PT in Motion recently reported on a newfield guidecreated by theJoint Commissionthaturges US health care providers to create a more inclusive and safe environment for LGBT (lesbian, gay, bisexual, and transgender) individuals. The new guide points out that LBGT patients struggle with overall lowered health status, higher rates of substance abuse, higher risk for anxiety or depression, and decreased access to insurance and health care services. Additionally, LGBT patients are not treated equally, facing refusals of care or delayed care, leading to distrust of the health care system.
One of the strategies described in the guide that will help improve communication and inclusion is the use of neutral language on commonly used forms. In a hospital this may include admission forms, in a clinic, all intake forms can use the term "partner", or "parent/guardian" may be substituted for father or mother. Verbal communication should also be free of assumptions. For example, "are you married?" implies heterosexuality to most people. Instead of referring to husband or wife, the guide suggests that you can ask, "Who are the important people in your life?", or, "Who is family to you?" Listening to and reflecting the patient's choice of language can demonstrate inclusion and help your patient feel more able to reply honestly.
Other concepts are shared towards creating a welcoming environment.For example, does your health care setting have a non-discrimination policy? Perhaps it could be more prominently displayed to demonstrate that your work environment does not tolerate discrimination of any type. Images of or descriptions of "family" should include various structures of family, including same sex couples. Your clinic can also display LGBT-friendly symbols such as the rainbow flag, the pink triangle, or a "Safe Zone" sign. Having a unisex or a single stall restroom may also be more comfortable for a patient.
There is an incredible amount of information available in this new guide, it is nearly 100 pages long and can serve as an excellent resource in your work place. The guide summarizes that "...all patients, regardless of social or personal characteristics, should be treated with dignity ad respect...and should feel comfortable providing any information relevant to their care, including information about sexual orientation and gender identity."
According to a research review by senior staff nurse Julie Patrick-Heselton, fecal incontinence in critical illness “…is distressing, unpleasant and frequently socially disruptive to patients.” Because patients who require intensive care often have diarrhea, skin care and avoidance of infection are important for patient health. If bowel care is not made a priority, patients can additionally suffer from abdominal bloating, vomiting, dehydration, urinary issues, and bowel obstruction and perforation according to the article. Skin that is exposed to excess moisture from urine or stool becomes more fragile and at risk for breakdown. If a pressure ulcer occurs due to skin breakdown, infection becomes a major health risk.
If you are working with patients who are at risk for skin breakdown due to urinary or fecal incontinence, it is important to provide education about skin protection including barrier creams. These topics are discussed in the Herman & Wallace course series, and handouts are available in the Urinary Incontinence and the Prolapse and Colorectal Care Manuals. This study refers to Cavilon Durable Barrier Cream, and describes its use with incontinence pads for maximizing protection. For most patients, anything that contains zinc oxide or other water-repelling substance can assist in keeping the skin less moist and therefore less susceptible to breakdown.
Another resource described in this article is the Flexi-Seal FMS (Fecal Management System). It is a device that uses a tube to divert loose or liquid stool into a bag so that skin is protected. Although this is not something that most patients in outpatient rehab would utilize, I can think of a few patients who may have been able to use such a device during periods of diarrhea and skin irritation. (One patient I recall had to periodically go through a medical procedure and take antibiotics, which always increased her fecal incontinence for several weeks. One strategy we also implemented was having her talk to a pharmacist about changing the form of antibiotic that she used from a broad spectrum to a narrow spectrum antibiotic, which was very helpful.)
While fecal incontinence may resolve in patients following a bout of critical care at hospital, I have worked with several patients who suffer from long-term diarrhea or from chronic infection of C. difficile. Diarrhea is not normal, and patients must be sure to be evaluated medically to reveal the cause of the issue. Many patients we meet in the clinic have been suffering from bowel issues for years, some for decades. Patients can routinely be screened by all providers (pelvic rehab providers or not) for bowel and bladder issues so that appropriate referral can be provided. Protecting perianal skin as well as reducing the psychosocial impact of fecal leakage is a goal that we can all work towards for the sake of our patients.
Last weekend Herman and Wallace faculty met in Florida to work on the Pelvic Therapy Practitioner Certification(PTPC) development. The team was led fearlessly by Patricia Young of Kryterion, who assists the Institute in creating a test of the highest quality. Working within the framework of the patient/client management model that appears in the Guide to Physical Therapist Practice (APTA), faculty worked on exhaustive lists of concepts with which a pelvic rehab therapist must be competent. The work completed this past weekend allows Kryterion to create the practice analysis that will be foundational for all other elements of the test development.
The intent of the PTPC is to recognize expertise in treatment of pelvic floor and pelvic girdle dysfunction. Some of the topics that will be included on the certification exam will be pelvic anatomy, pathophysiology, medical and rehabilitative interventions, outcomes measurement, and ethics. If you currently receive the Herman & Wallace newsletter, you will be notified when Certification information is updated. If you are not currently receiving newsletters, click hereif you wish to sign up.
While the faculty worked hour after hour to move the certification process forward, there was also a lot of sharing of knowledge, learning of new vocabulary words such as "criticality" and eating of excellent food such as the kale ceasar salad made by Institute administrator Siv Prince.The letters "BBGOSO" were substituted whenever someone wanted to refer to bowel, bladder, gynecologic, obstetric, sexual, and orthopedic conditions (I even heard a rumor about a t-shirt being created). Theweekend was a great opportunity to spend quality time with other people who are passionate about their work, and who all have unique contributions that he or she is willing to share. The next step of the PTPC process will involve many pelvic rehabilitation providers as a survey involving job tasks will be sent out to those on the Herman & Wallace list. Please consider participating in the survey when you see that e-mail.The Institute looks forward to having the Pelvic Therapy Practitioner Certification available as a means of recognizing the specialized care that you provide to your patients.
Appearing in the September issue of Diseases of the Colon and Rectum, an article was published regarding the long-term efficacy of using chronic implantation of the InterStim device made by Medtronic.120 patients (110 of them female) were given the surgically implanted treatment after a positive test period with external stimulation was utilized. (Even though the external stimulation was used in the test trial, an electrode was placed surgically in the foramen of S2,3 and/or 4.) The mean duration of fecal incontinence (FI) was 7 years. The mean length of follow-up that is reported on in this study is just over 3 years, and 83 of the 120 patients completed all or a portion of the follow-up. At the time of follow-up, 86% of the patients reported at least 50% improvement in the number of incontinence episodes per week. The mean rate of episodes of FI at baseline was 9.4 per week and this reduced to 1.7 per week. Full continence was achieved by 40% of the patients. Quality of life measures including the Fecal Incontinence Quality of Life Scale were also improved from baseline.
Patients who had fecal staining were not included in this research, instead the patients in this study had at least 2 episodes of frank fecal incontinence per week for at least 6 months. At baseline 60% of the patients experienced passive anal incontinence (leaking without being aware of leaking stool), and at follow-up this number was reduced to approximately 10%. The two highest etiologies for fecal incontinence reported was for obstetrical injury (55 of the patients) and post-surgical injury (25). The majority of those in the study reported significant improvements within 3 months of beginning the InterStim treatment.
Any such procedure is not free of risk, and in this study, complications included pain at site of implant, paresthesia, change in sensation of the stimulation, and infection.It seems that for pelvic rehab providers, our first instinct is to believe that every patient can benefit from rehabilitation and thus avoid surgery. While it is often the case that conservative treatment provides benefit, there are also patients who will not make progress for various reasons. For these patients, we can provide excellent education towards improving neuromuscular function and therefore continence, we also can improve a patient's knowledge when we are aware of other options such as InterStim. For patients who fail all other rehabilitative efforts, some type of surgery or other intervention may be required.
At the most recent International Pelvic Pain Society Meeting in Las Vegas, Thomas Findley, MD , PhD, discussed the continuously emerging science of fascia and the mechanisms that can produce pain when fascial tissues are dysfunctional. He described the fascial cells in the body as similar to tents, bearing compression or creating structure. It is the microtubules that bear compression in living cells. The fascial connective tissue "connects and disconnects." If you have seen the Bodies exhibit, you may recall the bodies that had everything removed except fascia, yet the structure still looked very much like a body.
Fascia covers every muscle, every nerve, every vessel, every fascicle of muscle. Dr. Findley explained that while muscle fibers have been found to be 7-8 cm long, fascicles can be found in the body that are 35 cm long. The concept of muscles that stop and start at an origin and an insertion is an illusion according to Dr. Findley, because the amount of connectivity from the muscle to the tendon and to nearby fascia create continuity that allows for functionality. One function of these fascial connections is to take part in dynamic compression of joints and loading of tissues. He gave the example that 85% of the gluteus medius muscle fibers attach into the fascia lata, not the muscle attachment itself. It is this connectivity that can help transmit force along the length of the thigh.
In relationship to pain, there is a layer of hyaluronic acid within the fascia that creates glide by acting as a lubricant. This acid can also act as an irritant and a "glue" when there is too much compression or dysfunction in the tissue. Fascia contains fibers for both nociception and proprioception. Some fiber elements of fascia turn over every 24 hours according to Dr. Findley. Within the pelvis, there are many layers of fascia with connections from the abdomen, the buttocks, trunk, and the thighs. We must continue to take into account these important fascial structures when treating those who have pelvic pain. We must also continue to take part in and look for research that expands the scientific knowledge as well as the clinical experiences of providers treating conditions such as pelvic pain.
Dr. Findley is the Executive Director of the Third International Fascia Research Congress to be held in Vancouver, BC, in March of 2012. For more information about how emerging fascial research can influence your practice, join the multidisciplinary gathering of clinicians and scientists at the meeting. The Institute incorporates myofascial treatment techniques in many of the courses offered, including a new course created by Ramona Horton, called Myofascial Release for the Pelvis.
Herman & Wallace faculty member Dawn Sandalcidi and Dr. Nel Gerig, who is in urology practice in the Denver area, gave a clear presentation at the most recent International Pelvic Pain Society (IPPS) Meeting about the treatment modality of dry needling for pelvic pain. Following a clear explanation of trigger points and the high prevalence of trigger points in the population of men and women who have chronic pelvic pain, the techniques of using needles in the muscles of the perineum was demonstrated by excellent images. The treatment can certainly include other portions of the body, such as the low back or thighs, as we know that these areas often become tense and painful during the course of pelvic pain.
Dry needling, called "dry" because there is no injectable such as lidocaine or cortisone used, is a technique that allows placement of a very small needle into the skin, muscle, or connective tissue of a hyper-irritable area in the soft tissue. This is done for the purpose of reducing the tension, pain, and connective tissue restrictions in the local area. In addition to the mechanical effect that the needle has, there are also neurophysiologic effects and chemical effects from the needle placement. Dry needling is commonly practiced in many other countries and is increasingly offered by physical therapists in many states. You need to check your state practice act to find out the current status of dry needling. Kinetacore is one continuing education provider that lists current states on their website who have either allowed or who have restricted dry needling.
Dawn Sandalcidi reported during her lecture that she finds the patient's muscles significantly decreased in tension, pain, and that patients report a significant decrease in pain levels following treatment that includes dry needling. She also noted that the technique allows her to "save her hands" as the needles can treat the trigger points very effectively. In states where dry needling is not practiced by physical therapists, it may be very helpful for the pelvic rehab provider to team up with someone such as a physician who is allowed to use needles. When a pelvic rehab provider and a medical provider work together to treat the patient, it is always the patient who benefits from such coordinated care. Increased research is needed to support dry needling for pelvic pain, and as Institute co-founder Holly Herman is known to say at courses, "What a great research project- you should do it!" The more "sharp" tools that are in our toolbox that are supported by patient outcomes and by research, the better we can serve our patients.
At this year's International Pelvic Pain Society (IPPS) meeting held in Las Vegas last weekend, I found myself wishing that I had reviewed neuroanatomy prior to the conference. Many speakers addressed portions of the brain such as the insular cortex as the brain continues to be a prominent piece of the puzzle in chronic pain anywhere in the body. Dr. Alain Watier, a Canadian gastroenterologist who specializes in treatment of pelvic pain, gave a lecture that included research based on chronic pain as well as practical advice for the clinician. He states in his lecture that a provider should be familiar with the neurobiology of pain. Functional brain imaging studies have identified that the brain can be activated simply by anticipating pain relief, and that the brain can then activate pathways that modulate a patient's pain experience. There is significant anatomy and physiology involved in the modulation of pain, and reduction in pain can be achieved through pharmacology as well as through the brain.
How do we encourage our patients to maximize the ability to use the brain for pain reduction? Here is a practical suggestion based on the idea that the brain must re-learn "normal" pain perception. The patient can be taught to actively engage the brain in soothing thoughts, feelings, memories, touches, smells, and new beliefs. When a patient experiences an increase in pain, she should "...flood the brain with memories of how they felt and who they were before pain." Patients can be taught to use mindfulness meditation, many forms of biofeedback (thermistor for skin temperature, mirror therapy, heartbeat regulation, and blood pressure. ) Cognitive behavioral therapy can be helpful in reducing anxiety as well as gastrointestinal disorders.Other techniques that can help a patient heal were discussed such as EMDR, hypnosis, art therapy, massage, and acupuncture.
When patients are dealing with chronic pain, according to Dr. Watier, is is critical to engage a multidisciplinary approach and to focus on changing the brain/body patterns of pain perception. The pelvic rehab therapist can play an important role in explaining that the brain can physically change during chronic pain experiences, and that to heal, the brain must be addressed in addition to the peripheral pain. The patient can be guided back to gentle, graded movements so that moving can again become a positive experience, even in small doses.
(A blog directing your patient to the computer should not ideally follow a post about avoiding the computer, however, this is a potentially very positive resource for both patients and pelvic rehab providers alike.) As a founding sponsor, Boston Scientific has funded through an educational grant the development of a new website called "Take the Floor: Voices for PFD" (pfd = pelvic floor dysfunction). You can access the new website here.It is developed by the American Urogynecologic Society (AUGS) and the AUGS Foundation.
Patients will find helpful information about urinary incontinence, bladder dysfunction, and bowel dysfunction including definitions, incidence, symptoms, prevention and treatment. Regarding treatment, the site recommends a medical examination to determine the best course of treatment. I especially think the resource page for caregivers is really useful, and the How To Talk About PFD page is excellent and gives some "conversation starters" that are really nice openers to discussing the potentially sensitive topics.
As a pelvic rehab provider you might also appreciate the Find A Provider link. Many rehabilitation professionals find that Urogynecologists have a head start on understanding the role of conservative care, pelvic floor strengthening or manual therapy techniques. You can also register to join the website community and follow contributions to the interactive portion of the site.
While the internet can provide amazing resources and connections for patients, the internet is also a place where our patients can find frightening, anxiety-producing information. How often do our patients post in "I was healed" chat rooms? One thing we often have to do is ask our patients who suffer from chronic pain to "stop checking the internet." Research published in the Journal of Urology addresses the question of quality of internet informationavailable regarding female pelvic floor disorders (PFD). Of the number of websites sharing health information about female PFD, there were few that were certified by the NGO Health on the Net. For urinary incontinence, pelvic organ prolapse, and overactive bladder, certification rates were between 27-29%. 44% of the sites were sponsored by for-profit entities. Whether a website is "certified" (a voluntary process) may be an interesting concept for our patients when they are looking for information on the net.
Also in relation to internet use by patients, researchers at the University of Washington wanted to know how information provided as "patient-expertise" differed from clinician expertise when advice was offered to patients going through breast cancer. Here is the full text article. The authors conclude that when patients give other patients advice (through chat rooms or books) they do not categorically try to doctor other patients. Instead, advice available from patient expertise included primarily medical or personal advice. Patients shared strategies for making medical choices, managing the daily challenges of life, as well as dealing with the emotional response to having cancer. The article also outlines suggestions for builders of health websites that can best serve patients.
In summary, the internet can be seen as an incredibly valuable tool. Patients who are immersed in the internet and come away with a fear-based approach to their illness or chronic pain may be best advised to limit their time spent on the computer. As a practical suggestion, here is a blog post about how to step away from your computer. After you read your H&W blog posts, of course.
In Menopause: The Journal of the North American Menopause Society, an article addressing the effects of menopausal symptoms that affect work is discussed. A cross-sectional sample of 208 Dutch women aged 44 to 60 years were evaluated using the Work Ability Index and the Greene Climacteric Scale. The conclusion of the study is this: "Menopausal symptoms are negatively associated with work ability and may increase the risk of sickness absence." When symptoms of menopause include hot flashes, sleep disturbances, mood swings, depression and anxiety, it is easy to consider how this could affect a woman's ability to perform her tasks with maximal success or to feel rested enough to attend work.
I found it very interesting to read a study about "menopausal interventions" at a newspaper company in Japan. This company has 907 employees, and 98 of them are women. The employee's health is managed by 2 occupational health nurses (full-time) and an industrial medicine physician (part-time.) A gynecologist was consulted to assist in improving the workplace for women who reported menopausal symptoms. Not only were women included in some of the cases described in this study, but a male employee with concerns about his wife's health was brought to the attention of the nurse and physician. While I cannot comment with any authority about healthcare in Japan, I appreciate the fact that menopause was identified as an issue, and then the workplace was educated about the effects of menopausal symptoms (not simply in terms of work output reduction but also in terms of mental stress and depression) and then interventions were applied with success reported.
What many healthcare advocates in the US have been hopeful towards is the development of a more proactive approach, and with healthcare dollars shrinking, shifting towards workplaces that assist in health management of employees may prove to be a part of that process. While the healthcare system is not a can of worms I aim to open, I would like to point out that many women suffering from menopausal symptoms are not getting the support needed to manage adverse symptoms. One of my favorite questions for a patient (this comes from Holly Herman, founding member of the Pelvic Rehab Institute) is, "Who is managing your hormones with you?" I recall the 56 year-old patient (who had a hysterectomy at 27!) saying, "well, I tried Premarin once after the surgery, and it didn't really help, so I stopped taking it." That was the extent of her assistance with hormonal management. Although hormone therapy is certainly not in the scope of practice of many therapist-rehab providers, asking such a question most certainly is. The patient can be encouraged to discuss any symptoms with her primary care or gynecologist, naturopath, or other provider who can discuss options for treatment.