Postpartum Exercise: Keepin it Real(istic)

Postpartum Exercise: Keepin it Real(istic)

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?

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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!

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Valsalva and the Pelvic Floor

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.

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Cancer and Fear- The Role of the Rehab Provider

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!

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TENS in Labor: What's New?

TENS in Labor: What's New?

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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.

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Amy Robinson, PT, PRPC, CLT - Featured Certified Pelvic Rehabilitation Practitioner

Amy Robinson, PT, PRPC, CLT - Featured Certified Pelvic Rehabilitation Practitioner

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

Amy Robinson

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.

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Pelvic Pain and Enteric Nervous System

Pelvic Pain and Enteric Nervous System

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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!

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Balloon-assisted Training in Dyssynergic Defecation

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness. Surface electromyography (sEMG a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia.

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation.

One study that compared biofeedback training to balloon-assisted training found that biofeedback was more effective in training patients for reduction of constipation. 65 patients, 49 women and 16 men, were included and were diagnosed with constipation and dyssynergia. In the balloon training (n = 31 patients were trained to expel the balloon with increased abdominal pressure and relaxed PFM, whereas in the biofeedback group (n = 34 the patients were trained to relax the pelvic floor muscles while increasing abdominal pressure. The good news is that while the biofeedback group reported higher levels of success in emptying, both groups reported positive effects of their training, with improved amount of stool passed, decreased maneuvers required to empty the bowels, and decreased time needed to defecate.

If you would like to learnabout sEMG for bowel dysfunction, sign up for the Pelvic Floor series 2A continuing education course. We are sold out for the rest of the year for PF2A, and the next opportunity to take the course will be next March in Madison, Wisconsin, or May of 2015 in Seattle. If you want to learn how to use balloon-assisted re-training techniques, you still have an opportunity this year to get into a course. Faculty member Lila Abatte has developed the Bowel Pathology, Function, Dysfunction, the Pelvic Floor course that still has seats left for the November, Torrance, California course.

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Nutrition and Healing

Nutrition and Healing

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Pelvic rehabilitation providers typically evaluate basic nutritional influences on a patient's bowel and bladder function. Instructing in dietary irritants, adequate and appropriate fluid intake (more water, less soda, for example and in the importance of whole foods and fiber's effects on the bowels is commonly included in a rehabilitation program. Although most therapists are not nutritionists, this level of patient education frequently improves a patient's function significantly, and has little potential for harm in the absence of medical conditions that may require fluid restriction, or avoidance of particular foods.

What is known about the impact of diet on commonly treated conditions? Consider interstitial cystitis, also known as painful bladder syndrome, and the varied experiences our patients report: for some, diet limitations dramatically control a patient's flare-ups, for others, there appears to be no rhyme or reason to diet and dysfunction. For patients who have irritable bowel syndrome (IBS research has suggested that a diet low in FODMAPS (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) may reduce the pain, bloating, and gastrointestinal symptoms in general. Other research describes the positive effect of the oligo-antigenic, sometimes described as a "severe" elimination diet, on the healing of chronic anal fissures.

The impact of nutrition on health and healing extends far beyond bowel and bladder dysfunctions as described above, but what is fact and what is fiction? Does the basic sciences research support the claims about nutrition's affects on pain and pelvic health? When is a pelvic rehabilitation provider obligated to refer a patient to a nutritionist or other provider? What resources are available to the clinician and to the patient when additional supportive services are not available? The Pelvic Rehabilitation Institute is thrilled to offer answers to all of the above questions through a new continuing education course on Nutrition Perspectives for the Pelvic Rehab Therapist that was written by Megan Pribyl, a physical therapist who also holds a dual-degree in nutrition and exercise sciences. From basic sciences, gastrointestinal anatomy, high-level functional nutritional concepts, to practical applications for the pelvic rehabilitation therapist, this course can provide the clinician with updated knowledge about the relationships and influences of nutrition on healing.

This course will be offered in Seattle, WA at the end of August- the perfect time to plan one last trip before back-to-school!

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New Care Guidelines for Prostate Cancer Survivorship

New Care Guidelines for Prostate Cancer Survivorship

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According to the American Cancer Society, approximately 233,000 new cases of prostate cancer will be diagnosed this year, and nearly 30,000 men will die from the disease. The diagnosis and treatment of prostate cancer in the United States has experienced significant shifts in the past few years, making management of cancer survivors challenging. One of the big changes in prostate cancer screening took place in 2011; the US Preventive Services Task Force recommended against routine prostate specific antigen, or PSA testing due to the level of potential harm such as psychological distress and complications from the biopsy. You can read a prior post about that here. New guidelines for providing care to prostate cancer survivors have been published by the American Cancer Society so that providers can better identify and manage the side effects and complications of the disease and recognize appropriate monitoring and screening of survivors.

In patients younger than 65 years of age, radical prostatectomy surgery is the most common intervention for prostate cancer. Long-term side effects of radical prostatectomy commonly include, according to the guidelines, urinary and sexual dysfunction. Urinary incontinence or retention can occur following prostatectomy, and sexual issues can range from erectile dysfunction to changes in orgasm and even penile length. Other common treatments, such as radiation and androgen deprivation therapy, are also related to urinary, sexual, and bowel dysfunction, as well as a long list of "other" effects.

These guidelines were developed using evidence as well as expert recommendations. Topics covered include obesity, physical activity, nutrition, smoking cessation, and surveillance. BMI as a baseline measure is recommended as a screening tool because elevated BMI is associated with poorer health outcomes. Increased physical activity can be related to higher quality of life and general benefits in cardiorespiratory health and physical function. Exercise recommendations are for 150 minutes/week of moderate intensity exercise or 75 minutes/week of vigorous intensity physical exercise. Nutrition suggestions include eating a diet that is rich in vegetables, fruits, and whole grains. Because smoking after prostate cancer increases the risk of recurrence, therapists should discuss the benefits of smoking cessation.

All of the above issues concern pelvic rehabilitation providers; patient concerns about sexual heath, urinary and bowel health, and subsequent pain in the abdomen or pelvis following treatment for prostate cancer are all conditions that can be positively influenced in the clinic. All of the lifestyle and wellness recommendations are ones that can be reinforced in pelvic rehabilitation, and patients can be referred for more specialized education when needed. To learn more about the care of men following prostate cancer, come to Male Pelvic Floor Function, Dysfunction, & Treatmentcontinuing education course in October in Tampa. Also, stay tuned for an announcement about our new Rehabilitation of the Post-Prostatectomy Course coming in 2015! (Send us an email if you are interested in hosting the new continuing education course that will focus on post-prostatectomy (and related issues) recovery!)

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Why 1x/week?

Why 1x/week?

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In pelvic rehab, if you ask therapists from around the country, you will most often hear that patients with pelvic dysfunction are seen once per week. This is in contrast to many other physical therapy plans of care, so what gives? Perhaps one of the things to consider is that most patients of pelvic rehab are not seen in the acute stages of their condition, whether the condition is perineal pain, constipation, tailbone pain, or incontinence, for example.

The literature is rich with evidence supporting the facts that physicians are unaware of, unprepared for, or uncomfortable with conversations about treatment planning for patients who have continence issues or pelvic pain. The research also tells us that patients don't bring up pelvic dysfunctions, due to lack of awareness for available treatment, or due to embarrassment, or due to being told that their dysfunction is "normal" after having a baby or as a result of aging. So between the providers not talking about, and patients not bringing up pelvic dysfunctions, we have a huge population of patients who are not accessing timely care.

What else is it about pelvic rehab that therapists are scheduling patients once a week? Is it that the patient is driving a great distance for care because there are not enough of us to go around? Do the pelvic floor muscles have differing principles for recovery in relation to basic strengthening concepts? Or is the reduced frequency per week influenced by the fact that many patients are instructed in behavioral strategies that may take a bit of time to re-train?

Pelvic rehabilitation providers are oftentimes concerned about the plans of care (POC) being once per week not because patients always need more visits, but because insurance providers are accustomed to seeing a POC with ranges of 2-3 visits per week, and in some cases, even 4-7 visits per week, based upon diagnosis, facility, and patient needs. To justify and support our once per week POC, we need only look to research protocols, to clinical care guidelines, and to clinical recommendations and practice patterns of our peers. For the following conditions, most of the cited research uses a once per week (or less) protocol or guideline:

Braekken et al., 2010: randomized, controlled trial with once per week visits for first 3 months, then every other week for last 3 months.

Croffie et al., 2005: 5 visits total, scheduled every 2 weeks.

Fantl & Newman, 1996: Meta-analysis of treatment for urinary incontinence, recommends weekly visits.

Fitzgerald et al., 2009: Up to 10 weekly treatments (1 hour in duration) was used in the largest randomized, controlled trial of chronic pelvic pain.

Hagen et al., 2009: Randomized, controlled trial using an initial training class, followed by 5 visits over a 12 week period.

Terra et al., 2006: Protocol used 1x/week for 9 weeks.

Weiss, 2001: 1-2 visits per week for 8-12 weeks.

Vesna et al., 2011: Children were randomized into 2 treatment groups with 1 session per month for the 12 month treatment period.

 

While not every patient is seen once per week in pelvic rehabilitation, Herman & Wallace faculty can tell you that once a week is the most common practice pattern observed for urinary dysfunction, prolapse, and pelvic pain. Certainly, a patient with an acute injury, a need for expedited care (limited insurance benefits, goals related to upcoming return to work or travel plans, or insurance expectations that dictate plan of care) may lead to frequency of visits that are more than once per week.

If you are interested in learning more about treatment care plans for a variety of pelvic dysfunctions, sign up for one of the pelvic series courses, and for special populations such as pediatrics, check out the Pediatric Incontinence continuing education course taking place in South Carolina at the end of this month!

References

Braekken, I. H., Majida, M., Engh, M. E., & Bo, K. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randominzed, controlled trial. American Journal of Obstetrics and Gynecology, 203(2), 170.e171-170.e177. doi: 10.1016/j.ajog.2010.02.037

Croffie, J. M., Ammar, M. S., Pfefferkorn, M. D., Horn, D., Klipsch, A., Fitzgerald, J. F., . . . Corkins, M. R. (2005). Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes. Clinical pediatrics, 44(1), 63-71.

Fantl, J., & Newman, D. (1996). Urinary incontinence in adults: Acute and chronic management. Rockville, MD: AHCPR Publications.

FitzGerald, M. P., Anderson, R. U., Potts, J., Payne, C. K., Peters, K. M., Clemens, J. Q., . . . Nyberg, L. M. (2009). Adult Urology: Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes. [Article]. The Journal of Urology, 182, 570-580. doi: 10.1016/j.juro.2009.04.022

Hagen, S., Stark, D., Glazener, C., Sinclair, L., & Ramsay, I. (2009). A randomized controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse. International Urogynecology Journal, 20(1), 45-51. doi: 10.1007/s00192-008-0726-4

Terra, M. P., Dobben, A. C., Berghmans, B., Deutekom, M., Baeten, C. G. M. I., Janssen, L. W. M., ... & Stoker, J. (2006). Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients. Diseases of the colon & rectum, 49(8), 1149-1159.

Weiss, J. M. (2001). Clinical urology: Original Articles: Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. . [Article]. The Journal of Urology, 166, 2226-2231. doi: 10.1016/s0022-5347(05)65539-5

Vesna, Z. D., Milica, L., Stankovi?, I., Marina, V., & Andjelka, S. (2011). The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding. Journal of pediatric urology, 7(3), 336-341.

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