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Blog posts tagged in Peer-Reviewed Articles

Research published in a Nursing journal highlights the need for pelvic rehab providers to assess for sexual dysfunction in women before, during, and after pregnancy. 200 women were interviewed about their return to sexual activity after pregnancy and childbirth, and the results demonstrate that women can (and do) have limitations in their sexual function around the entire peripartum period.

By Nina Matthews (Flickr: head to head) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia CommonsThe results of the survey concluded that before pregnancy 33.5% of the women reported sexual dysfunction, and this number increased to 76% during pregnancy, and to 43.5% following delivery. The types of sexual dysfunction included dyspareunia, vaginismus, and decreased desire and orgasm. The authors of the study correlated dysfunctions with Catholic religion, vaginal delivery without suture, dyspareunia during pregnancy, vaginismus before pregnancy, and with working more than 8 hours per day.

The information collected in this study raise important points with a variety of topics related to sexual function. How we as providers aim to address these topics with women can have a critical impact on the health of a woman and her family. Let’s look at some action items this research can lead us to:

How often do we hear of patients trying to explain their sexual pain to a partner, only to be doubted, not believed, or guilt tripped into having sex because of the lack of understanding of the condition? I’d say about as often as we hear of the other unfortunate misunderstandings about the nature of painful sexual function, such as people not wanting to be in a relationship for fear of sexual dysfunction limiting their participation, or believing that healthy sex is gone for good. Most of us are familiar with the phrase, “not tonight- I’ve got a headache” yet how often is the truth really that a person has a “pelvic ache?” And do headaches and pelvic pain go together? That is the question posed in research published in the journal Headache.

For 72 women who were being treated for chronic headache, a survey was administered to assess for associations between sexual pain and libido, a history of abuse, and to determine the number of women being treated for sexual pain. Nearly 71% of the women were diagnosed on the International Classification of Headache Disorders (ICHD)-III criteria with chronic migraines, nearly 17% with medication overuse headache, 10% with both chronic overuse headache and migraine. Below are some of the statistics from the survey.

Symptom % Respondents who Experienced Symptom
Pelvic region pain brought on by sexual activity 44%
Pelvic region pain preventing from engaging in sexual activity 18%
Among women who had pain:
Reported pain for < 1 year 3%
Reported pain for 1-5 years 35%
Reported pain for 6-10 years 29%
Reported pain for > 10 years 32%

Although the next statistics should not be so surprising based on prior literature and on our work in the clinics, 50% of the women had not discussed their pelvic pain with a provider. Of the women who had discussed their pelvic pain with a provider, 37.5% were currently receiving treatment, 31% had not received any treatment, 31% had received care in the past, and 1% did not provide an answer. Reasons for not receiving treatment included that no treatment was offered, pain was not severe enough to warrant care, or fear of pursuing treatment due to embarrassment. Unfortunately, rehabilitation was not a significant part of the treatment plan, even though all but one of the women said they would want to pursue care if available.

Peyronie’s disease is a condition in which there are fibrotic plaques (sometimes calcified) that can cause a curvature in the penis, most notable during erection. Pain as well as urinary and sexual dysfunction may occur with Peyronie's disease. Increased attention has been given in recent years to the relationship between male hormones, erectile dysfunction, and Peyronie's disease. According to the Mayo Clinic, testosterone, the predominant hormone affecting male physical characteristics, peaks during adolescence and early adulthood. Testosterone gradually decreases about 1% per year once a man reaches age 30-40. Some men experience symptoms from the decline in testosterone and these symptoms can include decreased sexual function, sleep disturbances changes in bone density and muscle bulk, as well as changes in cognition and depression. Because other factors and conditions can cause similar symptoms, patients with any of these changes should talk to their medical provider to rule out diabetes, thyroid dysfunction, depression, sleep apnea, and medication side effects, according to Mayo.

In an article published in 2012, Iacono and colleagues studied the correlation between age, low testosterone, fibrosis of the cavernosal tissues, and erectile dysfunction. 47 patients diagnosed with erectile dysfunction (ED) were included, with 55% of the 47 men being older than age 65. Having increased fibrosis corresponded to having a positive Rigiscan test- meaning that a nocturnal test of penile rigidity demonstrated abnormal nighttime erections. Low levels of testosterone also corresponded to erectile dysfunction. (This is an open access article with full text available) Another published article agreed with the above in that low testosterone is associated with Peyronie’s disease and/or erectile dysfunction. The authors are cautious, however, in describing the association between the variables, as causation towards plaque formation characteristic of Peyronie’s is not known.

The larger question about Peyronie’s disease is what a patient can do to improve the symptoms of the condition. Therapists who treat male patients are increasingly interested in this question, and many are working with their patients to address the known soft tissue dysfunction. Interventions may include teaching patients to perform soft tissue mobilizations and stretches to the restricted tissue, and educating the patient in what the available literature tells us about rehabilitation of this condition. Hopefully, as male pelvic rehabilitation continues to grow in popularity, more therapists will contribute case studies and participate in higher levels of research so that more men can add conservative care of Peyronie’s to their list of treatment options.

Have you ever tried to make a fitted sheet reach all corners of a mattress when there is a small, defective seam stitched into the middle of the fabric? No matter how much you pull or tug, the sheet won’t hug the last corner just right. If you get it to stay, the opposite corner flips off from the extra tension. Unless you release the snag the stitching created, you won’t ever get the sheet to fit smoothly. This is like the myofascial system in the body, where a snag in one area can affect another proximally or distally when normal movement tries to occur.

Even the pelvic floor can get myofascial restrictions and trigger points; however, this area is often ignored and seemingly insignificant when not fully understood. Pelvic floor fascial restrictions and trigger points can have paramount implications for the pelvic, abdominal, hip, and lumbar regions. This why pelvic rehabilitation practitioners should be equipped to evaluate and treat myofascial snags.

Pastore and Katzman (2012) published an article stating that 14%-23% of women with chronic pelvic pain have myofascial pelvic pain, and up to 78% of women with interstitial cystitis have myofascial trigger points. Once a trigger point in pelvic floor musculature is identified through palpation, it can refer pain to the perineum, vagina, urethra, and rectum, which seems obvious; however, pain may also refer to the abdomen, back, trunk, hip, buttocks, and lower leg. If palpation can provoke a referral pattern of pain, stretching and/or contraction of the musculature with that myofascial restriction will surely provoke a cascade of symptoms. How can we as clinicians just let statistics like this slide and figure “someone else should do that examination and fix it?” To demonstrate the efficacy in treating myofascial trigger points in pelvic musculature, consider the following study. Anderson et al (2015) had 374 patients follow a protocol of pelvic floor myofascial release of trigger points with an internal trigger point wand along with paradoxical relaxation therapy for 6 months. The goal was to see if patients with chronic pelvic pain syndrome could reduce their medication after following the protocol. At 6 months, a 36.9% reduction in medication use was noted in a complete case analysis, and a 22.7% reduction was revealed in the modified intention to treat (mITT) analysis. Patients no longer needing to take medication significantly correlated with the reduction of overall symptoms from following the protocol.

The concept of patient compliance, or adherence (a more preferred term), has been the subject of many medical studies, and adherence in pelvic rehabilitation is an aspect of rehab of critical interest. Recently published results of a survey questioning providers and the public about adherence in pelvic floor muscle training offers an insightful perspective. Researchers Frawley, Dumoulin, and McClurg conducted a web-based survey which was published in published in Neurourology and Urodynamics. The survey was completed by 515 health professionals and by 51 individuals from the public. Interestingly, but perhaps not surprisingly, health professionals and public respondents placed different value on which factors related to rehabilitation contributed the most to adherence.

Data collected in the study included topics such as barriers to adherence in pelvic floor muscle training (PFMT), perception of potential benefit of PFMT, therapy-related factors including therapeutic relationship, socioeconomic factors, and issues surrounding short-term versus long-term adherence, for example. For the providers, poor motivation was rated high as a barrier to short-term adherence, whereas the patients rated perception of minimal benefit from PFMT as the most important barrier. Facilitators of pelvic muscle training included aspects of access such as having appointments outside of the typical workday, or having childcare available, transportation, and not being bored by the exercise program or feeling that the therapist has adequate training and skills.

As suggested by the authors, perhaps that most important variable agreed upon by both providers and public is that of perceived benefit. In other words, patients need to believe that the exercise program can alleviate symptoms and that what they are doing in their particular program is going to achieve positive results rather than wasting time on a home program that will not be effective. This issue is one that can be easily remedied through appropriate patient education, communication with the patient about whether or not they understand the potential value and expected recovery through program participation, and adequate training of the therapist that allows for proper diagnosis and treatment planning. The study concludes by emphasizing that health providers “need to be aware of the importance of long-term patient perception of PFMT…”

Coccyx pain is a frequently encountered condition in pelvic rehabilitation practices. Although sitting is one of the primary limitations for patients who present with coccyx pain, or coccygodynia, defecation can be included in the list of functional complaints. This brings to mind the question: what does the coccyx do during defecation?

Coccygeal mobility was examined using MRI in this study by Grassi and colleagues. The authors included 112 subjects for the dynamic MRI research in positions of maximal contraction as well as straining for evacuation. Included in the study were subjects who complained of constipation, sense of incomplete evacuation of bowels, pain (not coccyx pain), organ prolapse, and minor trauma. Although the MRI was completed with the patient in supine (a non-functional defecation position), the authors reported that during a straining maneuver, the coccyx moves into extension, or backwards.

What if the coccyx does not move into extension during a straining maneuver? Is it possible for the coccyx to interfere with defecation? This appears to be true for a patient who appeared as the subject in the Journal of Medical Case Reports. The patient presented with an anteverted coccyx, and complained of “…worsening rectal pain developing an hour before defecation and lasting for several hours afterwards.” Pain was also reported during sitting on a hard surface. (See the linked article for an interesting image of the coccyx position and what is described as “rectal impingement.”) The patient was treated with coccygectomy which appeared to significantly reduce the symptoms (there are no outcomes tools reported in the case study, so progress reported is vague.) Although removal of the coccyx was the treatment in this particular case, the authors state that first-line treatment for coccyx pain includes conservative measures such as seat cushioning, coccygeal massage, stretching and manipulation, and injections, and that the majority of patients will respond favorably to these interventions.

Cognition in later years may be affected by premature menopause, according to an article published online in the British Journal of Obstetrics and Gynaecology. In the study 4,868 women at least 65 years old were assessed on a cognitive test battery and were evaluated for clinical dementia. Associations between the subject’s age at menopause, surgical versus natural menopause, use of menopausal hormone therapy, and cognitive function later in life were studied. According to introductory concepts described in the article, estrogen level changes postmenopause are associated with brain atrophy and memory complaints.

Variables such as verbal fluency, visual memory, psychomotor speed and global cognitive function can be negatively impacted by premature menopause

Tests were administered at baseline, and again at 2, 4 and 7 years from baseline. Tools included the Mini-Mental State Examination (MMSE) for global cognitive function, Benton’s Visual Retention Test (BVRT) for visual memory assessment, Isaacs Set Test for verbal fluency or semantic access, and the Trail Making Tests A and B for timed visual motor tasks of psychomotor speed and attention and executive function. Unrelated to cognitive function, The Rosow and Breslau mobility and Instrumental Activities of Daily Living scales, the Centre for Epidemiology Studies Depression Scale (CES-D), and other instruments were used to assess socioeconomic, demographic, lifestyle and health information. Dementia was also evaluated by a trained psychologist (or neurologist if subject was suspected to have dementia) and cases were assessed by a panel of dementia experts as a third step in the process.Symptoms of menopause (raster)

Natural menopause was noted in 79% of the subjects, surgical menopause in 10%, and 11% due to other causes including radiation, chemotherapy, or unknown. Less than 1 in 7 women was currently using hormone therapy, and over 1/5 used hormone therapy at menopause (most commonly reported treatment was transdermal estradiol- median time of use was 10 years).

The authors concluded that variables such as verbal fluency, visual memory, psychomotor speed and global cognitive function can be negatively impacted by premature menopause. Specifically, premature menopause including premature ovarian failure or surgical menopause at 40 years of age or less was independently associated with increased risk of poor verbal fluency and visual memory later in life. Premature menopause was also associated with increased risk of psychomotor speed and global cognitive decline. The primary conclusion of the article is that when an ovariectomy is being considering in younger women, the potential negative impact on cognitive function should make up part of the risk/benefit discussion. Hormonal influence during various stages of a woman’s life can have a dramatic impact on many variables impacting quality of life and rehabilitation efforts. To learn more about menopause, the Institute offers several courses that contain information about rehabilitation for women throughout the lifespan.

You’ve done a thorough evaluation of the lumbar spine. You’ve done all the special tests for hip pathology, but something is missing. Of course it could be a pelvic floor issue, but what else? Think about the middle child who gets ignored even if making a commotion or goes unnoticed unless being tripped over when standing still. Perhaps the missing link to your patient’s dysfunction is the sacroiliac joint, that “in between” area. If you are unsure how to assess and deal with the “middle child,” learning more about Sacroiliac Joint and Evaluation is something to add to your professional bucket list.

According to the special tests book by Chad Cook, a pain mapping test suggests a referral pattern of SI dysfunction as pain in the buttock unilaterally, below the level of L5, without symptoms in the midline. Often we are on a mission to make the lumbar spine the source of symptoms, but this provides some guideline as to where the pain would be located if the SI joint were the guilty party. If pain is found above L5, the SI joint is likely not the primary tissue in lesion. If the pain is bilateral, the issue is more than just SI joint.(Cook, 2013)

The special tests to diagnose SI joint dysfunction have been considered in a cluster. According to Laslett, distraction, compression, thigh thrust, Gaenslens, and Patricks are the primary tests used to assess SI dysfunction. Three or more of these tests being positive can help a clinician rule in SI joint as a diagnosis, with SI joint blocks being just as predictive. When pain cannot be centralized, and three of the tests are positive, there is a 77% probability the SI joint is the source of pain; and, in the pregnant population, there is an 89% chance the SI joint is the culprit of pain.(Laslett, 2008)

A recent systematic review published in The Lancet online describes the benefits of using music as a postoperative aid in recovery. Seventy-three randomized, controlled trials were included in the review, and the articles covered the use of music before, during, and after surgery. A wide variety of surgical procedures were represented in the research articles, and included cardiac procedures, mastectomy, urogynecologic and abdominal surgeries, and gastrointestinal surgeries and procedures. Interventions included listening to music with headphones, listening to relaxation training or “therapeutic suggestion.” Many of the studies included a control group with routine care or white noise, headphones without music.

The main results of the research is that use of music reduces postoperative pain, anxiety, and analgesia use, and improves patient satisfaction. The timing of or choice of music listened to in the studies did not significantly affect outcomes. Interestingly, even when patients were given general anesthesia, music was effective. And when patients chose their own music, there was a slight increase in reduction of pain and analgesia use.

How can this information be of use to pelvic rehabilitation providers? Perhaps one of your patients will be heading into surgery. A recommendation for listening to favorite music in the postoperative period could be made. Is music available to your patients in your setting? If so, what kind of music? Is the patient allowed to influence the type of music? Maybe the patient could play a favorite song list from their smart phone, or request a certain time period of music on a music subscription service you may use in the clinic. Regardless of how we use this information, it’s great to be reminded of the potentially positive ways that music can influence healing.

Carolyn McManus, PT, MS, MA is the author and instructor of "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain". Carolyn is a specialist in managing chronic pain, and has incorporated mindfulness meditation into her practice for more than 2 decades. Today she is sharing her experience by analyzing some of the most foundational research in the field of mindfulness and meditation.

Mindfulness awareness has been described as the sustained attention to present moment awareness while adopting attitudes of acceptance, friendliness and curiosity. (1,2) In patients with persistent pain, mindfulness has shown to reduce pain intensity, anxiety and depression and in improve quality of life. (3,4) Researchers suggest that mindful awareness may work through 4 mechanisms: attention regulation, increased body awareness, enhanced emotional regulation and changes in perspective on self. (5)

1. Attention Regulation: In chronic pan populations, improved attention regulation has been suggested to result in less negative appraisal of pain, greater pain acceptance and reduced pain anticipation. (6)

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