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Posted by on in Health

Today we present Part II of Michelle Lyons' discussion on sex after gynecologic cancer. Michelle will be teaching a course on this topic in White Plains in August!

 

In Part One of this blog, I looked at the sexual health issues women face after gynecologic cancer. In Part Two, I want to explore different treatment options that we as pelvic rehab specialists can employ to help address the many implications of cancer and cancer treatment

 

Treatment for gynecologic cancers, including vulvar, vaginal, cervical, endometrial and ovarian cancers, may include surgery, radiation therapy, chemotherapy, and/or hormonal therapy. We know that any of these approaches can have an adverse effect on the pelvic floor, as well as systemic effects on a woman’s body. Issues can include pain, fibrosis, scar tissue adhesions, diminished flexibility, fatigue and feeling fatigued and unwell. The effects on body image should not be under-estimated either. In their paper ‘Sexual functioning among breast cancer, gynecologic cancer, and healthy women’, Anderson & Jochimsen explore how ‘…body-image disruption may be a prevalent problem for gynecologic cancer patients…more so than for breast cancer patients’. The judicious use of manual therapy and local and global exercise prescription may be excellent pathways for a women to re-integrate with her body.

 

The following comes to us from Herman & Wallace faculty member Michelle Lyons. Michelle travels the world spreading the word about pelvic rehabilitation and the powerful benefits it can have on a patient's everyday life. Michelle will be teaching her newest course, "Oncology and the Female Pelvic Floor: Female Reproductive and Gynecologic Cancers" in White Plains, NY this August 14 - 15. Join her to learn more about evaluating and treating oncology patients.

 

According to the Scientific Network of Female Sexual Health and Cancer, ‘Sexuality is an experience that really is at the intersection of mind, body and relationship, and cancer treatment can impact all three of those elements”. Dr Sharon Bober of Dana Farber says ‘Part of the problem is that doctors are so focused on saving a cancer patient's life that they forget to discuss issues of sexual health. My sense is that it's not about physicians or health care providers not caring about your sexual health or thinking that it's unimportant, but that cancer is the emergency, and everything else seems to fall by the wayside".

 

If you harness the power of Google to look up female sexual dysfunction after gynaecologic cancer, you may see phrases like ‘Possible sexual side effects…’ or ‘Cancer treatment can cause physical changes that make having sex more difficult’ or even ‘cancer treatments may make intercourse painful’. To call these descriptions ‘understatements’ does not really do them justice.

Pain associated with menstruation is known as dysmenorrhea, and more than half of women have pain related to their period for 1-2 days per month, according to The American College of Obstetricians and Gynecologists. Primary dysmenorrhea is related to menstruation, and often begins within a short period of time once menses occurs, whereas secondary dysmenorrhea is often related to a condition within the reproductive tract such as endometriosis or fibroids. In the medical office, a medical history, a pelvic exam, and possibly an ultrasound or laparoscopy will be completed. Treatment may include medications such as NSAIDs which target the prostaglandins that often lead to symptoms of dysmenorrhea, birth control pills, or surgeries.

 

A recent literature review asked if physiotherapy can help with symptoms of primary dysmenorrhea. Of the articles reviewed, 186 were chosen, and included a range of articles from descriptive, experimental studies to prospective, randomized controlled studies. A variety of interventions and approaches were included in the review, such as TENS, abdominal massage, acupuncture, cryotherapy and thermotherapy, connective tissue, Pilates, and belly dance. All of the approaches demonstrated some therapeutic benefit, either in response to the immediate application of the intervention, or up to a few months after the intervention was applied or instructed.

 

This literature review echoes a prior systematic review that evaluated the effectiveness and safety of acupressure, acupuncture, aspirin, behavioral interventions, oral contraceptives, and other supplements, procedures, and complementary and alternative medical interventions. Click here to view the full-text article. In that particular review, the authors reported the following:

- high-frequency TENS reduces pain (but less so than ibuprofen)
- acupressure may be as effective as ibuprofen
- topical heat may be as effective as ibuprofen and more effective than paracetamol

Today we hear from Herman & Wallace instructor Dustienne Miller CYT, PT, MS, WCS. Dustienne instructs the Yoga for Pelvic Pain course. Join her next month at Yoga for Pelvic Pain, Cleveland, OH on July 18 and 19!

 

We all know yoga can help chronic headaches, insomnia, anxiety, low back pain, and a myriad of other conditions. How can we apply the principles and benefits of yoga to the treatment of chronic pelvic pain?

 

Breathing
As rehab professionals who treat chronic pelvic pain, we know how critical it is for our clients to learn how to downtrain the nervous system. Breath awareness and training are a useful tool in reducing sympathetic nervous system override. Some clients may not have the awareness that they are holding their breath because of pain, or even anticipation of pain. Because of the direct mechanical relationship between the diaphragm and the pelvic floor, breath holding can lead to pelvic floor muscle holding. By building awareness, which is a learned skill, the client begins to notice and eventually control non-optimal breathing patterns.

Posted by on in Guest Blog Post

The following message comes from Herman & Wallace faculty member Michelle Lyons. Michelle is a global advocate for pelvic rehabilitation and she will be teaching her "Oncology and the Pelvic Floor A: Female Reproductive and Gynecologic Cancers" course on August 14-15 in White Plains, NY.

 

Calling all Pelvic Rehab tweeters! On June 24th, there will be a tweetchat hosted by 'Living Beyond Breast Cancer' to discuss and explore the effects of breast cancer on sexual health. Topics will include:
- How diagnosis and treatment side effects can affect intimacy and sexuality
- How to communicate with your cancer care team and partner
- Tips and suggestions for managing these side effects

 

Now, while I think it is brilliant that we are talking about sexuality during and after cancer, the panel has no input from pelvic rehab providers! We have so much to offer women in terms of sexual rehab in an oncology setting but if our colleagues and patients don't know about us.....

Today we hear more from Susannah Haarmann, PT, WCS, CLT about how pelvic rehabilitation practitioners are suited to contribute to a breast oncology patient's medical team. Susannah will be sharing more insights and treatment tools at the Rehabilitation for the Breast Cancer Patient course taking place June 27-28 in Maywood, IL.

 

Most pelvic rehab practitioners are incredible problem solvers and independent thinkers. We understand that often our referrals from a physician occur after a battery of tests and ineffective medical interventions. We may agree to treat a patient only to find that the diagnosis is vague and the patient often feels lost and broken. So we take out our sleuth caps, ask as many subjective questions as it takes and see where our objective examination leads us. Afterwards we paint a picture of our findings, focus the patient on what is working, tell them where we are going to start and how we are going to build one brick at a time.

 

The same is true for rehabilitation and breast oncology. Most physicians don’t understand how our work as therapists can complement and alleviate the side effects of mainstream medical intervention, but when the pain medication no longer works, we are there. When the range of motion no longer exists to get the patient’s arm into a cradle for breast radiation, we are there. And when the patient walks in our door, we are there, quite often for a period of time that extends well beyond after treatments cease, because the potential side effects of breast cancer, if they occur, may take years or even decades to show up. The rehab practitioner understands how to prepare the patient, without fear, for what the road ahead may look like. The purpose of this education is to empower patients to serve as their own best advocates. Pelvic practitioners and breast oncology specialists are noted for their exceptional manual skills. We are also versed to pounding the pavement educating physicians, patients and other therapists alike about who we can serve and how we can be of service. We are definitely a unique breed of therapists.

The American Urological Association issued new guidelines in May of this year for the diagnosis and treatment of Peyronie's. The disorder, which you can read more about at this link, often leads to a curvature in the penis that can be painful, or that can lead to impaired sexual or urinary function. While the exact mechanism leading to Peyronie's is still being researched, what is known is that plaques (sometimes calcified) may form in a deep layer of thick connective tissue called the tunica albuginea that surrounds the penis.

 

In the clinical guidelines, the authors state that a diagnostic process should include documentation of the signs and symptoms of Peyronie's disease. This can include a careful history (assessing any penile deformity, limitations in sexual function, penile pain, and level of distress). In the medical office, an intracavernosal injection (check here for a Medscape article describing an algorithm) can be completed. The authors also state, in line with expert opinion, that a provider should only evaluate a patient's Peyronie's disease when possessing "…the experience and diagnostic tools to appropriately evaluate, counsel, and treat the condition." In regards to pelvic rehabilitation, understanding the condition and encouraging the patient to visit a medical provider who is appropriately trained to manage Peyronie's is valuable. Establishing a baseline for the amount of dysfunction and curvature aids the patient and physician in determining current and future care planning.

 

Available treatments include education about possible treatments as well as adverse reactions to medical treatment. Interventions might include oral NSAIDs, intralesional injections (to reduce the amount of scar/thickened tissue or pain), and surgeries. Surgical options include procedures to remove the plaque or scar tissue, remodel the penile tissues after plaque removal, and for more severe cases, to implant a penile prosthesis. (Recommendations for treatments to avoid due to potential for harm or for lack of evidence are also listed in the article.)

Today we hear from Susannah Haarmann, the instructor for Rehabilitation for the Breast Cancer Patient. If you want to learn how to implement your pelvic rehab training with breast oncology patients, join Susannah in Maywood, IL on June 27th and 28th.

 

Effective pelvic rehab practitioners demonstrate many skills which are especially suitable to treat people with breast cancer, however, the first idea that comes to mind is that they understand what my friend refers to as, ‘the bikini principle.’ She remarked this week that I treat the ‘no no’ areas; the private places that we rarely share…with anyone. The reproductive regions of the pelvis and chest wall both consciously and subconsciously are associated with a plethora of personal psychological and social connotations. A pelvic health practitioner has a raised level of sensitivity to working with this patient population; there is no true protocol in this line of work, effective treatment will require a deeper level of listening and being present with the patient, and a person’s healing of the pelvic region is likely to go beyond the physiologic realm.

 

The biopsychosocial model of treatment is especially pertinent to the pelvic and breast oncology specialties. The breasts have great biological importance for sexual reproduction and nurturing offspring. Psychologically, breasts represent femininity for many women (and imagine how the story would change for a male with breast cancer.) Furthermore, different societies tend to create a host of rules and guidelines about what is ‘breast appropriate.’ The rehab practitioner understands that a person’s perceptions of their breasts are unlike any others and the same holds true for their cancer journey and goals with therapy.

Aline J Flores, PT, PRPC

Today we are happy to celebrate Aline Flores, PT, PRPC! Aline is one of the newly minted Certified Pelvic Rehabilitation Practitioners, having passed the exam last month. Here's what she had to say about her career in pelvic rehab. Congratulations, Aline!

 

Tell us about your clinical practice
This year I opened Natura Physical Therapy, a small private practice specializing in pelvic pain and breast cancer rehabilitation. Manual therapy is a big part of our approach to patient care. I often utilize myofascial release, connective tissue manipulation, trigger point therapy, and manual lymphatic drainage during treat sessions and prescribe 2-3 specific exercises for patients to complete at home. I also provide education on the neurological/physiological/emotional response to pain and teach techniques for patients to be able to modulate this response, including breathing exercises and down training techniques. The majority of my patients are high stressed, overwhelmed and extremely hard on themselves. Helping patients become more compassionate towards themselves is a huge accomplishment.

 

How did you get involved in pelvic rehabilitation?
I was immediately interested in women’s health when I graduated from physical therapy school in 1997. I sought out a part time position to work/train with a therapist who was treating women with urinary incontinence. At that time I was only treating 1-2 pelvic patients a week primarily using biofeedback and muscle re-education. A year later I was hired by a hospital that was just starting a pelvic health program. Over the years I have been able to help this program grow from very basic pelvic health rehabilitation to treating much more complex pelvic health issues of like vulvodynia, pudendal neuralgia, and interstitial cystitis.

A recent study aimed to determine if an association is present between childhood functional constipation and parental child-rearing attitudes. Of the 133 studied children (ages 4-18), all were diagnosed with functional constipation and participated in a randomized, controlled trial evaluating the effectiveness of behavioral therapy compared with conventional treatment. Outcomes tools included the Amsterdam version of the Parental Attitude Research Assessment (A-PARI). The scale measures parental attitudes in the following domains: autocratic ("the child needs authority, strictness"), autonomy (encouraging independence), over-protection (prevent disappointments for the child), and self-pity (irritation with bringing up child.) (For more information about the methods, results, inclusion or exclusion criteria, you can download the linked article as full, free text.)

 

The study determined an association between defecation and fecal incontinence and parental child-rearing attitudes. For example, a highly overprotective or a high self-pity attitude both increased fecal incontinence, and that high autonomy and low autonomy attitudes were found to be detrimental to bowel health. The authors conclude that "…child-rearing attitudes are associated with functional constipation in children" and that parenting issues should be addressed when treating constipation in children. Specifically, if parenting issues are limiting the success of the pediatric patient or "when the parent-child relationship is at risk", referral to mental health services may be needed. The research study discusses concepts of education to "demystify" the dysfunction and positively affect parental attitudes.

 

 

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