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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.

The effects of endometriosis surgery on pelvic floor function is a topic of study in this research from Australia and published in an obstetrics and gynecology journal. The authors completed a retrospective cohort study via questionnaire that was sent to two groups of women: women with deeply infiltrating endometriosis, and women with endometriosis from other sites. Deeply infiltrating endometriosis is commonly defined as endometrial implants that penetrate the retroperitoneal space 5 mm or more, and the implants are often located in the Pouch of Douglas, the rectovaginal septum or on the uterosacral ligaments.

The questionnaires collected data about bowel and bladder health in addition to other symptoms. Results of the survey indicated that women with deeply infiltrating endometriosis reported higher levels of urinary stress dysfunction and bowel dysfunction. Fortunately, women with DIE also reported a significant improvement in bowel and bladder symptoms following the endometrial surgery. This study found no difference between the depth of the surgical excision and the postoperative bowel and bladder symptoms, despite the proposed mechanism of disruption to bowel and bladder systems via damage to the hypogastric plexus surgery. A trend in surgery is to perform nerve-sparing surgeries for endometriosis, which the authors point out have shown promise in decreasing urinary symptoms post-operatively as compared to non-nerve-sparing surgeries.

Patients who have endometriosis may have a wide variety of symptoms, and may be undiagnosed in early stages of symptoms that can include pelvic pain, bowel, bladder, and sexual dysfunction. Pelvic rehab providers are needed to address pelvic dysfunction in women to help promote quality of life and to provide tools in self-management of symptoms.

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.

Inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease (CD), according to Lan et al., are characterized by chronic inflammation in intestinal mucosa. There is little information available based on human studies that links nutritional support with inflammatory bowel disease. The authors of this article analyzed the available information about supplements that appear beneficial in healing the gut mucosa. 

The intestinal epithelium acts as a selective barrier, and inflammatory bowel disease can disrupt this important barrier, affecting absorption, mucus production, and enteroendocrine secretion. Intestinal wound healing, according to the linked article, is “dependent on the precise balance of several processes including migration, proliferation, differentiation, and apoptosis of the epithelial cells.” Although there are few human clinical studies (more are animal and cell model studies) there is evidence that both macronutrient and micronutrient deficiencies may exist in patients who have inflammatory bowel disease. Patients may have malnutrition of proteins, of minerals and vitamins. Following are some points from the article:

  • Arginine, glutamine, and glutamate are noted as amino acids that contribute to mucosal healing in animal studies, as well as threonine, methionine, proline, serine, and cysteine. 
  • Short-chain fatty acids, which are the result of metabolized dietary fiber (grains, legumes, fruits and vegetables), and resistant starch (beans, potatoes, brown rice) are a major source of energy for epithelial cells in the colon
  • Vitamin A deficiency is common in patients with newly diagnosed IBD
  • Vitamin D may decrease intestinal fibrosis, and reduce risk of Crohn’s relapse
  • Vitamin C and Zinc may both help heal epithelial wounds in the colon
  • During the remission phase, some foods may be poorly tolerated, such as dairy
  • During an active flare of IBD, a patient may require enteral nutrition 

The authors conclude that the exact mechanisms by which the various dietary compounds contribute to bowel healing is still unknown. Furthermore, the ability to make clear dietary recommendations is limited by the lack of clinical studies. At a minimum, this information can alert the pelvic rehab provider to discuss the potential benefits of nutrition on bowel health with patients. Many of us are quite comfortable giving advice about drinking appropriate amounts and types of fluid, or eating more whole and less processed foods. We can take our nutritional education a step further by encouraging a patient to discuss healing supplements with a provider and/or nutritionist to best support the healing bowel. If you are interested in learning more about nutrition and pelvic health, you might love our newer course Nutrition Perspectives for the Pelvic Rehab Therapist Kansas City in March of next year with instructor Megan Pribyl.

Postpartum perineal injuries can cause pain and dysfunction for a short or an extended period of time. Pelvic rehab providers are in a position to educate women about the immediate and long-term management of perineal pain. A 2015 study by Manfre et al. assessed the response of cortisone cream application to the perineum in the immediate postpartum period. The study was a randomized controlled trial involving 27 subjects with each subject serving as her own control. Three different treatments were given over a 12 hour period: corticosteroid, placebo, and no treatment. (The hydrocortisone cream was at 1% in an alcohol-based cream, the placebo was a non-medicated acetyl alcohol-based cream.) The cream was applied by an investigator who placed the cream on a Witch Hazel pad. The participants and the researchers were blinded to the type of cream applied, and the applications were randomized and took place within the first 12.5 hours after birth. Perineal pain levels were assessed immediately before cream application, and at 30 and 60 minutes after application. Using a visual analog scale (VAS), the symptom of pain was assessed and compared to baseline. In the study, the authors report that in the immediate postpartum period, women in their institution were often prescribed medication ranging from ibuprofen to hydrocodone. Topical medications, ice packs, heat packs are also mentioned as available treatments. Other pain medications or cold packs were available during the study; no other topical creams were utilized.

Results indicated that the participants responded positively to both creams with significantly more pain reduction than the no treatment group. The authors propose that both creams provided a soothing effect by providing moisture to the tissues, creating a protective barrier, and preventing friction and irritation. Because the placebo emollient cream was not significantly more expensive than the hydrocortisone cream, the article suggests using hydrocortisone on the postpartum perineum due to the medication’s potential beneficial anti-inflammatory effects. Also of note was that ice packs were used by less than half of the women in the study, and when ice was used, it was only during the first four hours after birth. One reason for the low frequency use of ice was thought to be the difficulty in maintaining ice application on the perineum.Manfre 2015

Because the pelvic rehab provider is in an optimal role as educator for pain reduction strategies, this study provides some interesting information to share with other birth providers and with patients. Learn more about postpartum patient care at Care of the Postpartum Patient, available in Seattle this March.

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