A recent case report in the Journal of Physical Therapy Science describes the benefits of specific strengthening of the subdivisions of the gluteus medius in a patient with sacroiliac joint pain (SIJ). The intervention is based in prior research that demonstrated varied muscle firing patterns in the gluteus medius during different exercises. The author of the study suggests that the stabilizing role of the gluteus medius can influence sacroiliac joint pain.
The patient in the case report was a 32 year-old female who complained of pain in the left iliac crest area and sacroiliac joints for 6 months. Symptoms worsened with forward bending, standing for more than an hour or walking for more than thirty minutes. Before and after a 3 week intervention of specific strengthening exercises, objective tests included the Gaenslen, Patrick, and the resistive abduction (REAB) test. These tests were all positive for pain provocation. Exercises were instructed for gluteus medius strengthening and were performed over a period of three weeks. Following the 3 week exercise intervention focused on gluteus medius strengthening, the patient's Visual Analog Scale improved from a 7/10 to a 3/10, and repeated objective tests were negative. Exercises for the various portions of the gluteus medius (GM) were prescribed at 3 sets of 30 repetitions/day and are as below:
Keeping in mind that this case represents only one clinician/patient interaction, we can ask ourselves several questions about the positive results of the intervention. Are we currently challenging the hip abductors enough with our patients who have pelvic girdle pain, and is there enough specificity in the exercises to challenge the appropriate muscle fibers? Can isolated strengthening of hip abductors in absence of other interventions have a positive effect on sacroiliac joint pain in our patients? Are there other plausible rehabilitation concepts inherent in performing these open and closed chain activities that contributed to improvement in this particular patient, rather than an isolated increase in muscle training for the gluteus medius? The sacroiliac joint can be a confounding source of pain, and at the same time, successes in treating patients who have SIJ dysfunction can be very rewarding. If you would like to learn more about evaluation and treatment of sacroiliac dysfunction, the next opportunity to take faculty member Peter Philip's course Sacroiliac Joint & Pelvic Ring Dysfunction, offered next in Seattle in January.
According to the World Health Organization (WHO) sexual health relies upon a "…positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence." This definition provides an excellent framework, yet how many of us were provided with the tools we needed growing up to understand the many domains that affect sexual health such as physical (how does sex work?), and social and psychological implications? Herman & Wallace Pelvic Rehabilitation Institute co-founder Holly Herman has been a long-time proponent of sexual health and function, and in courses, she might be heard asking participants to consider most individuals first sexual encounter: was it relaxed, were both parties informed, was the experience pleasurable? Regardless of a person's stance on when an individual should first engage in sexual activity and with whom, developing a life-long healthful approach to our own sexuality is clearly an integral part of optimizing quality of life.
Ff we expand this concept to the pelvic rehabilitation caseload we often face, how can we best meet the needs of our patients if our own education in sexuality was limited? How can we best understand the varied approaches to sexual health and function if the approaches do not match our own? Our world has fortunately shifted to include the recommendation that healthy sexuality begins in childhood. The American Academy of Pediatrics states that a simple step in childhood sexual development is in using the correct anatomical names for genitalia. How can youth and adolescent sexual health education and support be improved to further promote lifelong healthy sexuality?
An article published last year in the journal Public Health Reports addresses a paradigm shift from teenage pregnancy prevention to youth sexual health. The Oregon Youth Sexual Health Plan was developed in 2009 following a collaborative effort from state agencies and private partners, and focuses on "development of young people" and embracing "sexuality as a natural part of adolescent development." This article lends historical perspective to the advancement of the concept that adolescents have a right to sexual health knowledge, not simply in relation to reproduction and sexually transmitted disease, but also in relation to quality of life and interpersonal relations. The researchers also point out the failure of abstinence-only sex education to produce significant evidence of efficacy.
Goals of the youth sexual health plan include having young people use "accurate information and well-developed skills to make thoughtful choices about relationships and sexual health." Additional goals include that sexual health inequities are removed, rates of teenage pregnancy and sexually transmitted diseases are reduced, and non-consensual sexual behaviors are reduced. The Oregon Youth Sexual Health Plan is public policy, and one that may pave the road for other states seeking to move from a negative stance that focuses on potentially harmful impacts of sexuality to a positive sharing of needed information, knowledge, skills, and support in developing a healthy view of sexuality. If you would like to learn more about sexual health and sexual medicine, join Holly Herman at her course titled Sexual Medicine for Men and Women. The next opportunity to take this course is in January in Houston!
We are thrilled to announce that the results of the November 2014 administration of the Pelvic Rehabilitataion Practitioner Certification (PRPC) are in! Thirteen incredible therapists have joined the ranks of Certifed Pelvic Rehabilitation Practioners!
Huge congratulations to the follwing dedicated experts who sat for and passed the exam this fall:
Lauren Calabrese, PT, DPT
Nancy Corvigno, MSPT
Rhonda Fiorello, PT, MPT
Andrea Goldberger, PT
Natalie Hickenbotham PT
Lisa Hu, PT
Rene Lawson, PT
Holly Moody, PT
Susane Mukdad, DPT
Heather Rader, PT, DPT, BCB-PMD
Elizabeth Sellhorn, PT
Reeba Varghese, DPT
Rebecca Wilcox, MPT
Check back on our list of Certified Practitioners to learn more about these therapists, as well as the other professionals who already hold this distinction.
If you are interested in learning more about certification, check out our Certification page to download the application, learn about the requirements, and access study resources. The next administration of this exam will be May 1-15, 2015.
Can pelvic floor muscle training during the peripartum period prevent or cure urinary incontinence? A systematic review was completed by two pioneering pelvic rehabilitation researchers, Kari Bo, and Siv Morkved, physiotherapists who are experts in pelvic floor therapy. The authors included twenty-two randomized, controlled trials (RCTs) or quasi experimental design studies in the field of pelvic floor muscle training during the peripartum period. Interventions included in the eligible studies included exercise and biofeedback, vaginal cones, or electrical stimulation. As is reported among many systematic reviews, the variability among study populations, criteria, and outcomes measures was wide, however, the authors did conclude that pelvic floor muscle training (PFMT) during and after pregnancy can prevent and treat urinary incontinence (UI). This training should be supervised, the contractions instructed should be close to maximum effort, and at least eight weeks duration is recommended based on the review.
Research issues cited as having potential effects on the research reporting include the lack of outcomes data measuring adherence to the instructed exercise programs. Also brought into question is the practice of treating patients with pelvic floor dysfunction once per week, which may effectively provide a suboptimal dose of care if the effect of treatment is to hypertrophy muscles and provide a plan of care based on strength measures. In many studies, the control group was also completing pelvic muscle exercises as part of "usual care" and creating difficulty in assessing differences among treatment and non-treatment groups. Another question posed by the authors is that if physiotherapists, nurses, and physicians are instructing in exercises, is the instruction equivalent based on training? To improve this potential factor, Bo & Morkved suggest that fitness instructors and coaches should be trained in effective PFMT approaches.
The take home point of this study is that PFMT should be a routine part of women's exercise programs,especially during the peripartum period. Bo & Morkved also point out that UI is inhibitory to exercise participation, and should be considered when designing postpartum exercise guidelines. To learn more about postpartum challenges to recovery of pelvic health and function, join faculty member Jenni Gabelsberg in California this winter for the Care of the Postpartum Patient. The next opportunity to take this course is in January in Santa Barbara!
Researchers in Brazil assessed the effects of low-frequency and high-frequency TENS, or transcutaneous electrical stimulation on post-episiotomy pain. This randomized, controlled, double-blind trial included the two electrotherapy interventions as well as a control group. TENS was applied for 30 minutes to the three groups: the high-frequency TENS (HFT) (100 Hz, 100 ms) the low-frequency TENS (5 Hz, 100 ms), and the placebo group. Electrode placement was near the episiotomy in a parallel pattern, and pain evaluations were completed before and after TENS application in resting, sitting, and ambulating. (Electrode placement specifics can be found in the article that is available within the above link.) The interventions and pain evaluations were carried out between six and 24 hours after vaginal delivery.
The intensity of the HFT and LFT was controlled by the participants, with instructions to allow the sensation to be both strong and tolerable. A total of 33 participants completed the study, with 11 in the HFT group, 13 in the LFT group, and 9 in the placebo therapy group. The researchers found that for HFT and LFT, pain improved following application of the electrotherapy, and the effects of the pain reduction lasted one hour after the intervention. Because TENS is a low-cost, low-risk modality, TENS use may be a welcome addition for postpartum care following an episiotomy. The women using high or low-frequency TENS in this study reported that TENS was comfortable and that they would opt to use it again.
If you are interested in learning more about postpartum care and issues such as episiotomies which can interfere with return to function, join faculty member Jenni Gabelsberg in Santa Barbara in January. In addition to discussing a wide variety of common musculoskeletal conditions, she will discuss pelvic floor issues following childbirth that can impact a woman's postpartum recovery. Click here to view the learning objectives for Care of the Postpartum Patient as well as additional dates and locations for this course.
Researchers in Norway aimed to determine if an inpatient rehabilitation program (IRP) was superior to an outpatient rehabilitation program (ORP) in helping women return to work following treatment for breast or gynecological cancers. Being unable to work or having to reduce work capacity due to physical and mental challenges is common after cancer treatment. Accompanying changes in quality of life and health status affect women differently and is often based upon diagnoses, treatment interventions completed, education levels and work status, according to the authors. In this article, women attending separate inpatient and outpatient locations with programs designed to reduce drop-out from work by improving physical, psychological, and social health. 51 women were included in the inpatient program, with 50 in the outpatient program. The variables assessed for outcomes included change in work status, fatigue, and health-related quality of life. At time of admission and 6 months post-admission, women ages 18-67 completed the Fatigue Questionnaire (FQ), the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), and information about work status.
Interventions for both groups included physical exercise, patient education, and group discussions. Educational and group discussions included topics of cancer treatment and side effects, physical activity, nutrition, work rights and return to work issues, partnership and sexuality, psychological reactions to cancer, and coping strategies. The inpatient program involved 3 weeks of stay during the week, and a 1 week follow-up 8-12 weeks later. Educational training comprised approximately 15% of time, group discussions 25% of the time, and physical activity 60% of the time. Exercise activities included Nordic walking, hiking, spinning, stretching, and relaxation. The outpatient rehabilitation occurred 5 hours/day, 1 day/week for 7 weeks. The lectures in the ORP accounted for 25% of the total time, group discussions 25% of the time, and physical activity the remaining 50% of the time. Because of the significant decrease in time spent in rehabilitation, the authors proposed that the subjects in the inpatient program would experience more significant improvements.
Fortunately, both groups improved significantly, without the expected differences in outcomes between groups. In the inpatient program, 73% of the women improved their work status compared to 76% in the outpatient program. All subjects benefited from either program in health-related quality of life and in fatigue, but no significant differences were noted between groups. One reported difference between the intervention groups is that within the inpatient group, an immediate improvement in fatigue was noted. This improvement was attributed to the 1-2 exercise sessions per day in the IRP. The authors conclude that both inpatient and outpatient rehabilitation programs for women following intervention for breast and gynecological cancers can offer substantial benefit. This conclusion is positive in that some patients may not be able to travel to participate in inpatient programs, and the cost of an outpatient program is significantly less than inpatient programs. To learn more about oncological approaches for rehabilitation, the Institute has several courses available. Susannah Haarmann's Breast Oncology course is taking place in February in Arizona. The Oncology and the Pelvic Floor A course (about the female pelvis) is instructed by Michelle Lyons and is offered next in California in May. Check the website for updates to additional oncology course dates. If you are interested in hosting a course, please contact the Institute, and if you would like to be alerted when a particular course is scheduled in your area, let the Institute know and we can keep you informed of schedule updates!
Research published last year in Archives of Gynecology and Obstetrics describes the benefits of "triple therapy" for symptoms of urogenital aging in postmenopausal women. The triple therapy included pelvic floor rehabilitation, intravaginal estradiol, and Lactobacillus acidophili on symptoms of urogenital atrophy, urinary tract infections (UTI's), and stress urinary incontinence (SUI) in postmenopausal women. 136 women with postmenopausal urogenital aging symptoms were divided into two groups of 68 women. Group 1 received intravaginal treatment of combined estriol (30 mcg) and Lactobacillus acidophili (50 mg) and pelvic floor rehabilitation. Group 2 received intravaginal estriol (1 mg) plus pelvic floor rehabilitation. The intravaginal treatment was applied once/day for 2 weeks and then twice/week up to 6 months.
Symptoms of urogenital aging listed by the authors include lower urinary tract issues (urinary frequency and urgency, nocturne, dysuria, recurrent UTI's, and urinary incontinence (UI)), and vaginal or vulval symptoms (vaginal dryness, itching, burning, and dyspareunia.) The connection between the microbiota Lactobacillus acidophili and vaginal health is described in the article involves the proliferation of Lactobacillus acidophili that is stimulated by estrogen. The microbiota then is reproduced in the vaginal epithelium, reduces pH, and prevents colonization of pathogens that can lead to UTI's. The pelvic floor muscle training was completed "…as explained by Castro et al…" in reference to the 2008 study assessing the efficacy of pelvic floor muscle training, vaginal cones, electrical stimulation, and no active treatment. The pelvic floor training in the Castro study included group sessions of pelvic floor muscle contractions as follows: 10 repetitions of 5 seconds contract, 5 seconds relax; 20 repetitions of 2 seconds contract, 2 seconds relax; 20 repetitions of 1 second contract, 1 second relax; 5 repetitions of 10 seconds contract, 10 seconds relax; and 5 simulated cough with strong contraction with 1 minute rest in between.
In the study, the authors assessed outcomes of urogenital symptoms in women aged 55-70 including urine cultures, colposcopic and urethral cytologic findings, urethral pressure profiles, and urethro-cystometry before and 6 months after intervention. Results included that both groups demonstrated significant improvements in symptoms and signs of urogenital atrophy , and 76% of the triple therapy group (Group 1) reported improvement in incontinence versus 41% of Group 2. Subjects in the triple therapy group also were observed to have significant improvements in colposcopic findings, urethral pressure and closure, and in abdominal pressure transmission ratio to the proximal urethra. The study concludes that combination therapy of estriol, Lactobacillus acidophili, and pelvic floor rehabilitation should be considered first-line treatment for postmenopausal symptoms of urogenital aging. To learn more about menopausal evaluation and interventions, check out faculty member Michelle Lyons' new course on Menopause: A Rehabilitation Approach. The next opportunity to take this course is in February in Orlando.
Visceral therapy is used by manual therapists, and research continues to emerge that attempts to explain the underlying mechanisms of the techniques. A study published in the Journal of Bodywork & Movement Therapies in 2012 reports on the effects of visceral therapy on pressure pain thresholds. Osteopathic visceral mobilization was applied to the sigmoid colon in 15 asymptomatic subjects. Pressure pain thresholds were measured at the L1 paraspinal muscles and 1st dorsal interossei before and after intervention. Pressure pain thresholds at the level assessed improved significantly immediately following the visceral mobilization. The effect was not found to be systemic. Hypoalgesia, therefore, may be a mechanism by which visceral mobilization affects patients who are treated with this technique.
Another research study that aimed to assess the effects of visceral manipulation (VM) on low back pain found that the addition of VM to a standard physical therapy treatment approach did not provide short term benefits. However, when the 64 patients were reassessed at 2, 6, and 52 weeks following treatment, the patients in the group with visceral manipulation were found to have less pain at 52 weeks. The patients were randomized into 2 equal groups and were provided physical therapy plus a placebo visceral treatment or a visceral treatment in addition to physical therapy. The authors propose that there may be long-term benefits of including visceral therapy in rehabilitation approaches.
If you would like to learn more about visceral techniques as well as theory and clinical application, check out the updated schedules for Ramona Horton's Visceral Mobilization 1 (VM1): The Urologic System, and Visceral Mobilization 2 (VM2): The Reproductive System. The first opportunity to take VM1 is in January in New Jersey and VM2 is scheduled in September in Ohio.
Women who are diagnosed with and treated for breast cancer commonly suffer from decreased function and fitness, and may be at risk for increased rates of functional decline than women not treated for cancer. This topic is highlighted in a paper published earlier this year in the International Journal of Physical Medicine & Rehabilitation. The authors of this article acknowledge that exercise during and following treatment for breast cancer has significant positive health effects including physical and psychosocial benefits. Cardiorespiratory and resistance training are often recommended to patients as modes of exercise that a breast cancer survivor should participate in, yet the authors raise the question about safety of the recommended exercise programs.
A literature review was completed and in this study 73 studies were included. The studies described exercise programs for patients with breast cancer during treatment and following treatment. The exercise programs within the studies varied widely, with aerobic exercise being prescribed from 10-60 minutes/session, 20-300 minutes/week, at light to vigorous intensity, and with a frequency of 1-7 days/week. The resistance-based exercises, although based on standard exercise principles, also varied dramatically in instructed parameters, according to the authors.
Other key information the authors report from the literature review is that many of the research studies were not representative of the typical patient diagnosed with breast cancer. In fact, as is described in this open-access article, women in the studies were usually younger, had less advanced disease, and in general were more well than the typical patient. For example, listed exclusion criteria in many of the studies included cardiovascular disease, diabetes, COPD, and stroke- some of the most common conditions that a woman with breast cancer also reports.
The take-home point of the article is that because many of the subjects in the exercise studies were not representative of the typical patient with breast cancer, the exercise recommendations may not be appropriate for generalization to most patients during or following treatment for breast cancer. The authors recommend future research considerations that include finding out why women choose to participate in exercise trials or choose to exercise on their own. With so many women simply being given general exercise instructions, the issue of supervised versus unsupervised exercise training, especially for women with more advanced illness should be considered.
If you would like to add more knowledge and skills to your toolbox for treating women diagnosed with breast cancer, you can join faculty member Susannah Haarmann's course Rehabilitation for the Breast Cancer Patient. In 2015 this course is currently scheduled in February in Arizona and in June in Illinois. We hope that you can join us for this specialty course!
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
•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.