How does thoracolumbar fascia influence pain?

How does thoracolumbar fascia influence pain?

back

Research completed by medical faculty of Heidelberg University in Germany aimed to better understand the characteristics of pain that can be caused by different structures or tissues within the low back. Is the information gained applicable to all layers of tissues in the body? If so, how does that assist with our structural evaluation and interventions? If not, how do various body regions reflect the findings of this study?

Researchers injected saline into tissues of the back of 12 healthy subjects at differing layers of depth and tissue; the injections were guided by ultrasound. (This method of inducing muscle pain has been utilized and refined since the 1930's.) The authors describe prior studies indicating that thoracolumbar fascia is innervated by free nerve endings, and that lumbar dorsal horn neurons receive nociceptive input from fascia; these connections are theorized to relate to fascia as a potential cause of low back pain.

The volunteer subjects were both male (6) and female (6) and none had a history of back pain. 3 sessions were scheduled with at least 5 days between study sessions. Following saline injection, the subjects rated pain at 10 second intervals for two minutes, then at 30 second intervals for the next 23 minutes. Subjects also recorded on a body chart where the symptoms occurred. Pressure pain threshold was recorded using a pressure algometer at baseline and at 25 minutes post-injection. Pain quality was assessed with an outcomes tool that listed both affective and sensory items.

The authors conclude that, in response to saline injection, the thoracolumbar fascia is more sensitive to the chemical irritation than the erector spine muscles or the overlying cutis (the dermis and epidermis, or combined layers of the skin.) Areas of recorded pain were larger for fascial injection than for skin or muscle. However, hyperalgesia to blunt pressure as measured by the pressure pain threshold device could only be created by injections into the muscle. In summary, the article states that injection to the thoracolumbar fascia "…induces intense tonic pain with a strong affective component and a pain radiation similar to acute LBP," whereas hyperalgesia to pressure "…seems to require peripheral sensitization of muscle nociceptors."

Does this research offer a window into the symptomatology and etiology of varying pain complaints? Can we direct our treatment to the tissues that appear to be at fault? The more we know about the tissues of the body, how to differentiate structurally the ways in which pathologies present, perhaps we will continue to build our clinical reasoning upon the anatomy and pathological findings. For more research and clinical applications surrounding fascia, you still have time to sign up for faculty member Ramona Horton's courses on myofascial evaluation and interventions for pelvic dsyfunction.

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Constipation and Clinical Exam

For patients who are diagnosed with constipation, functional anorectal testing is often completed prior to referral for physical therapy. A recent study concluded that clinical examination of pelvic floor muscle function is critical for identifying a rectocele or pelvic muscle overactivity, and that anorectal function tests should be reserved for selected cases. Pelvic rehabilitation therapists are able to perform tests of the pelvic muscles and function during a patient's attempts to contract, relax, and bear down through the pelvic floor. These tests are easy to repeat and a patient can be instructed in corrective muscle techniques to improve the ability to empty the bowels.

Consider the patient who presents to the clinic after experiencing a defecography. In this test, a patient undergoes an imaging study while sitting on an elevated toilet seat. The patient is asked to bear down to evacuate a bolus of material that is placed inside the rectum. It is easy to understand why a patient finds this test to be "embarrassing." Following this test, when a patient is diagnosed with dyssynergia (when the puborectalis muscle contracts rather than lengthening and relaxing during attempt to defecate) he or she is frequently referred to pelvic rehabilitation. A pelvic rehab therapist can observe and palpate the same phenomena in the clinic: when asked to bear down or drop the pelvic floor muscles, if a patient instead contracts or is unable to lengthen the muscles, re-training can be implemented.

I have often wondered why a patient would need to complete this type of testing for constipation-related pelvic muscle dysfunction if the same patient could reverse a dysfunctional muscle pattern with a brief bout of pelvic rehabilitation. The research by Lam and Felt-Bersma (full-free text article linked above) appears to confirm this thought, concluding that anorectal functional testing contributes little to information that can be gained in clinical examination in women who have idiopathic constipation.

The authors studied 100 women who were diagnosed with idiopathic constipation and who fit the Rome III criteria. A prospective evaluation included an extensive questionnaire regarding complaints, abdominal, rectal, and vaginal examination, and anorectal function tests such as anorectal manometry (ARM)and anal endosonograpy (AUS). Exclusion criteria included inflammatory bowel disease, fissures, or fistula, and endocrine disorders orcolonic obstruction were ruled out. Of these 100 women, 25% were found to have hypertonia and dyssynergia of the pelvic floor, and 15% presented with a rectocele. During anorectal manometry, the authors also noted that women had difficulty relaxing during straining. In the group studied, 37 women complained of impaired evacuation, and interestingly, 40% of these women had a rectocele, yet no rectoceles were identified in the women who did not complain of impaired evacuation.

While medical screening for patients who complain of constipation is important, this research identifies a group of patients (those diagnosed with idiopathic constipation) for whom ARM or AUS testing does not contribute significantly to the evaluative process. The study is very valuable reading for pelvic rehabilitation providers as the authors clearly understand the role of rehabilitation and articulate the value ofpelvic floor muscle function in meaningful ways throughout the report. If you are interested in learning how to evaluate and treat patients who have constipation, there are 3 seats remaining in the PF2A continuing education course at the end of this month in Fairfield, California (right next to Napa, in case that interests you!) The PF2A course covers bowel dysfunction such as constipation, fecal incontinence, and other colorectal conditions, and also offers on Day 3 an Introduction to Male Pelvic Floor function and dysfunction related to pelvic pain and urinary dysfunction. Following the West coast PF2A, there are East coast and Midwest dates, click here to find the course information. Sign up early as this course always sells out!

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How does a first childbirth affect pelvic floor strength?

How does a first childbirth affect pelvic floor strength?

baby

While the literature is clear that childbirth is a risk factor for pelvic floor dysfunction, how does a first childbirth affect the pelvic floor muscles? Does a vaginal delivery, instrumented delivery, or cesarean delivery affect the muscles differently? These questions were addressed in a prospective, repeated measures study involving 36 women. Outcomes included pelvic muscle function via vaginal squeeze pressure and questionnaires, prior to and following childbirth. The women were first evaluated between 20-26 weeks gestation and again between 6-12 weeks postpartum. All participants were primiparas, meaning that they had not given birth previously, and were found to have a significant decrease in strength and endurance after their first childbirth.

Pelvic floor muscle strength and endurance testing included maximum voluntary contraction (3 repetitions for up to 5 seconds) , sustained contraction, and repeated contractions at least 15 times. Ability to correctly contract the pelvic muscles was assessed via vaginal digital testing (with one examining finger) and perineal observation. A Myomed device was utilized with a vaginal sensor to more accurately measure strength. At the time of postpartum measurement, 33 of the 36 women were breastfeeding, the instrumented deliveries were completed with vacuum extraction, and all episiotomies were performed as right mediolateral procedures. Although the women in the study were asked if they completed pelvic muscle exercises- they were not instructed in any specific exercises.

Prior to childbirth, there were no significant differences in pelvic muscle strength and endurance between the three delivery groups. Following vaginal delivery (assisted or unassisted) pelvic muscle strength was significantly reduced, but endurance was not significantly influenced by delivery mode. While in this study, patients who had a cesarean procedure had decreased pelvic muscle dysfunction, the authors also point out that cesarean "…performed for obstructed labor or after the onset of labor has been reported to be ineffective in protecting the pelvic floor."

This study aimed to document the effect of a first childbirth on pelvic muscle strength. The authors acknowledge that controlled studies with larger sample sizes are needed to make further claims about pelvic muscle health postpartum. Ideally, even though pelvic muscle strength is reduced, we can utilize this information to establish connections about labor and delivery, and more importantly, how to minimize the impact or maximize the healing of pelvic muscles following childbirth. To further discuss postpartum issues, join us for Care of the Postpartum Patient in Houston (June) or Chicago (September)!

 

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Ankles and SIJ's

Ankles and SIJ's

pelvis

When assessing sacroiliac joint (SIJ) stability and function, pelvic rehabilitation providers often use the single leg stand test. During transition from double-leg stance to single-leg stance, dynamic stability is required and there are several ways to describe the observed behaviors in patients. If a patient, for example, loses her balance when transitioning to a single leg stand, what is contributing to her loss of stability? Could it be the SIJ, abdominal and trunk strength, ankle proprioception, visual or vestibular deficits, or hip abductor weakness? Of course, these are not the only potential confounders to postural stability, yet represent some of the considerations of the rehabilitation therapist.

A recent study aimed to further define techniques to measure "time to stabilization" in a double-limb to single-limb stance. The authors measured 15 healthy control subjects and 15 subjects who presented with chronic ankle instability (CAI) and the researchers tested the ability to achieve stability in single-leg stance during eyes open and eyes closed tasks as well as with varied speeds of movement.

The research found that in subjects who had CAI, following transition to single-leg stance, increased postural sway was noted. In the same subjects, when performing the task with eyes closed, those with a history of ankle instability performed the transition much more slowly than those in the control group when allowed to choose their speed of transition. Prior research (described in the linked article) had postulated that time to stabilization (TTS) following double-limb to single-limb transition was an important variable to measure, yet this research did not find that the TTS was significantly different between the groups studied.

This research highlights the value of considering the total limb and trunk stability during testing of functional tasks, as well as considering visual assist versus eyes closed variables for task completion. The speed of task performance should also vary so that deficits can be perceived by the examiner. The authors of this research propose further specifications to future research that will add to the meaningfulness and accuracy of the described testing methods. They also conclude that in patients with chronic ankle instability, an altered and poorer strategy is used in the overcoming of a postural perturbation. If you would like to further explore the sacroiliac joint examination, evaluation and treatment, and discuss concepts of stability, join Institute faculty member Peter Philip at the continuing education course Sacroiliac Joint Treatment this July in Baltimore!

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4D Ultrasound in Women With and Without Provoked Vestibulodynia

4D Ultrasound in Women With and Without Provoked Vestibulodynia

pelvic

One of the challenges in assessing pelvic muscle function in women who have pain is to avoid triggering pain with the assessment tool. This challenge was met by the use of external measuring of pelvic floor muscles using transperineal four-dimensional (4D) ultrasound in this study by Morin and colleagues. Women who were asymptomatic (n=51) and symptomatic (n=49) were assessed with 4D ultrasound in supine with pelvic floor muscles (PFM) at rest and at maximal contraction. The women who were symptomatic were diagnosed with provoked vestibulodynia (PVD) and all of the women in the study were nulliparous. The data collected using the 4D transperineal US included anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus.

Results of the study indicated that women with provoked vestibulodynia had a significantly smaller hiatus, smaller anorectal angle, and at rest, a larger levator plate angle. These differences suggested an increase in pelvic floor muscle tone. Additionally, when the PFM were assessed at maximal contraction, subjects with PVD demonstrated smaller changes in levator hiatus narrowing were noted, with decreased displacement of the bladder neck and decreased changes in levator plate and anorectal angles. These changes are believed to demonstrate pelvic floor muscle weakness.

The authors describe the value of the assessment technique, 4D ultrasonography, as having terrific advantage over other research methods due to the lack of required insertion of the US. While pelvic rehabilitation providers may concur that increased pelvic floor muscle tone in association with pelvic muscle weakness is a common clinical finding, research that describes the phenomenon is needed and much appreciated. We continue to find answers in research such as this article that answers the fundamental question: do women who present with pelvic dysfunction demonstrate differences in pelvic muscle health than a pelvic-healthy population? If you would like to learn more about provoked vestibulodynia including evaluation and management, join faculty member Dee Hartmann at the Assessing and Treating Women with Vulvodynia continuing education course. We are currently confirming dates for this course, and if you would like to host the Vulvodynia course, contact us at the Institute!

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Post-prostatectomy Candidates for Transobturator Sling Surgery

Post-prostatectomy Candidates for Transobturator Sling Surgery

male sling

Surgery for prostate cancer can impair urinary function, and in the case of persistent urinary incontinence, patients may progress to surgical interventions. In order for physicians to conduct optimal patient counseling and surgical candidate selection for post-prostatectomy urinary incontinence (UI), the records of 95 patients were reviewed in this study. The patients were retrospectively placed into "ideal", n = 72, or "non-ideal", n = 23, categories based on chosen characteristics, and the results of their outcomes and satisfaction were consolidated. Men in the "ideal" group had the following characteristics: mild to moderate UI, external urethral sphincter that appeared intact on cystoscopy, no prior history of pelvic radiation or cryotherapy, no previous UI surgeries, volitional detrusor contraction with emptying of the bladder, and a post-void residual of < 100 mL. Patients who did not meet all listed criteria for the "ideal" group were placed into the "non-ideal" classification.

A cure for the surgery was considered total resolution of post-prostatectomy incontinence with the sling. Of the patients fitting into the ideal classification, 50% reported cure, and of the non-ideal group, 22% reported a cure. Satisfaction rates within the ideal group for the procedure were 92%, whereas the non-ideal group reported a 30% satisfaction. Although uncommon, complications occurring in both groups included prolonged pelvic pain and worsened urinary incontinence. The authors describe the importance of placing the correct amount of tension through the sling, and of leaving as much of the external urethral sphincter in place as possible. Another complication that occurred more frequently is that of acute urinary retention. In the ideal cohort, the 11 cases of urinary retention resolved within 6 weeks of surgery. Of interest is that 12 of the 23 men in the "non-ideal" category had to undergo further surgery with an artificial urethral sphincter.

This information can assist surgeons in guiding and advising patients about operative procedures for post-prostatectomy incontinence. (Ideally, every patient would "fail" a trial of pelvic rehabilitation prior to progressing to a surgery!) If a patient wishes to proceed with a sling surgery despite being in a "non-ideal" category, he could be advised of the known potential outcomes. This article offers support for pre-operative investigation techniques such as urodynamics. Our role as pelvic rehabilitation providers may allow us to discuss such research with patients and providers, and participate in discussions about the role of rehabilitation pre-operatively or post-operatively. If you would like to learn more about working with men who have pelvic floor dysfunctions, you still have time to book a flight to Orlando for the Male Pelvic Floor Function, Dysfunction, & Treatment course, where you can learn about male pelvic pain, incontinence and BPH, and male sexual dysfunction. This is the last opportunity to take this course this year!

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Paradigm for SIJ Assessment

Paradigm for SIJ Assessment

PelvicHip

If your experience of learning sacroiliac joint mechanics, testing, and treatment has been confusing at times, trust that you are not alone in this confusion. As students have emerged from training and coursework using a variety of models to understand the joint and surrounding structures, no wonder there is disagreement and inconsistency in clinical application of learned skills. Add to this the many names for a maneuver such as the one leg standing test, and we see that the more we can streamline updated clinical knowledge and practices, the better for our profession and for our patients. I recently enjoyed reading an article summarizing assessment and treatment of sacroiliac joint (SIJ) mechanical dysfunction by Dr. Manuel Cusi, who completed a PhD thesis regarding the joint. In the article, Dr. Cusi summarized a great deal of research-based concepts related to testing and treating this issue.

Although the structure and purpose of the sacroiliac joint are described as "controversial", the author points out the foundational concept that too much or too little stability within the SIJ can create dysfunction. The "self-bracing" mechanism is provided in the pelvic girdle via both form and force closure, and Dr. Cusi points out that this joint stability that is the aim of the self-bracing mechanism must be responsive to each specific loading condition, as a function of gravity, and with coordination of muscle and ligament forces. Also according to the article, in order to assess the SIJ, the focus must be on function rather than solely on anatomic pathology.

Mechanical testing is described as being generally divided into pain provocation or palpation tests. Although we can say, based on the literature, that no one SIJ test can provide reliable data, a cluster of several tests that are positive can provide meaningful information towards a diagnosis. In order to test various aspects of SIJ function, the following tests are listed in the paradigm model. A working knowledge of the tests below, as well as pelvic joint stability tests should comprise the clinician's "toolbox" of tests for the sacroiliac joint, and this is in addition to skills used for determining other causes of SIJ pain such as disease processes or referred symptoms.

•Posterior pelvic pain provocation test (or thigh thrust)
•Long dorsal sacral ligament palpation
•Trendelenburg test
•Stork test (or Gillet test)
•Active straight leg raise (ASLR)
•Patrick's FABER and Gaenslen's test

In relation to treatment approaches, exercise training is recommended as being divided into three stages: isolation (recruiting targeted muscle in isolation of other groups), combination (muscles are recruited in various combinations to develop endurance), and function (utilizing good technique once progressed to meaningful functional tasks). While this flow of exercise training may appear very logical, the author offers that failure to progress through these three phases may be due to several factors such as poorly designed exercises that lack specificity, progressing through exercises before patient has sufficient endurance, poor adherence, and lack of appropriate exercise technique. These factors are described in the article as intrinsic to the exercise program, whereas an extrinsic factor may be failure of the exercise program to work well because of poor ligamentous stability. In this case, the author further describes the therapeutic option of prolotherapy, which will be discussed in an upcoming post.

If you are interested in learning more about the above special tests or about treatment progressions based on technique and integration, check out Peter Philip's Sacroiliac Joint and Pelvic Ring Evaluation & Treatment. The next opportunity to take the course is in January in Seattle.

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Is your patient at risk for scapular winging during recovery from breast cancer?

Is your patient at risk for scapular winging during recovery from breast cancer?

shoulder

Scapular winging, also known as scapula alata (SA), describes the lack of proper muscular support that keeps the medial scapula positioned snugly against the thoracic wall. Potential causes of this condition include weakness of the serratus anterior, trapezius, and rhomboids, often related to nerve injuries of the long thoracic, spinal accessory, or the dorsal scapular nerve. Breast cancer and axillary surgery is a known risk factor for scapular winging, and the aim of a recent article was to identify patients who were at increased risk of developing the condition following radiotherapy.

Adriaenssens and colleagues report an incidence rate of scapular alata in the literature of 0-74.7%, a variability that does not help to deduce patients who are truly at risk. Women age 18 or older with a diagnosis of primary breast cancer removed by mastectomy or by breast-conserving surgery were included in their study. The pathological stage, treatment doses for radiotherapy and when applicable, the treatment doses for chemotherapy are described for the control and for the intervention group. The original study from which the data was collected is known as the TomoBreast clinical trial and focused on pulmonary and cardiac toxicity measurement. Within the data collection, scapular position was measured in physiotherapy prior to and 1-3 months following radiotherapy. (Check this link to learn more about radiotherapy.)

The physical examination included assessment of clinical symptoms like dysesthesia, heaviness, swelling, fatigue, warmth, burning, and pain. Measures of bilateral arm volume, shoulder range of motion, and the scapular slide test to assess the distance between the inferior angle of the scapula and the spine were completed. In standing, the scapula was observed for relaxed position and for scapular plane elevation to shoulder height; scapular alata was designated as present if inferior angle tilting or winging was noted.

Resulting analysis of the 119 eligible female patients include the following: prior to radiotherapy but after surgery, 10.9% (13 subjects) were positive for scapular winging. 1 to 3 months after completion of radiotherapy, winging resolved in 8 of the 13, and persisted in the remaining 5 subjects. New onset of scapular alata occurred in 1 subject. Significant factors for SA included young age, lower body mass index, and axillary dissection. Regarding the inverse relationship of increased weight to decreased scapular winging, the authors posit that patients with decreased body weight have less fat to cushion the nerves and therefore are at higher risk of nerve injury, OR that patients with higher body mass may not have winging as easily observed due to overlying adipose tissue. Having axillary lymph node dissection was confirmed in this study as a risk factor for scapular winging.

The authors conclude that scapular winging should be "actively evaluated" and describe assessments at various points in the treatment of breast cancer such as prior to surgery, following surgery, and prior to or following radiotherapy. As scapular winging correlated to loss of shoulder motion, quality of life may be impaired. If you are wanting to learn more about rehabilitation management of patients following breast cancer diagnosis and treatment, sign up now for faculty member Susannah Haarmann's Breast Oncology course in San Diego in 2 weeks! This is the last chance to take the course this year!

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Vulvar Pain Functional Questionnaire

The Vulvar Pain Functional Questionnaire (V-Q) is provided to help patients quantify the extent that pelvic pain is affecting their lives and helps the practitioner devise a treatment strategy based on the patient's account of her symptoms.

To score the VQ: add numerical values assigned to each response. These appear next to the check-boxes. The higher the score the greater the functional limitation. A diminishing score represents improvement.

This questionnaire was developed by Kathe Wallace, PT, BCB-PMD , Hollis Herman, DPT, PT, OCS, BCB-PMD and Kathie Hummel-Berry, PT, PhD and is free to download here.

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Internet Scam Targeting Physical Therapists

Recently, the Institute was made aware of an internet scam that is targeting physical therapists, including members of our teaching faculty. A bogus website called ComplaintsBoard has listed many PTs, including several respected Herman & Wallace faculty members, on a list of convicted sexual abusers. This site contains a similar list of doctors and lawyers that it claims have criminal records, meaning that patients or clients seeking professionals may find false and damning histories on internet search engines. The site then invites those whose names are posted to pay money through a different website to clear their records.

Clearly, this is the work of scam artists that are tarnishing the reputations of physical therapists. It is unclear who these perpetrators are, but they have targeted a number of respected professionals, including members of our faculty. Herman & Wallace is dismayed to see the character of professionals with whom we work and respect being attacked for profit. The APTA has been made aware of this, and is seeking legal action. If you find your name on such a list, please contact the APTA.

The Institute would like to make our community aware of this problem and to show our support of our faculty and our colleagues.

Please understand that, because we do not want to increase the web traffic to these scam sites, thereby increasing their efficacy, we will not be posting direct links to these sites.

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