In the world of pelvic rehabilitation, brain morphology has been a hot topic for several years. Research has identified changes in various brain structures in patients who have specific conditions: irritable bowel syndrome, chronic pelvic pain, among others. (See prior blog about the brain, pain, and pelvic rehab by clicking here.) The research related to meditation is deep and rich, and the medical system continues to acknowledge the potential health benefits and cost savings from this simple technique that requires no equipment. The National Center for Complementary and Alternative Medicine (a division of the National Institutes of Health) states that meditation may work through effects on the autonomic nervous system. The nervous system in turn regulates functions such as breathing, heart rate, and digestion.
I had the opportunity in 2006 to take a course titled Mindfulness-Based Strategies for Relaxation and Stress Management from Carolyn McManus. In addition to discussing an abundance of research from a variety of disciplines, Carolyn taught us practical strategies and clinical approaches for patient care. She also instructed us in mindfulness techniques so that we increased our own skill set. Carolyn has instructed similar strategies to health care providers from many disciplines and to her patients, many of whom have tried years of other types of therapy. Since that time, I have constantly recommended the CD's that Carolyn created for patients, and with the many approaches she has (including contract-relax and autogenic retraining) I have found that there is something for everyone. The Institute is honored to host Carolyn's continuing education course, Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain this November in Seattle. Keep in mind that the course is open to many disciplines- would this be a great course to take your student to, or to invite a referral source to attend with you? Undoubtedly, this course will offer beneficial information not just for the patients, but also for the participants to use in their own daily self-care.
In addition to Carolyn's new offerings, we are thrilled to host a course that is taught by siblings who represent the fields of physical therapy and psychiatry. How wonderful it will be to hear from Nari Clemons, PT, and Shawn Sidhu, MD, expert clinicians who treat patients from their own perspectives, and to be able to receive information from these different view points. You can sign up for the Meditation and Pain Neuroscience continuing education course taking place in Illinois in September. You can also read about Nari and Shawn's new course in Nari's recent blog post.
Now, back to the title of this post. Researchers studied MR images of 25 male patients while they were practicing a type of meditation termed loving-kindness. 10 of the men were deemed experts with practice in the technique for more than 5 years. Compared to the novices, the right angular and posterior parahippocampal gyri had increased gray matter in the experts. The authors note that the regions identified as being larger are related to affective regulation associated with empathy, anxiety, and mood. Bottom line? We are still learning a lot about meditation and the potential implications towards health, and there is continual attention given to understanding how the changes are created in the body. If you want to learn practical and evidence-based information about mindfulness and meditation, please join us at our new courses! And if you want some increased gray matter in some seemingly really valuable parts of the brain, practice a lot!
In a recently published study, an anti-inflammatory diet (AID) for inflammatory bowel disease (IBD) was offered to 40 patients as an adjunctive regimen. Retrospective medical chart review was utilized to assess dietary adherence and outcomes. Of the 40 patients who were offered the program, 13 patients did not attempt the diet. Of the remaining 27 patients who did attempt the AID, 24 of them had a good or very good response, 3 of them had a "mixed" response. After following the diet, all patients were able to discontinue 1 or more IBD medications, and all patients reported decreased symptoms such as improved bowel frequency. Interestingly, of the 3 patients who had an ambivalent or negative response to the AID, 2 of them were diagnosed with C-difficile, a very challenging condition to resolve.
Inflammatory bowel disease can include the diagnoses of Chrohn's disease and ulcerative colitis, and each are characterized by periods of relapse. Patients are often reliant upon medications such as corticosteroids or immunomodulators during flare-ups, and surgical interventions including colectomy. As medical theories have evolved, the authors of this study point out that the gut microbiome is believed to play an importnant role in IBD, and therefore treatments directed at improving intestinal microbiome have increased.
The IBD anti-inflammatory diet (AID) includes lean meats, poultry, fish, omega-3 eggs, particular carbohydrates, specified fruits and vegetables, flours from nuts and legumes, a few limited cheeses, cultured yogurt, kefir, miso and other foods rich in certain probiotics, and honey. Bananas, oats, blended chicory root, and flax meal are also included. Additional suggestions are given based on the acuity of patient symptoms such as pureeing food or avoiding food with seeds. The diet is detailed into "phases" that progress from Phase I+ to Phase IV, to be followed when the patient is in remission and without dietary restrictions.
As this study is a case series, the authors are hesitant to extrapolate findings beyond stating that "some of our patients with inflammatory bowel disease can benefit.." from an anti-inflammatory diet, with respect to decreased symptoms and a resultant decrease in medication usage. In the study, patients were primarily seen by a nutritionist. As the mechanism for the improvement noted with an AID is still theorized but not known, the article describes different proposed mechanisms for improved symptoms, such as changes in the gut flora, or gut mucosal healing due to decreased irritants.
As pelvic rehabilitation providers, we have a responsibility, not to counsel our patients in detailed nutritional regiments aimed at curing disease, but in educating our patients about the potential benefits of nutritional counseling and attention to diet. Many patients are not offered nutritional counseling, or need support in order to initiate or maintain dietary changes. We can play an important role in guiding our patients to help and in supporting them in their efforts to make lasting changes. If you find that you are working with more patients who have bowel dysfunction, and wish to increase your knowledge beyond the PF2A course, you still have time to register for the Bowel Pathology and Function course, taking place in June in Minneapolis, which addresses many factors specific to bowel health and pelvic rehabilitation approaches.
If you answered "yes" to all of the above questions, well done. A pelvic rehabilitation provider can indeed help a patient who presents with complaints of erectile dysfunction, and the highest level of evidence (randomized, controlled clinical trial) has been completed to support this claim. Medically, a patient with ED may be suffering from heart disease, diabetes, metabolic syndrome, or even multiple sclerosis and should be screened by a medical provider prior to working with a pelvic rehabilitation provider. Skilled listening, and screening tests such as blood pressure, balance, and medication screening can be utilized in the clinic to alert the therapist to a medical issue.
As many of our readers are members of the APTA Section on Women's Health, you may have seen a recent email inviting interest in a men's health subgroup. Hooray! As we know intimately, both men and women are underserved in the world of pelvic rehab. In our training programs, it was rare to learn about the specific pelvic floor muscles, let alone the male versus female sexual health dysfunctions. If you are interested in learning more about the clinical reasoning process, the anatomy, and the research behind erectile dysfunction, join Holly Tanner and Stacey Futterman in California at the end of the month in Torrance!
Male Pelvic Floor Function, Dysfunction, & Treatment not only covers male sexual health, but covers in depth the topics of urinary incontinence and male chronic pelvic pain. As many therapists are already working with patients following prostate cancer surgery, these topics are very applicable in current practice. The course is only a couple weeks away, and it's in sunny California near the ocean. The men in your care will thank you!
As rehabilitation providers move towards primary care for musculoskeletal dysfunction, the privileges bring responsibilities. Regardless of our level of training and degree attainment, screening for underlying medical conditions is at the forefront of our work at all times. During the postpartum period, it is understandable that a new mother may report fatigue, aches and pains, as she tends first to the needs of her newborn. Many pelvic rehabilitation providers love working with new mothers because we have such a powerful opportunity to serve, support, educate, and nurture our patients.
One important health risk to keep in mind in the postpartum period is blood clots, or thrombosis. Changes in a woman's physiology during the peripartum period alter her risk factors for experiencing blood clots, a topic that is discussed in our pregnancy and postpartum courses. A deep vein thrombosis, or DVT, often occurs in the calf area, but the upper extremity can also develop clots. While local injury can result from a DVT, a major risk of a DVT is the progression to a pulmonary embolism, when a blood clot travels through the blood stream to the lungs- this is a life threatening condition. An article in the New England Journal of Medicine reports that the most significant risk period is within the 6 weeks postpartum. Let's get to the heart of this issue: how do we screen for a DVT or pulmonary embolism?
According to the Mayo clinic, in about 50% of cases of DVT, symptoms are not noticeable. When they are, they include:
Warning signs of a pulmonary embolism:
If a patient is screened for the above, and you suspect a DVT, what should you do? If the first thought that comes to mind is the clinical test known as "Homans's Sign," unfortunately, that is not a current response. The best thing to do is to contact an appropriate provider (perhaps the referring provider, primary care provider, emergency room provider, etc) and report on the findings of Wells criteria. Providers can base further diagnostic testing upon this clinical prediction rule for DVT screening. To read an article about application of Wells criteria in the clinical setting, click here. If you google "Wells criteria" you will also find many reliable sites that calculate the test for you.
If you are already working with women in peripartum periods, please join us in our Peripartum Course Series! The next opportunity to take Care of the Pregnant Patient is April in Illinois and Care of the Postpartum Patient happens at the end of this month in California!
What happens to pelvic floor muscle activation in women who have prolapse and a pessary in place? Kari Bo, an extraordinary contributor to the field of pelvic health, and colleagues in Norway investigated this question. Twenty two women (who acted as their own controls) were measured for vaginal resting pressure and maximal voluntary pelvic muscle contraction with and without a ring pessary in place.The aim of the investigation was to determine if the pelvic floor muscles could improve in activation if the prolapse was repositioned. (The authors take the reader through prior research examples to build this clinical question and theory.) Conclusions of this research indicate that having a pessary in place improved the vaginal resting pressure (VRP) but did not create a statistically significant difference in maximal voluntary contraction (MVC).
For this study, 22 women with grade II-IV prolapse (according to POP-Q) who were able to demonstrate a voluntary pelvic muscle contraction were included. Excluded were women who could not tolerate a ring pessary, those who were breastfeeding or pregnant, women with neurological or musculoskeletal disease that could interfere with ability to contract, and cases in which the prolapse was so severe that measurement with the catheter was prohibited. Maximal contractions and an endurance contraction were measured in supine. No significant difference was noted in MVC or in endurance. A higher vaginal resting pressure, however, was recorded. The authors discuss several theories to explain the increase in resting pressure, but do not provide a conclusion as to the reason for this change. Is there a length change in puborectalis that optimizes the length/tension curve, for example?
Childbirth is one of the leading causes of supportive changes in the pelvic floor, yet women have varied levels of prolapse, and not all prolapses create symptoms or functional limitations. Experienced pelvic rehabilitation therapists will likely concur that there are patients who present with a seemingly severe level of prolapse who have minimal symptoms, and vice versa. While degree of prolapse and levator plate descent has been shown to improve in response to pelvic muscle rehabilitation, women also have reported improved symptoms in the absence of significant objective changes to the level of prolapse. One clinical message that this study adds to the literature is the conclusion that a therapist may not need to have a patient remove her pessary in order to accurately test the muscles. Keeping in mind that the patients were tested in a supine position, there may be clinical relevance for assessing a patient in other positions with and without a pessary in place.
If you enjoy "nerding out" and discussing the potential clinical implications that this type of clinical research provides, you can find more discussions about pessaries in our Pelvic Floor 2B course, next happening in Chicago area in July. This course will sell out, so get your seats soon!
Posttraumatic Stress Syndrome, also known as PTSD, is an unfortunate consequence of many women's birth experiences. While there are known risk factors, there is not currently a standardized screening method for identifying symptoms of PTSD in the postpartum period. One recent meta-analysis of 78 research studies identified a prevalence of postpartum PTSD as 3.1% in community samples and as 15.7% in at-risk or targeted samples. Risk factors for PTSD included current depression, labor experiences (including interactions with medical staff), and a history of psychopathology. In the targeted samples, risk factors included current depression and infant complications. Other authors have explored the relationships between preterm birth and PTSD, preeclampsia or premature rupture of membranes, and infants in the neonatal intensive care unit.
One of the main concerns of failing to identify and treat for PTSD in the postpartum period is the potential negative effect on the family. High levels of anxiety, stress, and depression may impact not only the mother's health, but also may affect her ability to meet her new infant's needs, or complete usual functions in work and home life. One study suggested that "…maternal stress and depression are related to infants’ ability to self-sooth during a stressful situation." Clearly, healthy moms promote healthy families, and each mother deserves the attention that her new infant often receives from the world!
How can we be a part of the solution? We have previously posted on the blog about screening for depression in the postpartum period. The US Department of Veterans Affairs lists multiple screening tools for PTSD as well. Here's another bit of exciting news: yoga has been identified as a method to reduce symptoms of PTSD. In a randomized, controlled clinical trial, the treatment arm was given 10 weeks (1x/week at 1 hour sessions) of "trauma-informed" yoga, whereas the control group was given information about women's health and self-efficacy in various domains. Interestingly, while both groups showed positive effects from intervention in the first half of the treatment, the yoga group maintained the improvements during the latter half of the study, while the control group relapsed.
You can learn about yoga for postpartum mothers, and learn how to integrate strategies to help heal postpartum symptoms of PTSD this summer at Ginger Garner's Yoga as Medicine for Labor & Delivery and Postpartum. The continuing education course takes place in Seattle, and we still have a few spots left! Don't miss this chance to add more amazing tools to your toolbox in support of women of any postpartum age.
What is a hymenectomy, and how does it relate to pelvic rehabilitation? To answer this question, an understanding of hymenal anatomy is useful. The hymen is tissue that lines and sometimes covers the vaginal opening. This layer of tissue can be thick or thin, and can have a variety of presentations based on embryological development such as micro perforations, bands, or septa which create distinct openings into the vaginal canal. During menstruation, having an opening through the hymen is critical so that menstrual discharge does not become blocked, and sexual function is optimized when the hymen does not create any narrowing or blockage. When the hymen completely covers the vaginal opening the condition is known as "imperforate hymen." Sometimes this anatomical variation is noticed during neonatal and early childhood examinations, unfortunately, the condition may also be undiagnosed.
Prior to her first gynecological examination, an adolescent female may be at risk for consequences of an imperforate hymen. Depending on the hymenal variation, a young female may experience urinary dysfunction or vaginal infection, but more typical is recognition of the issue when her menstrual cycle begins. Case reports in the literature describe the condition as presenting clinically as low back pain, or as abdominal pain.Complaints that may increase our suspicion about the condition in an adolescent patient may include amenorrhea, abdominal mass, abdominal pain, urinary retention, or constipation.
While it may be uncommon for us to encounter an adolescent with back or pelvic pain who has not been screened by a medical provider, knowing about the condition adds to our toolbox for medical screening. We may also meet patients who are referred to the clinic following a hymenectomy, a surgical procedure that removes all or part of a woman's hymen. In asymptomatic patients who have an imperforate hymen, a surgical procedure may be delayed until puberty, when estrogen's effects on the tissues may negate the need for a procedure. Click here to view basic images of the procedure, and here to access a Medscape article with further details about epidemiology, pathophysiology, and relevant anatomy.
Unfortunately, we know that patients frequently lack a referral for conservative care for pelvic pain or dysfunction that may arise from hymenal dysfunction or surgeries. One of my most memorable and endearing patients told me her horrifying memory of having a hymenal procedure as a young child without any anesthesia.Is that the reason that she developed severe pelvic muscle dysfunction in adulthood? While we can only speculate about this connection, the more we know about a patient's history and how the reported complaints may link to dysfunction, the better. If you would like to know more about hymenectomies and other special topics, come to California, Illinois, or Connecticut this year for one of our PF3 courses to hear from experts Holly Herman and Lila Abbate.
During the postpartum period, not only is a new mother adjusting to the needs of her infant, she is also recovering mentally, physically, and emotionally. Physical challenges can include fatigue, back pain, and healing abdominal or perineal wounds. Emotionally, women are also at increased risk for depression and anxiety which may negatively impact health of the mother and infant.
Recent research evaluated 6 clinical guidelines from the United Kingdom, Australia, and the United States for the postpartum period. (The authors point out that maternity care in these countries varies.) The guidelines fit into four main themes: maternal health, maternal mental health, infant health, and breastfeeding. Only 1 of the guidelines was deemed to have enough detail to provide data about both the mother and the infant that would guide the provider regarding care. The article states that "…scarcity of comprehensive guidelines for mothers and infants is a concern because of the stress many women experience at this time, the high burden of maternal morbidity postpartum and the significant interplay between the health of the mother and infant."
This information is valuable to the rehabilitation provider as we work with women in the postpartum period. We can initiate conversations about a woman's energy levels, sleep, and nutrition. We can inquire politely about her infant, about breastfeeding and support that she has at home. Our patients can be encouraged to discuss any concerns or anxieties about her healing or about parenting. If we do not know the answer, we can seek resources or recommend that the patient consult her healthcare team. Many women are not sure how they should be feeling, physically or emotionally, and the new mother should be reassured that any concerns she has are valuable issues to discuss. If she knows that you care about her symptoms and questions, she is more likely to express concern or share information that can help guide care, including referrals to appropriate providers.
The Peripartum series is designed to help the therapist learn about prenatal and postpartum care. Join faculty member Allison Ariail at Houston in June.
Postpartum mothers are often juggling intense schedules: infant feeding, mealtimes for other family members, work both in and outside of the home, and there is scarce time for self-care. Throw in the typical postpartum fatigue, potential for postpartum depression, adjustment to parenting or adding another child to a family, risk for weight retention, and the ability of a new mom to resume or begin exercises can be beyond daunting. An additional complication arises when a woman has been on bed rest, as she has lost muscle mass and cardiorespiratory function and endurance. How can we best set up a new mother for success?
Research published in the journal Clinical Sciences reports that regardless of exercise intensity, women receiving postpartum intervention experience health benefits. If a woman is unable to reduce the weight gain that occurs in pregnancy, by 6 months postpartum she will have increased risk factors for developing chronic disease, according to the authors. In the study, 20 women were instructed in nutrition advice and low intensity (30% heart rate reserve (HRR)) and another 20 women women were instructed in nutrition advice and moderate intensity(70% HRR) exercise. A group of controls (n = 20) was included and matched for BMI, age and parity.
The exercise program included supervised walking for 45 minutes, 3-4 times per week for 16 weeks. In order to achieve the target heart rate, some women walked with or without a stroller, or with a double stroller with added weight. The participants attended a supervised exercise session at least one time per week, and the first session was limited to 25 minutes, including a 5 minute warm-up and 5 minute cool down. Sessions were increased by 5 minutes per week up to a 45 minute limit. Pedometers were administered, home exercise logs were used to record distance when not in the clinic. and food intake diaries were completed. Each woman met with a nutritionist to be given a program that met her caloric needs and allowed for weight loss as appropriate. Women were screened for chronic disease at 7-8 weeks postpartum and again at 23-25 weeks postpartum.
Regardless of exercise intensity, both intervention groups lost body mass, had decreases in plasma low-density lipoprotein, and had reduced glucose and adiponectin concentrations, all positive changes for reducing chronic disease risk. As hypothesized, the control group did not experience the same positive changes. Here's the bad news: hanging on to increased BMI and low activity levels in the postpartum period can lead to lack of health. The good news: low-intensity walking programs and nutrition advice can improve risk factors for chronic disease. Many women may think they have to exercise at moderate intensity, 5-7 days per week, and while there may be additional fitness benefits from increased exercise intensity, our first goal for patients can be overall health versus fitness.
How do we get new moms into exercise? Make it reasonable, fun, social! Hold postpartum fitness classes at your clinic or at a local center. Teach the women who are in your care about wellness principles, or offer a community lecture. If you want to learn more about postpartum fitness classes, the topic is discussed in the Care of the Postpartum Patient and in Postpartum Special Topics. The next Postpartum class happens in early April, so check out the website for details!
Within the evaluation process for pelvic muscle health, a woman is often asked to "bear down" so that the examiner can assess muscle coordination. This maneuver is also utilized during assessment for prolapse or pelvic organ descent. Clinically, the patient's ability to perform a lengthening or bearing down is quite varied, depending upon many factors such as levator plate resting position, strength and coordination, childbearing status, and comfort with the maneuver. What are the implications of not being able to bear down? An interesting study published in 2007 concluded that women, when asked to perform a Valsalva maneuver (a forced expiration against a closed glottis), frequently co-contracted the levator ani muscles.
Participants included 50 nulliparous women between 36-38 weeks gestation and they were assessed with translabial 3D/4D ultrasound following emptying of the bladder. In almost half of the subjects, a pelvic floor muscle contraction was noted during the attempted Valsalva. Patients were provided with visual biofeedback to train the levator muscles to avoid a concurrent contraction, and despite the training, 11 of the 50 women were still unable to avoid a co-activation. (Keep in mind that for purposes of assessment, the prolapse would be best imaged or viewed if the levator muscles were not tightening.) For this reason, the study concludes that levator muscle co-activation is a significant confounder of pelvic organ descent. While a contraction of the pelvic floor muscles may be a positive, protective action when thoracic pressure is increased, a woman's degree of prolapse or pelvic organ descent may appear diminished during an examination. The authors of the study conclude that a clinician may have a false-negative finding for prolapse in the presence of strong, intact pubovisceral muscles.
This research highlights the value of being able to coordinate pelvic muscle activity with the trunk and with breathing. What is also very interesting is that the 50 women studied were all in late third trimester of pregnancy when assessed. Does the population studied have carry-over to non-pregnant women, or women who have never been pregnant? Does the co-contraction exist at the same rates for nulliparous, non-pregnant women? How will the lack of coordination for bearing down during increased trunk pressure affect labor and delivery? Is there a role for pelvic rehabilitation providers in assisting women who have difficulty coordinating the muscles of the trunk and pelvis prior to delivery? To the last question, I would answer "yes" when considering the women who have been referred to pelvic rehabilitation prior to labor and delivery. Having the opportunity to lengthen a tight, shortened pelvic floor, strengthen, alleviate pain in tissues from prior scars or from tension, and to improve confidence about the body's ability to perform the function of bearing down for childbirth can be a very positive preparation for a woman's childbirth experience.
For all the other research ideas that this article generates, we can see that many unanswered questions remain. Even when the research points us in valuable directions, having the skills to assess the patient to find out what is needed in her particular case is critical. For further refining of pelvic muscle assessment techniques, including skills for assessing and treating prolapse and pelvic organ descent, the Pelvic Floor Level 2B continuing education course offers lectures and labs. PF2B is next offered in early March in Oregon, and later this year in Illinois, North Carolina, and Missouri.