Even after teaching for a couple of decades, both in graduate level courses and in continuing education settings (live and online), I am humbled by all there is to learn and relearn about how to teach well. We all teach every day, regardless of what setting or roles we work in, and are required to share our thoughts and knowledge with respect, equanimity, and non-judgement. After teaching a course last month, I received feedback about an important topic that was not clearly addressed from an instructional or clinical standpoint, and the participant who brought it to my attention agreed to share her experience so that we as pelvic rehab providers can do a better job of addressing the issue when needed. The following post was written by Erin B. after I encouraged her to share her own thoughts about the issue.
"Having recently participated in the PF1 class after several years out of the classroom-style of continuing education, I made a few observations I felt compelled to share. (I do want to preface this with the fact that I am fully aware that my own insecurities play a role in my experiences and I recognize that they may alter my judgment of the situation.)
I am 5' 4" and currently 240 pounds. Although that is 50 pounds lighter than I was 6 months prior to attending this class, it is still significantly larger than 90% of the class participants, lab assistants and instructors. I am not someone who feels that fat is healthy. I do not feel that you need to act like I am in as good of shape as anyone else in the room. However, I do feel that there are certain assumptions made about me that are based on my physical appearance alone. Take a minute and think about your first reaction to seeing a person who is obviously overweight. (I do realize that I have made my own assumptions about some of you as well!) Just because you are much thinner and more fit looking I assume you exercise regularly, you always eat healthy and you judge me negatively for my appearance. I do know that my assumptions about you may be just as wrong as what I believe you assumed about me. However, when I see that the larger people in class have placed themselves more to the back of the room, when I have a hard time finding a lab partner and when the lab instructor struggles with how to say to the partner that got stuck with me "things may be different on her", I begin to feel like I am taking something away from the class experience for everyone else. I do not want to hinder another clinician's learning process so I don't push anyone to be my partner, but then I am actually denying myself the learning opportunities I came for. Not to mention that I may be denying the other participants the opportunity to learn how to handle a client that may look and feel like me.
The reality of our world is that there is a very large obese population. I firmly agree this leads to a multitude of chronic illnesses and astronomical medical costs for the individual and our society as a whole. It does need to be addressed on a large scale. However, we as clinicians don’t know where these individuals are on their weight journey. For someone like me who has made drastic lifestyle changes to move me in a positive direction but have not yet gotten my appearance in line with the "norm" that the health care professionals, the media and society are pushing, your response to me can be devastating to my progress, my hope and my desire to continue toward a healthier lifestyle. Again I want to acknowledge that this is as much my problem as it is for those around me and I am addressing this as well. But please have the awareness that an obese person above all is a PERSON FIRST! Then their physical size becomes just another item on the list of "facts" about them, instead of a source of anxiety and separation. Approaching an obese person with respect, acceptance, honesty and openness not only puts them at ease, it also strengthens the rapport that is so crucial in pelvic rehabilitation.
Although I was born and raised in the north east, I now live in Alabama, home of corn bread, fried chicken and sweet tea. The population I deal with is more likely to be at least overweight if not truly obese. So, quite honestly, the practical instruction of how pelvic floor evaluation and treatment may be different with the obese patient would be directly beneficial to my practice. This might include openly addressing in labs how to assess/reposition an obese patient will give each therapist an awareness and confidence when approaching this population and may minimize the patient's embarrassment and keep the doors of trust and communication open. Or taking a moment to recognize the larger participants in the classroom setting and professionally suggesting during a lab session how they can reposition themselves and still affectively achieve appropriate assessment/treatment for the patient would make the transition from class to the reality of the clinic more smooth. Also, taking a moment to offer suggestions for what the obese patient who can’t physically reach their perineum or even palpate the pubic symphysis and or coccyx and doesn’t have a willing partner to assist can do to effectively complete the rehab activities suggested. You have to admit, this is not an easy specialty of practice to broach in the first place, and anything to take the pressure off of the clinician and or patient is helpful!
I so greatly appreciate the respect and professionalism the many delicate topics related to pelvic health are addressed in this program. I would also appreciate that same respect and professionalism when it comes to the reality of the many different body types that are the represented in our practices!"
Thank you to Erin for sharing her thoughtful suggestions, and reminding instructors and fellow course participants that an open, curious and helpful approach is needed for all situations. We at the Institute will address this issue among our instructors so that we can provide more clear guidance regarding patient and provider positioning. Stay tuned for a blog post about helpful positioning and communication tips for working with patients who are obese.
Much has been made of the research indicating that a Caesarean section has a protective effect on the pelvic floor, with some women requesting a CS in order to avoid pelvic floor dysfunction (PFD). This practices raises concern about an elective approach to CS versus natural vaginal birth, as CS are by no means without risk to the mother, the fetus, and to the neuromusculoskeletal system. Recent research contributes to this discussion by assessing several variables including quality of life factors and pelvic dysfunction following either a CS or natural vaginal birth. Twenty one women who had given birth in the prior 36 months were recruited from daycare facilities. Subjects were categorized into normal vaginal delivery (NVD) or Caesarean section (CS). Subjects were only included if they gave birth to singletons, had not previously participated in pelvic rehabilitation, or if they did not had a history of pelvic surgery, neurologic issues or trauma that affected bowel and bladder function. Outcomes tools included the SF-36, and the Pelvic Floor Distress Inventory (PFDI). Within the PFDI, outcomes tools assessed urinary, colorectal, prolapse, and pelvic floor functional impact.
Nearly 70% of the women in the group studied were between the ages of 30 and 39, with ages ranging from 21-45. The number of subjects who had given birth vaginally was 16, by Caesarean section, 5. The authors report that approximately 75% of their subjects were Caucasian, had a household income of 70,000 or more, and nearly 80% had at least a four-year degree. The women in the CS group reported higher rates of urinary incontinence and pelvic pain (90% and 67%, respectively) when compared to the NVD group (50% and 23%). Women who gave birth via CS also had higher mean scores on the Urinary Distress Inventory, Colorectal-Anal Distress Inventory, and the Pelvic Organ Prolapse Distress Inventory. The authors also noted a correlation between pelvic organ prolapse and body mass index (BMI) greater than 25.
This research contributes to the literature about birth mode and pelvic dysfunction, and the study conflicts with other data that describes a protective effect of Caesarean birth mode on the pelvic floor. While avoiding vaginal delivery may indeed help reduce some injury to the pelvic floor, this study, even though the sample size was not large, reminds us that CS delivery can be associated with pelvic dysfunction and symptoms. This study was different from many prior reports in that the subjects were surveyed in the chronic rather than immediate postpartum period. If you are interested in learning more about postpartum rehabilitation, check out the Institute's offerings on this page: http://hermanwallace.com/postpartum.
Bowel dysfunction is a common condition with potential for devastating limitation in a person's quality of life. Constipation, one type of bowel dysfunction, is often associated with an ability to properly coordinate the pelvic floor muscles during an attempt to empty the bowels. Instead of the pelvic floor muscles lengthening to allow the anorectal angle to increase (reducing the "bend" in the distal part of the rectum) the pelvic floor muscles might contract and thereby restrict proper emptying of the bowels. When this "opposite" or "paroxysmal" contraction occurs, a patient may be diagnosed with paroxysmal pelvic muscle function, also called dyssynergic defecation because of the lack of coordination in the muscles.
A recent study demonstrated that biofeedback therapy can be an effective tool in improving pelvic floor function for patients who demonstrate dyssynergic defecation. Magnetic resonance defecography (MR defecography) was measured prior to and after intervention, with variables of anorectal angle and perineal descent among those studied. Standard therapy was administered to 11 patients diagnosed with dyssynergia, and 11 patients received biofeedback therapy. All patients met the Rome diagnostic criteria for functional constipation, and all patients had diagnostic testing with resultant evidence of dyssynergistic muscle patterns. In addition to the MR defecography as a pre- and post-test, patients completed assessments of symptoms, quality of life, and severity of depression.
Standard therapy consisted of instructions in bowel habits, daily exercise such as walking, diaphragmatic breathing, fiber and fluid intake, defecation techniques, and timed toileting (such as attempting bowel movement 30 minutes after eating). Therapy occurred over a period of 3 months with at least once per week phone supervision. The patients in the biofeedback group were instructed in concepts of dyssynergia and in contract-relax training. Rectal sensory training with a rectal balloon was utilized if the patient had poor sensory perception. Patients were trained how to increase intrabdominal pressure while relaxing the pelvic floor muscles. They were also instructed in pelvic floor muscle strengthening, relaxation, and coordination, and were asked to complete home exercises three times per day for 10 minutes. Clinic sessions occurred at twice per week for 12 visits, then once per week for 6 visits, or a total of 18 visits over 3 months.
The authors found that paradoxical contraction and perineal descent with attempt to defecate improved significantly in the treatment group. Constipation symptoms, and depression and several quality of life scales also improved in the treatment group. Interestingly, the sense of incomplete emptying improved in both the treatment and the standard care group. While the results of the intervention are very positive, it would be interesting to include abdominal wall massage, a common technique employed to improve bowel function with constipation. If the patients demonstrated a tight pelvic floor with dyscoordinated patterns of movement, perhaps manual therapy to release tension or any pain that was present may have also been appropriate. As this is the first study to demonstrate through MR defecography an improvement in dyssynergia following biofeedback therapy, the study is very valuable to pelvic rehabilitation therapists. If you are interested in learning more about bowel dysfunction, you can start with the Pelvic Floor 2A course, which instructs bowel dysfunction including dyssynergistic defecation. The pelvic floor series courses sell out quickly, and the next opportunity to take this course is in St. Louis in October. You can also still find seats in the 2A continuing education course in the December courses taking place in Boston and in La Jolla.
Update: Please note that this course is now only offered online through the instructor's website. For more information visit https://pelvicpainrelief.com/laser/
Laser Therapy For Female Pelvic Pain was developed by Isa Herrera MSPT, CSCS for Herman and Wallace specifically for women’s health clinicians. Ms. Herrera is the author of 4 books, including the breakthrough book, Ending Female Pain, A Woman’s Manual, now in its 2nd Edition. Ms. Herrera has appeared on several national TV and radios shows including on MTV True Life, The Regis and Kelly Show and NBC’s Today Show. She lectures nationally on the topic of women’s health and has been a passionate advocate about pelvic health for over 10 years.
Can you describe the clinical/treatment approach/techniques covered in this continuing education course?
Laser Therapy For Female Pelvic Pain Conditions (LTFPP) is a two-day intensive course that provides the clinician with hands-on experience and treatment protocols using low level laser for the relief female chronic pain conditions that include vestibulodynia, vaginismus, bladder, coccyx and scar pain.
“This class is one in which pelvic floor therapists bring their foundational knowledge of anatomy, neurology and previous training and learn to apply it to laser therapy. “ says Ms. Herrera. “In this class I will share with you my treatment protocols that I have used at my healing center for the last ten years. These treatment protocols are safe and help provide pain relief, reducing injury damage and loss of function. Your patients will oftentimes see immediate results,” she continued.
What inspired you to create this course?
“Clinicians deal with female chronic pain on a daily basis that can be problematic to treat and manage. There is an arsenal of tools, exercises and techniques at their disposal, but many times using a proven modality can help to accelerate the pain-relieving process for the patient. I created this course not only to help the women out there who suffer everyday with debilitating pain, but also to help clinicians achieve even more success with their treatments.”
What resources and research were used when writing this course?
- Atlas Of Clinical Anatomy-Frank Netters
- Grays Anatomy
- Ending Female Pain, 2nd edition, Isa Herrera
- Herman and Wallace PF 1, PF2, PF3
- V Book by Elizabeth G. Stewart and Paula Spencer
- Travell and Simmons Volume 2. Myofascial Pain and Dysfunction: The Trigger Point Manual. The Lower Extremities
- Current Research Articles on Low Level Laser Therapy
Why should a therapist take this course? How can these skill sets benefit his/ her practice?
“This class is for the clinician that is working in the field of women’s health and who typically treats female chronic pain conditions. Clinicians looking for a non-invasive modality, one that is easy to operate and provides reliable and effective treatment options, will see great value in this course. This course provides the clinician with protocols and applicable information on the safe usage of low level laser therapy for female pelvic pain,” says Herrera.
With words like jumping, diving, spiking, hitting, and blocking making up the game's activities, volleyball is clearly a sport that requires a healthy pelvic floor. We know that athletes are at risk for pelvic dysfunction, with symptoms ranging from tension to leakage, but what happens when the pelvic floor is reeducated? In a study addressing volleyball players, researchers assess the effectiveness of a pelvic muscle rehabilitation program on symptoms of urinary incontinence. 32 female athletes were divided evenly between a control group and an experimental group. Inclusions criteria for the sample was nulliparity, symptoms of stress urinary incontinence, age between 13 and 30, and leakage amount more than 1 gram on the pad weight test. Exclusion criteria is as follows: treatment time of less than six months, sport practice for less than two years, urinary tract infections (either current or repeated prior infections), intervention adherence less than 50%, or body mass index outside of the range of 18-25.
Before and after intervention, the athletes were given a baseline questionnaire, a pad test (in the first 15 minutes of volleyball practice), and they completed seven days of a bladder diary to track leakage. The treatment group were instructed in anatomy and physiology of the lower urinary tract, about urinary incontinence (UI) and UI in athletes, and in leakage prevention strategies. A 3-day bladder diary was completed to improve awareness of fluid intake and bladder habits. Pelvic muscle awareness and correct contractions, doing protective pre-contractions of the pelvic floor, and a home exercise program of quick and endurance pelvic muscle contractions in different positions were also instructed.
The results of the intervention include a significant decrease in urinary leakage in the treatment group. The education provided also allowed for prevention of negative coping strategies that were reported in the subjects: the athletes would conceal leakage by wearing a menstrual pad, decreased their fluid intake, or empty their bladder more frequently. This study contributes to the growing body of evidence linking sport to pelvic dysfunction, and more importantly, rehabilitation efforts to improvement. If you want to learn more about pelvic dysfunction in athletes, come to The Athlete and the Pelvic Floor with Michelle Lyons. This 2-day continuing education course took place recently in New York City and your next opportunity to take the class is in Denver in October!
In the treatment of pelvic dysfunction, collaboration among physicians and pelvic rehabilitation providers creates an optimal care situation for the patient. In a research article that will be published in the July issue of Journal of Lower Genital Tract Disease, physical therapist and Herman & Wallace Institute faculty member Stacey Futterman demonstrates how a partnership between disciplines provides information valuable to the field of pelvic rehabilitation. Stacey and physicians Deborah Coady, Dena Harris, and Straun Coleman hypothesized that persistent vulvar pain may be generated by femoroactebular impingement (FIA) and the resultant effects on pelvic floor muscles. Through the research, the authors attempted to determine if hip arthroscopy was a beneficial intervention for vulvar pain, and if so, which patient characteristics influenced improvements.
Twenty six patients diagnosed with generalized, unprovoked vulvodynia or clitorodynia underwent arthroscopy for femoroacetabular impingement. For 3-6 months following hip repair, patients were treated with physical therapy that included surgical postoperative rehabilitation combined with rehabilitation for vulvodynia. Time period for follow-up data collection ranged from 36-58 months. Six patients reported improvements in vulvar pain following surgery and did not require further treatment, and it is noted that these patients were all in the youngest age bracket (22-29). Among the patients who did not report sustained relief, relatively older ages (33-74) were noted, along with a tendency to have vulvar pain for 5 years or longer.
The relationship between hip and pelvic pain may come from the bony structures, hip muscles including but not limited to the obturator internus, and nerves such as the pudendal. The authors conclude that "All women with vulvodynia need to be routinely assessed for pelvic floor and hip disorders…" and if needed, treatment should be implemented to address the appropriate tissue dysfunctions. If you are interested in learning more about hip dysfunction so you can better screen for dysfunction such as femoroacetabular impingement, check out faculty member Steve Dischiavi's continuing education course. Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System takes place next in Durham, North Carolina in May.
Patients diagnosed with colorectal cancer may undergo a procedure called mesorectal excision as part of their oncology management. In this procedure, a significant portion of the bowel is removed along with the tumor. Total mesorectal excision refers to the entire rectum and mesorectum (peritoneum that connects the upper rectum.) The rectum is removed up to the level of the levator muscles, and this procedure is indicated for tumors of the middle and lower rectum. In a study published in the World Journal of Oncology, the authors report on female urogenital dysfunction following total mesorectal excision (TME).
Questionnaires were returned by 18 women (age range 34-86) who had undergone TME for rectal cancer. Results of the study are summarized in the chart below. (All patients had reported vaginal childbirth, and five had undergone total abdominal hysterectomy and oophrectomy.)
|5/18 (28%) were sexually active (with no complaints of dyspareunia)||Sexually active patients remained active but all reported discomfort with penetration
2 patients reported decreased libido due to stoma
|3/18 (17%) reported urinary urgency and frequency||Of patients with urinary symptoms, 80% persisted longer than 3 months post-surgery|
|7/18 (39%) reported stress urinary incontinence|
|New onset symptoms: 61% developed nocturia, 20% developed stress urinary incontinence, 1 patient required permanent catheter|
The authors conclude that rectal cancer treatment can worsen urinary symptoms of nocturia and stress incontinence. Patients who had also been treated with a hysterectomy were found to have more significant symptoms. A proposed mechanism of this increase in symptoms in women who had undergone a hysterectomy is the prior nerve dissection which, when added to the nerve dissection of the inferior hypogastric plexus and the hyogastric nerves for the total mesorectal excision, may have an additive effect. This study which is available full-text, free access, describes further the relationship between the autonomic nervous system in the female pelvis, pelvic function, and the surgery for rectal cancer. Data such as the information provided in this study allow medical providers and their patients to make well-informed decisions about surgeries and quality of life risk factors that may guide medical management of colorectal cancer.
If you would like to feel better prepared to manage post-surgical issues that arise following treatments for colorectal cancer in women, check out the Institute’s Oncology and the Female Pelvic Floor course taught by faculty member Michelle Lyons. This continuing education course happens next in May in Torrance, California.
Among the challenges in research for chronic pelvic pain is the lack of consensus about diagnosis and intervention. Prominent researchers and physicians J. Curtis Nickel and Daniel Shoskes describe a methodology for classification of male chronic pelvic pain using phenotyping, which can be simply described as “a set of observable characteristics.” The authors point out in this article that men with complaints of pelvic pain have historically been treated with antibiotics, even though now it is known that most cases of “prostatitis” are not true infections. With most patients having chronic pelvic pain presenting with varied causes, symptoms, and responses to treatment, Nickel and Shoskes acknowledge that traditional medical approaches have not been successful.
In an attempt to improve classification of patients and subsequent treatment approaches, the UPOINT system was developed. The domains of the system include urinary, psychosocial, organ specific, infection, neurological/systemic conditions, and tenderness of skeletal muscles, and are listed below. Within each domain, the clinical description has been adapted from the original study (which can be accessed full text at the link above.)
-Urinary: CPSI urinary score > 4, complaints of urinary urgency, frequency, or nocturia, flow rate , 15mL/s and/or obstructed pattern
-Psychosocial: Clinical depression, poor coping or maladaptive behavior such as catastrophizing, poor social interaction
-Organ specific: specific prostate tenderness, leukocytosis in prostatic fluid, haematospermia, extensive prostate calcification
-Infection: exclude patients with evidence of infection
-Neurological/systemic conditions: pain beyond abdomen and pelvis, IBS, fibromyalgia, CFS
-Tenderness of skeletal muscles: palpable tenderness and/or painful muscle spasm or trigger points in perineum or pelvic muscles
Within the initial research utilizing the UPOINT classification system, the authors report that most patients fall into more than one domain, and that the more domains a person is identified with, the more severe the symptoms. The domains leading to the highest impact are the psychosocial, neurological/systemic, and then the tenderness domain. The referenced article points out that the most impactful domains are the ones that are non-prostatocentric, or focused on dysfunction within the prostate itself. Phenotyping may indeed lead to improved classification of and treatment of male chronic pelvic pain. If you are interested in learning more about male chronic pelvic pain, there are still two opportunities to take the Male Pelvic Floor continuing education course this year. In August of this year, the course will take place in Denver, and in November, the male course will return to Seattle.
You know how some women report that they have a mild prolapse that feels better if they wear a tampon during strenuous activity, or that a tampon worn (temporarily) helps avoid urinary leakage? Using a tampon instead of a pessary seems like a great fix, with one problem: tampons are not designed to be used as a pessary. They are designed to be absorptive and to expand to fill the vaginal canal as they expand. Some women can even suffer from toxic shock syndrome - a condition related to bacterial infection and associated with super-absorbent tampon use, contraceptives, and diaphragm use. What if an item could be used that is similar to a tampon, but not absorptive, and that provided more support than a cylindrical-shaped tampon? That must have been what Kimberly Clark, the manufacturer of a new product, created to fit this need.
The Impressa is marketed as a device for urinary incontinence that a patient can buy over-the-counter. The product comes in an applicator and can be inserted similarly to the way a tampon is, but the Impressa is not made to absorb leaks. Once inserted, the product has an interesting shape that is designed to help support the urethra. The device comes in 3 sizes labeled 1, 2, and 3, and the product has a "sizing kit" with 2 of each size in a box that can be trialed for finding the best fit. It will be interesting to see how valuable this product is and we will only know as we begin to hear feedback from their use. Pessary fit is a tough process in that providers and patients often have to go through a period of trial and error for best fit, and also because providers are poorly reimbursed for management of pessary fit and use. (Click here to read more on the blog about prolapse and pessaries.)
It appears that the product is not yet widely available, but it will be interesting to hear women's' experiences about the product. Having an option for an affordable, disposable pessary-like device that is available over-the-counter could be a very helpful option to know about. Health professionals can go to the website impressapro.com to send an email requesting a sample or more information. And thank you to certified Pelvic Rehabilitation Practitioner Joyce Steele for sharing information about the Impressa as this may be something your patients start asking more about. To learn more about prolapse management and female pelvic floor dysfunction, come to one of our intermediate-level continuing education courses, PF2B. The next opportunities to take this class (that aren't sold out!) are in Connecticut, North Carolina, and Missouri this year.
Patients who suffer severe bladder damage or bladder disease such as invasive cancer may have the entire bladder removed in a cystectomy procedure. Once the bladder is removed, a surgeon can use a portion of the patient's ileum (the final part of the small intestines) or other part of the intestine to create a pouch or reservoir to hold urine. This procedure can be done using an open surgical approach or a laparoscopic approach. Once this new pouch is attached to the ureters and to the urethra, the "new bladder" can fill and stretch to accommodate the urine. As the neobladder cannot contract, a person will use abdominal muscle contractions along with pelvic floor relaxation to empty. If a person cannot empty the bladder adequately, a catheter may need to be utilized. (A prior blog post reported on potential complications of and resources for learning about neobladder surgery.)
During the recovery from surgery, patients will wear a catheter for a few weeks while the tissues heal. Once the catheter has been removed, patients may be instructed to urinate every 2 hours, both during the day and at night. Because patients will not have the same neurological supply to alert them of bladder filling, it will be necessary to void on a timed schedule. The time between voids can be lengthened to every 3-4 hours. Night time emptying may still occur up to two times/evening. Patient recommendations following the procedure may include that patients drink plenty of fluids, eat a healthy diet, and gradually return to normal activities. Adequate fluid is important in helping to flush mucous that is in the urine. This mucous is caused by the bowel tissue used to create the neobladder, and will reduce over time.
Urinary leakage is more common at night in patients who have had the procedure, and this often improves over a period of time, even a year or two after the surgery. As pelvic rehabilitation providers, we may be offering education about healthy diet and fluid intake, pelvic and abdominal muscle health and coordination, function retraining and instruction in return to activities. In addition to having gone through a major surgical procedure, patients may also have experienced a period of radiation, other treatments, or debility that may limit their activity levels. The Pelvic Rehabilitation Institute is pleased to offer courses by faculty member Michelle Lyons in Oncology and the Pelvic Floor, Part A: Female Reproductive and Gynecologic Cancers, and Part B: Male Reproductive, Bladder, and Colorectal Cancers. If you would like to explore pelvic rehabilitation in relation to oncology issues, there is still time to register for the Part A course taking place in Torrance, California in May! If you would like to host either of these courses at your facility, let us know!