In a case report published within the past year by physical therapist Karen Litos, a detailed and thorough case study describes the therapeutic progression and outcomes for a woman with significant functional limitation due to a separation of her diastasis recti muscles. The patient in the case is described as a 32-year-old G2P2 African-American woman referred to PT at 7 weeks postpartum. Delivery occurred vaginally with epidural, no perineal tearing, and pushing time of less than an hour. Primary concerns of the patient included burning or sharp abdominal pain when lifting, standing, and walking. Uterine contractions that naturally occurred during breastfeeding also worsened the abdominal pain and caused the patient to discontinue breastfeeding. The patient furthermore reported sensations that her insides felt like they would fall out, and abdominal muscle weakness and fatigue with activity.
Although many other significant details related to history, examination and evaluation were included in the case report, I will focus on the signs, interventions, and outcomes recorded in the paper. Diastasis was measured using finger width assessment and a tape measure. (Although ultrasound is more accurate and valid, palpation of diastasis has been demonstrated to have good intra-rater reliability as used in this study. Measures for interrecti distance (IRD) at time of evaluation were 11.5 cm at the umbilicus, 8 cm above the umbilicus, and 5 cm below the umbilicus. The patient also reported pain on the visual analog scale (VAS) of 3-8/10.
Interventions in rehabilitation included, but were not limited to: instruction in wearing an abdominal binder, appropriate abdominal and trunk strengthening (promotion of efficient load transfer and avoidance of exercises that may worsen separation), biomechanics training with functional tasks such as transfers, self-bracing of abdominals, avoiding Valsalva, postural alignment and symmetrical weight-bearing strategies. Plan of care was developed as 2-3x/week for 2-3 weeks, the patient was seen for 18 visits over a four month period. Therapeutic exercise was progressed to include general hip and trunk muscle strengthening towards a goal of stability during movement. Cardiovascular training progressed to light treadmill jogging and use of an elliptical.
After 18 visits, functional goals were all met and included picking up her baby, holding her baby for 30 minutes, standing or walking for at least an hour. VAS pain score progressed to 0 on the 0-10 scale. The diastasis was measured at discharge to be 2 cm at the umbilicus, 1 cm above the umbilicus, and 0 cm below the umbilicus. This case report is first an excellent example of a detailed case example. Second, while the separation dramatically improved, most importantly, the patient’s function improved and her goals were met. This case is a wonderful example of how sharing details of a patient’s rehabilitation efforts can be useful for other rehabilitation therapists to consider when developing a plan of care.
If you are interested in discussing more about postpartum care, check out the first in our peripartum series, “Care of the Pregnant Patient” taking place next in Boston in May with Institute co-founder Holly Herman.
Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, score on the PERFECT scheme, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.
||sEMG biofeedback PFMT: Use of intravaginal sensor and 30 slow, maximal-effort contractions followed by 3 minutes of fast, maximal-effort contractions in supine.
||Sham NMES: sacral surface electrodes with pulse width of 50 ms at 2 Hz, on/off 2/60 seconds for 30 minutes
|| Intravaginal NMES: 200 ms at 10 Hz for 30 minutes using vaginal sensor.
||TTNS: surface electrodes in the left lower leg with pulse width at 200 ms at 10 Hz for 30 minutes.
|Group 1, n = 6||X||X|
|Group 2, n = 7||X||X|
|Group 3, n = 7||X||X|
The following factors made up some of the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, 4 month history of stable symptoms, currently participating in a sexually active relationship, and able to contract the pelvic floor muscles. Participants were excluded if they had delivered within the prior 6 months, had pelvic organ prolapse (POP) greater than stage I on the POP-Q, were perimenopausal or menopausal. Neurologic function symptoms were also monitored so that subjects could be evaluated for any potential flare-up. Home program instruction in PFMT included 30 slow and 30 fast PFM contractions to be completed in varied postures 3x/day.
Results included that all groups improved via the PERFECT scheme evaluation. Other specific indicators of improvement were noted for each group, and the use of the FSFI provided measures of sexual function. The authors conclude that pelvic floor muscle training (with or without electrostimulation) can produce positive changes in sexual arousal, vaginal lubrication, sexual satisfaction and sexual lives. The use of PFMT with intravaginal NMES "…appears to be a better treatment option than PFMT alone or in combination with PTNS in the management of the orgasm, desire and pain domains of [the FSFI]." You can find the abstract of the article by clicking here.
Patients who are managing disease symptoms of MS have many aspects of the disease that can interfere with sexual health, such as energy levels, neurologic impairment, and pain. Use of modalities such as biofeedback and/or electrotherapy may be useful adjuncts in the care of women who have MS. Prior research has identified the benefits of electrotherapy for urinary dysfunction in patients who have MS. The described research allows us to consider inclusion of these tools along with pelvic floor muscle training when working with women who experience sexual dysfunction as a part of MS.
In order to refer patients to needed care, it is vital that health care providers understand the roles that each provider plays. Within pelvic rehabilitation, this issue presents barriers and opportunities, as many providers do not know about pelvic rehabilitation, and about the wide scope of care that we can provide towards bowel, bladder, sexual dysfunction, and pelvic pain in men, women, and children. An article written by a physiotherapist and published in the British Journal of Midwifery highlights the issues such barriers can cause. Utilizing a focus group of seven 3rd year midwifery students, a researchers asked questions about student midwives' perceptions of the physiotherapist's role in obstetrics. Five distinct themes were proposed as a result of the focus group interviews:
1. Role recognition: in order to enable services for patients, understanding other professional roles is valuable.
2. Lack of knowledge: participants expressed a lack of knowledge about the physiotherapy role, and the students wondered if they should be seeking out that knowledge, or if the physiotherapists should be educating the midwives about their role. Prior inter professional education opportunities, which provides the students with potential for understanding other professions, were not viewed as positive by the students.
3. Perceived views existed: Although participants did not have a clear view of what a physiotherapist's role is in obstetrics, they had developed ideas (accurate or not) about the role.
4. Utilization of physiotherapy: Numerous barriers to utilization of physiotherapy in obstetrics rehabilitation were identified, and variations in referrals and utilization of PT were noted.
5. Benefits of physiotherapy: Participants' lack of knowledge, lack of feedback from patients, and issues such as waiting periods prior to getting care limited the stated benefits of physiotherapy care in obstetrics.
In order to avoid working independently of each other, physical therapists and midwives, along with other care providers for women, must understand the complementary roles we play. One of the best ways that we can create a shared understanding is through spending time in each other's educational or clinical environments. Each of us can take responsibility for providing some level of education towards teaching other providers what we do, what we know, and how we can collaborate. One of the ways that the Institute attempts to make this task easier is to provide you with presentations that are already created for this purpose. Our "What is Pelvic Rehab?" powerpoint presentation allows you to edit the slides created for referring providers. Within the presentation, basic information about pelvic therapy and specific research about pelvic rehabilitation for various conditions is combined. To check out the "What is Pelvic Rehab?" presentation and other patient and provider education materials, head to the Products and Resources page and see what information may help you (and your patients) share information about the role of the pelvic rehabilitation provider in collaboration with other health professionals.
Researchers using a community-based sample in the upper Midwest cities of Minneapolis/St. Paul surveyed 138 women between the ages of 18-49 with diagnosed vulvodynia. Vulvodynia was classified as primary (pain started with first tampon use or sexual penetration) or secondary pain started following a period of intercourse that was not painful. The authors aimed to determine the rates of remission of vulvar pain versus pain-free time periods. Remission was defined in this study as having at least one period of time that was pain-free for at least 3 months. Generalized vulvodynia categorization was made after clinical exam and was determined by the subject having pain at each point on the perineal “clock” with cotton swab provocation.
The authors reported that women diagnosed with primary vulvodynia were 43% less likely to report vulvar pain remission that women with a diagnosis of secondary vulvodynia. They also found that obesity and having generalized versus localized vestibulodynia was associated with reduced rates of remission. The theory was discussed that women who have different types of vulvodynia may have varied underlying mechanisms of pain that lead to differences in symptoms. Specifically, the paper reports on recent brain imaging work that suggests women who have primary vulvodynia demonstrate more characteristics of central pain processing.
In relation to health behaviors (such as seeking pain therapy), the authors state that the data may not be sufficiently powered to determine the influence of therapy on remission. They do agree that “…understanding of both spontaneous remission and improvement owing to therapy will ultimately provide guidance in developing more effective interventions.” Because a significant portion of women do not seek care for vulvar pain (for unknown reasons), a bias is created in the research through the lack of representation of those women who are not being studied through healthcare access.
The research concludes with a few familiar themes including the need for more research studying the clinical courses of primary versus secondary vulvodynia. We are also left with questions about which women seek care and why, how their clinical outcomes and remission history may differ based on intervention and other intrinsic variables such as body mass index, and how central pain processing affects pain duration and remission. If you are interested in learning more about vulvodynia, come to one of our newer courses offered by faculty member Dee Hartmann, Assessing and Treating Women with Vulvodynia. Two entire days are spent discussing vulvodynia theory and clinical skills for helping women optimize their health and function. You still have a few weeks to sign up for this course that takes place next in April in Minneapolis!
A report in The Canadian Journal of Human Sexuality describes the level of emphasis placed on particular sexual health topics in Canadian medical schools. Both the level of emphasis and the utilized teaching methods among 51 residency programs for obstetrics and gynecology (OBG), family medicine (FM), and undergraduate medicine (UGM) were evaluated. Program Directors and Associate Deans of the respective programs were electronically surveyed about the following topics: contraception, disease prevention, sexual violence/assault, childhood sexual abuse, sexual dysfunction, childhood and adolescent sexuality, role of sexuality in relationships, aging and sexuality, sexual orientation, gender identity, disability, and social and cultural differences.
The topic that received the most emphasis among the 3 program types was “information and skills for contraception.” Disease prevention for sexually-transmitted diseases was also a high-ranking topic.
The authors point out that while it seems understandable that OBG residencies may not include a significant amount of training in male sexual health, there was an absence of evidence on training in child sexual abuse and adolescent female sexuality in the OBG programs. The article notes other omissions of emphasis such as the lack of training among family practice residencies in transgender and gender identity issues, disability and sexuality, and cultural differences.
This article gives some insight into potential topics of training in human sexual health, and the lack of education in physicians regarding topics of sexual function and dysfunction. In addition to lacking knowledge of some topics in childhood, adolescent, and men’s and women’s health, we can be certain that most providers are not instructed in the role of pelvic rehabilitation providers for sexual dysfunction. How can we contribute to a provider’s knowledge of rehabilitation of sexual dysfunction?
Core lectures, including grand rounds and clinical training made up the primary modes of education for sexual health topics. What if each of us reached out to local training programs, or to local teaching hospitals, or even clinical groups and provided an educational platform about our role in sexual health?
In order to provide such training, you might feel as though you need additional resources and knowledge about sexual health and healing. If you would like to explore how we can maximize our contributions to men and women with sexual dysfunction, and explore your own thoughts and beliefs about sexual health, check out Herman and Wallace Pelvic Rehabilitation Institute co-founder Holly Herman’s course on Sexual Medicine for Men and Women taking place next in April in New Jersey.
Research in the field of sexual dysfunction has taught us several things about patients and healthcare visits. Most medical providers don’t ask about sexual function, most patients don’t bring it up, and women’s sexual health has a history of being undervalued and under-evaluated. Authors Maciel and Lagana describe the common myth that as women age, sexual interest decreases, and review literature to propose improved strategies. The study highlights the fact that there are positive physical health effects for older adults, and that by approaching sexual desire through a biopsychosocial method, further understanding of the issues can be gained.
Several factors have been found to be linked to healthy sex in older females. Having a positive attitude towards sex, an interesting an interested partner, good health, and a willingness to experiment sexually can all contribute to an active sex life. Women who are dealing with high stress, anxiety, and depression are known to be less sexually active. In this paper, the authors describe the work of Sobecki and colleagues, who found that older women have just as much interest in talking about sexual health as younger women, but that doctors aren’t usually asking about it. Sobecki et al. found that a patient reported feeling less embarrassed about bringing up sexual dysfunction if the medical provider demonstrated a professional demeanor, comfort with the topic, and a disposition that is kind and empathetic.
This last point seems worthy of pause and reflection in relation to the role of the pelvic rehabilitation provider. I would submit that most pelvic rehab therapists are highly capable of presenting a professional, kind, and empathetic demeanor. I wonder how many of us, however, had enough education regarding sexual health to demonstrate to patients a level of “comfort with the topic” that inspires a patient to bring up sexual concerns. The more comfortable we are with our own sexuality and the more knowledgeable we are about sexual health practices that are outside of our own experiences, the more we have to offer to our patients.
This excellent review article describes issues that older women often face: menopausal shifts in hormones and vaginal and perineal health, concerns about body image and self-worth. The authors also point out that the healthcare system has medicalized menopause, so that most women are offered little more than pharmaceuticals. One simple suggestion offered in the article is use of the Decreased Sexual Desire Screener that can help identify areas of concern in sexual health. If you are interested in learning more about sexual health and dysfunction, check out Institute founder Holly Herman’s Sexual Medicine for Men and Women continuing education course taking place next in April in New Jersey. If that date does not work for you, you could sign up early for the next course in San Diego in November!
An article appearing this year in Arthroscopy details a systematic review completed to determine if asymptomatic individuals show evidence on imaging of femoroacetabular impingement, or FAI. Cam, pincer, and combined lesions were included in the results. To read some basics about femoroacetabular injury, click here. Over 2100 hips (57% men, 43% women) with a mean age of 25 were studied. (Only seven of the 26 studies reported on labral tears.) The researchers found the following prevalence in this asymptomatic population:
Cam lesion: 37% (55% in athletes versus 23% in general population)
Pincer lesion: 67%
Labral tears: 68%
Mean lateral and anterior center edge angles: 30-31 degrees
The authors conclude that femoroacetabular impingement tissue changes and hip labral injury are common findings in asymptomatic patients, therefore, clinicians must determine the relevance of the findings in relation to patient history and physical examination. Because hip pain is a common comorbidity of pelvic pain, knowing how to screen the hip joint for FAI or labral tears, rehabilitate hips with joint dysfunction, and help someone return to activity following a hip repair is valuable to the pelvic rehabilitation therapist.
As the athletic population may have increased risk of hip injuries due to overuse, traumatic injury, or vigorous activity, being able to address dysfunction in both high level and less active patients is necessary. Herman & Wallace faculty member Steve Dischiavi has developed a course rich in athletic examples and including education about activating fascial systems in various planes. If you are ready to step up your game related to Biomechanical Assessment of the Hip & Pelvis, check out this continuing education course taking place next in Durham, North Carolina in May.
The merriam-webster online dictionary defines reflex as "an action or movement of the body that happens automatically as a reaction to something" or as "something that you do without thinking as a reaction to something." This reflexive action ideally describes what the pelvic floor does when we perform an activity that increases intra-abdominal pressure- and that can help us tighten the pelvic floor protectively so that urine is not expelled from the bladder and out the urethra. A research article by Dietz, Bond, & Shek asked if childbirth interrupted the body's natural reflex of contracting the pelvic floor muscles during a cough.
84 women completed the study, which utilized ultrasound measurements to assess reflex contraction of the pelvic floor during a cough. The women were pregnant with their first child (a singleton) and were between 33-37 weeks gestation. Prior to childbirth, 98% of the subjects demonstrated a reflex contraction of the pelvic floor muscles. At a postpartum visit at least 3 months postpartum, the number of women completing a reflex contraction was reduced to 75%. In addition to fewer women demonstrating a shortening contraction during a cough in the postpartum women, the intensity of the contraction was also reduced.
To collect the data, the researchers prospectively completed 4D (4-dimensional) ultrasound (US) volume measurement of the pelvic floor during a cough. They used levator hiatus diameter changes to quantify reflex action of the pelvic floor muscles. From prenatal to postnatal visit, the magnitude of the reflex contraction decreased from 4.8 mm to 2.0 mm (the number represents the mean difference in midsaggital diameter between rest and maximal contraction.) In the antenatal visit, 26 of the 84 women complained of stress urinary incontinence, at the postpartum visit, 20 reported stress incontinence. An association was noted between a lower magnitude of reflex contraction and stress urinary incontinence.
The authors conclude that pelvic floor reflexes are altered by childbirth. The study offers theories as to why the reflexive contraction is interrupted, such as nerve injury or muscle damage, but did not make concrete conclusions about the causes of reflex interruption. Regardless of the mechanism that interrupts a reflexive contraction, this study highlights the value and importance of teaching women to retrain this importance reflexive contraction, and not only for a cough, but for any activity that may create a significant change in intra-abdominal pressure. If you are interested in learning more about postpartum rehabilitation, check out the Care of the Postpartum Patient, which will be offered next in Boston in May!
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Tina Allen, PT, BCB-PMD, PRPC
How did you get started in pelvic rehab?
I was about 5 years into my career as a PT when for some reason I had patients who where comfortable with me enough to ask questions like, "I'm leaking. Is that normal after giving birth?", "Since my total hip replacement I've been leaking urine" and "I have pain sometimes when I'm have sex...is that normal?". I was working in Outpatient Orthopaedics and I had no idea if it was normal. I searched and found out that it wasn't. After whispering to my patients that it wasn't normal, that I read that there where things they could do about it and then slipping them pieces of paper with instructions on how to maybe make it better; I decided I should learn if there was something a PT could do to help. I spent time with Ob/Gyn's and Urologists learning from them and applying my musculoskelatal knowledge to what they taught me. I was still in denial that I could help folks but then I started getting patients specifically referred to me for these conditions. I finally found that there where classes I could take! Imagine! That was 20 years ago now!
Who or what inspired you?
My patients have always been who inspires me! The questions they ask and how they face what they are going through has always pushed me to figure out ways to help them along their paths to healing and improved function!
I must also include all the PT's whom take our courses. Watching everyone lean into the uncomfortableness of what we teach and the questions everyone asks all in the hopes of helping that client whom walks into the clinic on Monday is inspiring.
What have you found most rewarding in treating this patient population?
It has to be that first session with a patient whom when you educate them on anatomy and function of the urogynecolgical system including fascia and what is needed for function (intimacy, continence etc) and I can see the light bulb go off for them on how everything is connected and everything has to be treated as a whole.
What do you find more rewarding about teaching?
This has to be the inspiration I get a thrill from being with a room of Pelvic Rehab therapists. We all work behind closed doors all day and getting to be in a room with such amazing like-minded therapists gives me a shot in the arm. To watch us all click in and problem solve how to serve our population of clients is inspiring for me.
How did you get started teaching pelvic rehab?
I was lab assisting courses for Kathe and Holly for years. Then one year Holly Herman just kept saying to me, "Why aren't you teaching?" "You could teach this?" "Tina, why don't you take this lecture?" "Tina, how many patients do you see like this in a day? What would you do?" I almost starting avoiding her Then I talked to Kathe about teaching and she said she was just waiting for me to say I was ready to start. That's our founders; always encouraging us to do more and contribute more!
What was it like the first time you taught a course to a group of therapists?
The first time I taught was terrifying! I'm a bonafide introvert (have multiple personalty tests to prove it) and standing in front of 40+ folks talking was not my idea of a fun way to spend a weekend. After the first lecture or two I found a rhythm and relaxed into it. By the afternoon or maybe the next day I was very excited to be around so many clinicians interested in learning and treating Pelvic Rehab.
What have you learned over the years that has been most valuable to you?
That my clients journey is their journey and I get to be a part of it. It's a privilege but it is still their journey. My hope is that where ever they meet me along their path I can assist them to their next step. As long as I get out the way that can happen.
What is your favorite topic about which you teach?
My favorite part of every course are the lab sessions. Getting to teach at each table in small groups and helping clinicians refine their observation and palpation skills is what makes me happy!
A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.
|Examples of Research Cited
||Ideas for Addressing Potential for Harm|
|dropped handlebar position increases pressure on the perineum and can decrease genital sensation||encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily|
|chronic trauma can cause clitoral injury||encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able|
|saddle loading differs between men and women||women should consider specific fit for bike saddles|
|women have greater anterior pelvic tilt motion||is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?|
|lymphatics can be harmed from frequent infections and from groin compression||patients should be instructed in positions of relief from compression and in self-lymphatic drainage|
|pressure in the perineal area is affected by saddle design, shape||female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues|
|unilateral vulvar enlargement can occur from biomechanics factors||therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use|
|genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve||therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation|
Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.
Within a pelvic rehabilitation setting, applying all orthopedic and specific pelvic rehabilitation skills is necessary for women cyclists who present with pelvic dysfunction. Because injury to the perineal area including the pudendal nerve can have negative impact on function such as bowel, bladder, or sexual health, skills in helping a patient heal from compressive or traumatic cycling injuries is very valuable. To learn more about pudendal nerve health and dysfunction, the Institute offers a 2-day course titled Pudendal Neuralgia Assessment, Treatment and Differentials: A Brain/Pain Approach. This course is offered next in Salt Lake City in April, so sign up soon!