 83% satisfaction rate, and only 10% in the control group. Reasons cited for dissatisfaction with the medication used by the control group included side effects of drowsiness, nausea and vomiting. Other results included decrease augmentation of labor needed in TENS group, mode of delivery and length of first stage of labor was similar among groups. Very compelling is the fact that Apgar scores were significantly higher in the TENS group despite all infants being healthy.

While it is appropriate and necessary to use caution when applying modalities with patients who are pregnant, this study offers further support about the efficacy of TENS for pain control in labor, and furthermore, this research highlights the perceived value of TENS use via satisfaction reports. (For a fantastic site to find evidence-based, current information about modalities, go to Tim Watson's website at www.electrotherapy.org) A woman's right to have a birth that is safe for her and her baby, with the added element of pain relief options that a laboring woman can choose for herself is critical. Healthy pregnancy, labor and delivery is a mission that the Pelvic Rehabilitation Institute includes in our mission, and Institute co-founder Holly Herman has led the field in educating therapists about peripartum rehabilitation across the United States (and now the world!) for decades.

This year we unveiled the Peripartum course series, designed by Holly Herman and faculty members Jenni Gabelsberg, Michelle Lyons, and Holly Tanner. Come join us at one of the courses focusing on Pregnancy, Postpartum, or Special Topics. Your next opportunity for each can be found here. We still have a few seats in the Care of the Pregnant Patient course in April in Illinois, Care of the PostpartumPatient course in March in California, and the next chance to take Peripartum Special Topics is in Texas in October.

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy Robinson, PT, PRPC, CLT.

What/who inspired you to become involved in the pelvic rehabilitation field?:

I first learned about pelvic rehabilitation while I was a student at the Indiana University Physical Therapy program. The instructor brought in speakers for special topics sessions and I must admit I knew at that moment that pelvic rehab was an area of interest for me. However, I was hesitant to start in the area of pelvic health as I felt I needed to gain experience as a new graduate, and I also wasn’t sure I would feel comfortable performing pelvic examinations. I chose to work in a hospital setting for one year, a long term care setting for 2 years, and then transitioned into outpatient physical therapy. There were numerous times in each of those settings that it was apparent pelvic rehabilitation was the missing link in the patients’ treatment plan. In 1998 we had a physician, Dr. Scott Miles, approach the president of the rehabilitation company that I worked for and request that they train a women’s health physical therapist. This was my opportunity and I took my first course with Kathe Wallace, PT. I remember thinking that she was a wealth of knowledge and her enthusiasm allowed me to get over the trepidation of performing pelvic examinations. She allowed me to focus on the examination process itself, how to apply critical thinking to the patient symptoms and evaluation findings, and how to pick the appropriate treatments. I was hooked! I feel very blessed to have had the opportunity to participate in several continuing education courses all over the country from so many very talented Pelvic Health Practitioners and each and every one of them have inspired me in some way to continue to learn and perfect my skills as a pelvic practitioner.

What patient population do you find most rewarding in treating and why?

I truly enjoy treating patients who have a diagnosis of pelvic pain. There are so many different types of pelvic pain and the complexity of the cases fascinate me. I thrive on working together as a team with my client to identify the issues at the root of their pain. There are no two pelvic pain patients who are alike which allows me to create an individualized plan for each patient. It is always very rewarding when a patient who has been suffering with pain for years meets their therapy goals, has the knowledge to self treat, and can complete ADLs and work functions, all being done without pain limiting them.

What role do you see pelvic health playing in general well-being?

Pelvic health affects women and men across the life span. The core musculature must activate correctly in order to maintain function. I continually explain to my patients that the pelvis is similar to the foundation of a house. If the foundation is not laid correctly in a house, the doors and windows don’t open and close as they should and the floors will not be level. In the pelvis if the alignment is not correct, the musculature and ligamentous systems cannot function optimally which leads to injury, pain, and an overall decrease in function over time. Pelvic health should be addressed on the medical history portion of the intake paperwork for all patients who attend physical therapy. If the medical history identifies potential issues with pelvic health, a referral should be made to a qualified pelvic practitioner.

What motivated you to earn PRPC?

I think it is critical in today’s market to be able to identify yourself as a practitioner who has taken the time and made the effort to truly understand such a complex area of the human body. Several years ago when Women’s Health became the hot topic, I noticed there were several hospitals and therapy companies that were sending Physical Therapists to one course and then marketing that they had a Women’s Health program. Unfortunately, this issue continues today and there are so many women and medical practitioners who feel that pelvic rehabilitation is a waste of time and money due to the poor outcomes they have had while under the care of unqualified pelvic practitioners. There are many days in my practice that I evaluate patients who on average have seen 10 different physicians and two pelvic practitioners and still have experienced little to no relief of their symptoms. I feel earning PRPC allows medical practitioners and potential clients feel more confident in my skill set.

Learn more about Amy Robinson, PT, PRPC, CLT at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

This post was written by H&W faculty member Peter Philip, who developed a course on chronic pelvic pain and differential diagnosis for the Institute.

The gut "has a mind of its own." The nervous system within the gut, also called the enteric nervous system (ENS), is located within the sheaths of tissue lining the esophagus, stomach, small intestine and colon. This network consists of neurons, neurotransmitters and proteins that have the distinct capacity to function quite independently. The system can also learn and remember; the joys and sadness that one experiences throughout the day are often reflected within the functional integrity of the enteric nervous system.

Anatomically, the enteric nervous system is connected to the central nervous system via the vagus nerve. “Command neurons” from the brain communicate with the interneurons of the enteric nervous system via the myenteric and the submucosal plexuses. These command neurons together with the vagus nerve, monitor and control the activity of the gut. The ENS is responsible for motility, for ion transport, gastrointestinal (GI) blood flow, and is associated with secretion and absorption. Sensors for sugar, protein, and acidity are a few of the ways that the contents of the gut are monitored within the system.

The enteric nervous system contains 100 million neurons- more neurons than in the spinal cord! Neuropeptides and other neurotransmitters such as serotonin, dopamine, glutamate, norepinephrine and nitric oxide are located within the enteric nervous system. During stressful situations, stress hormones are released in the stereotypical fight-or-flight response, which in turn stimulate the sensory nerves of the ENS, leading to what is experienced as the “butterflies”. Fear also amplifies the release of serotonin leading to a hyperstimulation and resulting in diarrhea. The common experience of “choking under stress” can occur due to stimulation of the esophageal nerves.

Medications and drugs will often have unforeseen consequences on the enteric nervous system, and this is an important fact to consider in patient care. Drugs such as Prozac act by preventing serotonin uptake, which leaves the neurotransmitter at abundant levels in the central nervous system (CNS.) In small concentrations, this effect can cause a hastening of gut motility, and in greater concentrations, motility can be paradoxically retarded. Antibiotics can also impact the receptors of the ENS and produce oscillations, creating symptoms of cramping and nausea. The ENS is responding to stress by increasing secretions of histamines, prostaglandin, and other pro-inflammatory mediators. The purpose is protective in nature, because the brain is preparing the GI for mechanical insult, yet the unfortunate secondary effect is also that of diarrhea and cramping.

Fully understanding the neural integration of the ENS with the CNS, and where along the spinal column afferent information terminates is helpful in understanding our patients who suffer with pelvic and digestive pain. Through the integration and understanding of embryogenesis, the clinician will have a more clear understanding of how and where to apply treatments for optimal pain reduction and restoration of function. During the course, Differential Diagnosis of Chronic Pelvic Pain, the participants will learn about the enteric nervous system's relationship to the central nervous system, and much more!