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.
This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Menopause: A Rehabilitation Approach. She will be presenting this course this February!
Osteoporosis, pelvic organ prolapse, and incontinence are common in postmenopausal women. (Richter et al 2012) What do they have in common? Research has implicated collagen and other extracellular matrix abnormalities in the etiology of these conditions, but the other commonality they share is that all three conditions are responsive to skilled pelvic rehab.
Osteoporosis is characterised by compromised bone quality, which may lead to vertebral fractures, particularly in the thoracic spine – these are the most prevalent female osteoporotic fractures. The amount of bone tissue in the skeleton, known as bone mass, can keep growing until around age 30. At that point, bones have reached their maximum strength and density, known as peak bone mass. Women tend to experience minimal change in total bone mass between age 30 and menopause. But in the first few years after menopause, most women go through rapid bone loss, a “withdrawal” from the bone bank account, which then slows but continues throughout the postmenopausal years.(nih.gov).
Thoracic osteoporotic fractures are strongly correlated with spinal deformity and height loss, hypothesised to increase intra abdominal pressure. Height loss inherent with osteoporosis is significantly associated with urinary incontinence which is associated with pelvic organ prolapse (Chiarelli & Sibbritt 2012)
So when should women start thinking about bone health? There is an old Chinese proverb ‘The best time to plant a tree was twenty years ago. The next best time is today.' So, ideally, thinking about bone health should begin in adolescence and not wait until peri-menopause BUT there are many strategies that we as pelvic rehab providers can share with all women at risk (essentially all of us!).
Sinaki et al in 2010 in her paper ‘The role of exercise in the treatment of osteoporosis’ showed that specific therapeutic exercise programming, in conjunction with optimal nutrition can halt and even reverse the effects of osteoporosis. However, evidence shows that not all exercise is equal when it comes to building strong, healthy bones or preventing osteoporosis. In fact, some forms of exercise may be linked to a decrease in bone density and lead to bone loss and osteoporosis even in elite athletes. This is where the skilled therapist has a role to play. In my new course ‘Menopause – a Rehab Approach’ I will be looking at all aspects of bone health promotion including exercise, nutrition and ergonomics. Come and enjoy some winter sun with me in Orlando in February, and learn how to meet the needs of peri menopausal women safely and effectively!
‘In women, osteoporosis and urinary incontinence are prevalent, progressive disorders’ (Chiarelli & Sibbritt 2012).
The Pelvic Health Certificate (PHC) includes a number of courses on male and female pelvic health.
At Herman & Wallace, we think it's wonderful to see yet another example of pelvic rehab being offered and promoted as part of "mainstream" physical therapy practice, particularly by an organization that has previously focused on orthopedics, manual therapy and sports medicine. The increased number of continuing education offerings on the topics of pelvic floor dysfuntion in men and women means that all the hard work our amazing faculty, course participants and certifed therapists have done over the years has finally brought pelvic rehab into the limelight!
Just like H&W, Evidence in Motion's program shys away from using "women's health" to stress that these courses cover pelvic dysfunction in men and women throughout the life cycle. While we are taking some issue with their contention "Sadly, once you are finished with school, you’ll be hard pressed to find a continuing education course that mentions the pelvic floor unless you find a course with “women’s health” in the title" (AHEM! Over here! Check out our incredible course offerings and our amazing and inspiring Certified Pelvic Rehabilitaton Practitioners!) we think it's wonderful to see yet another organization trying to get the word out to therapists, patients and referral sources about the incredible work our therapists do!
This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course,Rehabilitation for the Breast Oncology Patient.
One year ago I received a phone call from my father on behalf of a friend, named Lynne,* from Oregon who was navigating her way through cancer treatment and jumping many medical and personal hurdles. “Susannah,” my father said, “Lynne is having terrible pain in her breast and arm and is unable to move it above her head. It started a couple of weeks after her surgery and months later it is still bothering her. She is a very active lady and this is really getting her down. Nobody can tell her what it is. Do you know what could be causing this?”
“Yes, dad, it sounds like lymphatic cording,” I said. I contacted Lynne and was able to speak with her physical therapist. Within a few weeks of treatment Lynne’s pain was gone, she had regained full range of motion in her shoulder and was back to paddling.
Lymphatic cording is a relatively common phenomenon occurring in approximately 43% of patients status post axillary lymph node dissection and 20% of patients after sentinel lymph node biopsy (Torres Lacomba et al, 2009) (McNeely et al, 2012). Not only are most therapists not familiar with this phenomenon, but many doctors are unable to identify a reason for the acute loss of shoulder range of motion and pain that can occur after axillary node dissection or mastectomy. Lymphatic cording does not only cause physical dysfunction and discomfort, it can also impede necessary medical treatments. In order to receive radiation to the axilla, a patient must be able to hold their arm in a cradle which requires maintaining a position of shoulder flexion and abduction.
But there is hope. Manual releases for lymphatic cording are one of the most efficient and effective methods of decreasing pain and restoring range of motion. Significant improvements in pain and range of motion are possible after one treatment and often resolve in as little as three sessions. These techniques require skilled assessment from a rehabilitation practitioner who understands basic anatomy and function of the lymphatic system and can provide progressive manual therapy treatment. The therapist must be able to identify the different types of lymphatic cording in order to determine functional prognosis and provide the most effective treatment.
Lymphatic cording has been described as ‘self-limiting,’ explaining that in most cases it resolves within 2-3 months, however, a cascade of physical dysfunction may occur from even the presence of this ‘temporary’ impairment. Within two months, an individual may develop compensatory mechanisms of movement which may lead to postural deficits and pain related to muscular trigger points, chronic headaches or shoulder impingement syndromes. Impairments such as this may also prevent a person from performing employment tasks or fulfilling family responsibilities; this can be detrimental to self-worth and affect quality of life. It is important to note, however, that the presence of lymphatic cording in clinical practice has been noted for months or even years after surgery (Kepics, 2007).
We as rehabilitation professionals are acutely aware that a patient’s investment is therapy is often based upon the reward of function and body restoration. In my opinion, lymphatic cording is a rewarding condition to treat because of its often quick response to manual release techniques and exercise. Lymphatic cording is a common and misunderstood phenomenon; I hope that one day every community in America will have a confident and skilled therapist at hand who is able to treat this often times perplexing condition.
*Permission granted for use of first name
Join Susannah this February in Phoenix where she will be teaching Physical Therapy Treatment for the Breast Oncology Patient
Kepics, J., Treatment of axillary web syndrome: a case report using manual techniques. 2007; University of Scranton, case report.
McNeely, M., Binkley, J., Pusic, A., Campbell, K., Gabram, S., Soballe, P., A prospective model of care for breast cancer rehabilitation: postoperative and post reconstruction issues. Cancer. 2012. 188 (8) 2226-2236.
Torres Lacomba, M., Mayoral Del Moral O., Copariias Zazo J., et al. Axillary web syndrome after axillary dissection in breast cancer: a prospective study. Breast Cancer Res Treat 2009; 117: 625-630.
Consider the significant numbers of patients who suffer from post traumatic stress disorder, or PTSD. In the pelvic rehabilitation setting, we can think of the patients who may have experienced abuse, a loss of a child, witnessing violence, or other potential precursor. We know from the literature that there is a correlation between traumatic events such as abuse and women who have pelvic pain, within the military population, and among women who experience birth trauma. How then, can we provide patients with self-management tools to address common challenges that accompany PTSD?
Research published online this month in the journal "Mindfulness" states that in patients exposed to trauma, "…those with relatively high levels of mindfulness skills tend to have lower levels of symptoms. The article highlights previous research that has described benefits of mindfulness skills as including decreased anxiety and depression. Mindfulness-based interventions, according to the article, focuses on the development of the skills of awareness (the ability to focus on the here and now, aware of both inner and outer experiences) and acceptance (having a curious, nonjudgmental and open attitude.)
In this study, 101 patients diagnosed by a psychiatrist or psychologist with PTSD completed questionnaires including the Mini-International Neuropsychiatric Interview. The authors found skills in mindfulness correlated negatively with severity of symptoms and with "reactivity" or a tendency to respond with anxiety or depressive thoughts in response to stress. These positive relationships between mindfulness skills and symptoms of PTSD may have a significant impact on many of our patients who suffer from a variety of dysfunctions impacting health.
There is still time to sign up for Carolyn McManus's practical course on mindfulness training. Keep in mind that all therapists (not just pelvic rehab providers) will find this course immediately applicable to their caseload. Join us this November in Seattle for our new offering: Mindfulness-Based Biopsychosocial Approach to Chronic Pain.
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Angela Treadway, DPT, BCB-PMD, PRPC
Describe your clinical practice:
I work within a busy Urology practice with 2 physicians, 2 mid levels, and a psychologist specializing in sexual medicine. As the pelvic floor physical therapist member of this team, I serve the urological, colorectal and sexual medicine needs of the men and women referred from within the practice and from outside specialist and primary care physicians. We have recently added a second office and will be recruiting a second pelvic floor physical therapist to join our team.
What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Two principles appear to be foundational to H&W courses. Firstly, always ask questions and keep learning from your peers. Whether one has 3 years of experience or 30, each clinical story has a pearl of wisdom in it. Secondly, when determining exactly who your peers are, be sure to include all providers whose scope of practice includes the pelvic floor. Only then can the conversation have its richest content. These principles help keep me open and probably led me to the multidisciplinary setting where I am able to problem solve with providers looking at clinical situations through completely different filters than a physical therapist has. This keeps my clinical eye sharp and problem solving juices flowing.
What do you find is the most useful resource for your practice?
I keep Herman & Wallace Pelvic Floor Level 1 -3 course manuals handy for reference. A well worn copy of Netter is usually open on either my desk or the desk of the female urologist seated next to me. We often problem solve together using Netter. My go-to text is Evidence Based Physical Therapy for the Pelvic Floor (Bo, Bergmans, Morkved, Van Kampen).
What motivated you to earn PRPC?
Because my practice is 50/50 men and women, I wanted to acquire the ultimate in current and cutting edge knowledge pertinent to my population. In my experience, H&W courses and exams are designed to fuel the learning process. The PRPC preparation materials and even the exam followed that design. I came away with an integrated understanding of what I solidly knew. I also gained a firm grasp on what needed strengthening in my knowledge base.
What is in store for you in the future?
For most of my 30 years in practice I have taught both public outreach classes and special topics courses in PT and PTA programs. I love to teach and will continue looking for opportunities. Writing is also a passion. I have 4 book outlines in queue and the first book is due out by Christmas.
Learn more about Angela Treadway, DPT, BCB-PMD, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.
This post was written by H&W instructor Elizabeth Hampton. Elizabeth will be presenting her Finding the Driver course at Marquette University in 2015!
In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (women aged 18-50 y) is approximately $881.5 million per year. (Singh et al). Most physical therapists start their pelvic health practice focusing on incontinence only to find their practice filling with pelvic pain clients who need our help. One of the most common questions we hear in Herman & Wallace’s Urogynecologic Pain course (PF2B) is, “What do we focus on first during a pelvic pain evaluation? A direct pelvic floor assessment or a musculoskeletal exam?” The answer depends upon many factors, including client presentation and goals, client history, functional assessment, clinical toolbox in addition to sound clinical reasoning. In addition to the direct pelvic floor assessment, there are additional key musculoskeletal screening tests that are an essential part of a pelvic pain assessment.
Peery et al (2012) noted that abdominal pain was one of the most common presenting reasons for an outpatient physician visit in the United States. Abdominal pain is one of the many complaints that our clients may report requiring differential diagnosis including urogynecologic, colorectal, musculoskeletal, visceral or neurogenic causes. Lower abdominal quadrant pain may denote serious emergent pathology. Clinical findings, physical exam and client symptoms in addition to smart differential diagnosis must be used to determine if the abdominal pain is musculoskeletal in nature. Direct access requires clinicians to be able to perform a skilled initial screening for abdominal pain in order to determine if it is abdominal wall versus a visceral origin. Assessment of bowel and bladder function and habits are essential to perform. This blog specifically addresses two physical exam tests that can be performed as part of the physical therapy screening of abdominal wall pain. According to Cartwright et al, the location of the abdominal pain should drive the evaluation. The screening of abdominal pain may include two common tests that are used to determine if pain is due to abdominal wall versus a visceral origin.
Carnett’s test is a simple clinical test that assesses abdominal pain response when a client tenses their abdominal muscles. A positive Carnett’s sign denotes the origin of symptoms within the abdominal wall with a negative tests suggesting intra-abdominal pathology. The test is performed in supine, the clinician palpating the area of abdominal pain and has the client lift their head and shoulders off the table. Conditions such as myofascial trigger points, scar and muscular pain would be flared with palpation of the contractile tissue with activation of the abdominal wall muscles. If the pain is due to visceral origin, appendicitis for example, the pain would remain unchanged with palpation with head lift. Although some perform Carnett’s test by lifting both legs off the table, this method may cause unnecessary pain in clients with poor lumbopelvic stability. (Figure 1) The head and shoulder lift option is felt to be comparable method of performing Carnett’s test.
Blumberg’s or Aaron’s sign is one physical exam test most commonly used to rule in appendicitis, peritonitis or a visceral driver of right lower quadrant pain. The test is performed by the clinician applying deep pressure over McBurney’s point (Figure 2) with an abrupt and rapid release of pressure. Although there are anatomical variations in appendix location, pain reproduction is consistent with a positive test and immediate referral to the ER is indicated.
In the Herman Wallace course “Finding the Driver in Pelvic Pain” participants learn a comprehensive musculoskeletal screen for functional mobility, abdomen, neural mobility and conductivity, pelvic ring, pelvic floor and biomechanical contributing factors to pelvic pain. Evidence based test item clusters are defined, along with their diagnostic accuracy, for all associated systems in order to outline a comprehensive screen for pelvic pain clients. To learn more about musculoskeletal screening for pelvic pain, check out faculty member Elizabeth Hampton PT, WCS, BCB-PMD’s course Finding the Driver of Pelvic Pain, which is next offered at Marquette University, April 23-25th, 2015.
What are the roles of hip labrum innervation in both nociception and proprioception? Canadian researchers tackled this question by studying hip joints that were harvested during total hip replacement or hip resurfacing surgery. Twenty labrums were harvested and the structures in the labrum were divided into four quadrants including antero-superior (AS), postero-superior (PS), antero-inferior (AI), and postero-inferior (PI). The mean age of the subjects was near 60. The authors reported the following:
•Labral innervation is from a branch of the nerve to the quadratus femoris and the obturator nerve.
•All labrum samples had abundant free nerve endings according to the authors. These nerve endings are responsible for nociception transmission.
•Three different types of nerve end organs were noted: Vater-Pacini, Golgi-Mazonian, and Ruffini corpuscles. These nerve end organs operate to provide proprioception through their roles in pressure, deep sensation, and temperature.
•The free nerve endings and nerve end organs were observed more often in the AS and PS zones.
•The nerve endings were noted to be abundant in the superficial zones of the acetabular labrum which were for the most part avascular.
•The antero-superior zone of the labrum has abundant free nerve endings, a fact that correlates with the location of common labral tears and that also fits with the pain produced using a maneuver to test impingement in the hip (flexion, adduction, internal rotation).
•No significant differences in age was noted with respect to the innervation.
The study further states that a labral debridement may ease pain with removal of the free nerve endings, yet the labral repair may best allow for proprioceptive abilities and higher function in the injured hip. The authors also describe the findings that there are abundant myofibroblasts in the labrum that may account for the labrum's ability to heal. To learn more about healing labrums and getting patients moving, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is in March in Houston.
How long do hot flashes last in a woman's life? One recent study asked this question by following 255 women from premenopause to natural menopause. The authors found that moderate to severe symptoms of hot flashes continued on average 5 years after the date of the woman's last period. Unfortunately, up to 1/3 of the women continued to report hot flashes 10 or more years after menopause. Results also found that risks for hot flashes were higher in women who were African-American or in obese, white women. Higher education level was found to be protective against hot flashes.
The Mayo clinic states that while the exact cause of hot flashes is not known, there are several factors that may influence their occurrence. Changes in reproductive hormones in addition to hypothalamic shifts create a sensitivity to even slight changes in temperature. Women can experience a wide range of menopausal symptoms, with hot flashes ranging from sudden feelings of warmth that occur a couple times per day to profuse sweating that can occur up to one time per hour.
Menopause.org is a helpful resource for our patients, and lifestyle changes are offered such as avoiding stress, breathing techniques, and creating strategies to maintain body temperature within a limited range. Hormonal treatment and non-hormonal options are also described on this site, and while certain hormonal options may be contraindicated for some patients, there are therapies such as sleeping medications that may improve quality of life for a woman who is suffering significant sleep disruption. Decisions to utilize hormonal drug therapy may depend on many factors, such as benefits to risk ratios, if the patient has her uterus, and age of the patient. Many nonprescription options are also available, with conflicting or little evidence to support many of the claims. Regardless of the remedy that a patient may take for her menopausal symptoms, keep in mind that all medications or supplements should be reported to the physician and/or pharmacist so that drug interactions can be screened. Even herbal supplements can have a negative impact on other drugs that a woman is taking, so she should always fully disclose her medications, supplements (including teas!), creams, and other natural remedies.
If you are working with more women in the perimenopausal period, you may have questions about the hormonal changes and effects on rehabilitation. Faculty member Michelle Lyons will offer her new continuing education course called Menopause: A Rehabilitation Approach. At this course she will systemic changes in menopause, bone health, perimenopausal pelvic floor issues, sexual health, weight management, and procedures such as hysterectomy. The next opportunity to take this course is in February in Orlando - what a great time to head to the sunshine!
This post was written by H&W instructor Jennafer Vande Vegte.
Biofeedback is a truly wonderful tool for a pelvic floor physical therapist. Using surface EMG can really help a patient learn how to control a muscle (typically the pelvic floor) that has been under improper voluntary or involuntary control, sometimes for many years. A recent article on biofeedback in medicine looked at the effectiveness of using biofeedback to treat a number of medical conditions (not just for pelvic floor function) and reviewed pertinent research. Using biofeedback for the treatment of urinary incontinence got the best rating (Level 5) as efficacious and specific. Treatment for constipation met Level 4 criteria for effectiveness while treating urinary incontinence in men, vulvar vestibulitis and fecal incontinence received a Level 3 rating as probably efficacious. (Frank et al., 2010)
It is wonderful when we have evidence that what we do as therapist works. But another question we might have is "HOW does it work?" Emmanuel and Kamm (2001) saw that biofeedback for constipation was effective in retraining faulty pelvic floor function but also noted that many patients undergoing treatment for elimination disorders also saw their transit time and bowel movement frequency improve. They theorized that this may be a response of the extrinsic autonomic nerves sending signals from the brain to the gut. They used mucosal laser Doppler flowmetry to show whether treatment changed extrinsic innervations, if autonomic changes were gut specific (or if there were cardiovascular changes as well) and whether gut transit was affected.
Forty-nine patients with idiopathic constipation had about five biofeedback sessions. Twenty-nine reported improvements in symptoms. Thirteen of twenty-two people with slow transit developed normal transit. There was a significant increase in rectal mucosal blood flow in patients who had subjective improvement compared to those who did not.
The authors concluded that biofeedback treatment to the pelvic floor can affect more than just the muscles and in some people did in fact improve the activity of the direct cerebral innervations to the gut while also improving transit time. This effect did not carry over to the cardiovascular system and is thought to be gut-specific.
As a pelvic rehabilitation provider who is always asking questions, this article makes me wonder if the same principles can apply for other visceral/pelvic floor conditions. For example, does biofeedback to the pelvic floor help with autonomic regulation of over active bladder? How about with interstitial cystitis or endometriosis? Could we show that improving pelvic floor function helps down-train the body's global autonomic stress response? It is exciting to see our body of research growing and adding new dimensions of understanding to the rewarding work that we are privileged to perform.
To learn more about pelvic pain, biofeedback, and relaxation principles, our Level 2A and 2B continuing courses cover topics such as constipation and pelvic pain. Check out the 2A series by clicking here, or the 2B series by clicking here. Remember that these courses sell out many months in advance, so if you see a location that is near you (or that you want to visit!) sign up early!