This post was written by H&W instructor Ramona C. Horton, MPT. Ramona will be instructing the courses that she wrote on "Visceral Mobilization" this month.
A recent blog post on NPR highlighted an innovative option for dealing with the exorbitant cost of infertility treatment. According to The American Society of Reproductive Medicine (ASRM) the average price of an in vitro fertilization (IVF) cycle in the U.S. is $12,400. Perhaps physical therapist can offer an alternative to these high costs as well.
In a case series recently published in the journal of the American Osteopathic Association 10 infertile women were treated with 1 to 6 sessions of manual therapy applied to the pelvic region by a physical therapist. Techniques included muscle energy, lymphatic drainage, and visceral mobilization. Six of the 10 women conceived within 3 months of the last treatment session, and all 6 of those women delivered at full term. The important thing to note is that fecundancy rates over 3 months in a normal population is 57%. Current literature estimate that 30-50% of infertility can be linked to mechanical causes.
The author of this study is currently collaborating with Herman & Wallace faculty member and developer of the visceral mobilization and myofascial curriculum Ramona Horton on an innovative research project to further document the effectiveness of physical therapy intervention in the field of infertility. The study MISS, Mechanical Infertility Systematic Study: a Randomized Multicenter Trial of Manual Therapy Interventions for Females with Somatic Pelvic Dysfunction and Infertility has been submitted for its initial funding grant through the APTA. MISS will be a randomized clinical trial comparing pelvic manual therapy (PMT) to global massage therapy (GMT) over a 3 month treatment period. At the time of this writing, 15 therapists at multiple sites have completed the training to participate as a researcher in MISS. The infertility protocol that will be utilized in MISS is a component of the visceral mobilization for the reproductive system course. Stay tuned for more information on the progress of MISS, the goal is to have as many as 25 sites participating.
This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Pelvic Floor Level 1 course Boston this October.
Several weeks ago some of my fellow faculty members and I were discussing the resting tone of the pelvic floor. These days we take it for granted that we know there is constant low-level activity in the pelvic floor and anal sphincter in order to provide continence. However, how did this information come about? I took it upon myself to do some research to find out the beginnings of this knowledge. What I found was interesting and thought I would share.
In the late 1940’s and early 1950’s the belief was held that the pelvic floor and external anal sphincters were inactive at rest, like other striated muscle throughout the body. Activity was believed to be initiated by afferent impulses from the rectal ampulla and anal canal. In 1953 Floyd and Walls found activity in the external anal sphincters at rest, even during sleep. In 1962 Parks, Porter, and Melzak published a study examining the pelvic floor muscles and the external anal sphincters using electromyography recordings. They also found activity in these muscles at rest. They hypothesized the activity was maintained by spinal reflex. These researchers looked at the activity in a healthy population, a paraplegic population, and a population that had undergone a rectal excision. When examining the paraplegic population (all subjects had complete SCI injuries above L3), they did identify activity of the pelvic floor at rest.
With respects to the rectal excision population, they examined patients whose rectums were removed, but the somatic muscles, external sphincters, and the levator ani remained with innervation intact and the muscles were sutured to provide a muscular pelvic floor. These patients also exhibited activity in the pelvic floor and anal sphincter at rest. These patients were important to the study in order to rule out that the reflex was not coming from somewhere in the rectal wall. Additionally, these researchers discovered this resting activity that was present the anal sphincter was inhibited during defecation in response to a certain degree of rectal distension.
So what did all of this new information mean to these researchers? It meant that the pelvic floor and external anal sphincter were unique due to the fact they were activated at rest, and without this activation continence would not be maintained. They determined the activation to be reflex and termed it “postural reflex of the pelvic floor.” Additionally, they termed the inhibition due to rectal distension “the rectal inhibitory reflex,” which also was due to a reflex arc. This new information was groundbreaking for the time and lead to other research that provided us with the knowledge that we have today! Thank goodness for these researchers as well as the many others who have furthered the advancement of knowledge about the pelvic floor!
Learn more about Allison and the Pelvic Floor Series by visiting our website!
1. Floyd, Walls. Electromyography of sphincter ani externus in man. J. Physiol. 122: 599, 1953.
2.Parks, Porter, Melzak. Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis. Colon Rectum. 5 (6): 407. 1962.
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Kathleen Novicki PT, PRPC
What makes you the most proud to have earned PRPC?
I have logged countless hours researching, studying, practicing, developing, teaching and contemplating the field of pelvic rehabilitation. I am so proud to have an official recognition of my expertise and knowledge.
What advice would you give to physical therapists interested in earning PRPC?
The Pelvic Rehabilitation Practitioner Certification is important to recognize those professionals that have put the time, energy and effort into truly becoming an expert in the field of pelvic rehabilitation. It is beneficial to our practice. It is beneficial to our patients. It is a reward to you for all that you will or have invested into your profession.
Describe your clinical practice:
My private practice is The Center for Pelvic Floor and Core Rehabilitation. My growing practice at this time includes 4 Physical Therapists, 2 Physical Therapist Assistants and a Massage Therapist. We only treat pelvic related disorders of both men and women. We service the greater Cincinnati area with 7 locations. My practice emphasizes evidence based, one on one evaluation and treatment of pelvic disorders.
How did you get involved in the pelvic rehabilitation field?
I opened my private practice in 1988, (Sports Therapy, Inc.) treating orthopedic and sports related disorders. I received a significant amount of patients suffering from SIJ disorders and/or pelvic pain from area Gynecologists. I felt I needed more information to effectively treat this population since undergraduate studies at that time failed to cover the pelvic region sufficiently. I enrolled in Texas Women’s University’s two-year distance learning program and earned a Certificate in Advanced Women’s Health. After receiving this Certification, word of mouth spread to Urogynecologists, Colon and Rectal, Urologists, Primary Care, and Ob/Gyns.
What/who inspired you to become involved in pelvic rehabilitation?
My patients with pelvic dysfunction that were referred to me for pelvic pain or sacroiliac pain were my inspiration to seek out information on pelvic rehabilitation. This was before medline! I traveled 30 minutes to the UC Medical Library to order research articles in order to determine my own evidenced based treatment. Some of those names in my research included: Arnold Kegel, George H Thiele, John Perry, Elizabeth Noble, Kari Bo, JO Delancey, L. Lewis Wall, Ingrid Nygaard. Holly Herman and Kathe Wallace offered my first continuing education course in 1996!
Learn more about Kathleen Novicki PT, PRPC 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 instructor Carolyn McManus, PT, MS, MA. Carolyn will be instructing the course that she wrote on "Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain" in Seattle this November.
I have taught Mindfulness Based Stress Reduction at Swedish Medical Center (SMC) since 1998. Over the years I have had many healthcare providers take the course and have long thought it would be wonderful to tailor a program specifically for healthcare professionals. I had the opportunity to do so this summer when, along with my colleague Diane Hetrick, PT, we designed and taught Mindfulness and Compassion Cultivation Training for physicians at SMC. The course was a great success. Physicians reported one of the most popular components of the program were our “on the spot” mindful practices. These are simple, easy-to-do strategies that any provider can employ to center, calm the body and steady the mind during a busy workday. They not only help reduce stress, but can influence brain activation to promote better decision making.
Research shows, under stress conditions, the amygdala activates stress pathways in hypothalamus and brainstem, evoking high levels of noradrenaline and dopamine release, impairing prefrontal cortex function. (1) Research also shows mindful practices reduce stress-related brain activity and improve executive functioning. (2, 3) I am delighted to share these powerful and practical “on the spot” mindful practices in my November course. My intention is for participants to have mindfulness skills to use for their own well-being the minute they walk in their clinic door on Monday.
Learn more about Carolyn's course Mindfulness-Based Biopsychosocial Approach to Chronic Pain and join her in Seattle this fall!
1. Arnsten AF. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci 2009:10(6):410-422.
2. Holzel BK, Carmody J, Evans KC, et al. Stress reduction correlates with structural changes in the amygdala. Soc Cogn Affect Neurosci. 2010;5(1):11–17.
3. van den Hurk PA, Giommi F, Gielen SC, et al. Greater efficiency in attentional processing related to mindfulness meditation. Q J Exp Psychol (Hove) 2010;63(6);1168–1180.
When a woman is interested in a trial of labor after previous cesarean delivery (TOLAC), she and her health care providers will consider the pros and cons of delivery methods. Researchers have aimed to predict success with vaginal birth after cesarean section (CS), with the intention of limiting the risk factors for both the mother and the fetus. A failed trial of labor following a CS may be associated with higher maternal and perinatal morbidity, according to the American College of Obstetricians and Gynecologists (ACOG) practice bulletin.
The goal of a study published last year was to develop a model for predicting success in women desiring a vaginal birth after cesarean (VBAC) section. All women had one prior CS, all were carrying singletons. Transvaginal ultrasound was utilized to evaluate the Cesarean scar (CS) at 11-13, 19-21, and 34-36 weeks' gestation in 320 women. The measurement of the scar was termed residual myometrial thickness (RMT), and the measurements also included the change in RMT from the 1st to 2nd trimester. With increased evidence that CS healing and myometrial thickness in the lower uterus may improve success with VBAC, this study is the first to assess scar dimensions across the first and second trimesters.
The CS scar was visible in 89% of the women. Of these, 153 of the 284 were excluded from the prediction model development due to having had more than one prior cesarean delivery, so the hospital protocol of scheduling cesarean was followed. The remaining women were offered a vaginal birth trial, with 10 of the 131 undergoing CS prior to labor for varied reasons. The final count of women included in the analysis was 121, and of these cases, 74 had successful VBAC, 47 experience failed trials of labor, primarily due to fetal distress, failure to progress, or possible scar rupture. (In the women who did not have a visible scar, 82% had a successful vaginal delivery.)
The median residual myometrial thickness, or RMT, was higher in patients who had a successful VBAC. Clinical usefulness, according to the study, is that use of the model may lead to fewer emergency CS deliveries through identification of women who will be successful with VBAC.
The authors concluded that measurements of a CS, when applied to a mathematical model, can predict success of a vaginal birth after CS. This information may be very interesting to discuss with our referring providers, our colleagues, as well as our patients. Any research that sheds light on variables to predict success with a VBAC may promote vaginal deliveries and hopefully prevent emergency cesarean deliveries. Educating our patients so they can be more informed and advocate for themselves is a key role. While we are always mindful of not overstepping our scope of practice, such as advising a woman if she should choose one method of delivery over another, the information about the scar thickness in predicting VBAC success may be very useful to both her and providers. For more information about peripartum issues, check out our Peripartum Course Series on the course page. There is still time to sign up for the Care of the Postpartum Patient continuing education course later this month in Chicago!
A systematic review aimed to identify the burden of the most significant complications of postoperative abdominopelvic adhesions. Of the nearly 200 studies included in the review, the following categories were included: small bowel obstruction (n=125), difficulties during subsequent operation (n=62), infertility (n=11), and chronic pain (n=5). The incidence of postoperative small bowel obstruction, assessed among nearly 108,000 patients in 92 studies, was 9% overall. The incidence of adhesive small bowel obstruction was 2.4% and was highest in pediatric and in lower gastrointestinal tract surgery. The authors report a high rate of chronic abdominal pain in patients who were followed after lower gastrointestinal tract surgery, with adhesions identified as a significant cause of this pain. Following colorectal surgery for small bowel disease, pregnancy rates were found to be dramatically lower than the pregnancy rates in those who were medically treated. Additionally, patients who have had a prior surgery may require additional time in a subsequent procedure due to scar tissue, and adhesiolysis, used to break up adhesions, can lead to bowel injury.
Patients with postoperative adhesions, according to the systematic review, are most often treated by providers other than the one who did the surgery; the lack of awareness of the complication may be one reason that the incidence of adhesions is underestimated. The value of being aware of the higher incidence of postoperative adhesions may be in early recognition of a complication, surgical decision-making, and patient counseling. While the research is young in relation to adhesions and pelvic rehabilitation, one study that we previously discussed in the blog addresses visceral mobilization techniques in an animal model. While the animal model research is promising, there are numerous case reports describing the positive effects of visceral mobilization techniques for abdominopelvic pain, and therapists always report on the equally positive changes to their clinical practice outcomes after adding visceral techniques to their toolbox.
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Janelle Trippany PT, DPT, CLT-LANA, PRPC
How did you get involved in the pelvic rehabilitation field?
I knew that I wanted to treat the pelvic floor as soon as I attended the 3 hour lecture regarding this niche of rehab while I was earning my DPT. The woman giving the lecture was so knowledgeable and so passionate about what she was doing with her life. I was fortunate enough to be able to have my last 12 week clinical with a woman who specialized in pelvic rehab, and from there I was completely sold. Unlike many others in this field, I went straight into a job in a women’s health clinic. While I have moved on from there to my current job, I will always continue to be involved in the pelvic rehabilitation field.
Describe your clinical practice:
I work in an outpatient physical therapy clinic located in a small, community hospital on the southern outskirts of Chicago. I am the only pelvic rehabilitation specialist and I treat a wide variety of patients. Most frequently I see patients with urinary incontinence and women with pre/postnatal complaints. Our hospital also features a breast cancer treatment center. I am a Certified Lymphedema Therapist with a LANA certification, so I treat patients with lymphedema as well. There are many times where these two specialties overlap and I consider myself fortunate to be able to help people achieve their goals and be their best selves.
What inspired you to become involved in pelvic rehabilitation?
I have always wanted to be an advocate for women. There are so many times when a patient comes to me as a last resort, when she has been told over and over that there is nothing that can be done to help her. She has been told that her problem is a result of her age or because she’s had too many children and that she just has to get used to it. To me, that is unacceptable. I want women to know that there is help, that someone does care that they are too embarrassed to leave their house because they have fecal incontinence or are unable to have intercourse because they are in too much pain. I believe that everyone should have the opportunity and resources to participate in this kind of physical therapy.
What motivated you to earn PRPC?
I believe that knowledge is power. And with knowledge comes understanding and then, hopefully, change. If we want to modify the way our current health care system treats individuals with these issues, we have to educate as many people as possible. With this certification, I now provide education to patients, physicians and other healthcare professionals as a distinguished expert in my field. I think professional certifications, such as the PRPC, are necessary to promote progress for this discipline in healthcare.
Learn more about Janelle Trippany PT, DPT, CLT-LANA, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.
One of the questions we frequently receive at the Institute is "Do you have any research about ___________?" At times, therapists are looking for information that can help with patient care, or they might be looking for support in a claims denial letter, or foundational material for a presentation. If you have been taught how to find articles, this may seem like a simple task. Many of us therapists went to school when the only use of a computer was for word processing, if we were lucky enough to have progressed from the typewriter or even the electronic typewriter. (Imagine no Google, no Wikipedia, and no Amazon to purchase textbooks!) There are basic search skills that can be shared so that every person interested in a particular topic can find recent articles in free search engines. While the full article may not be available, many times you will have access to full articles that synthesize recent works. (One website that you can use that offers full text article access is PubMed Central.) If you are not interested in reading articles, but prefer to read a scholarly summary of a health topic, check out www.uptodate.com, where you can subscribe to have full access to excellent evidence-based summaries. You can read through the reference lists on the site as well to see if there is a resource that you want to track down.
One method of finding articles is to go to www.googlescholar.com. In the search bar, type in the topic you are interested in, such as "urinary incontinence." You will then be provided with a list of all articles that have urinary and/or incontinence in the title or in the key words of the research. An even more refined way to conduct your search is by using Boolean terms, in which you connect your search words by "AND" or other key terms. To see this in action, let's say you want to know if there is any research about urinary incontinence and prostatectomy surgery. Try completing a google scholar search by typing in the following: "urinary incontinence" AND "prostatectomy". (Be sure to use the quotation marks and type the word "AND" in capital letters.) You will see that you come up with some very nice articles about the specific topic you searched. To make sure you are looking at recent articles, go to the left side of the search page and under the words "Any time" choose an option such as "Since 2010" so that you are seeing articles from within the last 5 years. Next, maybe you want to know if there is evidence for rehabilitation. Add the word rehabilitation, like this: "urinary incontinence" AND "prostatectomy" AND "rehabilitation". You will see that you now have even more results specific to rehabilitation of the condition. On the right side of the page you might see a link that starts with [PDF] where, if you click on it, you will usually be brought to the full article rather than just the abstract. If you see an article that you think fits your search, you can also click on "Related articles" located under the brief description of the article.
Being able to look up articles serves many purposes, including staying updated on patient care, and discussing evidence with peers, providers, and patients. Another valuable reason to find your own research is when studying for certification exams such as the Pelvic Rehabilitation Practitioner Certification (PRPC). On the PRPC certification page on our website, you can find a list of some articles for which we have added links. (Remember that there is no need to print out articles anymore! Save a tree and simply save the articles as a PDF file. You can name the article by the author's last name, year and main topic, and store in a folder on your computer so it is easy to access- no file drawer required!) If you are thinking about taking the PRPC exam, there is no time like the present to get your application put together! The deadline for applying is October 1 of this year, with the test taking place in the first couple weeks of November. Personally, I have enjoyed reading the blog posts introducing therapists who have earned their PRPC title- the reasons for seeking the distinction are very interesting and meaningful. We would love to see your name on the list of certified therapists, so check out the details on the website and contact us if you have any questions about the PRPC application process!
This post was written by H&W instructor Peter Philip, PT, ScD, COMT, PRPC. Peter will be instructing the course that he wrote on "Differential Diagnostics of Chronic Pelvic Pain" in Connecticut this October.
We have ourselves a wonderful profession, one in which we have the education that allows us to directly and often immediately impact our patients' well-being. Very often, patients come to us with the most intimate and consuming injuries. Often, our patients have been to several other clinicians seeking assistance. Many have been told that their ailment is psychosomatic, and that they should ‘get over it’, or medicate themselves through their pain.
Many patients have lost their ability to live the life that they had enjoyed for so many years prior because of this gnawing pain that involves a region of their body that they’d rather not discuss, let alone have poked and prodded. Many of our patients suffer so greatly that they’ve lost their relationships, employment and enjoyment of life. Many clinicians have had the experience of losing a patient, one that had suffered for too long and decided that death was the only reasonable means to eliminate their pain. Yes, those of us that have chosen to help those suffering with pelvic pains and dysfunctions have knowingly or unknowingly accepted the responsibility to address those ailments and individuals that suffer greatly; our responsibility is enormous.
This comes to mind after a recent phone call that I received from a woman that lives in California. She reports that she’s been suffering for years with dyspareunia, and that the treatment she’s received to date has done minimal to alleviate her pain. She states that she’s been the recipient of deep vaginal massage for months, attempted and forced dilation, all without true success or carryover from visit to visit. She is becoming despondent and losing hope. She feels as if this is to be her life from here going forward.
Upon questioning, she was unable to explain the reason “why” her pelvic musculature developed “spasms”, and why an otherwise healthy woman could fall from a state of “normal health” to that of a “chronic pain patient” without hope. She reported that her “fascia” was being “stretched”, and when questioned, she explained that she’d not been told how or why her fascia has become taut, or why the musculature had spasmed! This, to me, is unconscionable. Current research indicates that fascia actually tightens with stretching, and muscles do not spasm of their own accord. Local swelling and inflammatory mediators tighten fascia. The underlying cause of the local swelling must be addressed in order to release the fascial tension. In order to heal, the patient must understand this so as to best prevent the activities or positions that account for local swelling in the first place. As for a muscle spasm, there are many reasons this may occur, and it is our duty as professionals to deduce the cause of our patient’s muscle spasm, and then to apply a tissue, or joint specific treatment that properly addresses the lesion in order to eliminate these for our patients. To do so, the clinician must know which structures may be responsible in the formation of a spasm, and must understand the hierarchy of which is to be addressed and how to specifically address each in order to best offer appropriate treatment for each patient. That way, the clinician can offer a direct and patient-specific treatment to effectively eradicate our patients suffering.
It is my goalm whether working with a patient or lecturing nationally, to provide patients and the medical community alike with the means to accurately and efficiently deduce the origin of fascial restrictions, muscle spasms and pain. Providing patients and clinicians the knowledge and means of eliminating pain and dysfunction is the most wonderful blessing, and beautiful burden to bear.
It is my intention to provide the medical community the means to which they, too, can deduce the specific tissue at fault for each patient in order to provide the most patient specific care required to attain immediate and last wellness. This information and more is discussed during both courses I teach: Differential Diagnostics of Chronic Pelvic Pain, and Evaluation and Treatment of the Sacroilliac Joint and Pelvic Ring.
Our beautiful burden is our wonderful blessing. We, as professionals, have been given the gift of knowledge and expertise and our burden is to ensure that our patients receive the benefit of that knowledge.
In an article describing vascular dysfunction in women with chronic pelvic pain (CPP), Foong and colleagues describe the common finding of pelvic venous congestion. This study aimed to determine changes in microcirculatory function in women with chronic pelvic pain compared to controls. Eighteen women presenting with chronic pelvic pain of at least 1 year and 13 women without pelvic pain or congestion were evaluated for isovolumetric venous pressure, miscrovascular filtration capacity, and limb blood flow. All women were of reproductive age, menstruating regularly, and measurements were made during the mid follicular and the midluteal stages of the same 28 day cycle. The 18 women with CPP fit previously established criteria for pelvic congestion.
The women in the patient group were re-evaluated at 5-6 months following treatment for pelvic congestion, with treatment including medication-induced suppression of ovarian function for 6 months, and in 4 patients, hysterectomy and bilateral salpingo-oopherectomy. All of the patients received daily hormone replacement therapy (Premarin and Provera) "…to minimize the hypo-oestrogenic effects of treatment."
Findings of the research include an elevation in isovolumetric venous pressure, or Pvi in women with CPP compared to controls. Interestingly, there were no changes related to menstrual cycle in measures of microvascular filtration capacity and and limb blood flow. The conclusion of this study is that women with chronic pelvic pain may present with systemic microvascular dysfunction. The noted increase in Pvi "…may be attributable to systemic increases in post capillary resistance secondary to neutrophil activation." Following treatment for pelvic congestion, the value changes in isovolumetric venous pressure were no longer present.
This research highlights the noted changes in microcirculatory function in women with chronic pelvic pain. The obligatory chicken and egg conversation weighs in: does pelvic congestion lead to pelvic pain, or does pelvic pain always precede pelvic congestion? While the answer is probably that either condition can cause and perpetuate the other, as pelvic rehabilitation providers, our first thought might be: what would the research outcomes be if the treatment were not medication-induced ovarian suppression or surgery, but therapy directed to the pelvic pain and congestion? The Institute offered, for the first time last year, a course that allows the therapist to address pelvic pain through treatment of pelvic lymphatic drainage. The Lymphatic Drainage for Pelvic Pain continuing education course is a 2-day class instructed by Debora Hickman, a certified lymphedema therapist. Sign up now to save your seat in October in San Diego, and if you can't make this course, contact us to let us know you are interested in this special topics course, and we will keep you informed of any new course bookings!