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The day my son was born, my daughter had not defecated for 5 days, and her pain was getting pretty intense. My husband and his mom took her to Seattle Children’s Hospital for help, and they suggested using Miralax and sent them away. When they got back to my hospital room, my daughter was straining so hard it looked like she was about to give birth! Being physical therapists, my husband and I massaged her little muscles and told her to take deep breaths, and eventually she did the deed, yet not without a heart-breaking struggle. Little did I know then there is actually research to back up our emergency, instinctual technique.

Zivkovic et al (2012) performed a study regarding the use of diaphragmatic breathing exercises and retraining of the pelvic floor in children with dysfunctional voiding. They defined dysfunctional voiding as urinary incontinence, straining, weakened stream, feeling the bladder has not emptied, and increased EMG activity during the discharge of urine. Although this study focuses primarily on urinary issues, it also includes constipation in the treatment and outcomes. Forty-three patients between the ages of 5 and 13 with no neurological disorders were included in the study. The subjects underwent standard urotherapy (education on normal voiding habits, appropriate fluid intake, keeping a voiding chart, and posture while voiding) in addition to pelvic floor muscle retraining and diaphragmatic breathing exercises. The results showed 100% of patients were cured of their constipation, 83% were cured of urinary incontinence, and 66% were cured of nocturnal enuresis.

More recently, Farahmand et al (2015) researched the effect of pelvic floor muscle exercise for functional constipation in the pediatric population. Stool withholding and delayed colonic transit are most often the causes for children having difficulty with bowel movements. Behavioral modifications combined with laxatives still left 30% of children symptomatic. Forty children between the ages of 4 and 18 performed pelvic floor muscle exercise sessions at home, two times per day for 8 weeks. The children walked for 5 minutes in a semi-sitting (squatting) position while being supervised by parents. The patients increased the exercise duration 5 minutes per week for the first two weeks and stayed the same over the next six weeks. The results showed 90% of patients reported overall improvement of symptoms. Defecation frequency, fecal consistency and decrease in fecal diameter were all found to be significantly improved. Although not statistically significant, the number of patients with stool withholding, fecal impaction, fecal incontinence, and painful defecation decreased as well.

The 2012 guidelines for the treatment of overactive bladder in adults (updated in 2014) recommends as first line treatment behavioral therapies. These therapies include bladder training, bladder control strategies, pelvic floor muscle training, fluid management- all tools that can be learned in the Institute’s Pelvic Floor Level 1 course. These behavioral therapies may also be combined with medication prescription, according to the guideline.

Geriatric Bladder ConditionsWhen medications are prescribed for overactive bladder, oral anti-muscarinics or oral B3-adrenergic agonists may be prescribed. Although these drugs may help to relax smooth muscles in the bladder wall, the side effects are often strong enough to make the medication difficult to tolerate. Side effects of constipation and dry mouth can occur, and when they do, patients should communicate that to their physician so that the medication dosage or class can be evaluated and modified if possible. We know that patients who have constipation tend to have more bladder dysfunction, so patients can get stuck in a vicious cycle.

Although patients and their medications are screened at their prescriber’s office and often at the pharmacy, it is important to remember that therapists are an important part of this safety mechanism. Patients may not be candidates for anti-muscarinics if they have narrow angle glaucoma, impaired gastric emptying, or a history of urinary retention. When patients are taking other medications with anticholinergic properties, or are considered frail, adverse drug reactions can also occur. Our geriatric patients may have some additional considerations, not just in medication screening, but also in evaluation and intervention. If you are interested in learning more about pelvic rehabilitation for those in the geriatric population, check out our new continuing education course, Geriatric Pelvic Floor Rehabilitation with Heather S. Rader, PT, DPT, BCB-PMD. The next opportunity to take the class is January 16-17, 2016 in Tampa.

ACOG (American College of Obstetrics and Gynecology) describes hysterectomy as a treatment of last resort, but studies show that anywhere from 10 to 90% of hysterectomies performed in the United States are not medically necessary, evidenced by the fact that today, approximately 90 percent of hysterectomies are performed electively. Corona et al stated: ‘…that alternatives to hysterectomy are underutilized in women undergoing hysterectomy for AUB, uterine fibroids, endometriosis, or pelvic pain. The rate of unsupportive pathology when hysterectomies were done for these indications was 18%.’

The US has the highest rate of hysterectomy in the industrialized world; it is the second most common surgical procedure carried out on women. 1 in 3 American women have their uterus removed by the age of 60, with the highest rates in women aged 30-54 (according to Corona et al in 2014, one in five women may not need it).

Reasons for hysterectomy include cancer, bleeding with childbirth and severe infection with uterine damage, all of which make up about 10% of cases. The other 90% are made up of medical, non-surgical and other surgical reasons, such as for menstrual cramps, heavy bleeding and fibroids. Unfortunately, too many women are also having hysterectomies as a treatment option for endometriosis (instead of laparoscopic excision, histological confirmation and pelvic rehab follow up)

Tagged in: Hysterectomy

The eve of my daughter’s 5th birthday has me reminiscing about my first pregnancy. I had recently surrendered my ACL on a ski slope and was contemplating surgery when I got confirmation I was pregnant. A seasoned surgeon had told me if I just wanted to return to running and not ski or do cutting sports (without a brace, anyway), I would probably be fine; so, I chose to forego the surgery and was running again 7 weeks later. Being my first pregnancy, I was not sure how hormones would affect my knee stability without an ACL or if the impact was safe for me and the baby or if my doctor would approve of my exercise choice of running. After all, pending ligamentous laxity from hormonal changes made running without an ACL seem risky while pregnant; but, runners tend to be, well, stubborn, when it comes to being able to run.

Deghan et al (2014) discuss the hormone relaxin and its effect on bone, muscle, tendon, ligaments, and cartilage. Interestingly, relaxin actually plays a role in the healing and remodeling of certain tissues in the body such as muscle and bone. However, the article also emphasizes how relaxin has been shown to reduce the integrity of the ACL and put female athletes at risk for injury. Lucky for me, that hormone couldn’t have its way with my knee since the ACL was already gone!

A study in the British Journal of Sports Medicine just published online October 4, 2015, encourages running and other high-impact sports before pregnancy to decrease the risk of pelvic girdle pain. The patients engaging in such exercises prior to being pregnant showed a 14% lower risk of having pelvic girdle pain during pregnancy. Out of 4069 women, 12.5% of the 10.4% of women who experienced pelvic pain were non-exercisers pre-pregnancy. The women who exercised 3-5 days per week and participated in high-impact aerobic exercise prior to being pregnant had less pelvic pain while pregnant.

Although awareness of pelvic rehabilitation is growing, patients who are referred for pelvic rehabilitation usually have more questions than the average patient about attending therapy. This can mean that you as a provider are burdened with a lot of phone calls or emails that go something like this: can I come to the clinic if I’m on my period? what are you going to do? are you familiar with my condition? how long will it take to get better? Consider how often these questions occur with patients who have knee pain, or headaches, and you may find that pelvic rehab is perceived by patients as quite unique from other types of rehab. How can you avoid trying to find time in your busy clinical schedule to tackle these additional communications? You can start by educating your front desk to handle patient care questions related to pelvic rehab, such as the following frequently asked questions:

  • Do I need a referral from a doctor?
  • What will we do on my first visit?
  • What is biofeedback?
  • What is ____________ (proctalgia fugax, interstitial cystitis), etc?
  • I have my period, should I reschedule?
  • Do you do internal work?
  • Will my insurance cover this?

It is likely that the patient will ask to speak directly with the therapist, so you can first encourage your support personnel to politely inquire if there is something he or she could help in answering. Create a list of conditions along with a brief description of its definition, and a few examples of skills that a pelvic rehab provider has to offer. Your support staff can also offer to mail a brochure or flyer that you create which answers some of the frequently asked questions. Providing an “FAQ” section on your website that can be referred to may also decrease some of the stress of trying to play phone tag. Make no mistake that if you DO have the time to follow-up with a patient who has a question, you may create a connection that is really important for that patient in regards to scheduling an appointment. On the other hand, if you don’t have time set aside in your day for such calls or emails, you risk having the patient not get her questions answered. A form (on your site or as a written resource) might have some of the commonly asked questions written out, and you could use the ones below as an example to get you started.

Tagged in: Clinical Practice

Commonly in physical therapy we treat patients with osteopenia or osteoporosis, however, they are usually in our office for another diagnosis such as back, hip, or pelvic pain as the primary complaint and we learn about the osteoporosis from health history review. Physical therapy is an opportunity to provide them with not just relief from their primary complaint, but a chance to learn from a professional how to move in a more healthy way and learn the right ways to exercises to make a regular routine that can help them to protect their body and even slow or stop bone mineral density loss. This is important as the primary concern for a patient with the diagnosis of osteoporosis is risk of fracture (especially of the hip or spine) due to minimal trauma because of low bone mineral density. So let’s make sure we are giving patients comprehensive exercise programs that address their primary complaint, however be comprehensive and include exercise modes that may reduce fractures and may improve bone mineral density.

An interesting article by Palombaro et al1 in 2013 from Physical Therapy discusses a Cochrane review by Howe et al2 and applies the findings from this review to an example patient similar to the participants reviewed in the study. The goal of the article is to link evidence in the literature with how we practice as PT’s. The topic explored in the systematic review by Howe et al was exercise for the management of osteoporosis in women postmenopause and which exercise approaches reduce the loss of bone mineral density or reduce chance of fractures in women who are healthy postmenopause. The systematic review2 included 43 randomized controlled studies of postmenopausal women age 45-70 where the intervention groups included exercises that improved aerobic capacity or improved aerobic capacity and muscle strength and had a comparison group completing “usual activity: or placebo intervention. The duration of exercise lasted from 6 months to 2 years in the various studies. The results of the review demonstrated decreased bone loss (of the spine or hips) in groups who performed any type of exercise compared to the control groups. The review also performed additional sub group analysis to take into account the various types of exercise programs in the studies and found favorable effect for all types of exercises completed (dynamic, low force, high force, weight bearing, or non-weight bearing) all had favorable effect on bone density. The take home message from this systematic review is that exercise programs combining various forms of exercises lasting 6 months to 2 years resulted in reduced risk for fracture, and a slightly beneficial effect on bone mineral density of the spine, trochanter, and neck of the femur in postmenopausal women with osteoporosis.

At the end of this article1 the authors give a case of an active, postmenopausal female patient with history of osteopenia without a fracture seeking PT for an unrelated complaint. The authors took the findings from this review and showed the relevance of the findings, applying it to the patient and the outcome of care for this patient when giving her an exercise program. We can implement findings from this review simply to the common question posed by our patients… “what exercises should I be doing to help with my osteoporosis?”

Earlier this year, 3 prominent societies representing pelvic health met to discuss and update terminology for vulvar pain. The result is the “2015 Consensus Terminology and Classification of Persistent Vulvar Pain.” A complete list of the updated terminology can be accessed on the website of the International Pelvic Pain Society. The updated document takes into account the additions of the terms Primary versus Secondary Vulvodynia, intermittent versus persistent pain, and considers research-based interventions for the suspected etiologies of pain. Some of the other updates are highlighted below.

  • Replace the term “unprovoked” with “spontaneous”
  • Use the term “vulvar” rather than “vulvodynia” in the title of the terminology
  • Vulvar pain definition removes the word “burning” from description

Vulvar pain can have a known cause, and the categories within vulvar pain caused by a specific disorder are: infectious, inflammatory, neoplastic, neurologic, trauma, iatrogenic, and hormonal deficiencies. Vulvodynia, defined as vulvar pain at least 3 months in duration, and without a clear identifiable cause, is described as having “potential associated factors.” There are also descriptor terms such as localized, provoked, or mixed, and terms such as intermittent, persistent, constant, immediate or delayed.

The terminology document recognizes that a patient may have a specific condition or diagnosis, and also be diagnosed with vulvodynia. As this consensus document is designed to replace the ISSVD terminology from the 2003 publication, becoming familiar with the updates is valuable for pelvic rehabilitation providers. The evaluation and treatment of vulvar pain is introduced in the Insitute’s Pelvic Floor Level 1 continuing education course, and further developed in the Level 2B course. For an immersion in the topic of vulvar pain, check out the Institute’s course on Vulvodynia: Assessment and Treatment instructed by Dee Hartmann. Your next opportunity to take the course is this March in Houston.

Tagged in: Coding Vulvodynia

Can patients benefit from a non-face-to-face treatment program for stress urinary incontinence? A recent study addressing this question was published in the British Journal of Urology International. This randomized, controlled trial utilized online recruitment of 250 community-dwelling women ages 18-70 years. Criteria was stress urinary incontinence (SUI) at least 1x/week, diagnosis based on self-assessment questionnaires, 2 days of bladder diaries, as well as a telephone interview with a urotherapist. The Outcomes tools included the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF), the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), the Patient Global Impression of Improvement, health-specific quality of life (EQ-VAS), use if incontinence aids, and satisfaction with treatment.

The participants were randomized into 2 pelvic floor muscle training groups: an “internet-based” group (n=124) and a group who were sent information in the mail (n=126). The internet-based program contained information about pelvic muscle contractions (8 escalating levels of training), behavioral training related to lifestyle changes. The internet group received email support from the urotherapist, and the postal group did not. Pelvic floor muscle training was instructed at at least 8 contractions 3 times/day. After the 3 month training period, the internet-based treatment group was advised to continue pelvic floor muscle training 2-3 times/week, whereas the mail training group were not given any advice about continued training frequency. Follow-up data was collected at 4 months post-intervention, at 1 year and 2 years. At 2 years follow-up, 38% of the participants were lost from the study.

Within both groups, the authors report that the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) showed “highly significant improvements” after 1 and 2 years compared to baseline data. Much of the improvement occurred within the first 4 months of the study “…and then persisted throughout the follow-up period.” When comparing the internet group to the mail-only group, the perception of improvement following treatment was higher. Approximately 2/3 of the women in both groups reported satisfaction with the treatment even at the 2 year follow-up. The authors conclude that the internet or mail-based exercise programs may “…have the potential to increase access to care and the quality of care given to women with SUI [stress urinary incontinence] in a sustainable way.” Additionally, not all patients will improve significantly unless they have one-on-one intervention, leaving plenty of patients who do need our direct care.

After pushing a double stroller for a 3 mile run to the park yesterday, I had a flare up of hip pain that made me doubt my ability to get my kids back home. While they were playing, a hanging ladder caught my eye and sent my manual therapy wheels spinning. I carefully slipped my leg over one of the rungs, angled my body just right, and leaned away to distract my hip. I noticed a toddler staring at me, so I politely told her, “I’m just mobilizing my hip joint, sweetie, but you can go ahead and climb now!” My relief was almost immediate, and I realized my patients need to know how to help themselves, too! We all know how to prescribe home exercises for patients regarding stretching and strengthening, but once a therapist is competent performing joint mobilizations, the need for this arthokinematic movement is often found to be essential prior to the osteokinematic movement of stretching. The hip joint in particular is affected by pathologies of the lumbar spine, the sacroiliac joint, and the pelvic floor. When the hip joint is not moving around the proper physiological axis, then the knee can be negatively impacted as well as the areas just mentioned.

Therapists need to discern whether a patient is appropriate for self-hip mobilization instruction, as a “motor moron” probably would not be a good candidate to whom you would explain how to perform mobilizations at home. When you realize a patient “gets it,” then you can suggest the techniques to that patient. Reiman and Matheson (2013) presented a paper regarding suggestions for self-mobilization of the hip joint. They demonstrate an inferior-posterior hip glide with a towel, weight, and a step with or without muscle reeducation in hip flexion; an inferior and lateral glide with hip flexion movement; a hip posterior glide with or without movement; a hip lateral glide with or without muscle reeducation; a hip anterior glide with or without muscle reeducation; and, a long axis distraction mobilization. The authors conclude the efficacy of their protocol and techniques are not completely backed up by evidence yet and recommend they be implemented as an adjunct to evidence based practice, not a primary treatment approach.

Regarding the efficacy of hip mobilization in the clinic by a skilled clinician, a study by Makofsky et al, (2007) discusses the effect of inferior hip joint mobilization on hip abductor force. This study leaves little doubt that mobilizing the hip can facilitate contraction of the gluteus medius. A 17.35% increase in hip abduction torque was noted immediately after the inferior Grade IV hip mobilization; whereas, the control group without mobilization experienced a 3.68% decrease in hip abduction torque. We generally see patients much less often than our services are needed, so being able to teach patients how to mobilize on their own to supplement our work could be extremely effective in the long run.

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