Recent data suggests that there are about 4 million American women diagnosed with endometriosis, but that 6/10 are not diagnosed. Currently, using the gold standard for diagnosis there are potentially 6 million American woman that may experience the sequelae of endometriosis without having appropriate management or understanding the cause of their symptoms.
The gold standard for endometriosis is laparoscopy either with or without histologic verification of endometrial tissue outside of the uterus. However, there is a poor correlation between disease severity and symptoms. The Agarwal et al study suggests a shift to focus on the patient rather than the lesion and that endometriosis may better be defined as “menstrual cycle dependent, chronic, inflammatory, systemic disease that commonly presents as pelvic pain”. There is often a long delay in symptom appreciation and diagnosis that can range from 4-11 years. The side effects of this delay are to the detriment of the patient; persistent symptoms and effect of quality of life, development of central sensitization, negative effects on patient-physician relationship. If this disease continues to go untreated it may affect fertility and contribute to persistent pelvic pain.
The authors suggest a clinical diagnosis with transvaginal ultrasound for patients presenting with persistent or cyclic pelvic pain, patient history, have symptoms consistent with endometriosis, or other findings suggestive of endometriosis. The intention of using transvaginal ultrasound is to make diagnosis more accessible and limit under diagnosis. It is not intended to minimize laparoscopy as a diagnostic tool or treatment option.
The algorithm for a clinical diagnosis evaluates patient presentation of the following:
Of course, there are differential diagnosis for endometriosis, and those are symptoms of non-cyclical patterns of pain and bladder/bowel dysfunction that would indicate IBS, UTI, IC/PBS. A history of post-operative nerve entrapment of adhesions. Examination positive for pelvic floor spasm, severe allodynia in vulva and pelvic floor, masses such as fibroids. It is important to note that these other diagnoses can coexist with endometriosis and do not rule out possible endometriosis diagnosis.
Hopefully, diagnosing individuals earlier and possibly at a younger age would limit the disease severity and symptoms. This would allow this population to limit the possibility of central sensitization and pain persistence that can affect so much of daily life. Earlier diagnosis may affect infertility and allow this population to make informed decisions about family and career from a place of empowerment.
Agarwal SK, Chapron C, Giudice LC, Laufer MR, Leyland N, Missmer SA,Singh SS, Taylor HS, "Clinical diagnosis of endometriosis: a call to action", American Journal of Obstetrics and Gynecology (2019), doi: https://doi.org/10.1016/j.ajog.2018.12.039.
The need for artful incorporation of Hippocrates’ wisdom is great in today’s healthcare landscape. As conversation of nutrition broadens into multidisciplinary fields, his wisdom resonates: first, “we must make a habit of two things; to help; or at least to do no harm”. Second, we must modernize the ancient adage: “let food be thy medicine and let medicine be thy food”. And finally, health care providers will do well to be guided by his insight that “all disease starts in the gut”. Hippocrates’ keen observations during his era, modern science is confirming, hold keys to the plight of our times as we seek to find better ways to manage complex conditions commonly encountered in pelvic rehab practice settings and beyond.
Considered some of the oldest writings on medicine, the “Hippocratic Corpus” is a collection of more than 60 medical books attributed directly and indirectly to Hippocrates himself who lived from approximately 460 to 377 BCE.2 According to the Corpus, Hippocratic approach recommends physical exercise and a “healthy diet” as a remedy for most ailments - with plants being prized for their healing properties. If -during illness states - employment of nourishment and movement strategies fail, then medicinal considerations could be made. This logos - the ancient Greek word for logic - is the art of reason whose relevance today is perhaps more poignant than in ancient times.
In this logos, by making a habit of helping, or at the very least, not harming, it becomes particularly important to identify the unique nutritional landscape that surrounds us. The Hippocratic Oath emanates reason. It is logical that we would seek to practice (healthcare) to the best of our ability, share knowledge with other providers, employ sympathy, compassion and understanding, and help in disease prevention whenever possible.2 One of the most helpful and powerful aspects of rehabilitation is the gift of time we have for meaningful and instructional conversation with our clients. Our interactions with clients can and should address the realm of nutrition as it relates to the health of the mind and body. Because, after all - to help - is why many become health care providers in the first place.
Detailing a “healthy diet” in Hippocratic times was certainly simpler, as the uncontrolled variable of processed foods- as we know them- did not exist. Therefore, we reflect upon the quote: “let food be thy medicine and let medicine be thy food” and acknowledge that this modern food landscape is vastly different 1 than in ancient times. Compounding the issue, our standard logic for helping has gotten somewhat out of order. And both medicine and food carry meanings today reflective of modern times. The issues of poly-pharmacy and the tragedy of medically prescribed unintentional overdoses (or intolerances) remind us of our ‘medicine first’ mentality and the unfortunate reality that medicine is not the cure-all we so wish it could be. Further, not all ‘food’ today is food. Real food sustains and nourishes us. Real food can also heal. We need to celebrate real food for being real food, and champion it’s miraculous ability to support, heal, and transform the human condition.
Finally, health care providers will do well to be guided by Hippocratic insight that “all disease starts in the gut” and to logically extrapolate the opposite: much healing can begin in the gut. It is through this ancient concept that we can organize our modern science and begin to concretely and intentionally help heal ourselves and others from the inside out. Once we understand the key role of digestion and our gut on our health and well-being, the rest is pure logic. We simply need a map for navigation of these universal concepts to go along with our renewed appreciation for the art of reason.
Let Nutrition Perspectives for the Pelvic Rehab Therapist help provide this map. Evolve your nutritional logos into a beautiful and nourishing framework by joining the hundreds of pelvic rehab therapists and other health care providers who have attended Nutrition Perspectives in Pelvic Rehab. Be inspired and empowered on your integrative journey. Live courses will be offered at three sites in 2019: March 1-3 in Arlington, VA, June 7-9 in Houston, TX, and October 11-13 in Tampa, FL!
Fardet, A., Rock, E., Bassama, J., Bohuon, P., Prabhasankar, P., Monteiro, C., . . . Achir, N. (2015). Current food classifications in epidemiological studies do not enable solid nutritional recommendations for preventing diet-related chronic diseases: the impact of food processing. Adv Nutr, 6(6), 629-638. doi:10.3945/an.115.008789
Biography.com https://www.biography.com/people/hippocrates-082216. Accessed January 11, 2019.
Faiq Shaikh, M.D. is a dual fellowship-trained nuclear medicine physician & Informaticist, with a focus on translational research in the domains of Cancer imaging, Radiomics, Genomics, Informatics and Machine learning applications in Medicine. He has written more than 35 scientific articles and abstracts and 3 book chapters on related topics.
Pelvic floor weakening is a common (occuring in half of women 50+) condition that leads to descent of the urinary bladder, uterovaginal vault, and rectum in the females, leading to urinary and fecal incontinence, and in extreme cases, pelvic organ prolapse.
Pelvic floor weakness is caused by a variety of factors, most of which increase the intra-abdominal pressure, such as pregnancy, multiparity, advanced age, menopause, obesity, connective tissue disorders, smoking, chronic obstructive pulmonary disease, etc. All these conditions lead to weakness of the pelvic musculature, ligaments, and fascia support result in descent of the pelvic floor organs.
The pelvic floor is divided into three compartments:
The structures in these compartments are supported by muscles, fascia, and ligaments anchoring them to the bony pelvis.
The endopelvic fascia is the most superior layer and covers the levator ani muscles and the pelvic viscera. Laterally, it forms the arcus tendineus. It attaches the cervix and vagina to the pelvic side wall as the parametrium and paracolpium. Posteriorly, the endopelvic fascia forms the rectovaginal fascia between the posterior vaginal wall and the rectum.
These fascial condensations are not well visualized on conventional MRI but their defects may be seen indirectly through secondary findings. These ligaments are not visualized on conventional MRI but may be visualized with an endovaginal coil which allows higher resolution and signal-to-noise ratio.
The levator ani muscles lie deep in relation to the endopelvic fascia and comprise of the puborectalis and the iliococcygeus muscles. Posteriorly and in the midline, the iliococcygeus condenses to form the levator plate. These are all well visualized on MRI. The perineal membrane lies inferior to the levator ani muscles and separates the vagina and rectum, which may be damaged during vaginal delivery when episiotomy is performed.
Pelvic floor relaxation is the weakness of the supporting muscles, fascia, and ligaments. This weakness progresses with age and may be related to hypoestrogenic states, such as menopause.
Accurate assessment of all compartments of the pelvic floor is necessary for surgical planning in order to minimize the risk of recurrence.
Methods for the assessment of pelvic floor weakness include urodynamics, voiding cystourethrography, ultrasonography of the bladder neck and anal sphincter, fluoroscopic cystocolpodefecography, and MRI - which m is now the standard-of-care for preoperative planning for pelvic floor dysfunction, although it’s still not used for routine assessment.
MRI visualizes all three compartments of the pelvic floor and the pelvic support muscles and organs. We perform dynamic MRI of the pelvic floor with the patient in the supine or lateral decubitus positions. Conversely, MRI defecography or fluoroscopic cystocolpodefecography are performed in the sitting position, which is closer to the physiologic state. MR defecography is not superior to dynamic supine MRI for depiction of clinically relevant bladder descent and rectoceles. Overall, MRI accurately detects enteroceles and its contents when compared with fluoroscopic cystodefecography.
The preferred MRI pelvis protocols include: Ultrafast, large-field-of-view, T2-weighted sequences such as single-shot fast spin-echo (SSFSE), and half-Fourier acquisition turbo spin-echo (HASTE). After the dynamic examination is completed, small-field-of-view (20–24 cm) T2-weighted axial fast spin-echo (FSE) or axial turbo spin-echo (TSE) sequences are acquired to obtain high-resolution images of the muscles and fascia of the pelvic floor. The entire examination is typically completed in 20 minutes. This exam is performed with a torso phased-array coil wrapped around the pelvis. Endovaginal coil may be used to improve the spatial resolution of the pelvic ligaments, but it is invasive and can be uncomfortable.
MRI visualizes the uterus, cervix, and rectovaginal space. Ultrasonic gel may be administered into the vagina and rectum for better visualization. Also, incompletely voiding the urinary bladder improves visualization of the bladder and anterior vaginal wall prolapse.
For patients with a rectocele, patient is imaged after having evacuated the rectal contents. Chronic constipation and perineal hernias show as ballooning of the iliococcygeus muscle. The level of the pelvic floor is demarcated radiologically on the midsagittal image using the pubococcygeal line (from the most inferior portion of the pubic symphysis to the last horizontal sacrococcygeal joint). The levator plate should be parallel to the pubococcygeal line in normal cases.
The H line (5 cm) extends from the inferior symphysis pubis to the posterior anorectal junction on the midsagittal image and depicts the levator hiatus. The M line (2 cm) goes perpendicular from the pubococcygeal line to the most distal aspect of the H line and depicts the descent of the levator hiatus from the pubococcygeal line. Pelvic floor prolapse causes sloping of the levator plate and increasing length of the H and M lines, indicating widening and descent of the levator hiatus.
The T2-weighted axial images of the pelvic floor should be analyzed for signal intensity, symmetry, thickness, and fraying of the pelvic floor muscles. Bladder neck at strain should be less than 1 cm away from the pubococcygeal line. Descent of the bladder neck below the pubococcygeal line depicts the prolapse of the urinary bladder through the anterior vaginal wall resulting in a cystocele. Descent of the bladder neck during strain results in clockwise rotational descent of the bladder neck and proximal urethra. Distortion of the periurethral and paraurethral ligaments is seen in stress urinary incontinence. The normal butterfly shape of the vagina may also be altered by weakening of the paravaginal ligaments as it is displaced posteriorly. Prolapse of the middle compartment is associated with the vaginal apical prolapse and damage to the paracolpium seen in post-hysterectomy patients. On midsagittal MR images, descent of the uterus, cervix and vagina usually suggests disruption of the uterosacral or cardinal ligaments and elongated H and M lines. Pelvic organ prolapse increases the urogenital hiatus in the levator muscles. Caudal angle of more than 10° between the levator plate and the pubococcygeal line on midsagittal image is a sign of pelvic floor weakness.
On the midsagittal image, rectocele is identified by a rectal bulge of more than 3 cm (from anal canal and the tip of the rectocele). Contrast-enhanced MR shows hyperintense T2 signal in peritoneal fat contents in peritoneoceles, the hyperintense fluid-filled small-bowel loops in enteroceles, and the hyperintense gel-filled rectum/sigmoid colon in rectoceles/sigmoidoceles. Intussusception of the rectum on MR is seen as rectum invaginating distally toward the anal canal (MR defecography is superior to dynamic supine MR for this indication).
Performing MRI for pelvic floor dysfunction when indicated for surgical planning and the assessment if the extent of disease may reduce the risk of surgical failure.
This information is extremely useful to urogynecologists and surgeons.
MRI of pelvic floor dysfunction: review. Law YM, Fielding JR. AJR Am J Roentgenol. 2008.
Authors: Tamara Rial, PhD, CSPS, Kathleen Doyle-Elmer, PT, DPT and Rebecca Keller, PT, MSPT, PRPC
Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care Level 2 and 3 in Princeton, New Jersey in September, 2019. Rebecca Keller and Kathleen Doyle-Elmer are certified Low-Pressure Fitness specialists with training in rehabilitative ultrasound imaging. In this article, the authors discuss and explore the use of transabdominal ultrasound during Low Pressure Fitness on the abdominal and pelvic floor structures.
Real-time ultrasound imaging is a reliable and valid method to evaluate muscle structure, activity and mobility. Over the past few years, there has been increasing interest in the use of transabdominal ultrasound in the field of rehabilitation. The additional value of ultrasound imaging is that it allows for real-time analysis and visual feedback during the performance of pelvic floor and abdominal exercises (Hides et al., 1998). In the field of pelvic health, this is of notable importance when assessing proper movement of the deep abdominal and pelvic muscles during voluntary muscle actions. Transabdominal ultrasound has been found to be a safe, noninvasive, and accurate method to assess and observe muscular and fascial activity (Khorasani et al., 2012). When therapists learn how to properly use and apply ultrasound imaging, this technique can be a comprehensive tool for the clinician and a comfortable procedure for the patient. Moreover, it may be the method of choice for some patients who don’t want to have an internal pelvic examination (Van Delft, Thakar & Sultan, 2015). In this regard, a cross-sectional study found a moderate-to-strong correlation between ultrasound measurements and both digital examination and perineometry for the assessment of pelvic floor muscle actions (Volløyhaug et al., 2016).
Recently, Low Pressure Fitness has gained popularity as a pelvic floor training program aimed at reducing pressure on the pelvic structures while engaging the stabilizing muscles through postural and breathing exercises. In order to evaluate proper execution of Low-Pressure Fitness exercises as well as abdomino-pelvic muscle function during this type of training, real-time transabdominal ultrasound can be a clinically relevant tool.
The amount of movement of the bladder base on transabdominal ultrasound is considered an indicator of pelvic floor muscle mobility during pelvic floor muscle exercises (Khorasani et al., 2012). When properly executed, the Low-Pressure Fitness technique will allow the bladder to lift and the pelvic floor muscles to contract. These observed actions can be cued and progressed due to the real-time imaging biofeedback of the ultrasound. Because of the postural activation and diaphragm lift occurring during Low Pressure Fitness, the bladder fascial support system is tensioned resulting in a desirable bladder lift.
For example, we used a Pathway® Musculoskeletal Rehabilitative Ultrasound Imaging unit with a curvilinear transducer and Prometheus Pathway® rehabilitative ultrasound software utilizing the pre-set parameters (Abdominal Wall 7.5MHz and Bladder 5.0MHz) during a Low-Pressure Fitness basic supine posture. A standardized bladder filling protocol was used before imaging to ensure sufficient bladder filling to allow clear imaging of the base of the bladder and pelvic floor muscles.
For the transverse view, radiologic standards were used, and the ultrasound transducer was placed in the transverse plane suprapubically and angled in a caudal/ posterior direction to obtain a clear image of the inferior-posterior aspect of the bladder. The participant was asked to perform the Low-Pressure Fitness Demeter exercise in the supine position with a neutral pelvis and knees flexed (Figure 1).
The following video illustrates the pelvic floor/urinary bladder during: a) resting position; b) active pelvic floor contraction; c) Low Pressure Fitness Demeter exercise and; d) Low Pressure Fitness Demeter exercise combined with a voluntary pelvic floor muscle contraction. It is noticeable a greater bladder lift and pelvic floor activation with the postural and breathing cueing added to an active pelvic floor contraction than with the pelvic floor contraction alone.
The lateral abdominal muscle ultrasound assessment allows us to observe the structural changes produced in the transversal section of the abdominal muscles in the midpoint between the anterior iliac crest and the costal angle. At low levels of contraction, the extent of transverse abdominis thickening measured using ultrasound is reported to be a valid method of assessment compared with either fine wire electromyographic measures of transverse activity (McMeeken et al., 2004). It is well established in the scientific literature that the lateral abdominal muscles provide stability to the trunk in different functional activities. Therefore, the assessment of the size, thickness and sliding of the abdominal wall is important for patients who present with lumbo-pelvic and/or pelvic floor dysfunctions. In this regard, patients with low back pain show different abdominal wall muscle activation patterns (i.e. less slide of the abdominal fascia and muscle thickness) than those without low back pain (Gildea et al., 2014; Unsgaard-Tondel et al., 2012).
Figure 2 shows the three muscle layers of the lateral wall in the resting position. The superficial layer corresponds to the external oblique, the middle layer to the internal oblique and the deep layer to the transverse abdominal muscle.
A key breathing component of the Low-Pressure Fitness program is the abdominal vacuum which manipulates intra-abdominal, intra-thoracic and intra-pelvic pressures during the breath-holding phase. Another key aspect of Low-Pressure Fitness is the shoulder girdle activation, spine elongation and ankle-dorsiflexion (Rial & Pinsach, 2017). Of note, previous studies have demonstrated greater transverse abdominis activation when performing ankle dorsi-flexion (Chon et al., 2010). We used transabdominal ultrasound to assess the lateral abdominal wall response during ankle dorsiflexion, shoulder girdle activation and the abdominal vacuum during Low Pressure Fitness.
In the following video, a voluntary (active) abdominal contraction is performed in order to distinguish this action from the involuntary abdominal contractions during Low Pressure Fitness. Afterwards, the postural technique of ankle dorsiflexion and shoulder girdle activation are performed in the Demeter exercise with arms in middle position (Figure 1). Lastly, an abdominal vacuum maneuver is added to the postural technique. If the exercises are properly executed, the progressive sliding and thickness of the abdominal muscles throughout exercise sequence should be observable (Figure 3).
Muscle thickness of the transverse and internal oblique as well as a noticeable slide of the anterior abdominal fascia are observable during the Demeter exercise of Low-Pressure Fitness. This exercise pattern reflects an abdominal draw-in maneuver and a “corseting effect”. In this regard, notice the lateral pull or displacement of the edge of the anterior fascial insertion of the transverse the internal oblique muscle.
Navarro et al., (2017) used transabdominal ultrasound to assess the muscular responses of the pelvic floor and abdominal muscles in a group of women who underwent pelvic physiotherapy over two months. They found a significant increase in the transversal section of the transverse abdominis, external oblique, and internal oblique muscles when compared to resting in the supine position. Similar to the position assessed by Navarro et al. (2017), we also assessed the pelvic floor and abdominal muscle responses during a Low-Pressure Fitness supine exercise.
Transabdominal ultrasound can provide a noninvasive and informative visual biofeedback when training patients with Low Pressure Fitness. This ultrasound imaging can be a valuable tool to both the client and the clinician to objectify progress, assist with validating correct Low-Pressure Fitness form with positioning and vacuum/hypopressive maneuver as well as a motivational technique for the client. As demonstrated during our rehabilitative ultrasound imaging, observable bladder lift, pelvic floor activation and desirable lateral abdominal muscular corseting (slide and thicking) occurs during Low Pressure Fitness postural exercises and breathing. Since Low Pressure Fitness is a progressive exercise program, qualified instruction, technique driven progression and understanding pelvic floor health are needed to optimize patient outcomes.
Chon SC, Chang KY, You JS. Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study. Physiotherapy 96: 130-6, 2017.
Gildea JE, Hides JA, Hodges PW. Morphology of the abdominal muscles in ballet dancers with and without low back pain: a magnetic resonance imaging study. J Sci Med Sport. 17(5): 452-6, 2014.
Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology, 80: 673-7, 2012.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19: 337–342, 2004.
Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther. 3:125-131,1998.
Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia 39: 187-94, 2017.
Rial T, Pinsach P. Practical Manual Low Pressure Fitness Level 1. International Hypopressive & Physical Therapy Institute, Vigo, 2017.
Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen J, Vasseljen O. Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up. Br J Sports Med, 46(10): 729-34, 2012.
Van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol, 45: 217-22, 2015. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. Ultrasound Obstet Gynecol 47: 768-73, 2016.
Several weeks ago, I evaluated a patient who was referred to me from a fellow physical therapist. The patient was suffering from sacroiliac joint and low back pain. The patient is a 34-year-old nulliparous woman who is physically fit and participates in several outdoor activities. The therapist had fully evaluated the patient and did not find any articular issues within her spine or pelvis. What she did find was weakness in her local stabilizing muscles and tightness in her global stabilizing muscles. The therapist has an ample amount of clinical experience at treating low back and pelvic pain issues. She is adept at using different verbal cues, positions, and tactile cueing in order to help encourage proper activation of the local core muscles. However, the therapist knew the patient was not getting her local core muscles to fire properly. She didn’t know what else to do with this patient in order to get her to properly activate these muscles. She had tried numerous positions, verbal and tactile cueing without success.
Do you ever have patients where you feel stuck, who are not progressing as you would like them to in treatment? We all do! It is frustrating, isn’t it? The physical therapist called me and asked me to evaluate the patient using real-time ultrasound imaging. The therapist said “If the patient can just see what she is doing, she will then be able to learn how to work the muscles correctly.” She referred the patient to me so I could use ultrasound imaging within the treatment to better assess her activation strategies and use the imaging for biofeedback for with the patient. The patient was amazed with the ability to see what the different layers of muscles were doing. We found she was contracting her TA but only on her left side, and her deep multifidus was not firing at all. Using the ultrasound images, the patient was able to learn the proper way to activate her muscles. She is now working on a strengthening program for her local core muscles including her TA, pelvic floor, and multifidus. Within two treatments, the patient was able to fire her muscles in a different way and reports her back has felt better than it has in years!
The Pathway Ultrasound Imaging System, available from The Prometheus Group, is a portable ultrasound solution for pelvic rehab
I cannot emphasize enough how using ultrasound might change your practice! It not only can help you when you are stuck with a patient’s progress, but it can attract more patients to your practice. There are a lot of visual learners out there and access to visual images in therapy can influence progress and the results that are achieved. You not only can use the ultrasound to retrain the local core muscles for back and pelvic instability patients, but you can use it for incontinence patients, prolapse patients, and post prostatectomy patients as well. You can strengthen the pelvic floor without having to disrobe the patient each visit. How many men and women would appreciate that?
If you are interested in learning more about how you can use ultrasound in your practice, join me in August in New Jersey, or in November in California for Rehabilitative Ultrasound Imaging - Women's Health and Orthopedic Topics! See you there!
I’m Elizabeth Hampton PT, DPT, WCS, BCB-PMD and I teach “Finding the Driver in Pelvic Pain”, which offers practitioners a systematic screening approach to rule in or rule out contributing factors to pelvic pain. This course helps clinicians to understand and screen for the common co-morbidities associated with pelvic floor dysfunction, like labral tears, discogenic low back pain, nerve entrapments, coccygeal dysfunction, and more. Importantly, it also coaches clinicians to organize information in a way that enables them to prioritize interventions in complex cases. I've noticed that there are some questions that course participants frequently have as they talk through common themes in their care challenges and wrote this blog to share some clinical pearls you may find to be helpful for your own practice or as an explanation to your clients.
Here are some of the most common questions that I get when teaching Finding the Driver in Pelvic Pain:
1) Question: How do I even start to organize information when a client has a complex history and I am feeling overwhelmed?
I write down a road map with key categories: Bowel and bladder; Spine; Sacroiliac Joint/Pubic Symphysis; Hip; Pelvic floor muscles; biomechanics; respiration; neural upregulation; whatever details can be fit into ‘big buckets’ of information. I use it to both organize my thoughts for my notes, as well as educate the client as to what my findings are and the design of their treatment program.
2) Question: How do you get your clients to do a bowel and bladder diary?
I am proud to say that I can talk anyone into a 7 day bowel and bladder diary because I tell them how incredibly helpful it is to understand the way their body responds to what they eat, drink, and daily habits. It’s my secret weapon to snag clients to start connecting with their body and listening to their details, educate about defecation ergonomics and what happens in multiple systems when there is pelvic floor overactivity. It’s a great teaching tool that facilitates self-reflection and how their self-care choices impact their body’s behavior.
3) Question: How do you educate clients about pelvic floor function so they don’t focus so much on Kegels?
Pelvic floor muscles do three things:
They contract gently, or powerfully, with no discomfort, and totally normal breathing; PFMs should have the same kind of nuanced control like your voice does: they should be able to do a gentle contraction, like a “whisper” or a powerful contraction, like a “shout”, depending on the task position and intent.
They relax fully and completely when the body is resting in support, or they should be able to relax to a supportive level when they are needed posturally. Relaxation should be its own celebrated event!
They should be able to relax and gently lengthen.
Faculty member Elizabeth Hampton PT, DPT, WCS, BCB-PMD is the author and instructor of Finding the Driver in Pelvic Pain, a course designed to help practitioners utilize differential diagnosis in evaluating pain. Join Dr. Hampton in Portland, OR on July 27-29, 2018 or November 2-4, 2018 in Phoenix, AZ.
Recently, I had a patient present to my practice with unretractable vaginal pain that was causing her quite a bit of suffering. Peyton (name changed) had been referred by a local osteopathic physician. For around a year, she had increasing severe vaginal pain. There was no history of assault, trauma, fall, or injury around the time of onset of symptoms. However, she had a kidney infection that caused back pain in the month prior to her pain onset.
Peyton is home schooled, but she was unable to attend outings that required longer sitting, such as field trips or church. She also was having some urinary retention with start and stop stream and resultant urinary frequency. Peyton’s mother said the pain was distressing to Peyton and would cause her to cry. She had an unremarkable medical history. However, under further questioning, we discovered she did have a history of bed wetting later than usual (until age 7) and she had persistent leg pain. With standing longer than 15 minutes, her legs would hurt and feel weak, which prevented her from performing sports or being physically active. She also had experienced some achy low back sensations since the kidney infection. Peyton had been screened by urology, her primary care, an osteopath, as well as a vulvar pains specialist who diagnosed her with nerve pain, but said there is no good viable treatment.
Objective findings revealed normal range of motion in her spine with the exception of limited forward flexion (feeling of back tightness at end range). Hip screening was negative for FABERS, labral screening or capsular pain patterns. General dural tension screening was positive for increased lower extremity and sensation of back tightness with slump c sit. Neural tension test was positive bilaterally for sciatic, R genitofemoral, L Iliohypogastric and Ilioinguinal nerves, and bilateral femoral nerves. Patient had a mild, barely perceptible lumbar scoliosis, and development of bilateral lower extremities and feet was symmetric and normal.
Because of the child’s age, we did not perform internal vaginal exam or treatment. This required treating the nerves that supply the vaginal area. All treatments were done with the patient’s mother present with both consent of the child and the mother.
For treatment, we started with the three inguinal nerves (Ilioinguinal, Iliohypogastric and genitofemoral) because of their relationship with the kidney (symptoms came on after kidney infection) as well as the correlation with the patient’s most limiting symptoms (genital pain). We cleared the fascia along the lumbar nerve roots, the lateral trunk fascia, the psoas, the inguinal region, the entrapments along the kidney and psoas, the inguinal rings and canal, and worked on neural rhythm (these techniques can be learned at the Pelvic Nerve Manual Assessment and Treatment class that I will be teaching later this month).
Over the next weeks, we used similar treatments for the sciatic nerve, femoral nerve, pudendal, and coccygeal nerves. We noted that the patient had an area of restricted tissue along her coccyx that was adhered, and her symptoms had some correlation with tethered cord. We did lots of soft tissue work along the coccyx and working along the coccyx roots, including some internal rectal work. We also did fascial and visceral work in the bladder region, as well as in the lumbar and sacro-coccygeal region.
Peyton’s referring physician and mother were notified of findings and possible tethered cord symptoms (leg weakness and pain, bladder symptoms, delayed nocturnal continence). The patient’s family felt she was getting better and was not interested in any kind of surgical intervention, and her physician also felt that with our progress, he was not interested in exploring that referral, unless the family was interested.
After just 4 treatments Peyton was no longer having any vaginal symptoms and was emptying the bladder normally. After 8 treatments Peyton was reporting no more lumbar pain or lower extremity symptoms, and follow up treatments were reduced to once a month. The patient was given a home program of neural flossing in a small yoga program we recorded on her mother’s phone. We had her mother work on the small area that remained adhered along patient’s tailbone. The area is much smaller, but it reproduces some pelvic pain for the patient, so we are carefully and slowly working along this area because of some of the global neural sx it produces.
The patient’s mother reports she is more active, no longer complaining of leg or vaginal pain. The patient has less generalized anxiety and she is able to void fully. When the pt grows in height, there is a return in some symptoms, likely due to increased neural tension. So, we have the family on standby and when the patient grows, they come back in for 2 visits, which is usually enough to get the patient back to her new baseline.
My 6 year old girl (going on 13) asks “Alexa” to play the Descendants II soundtrack over and over again. So the song, “Space Between,” was lingering in my head while reading the most recent articles on pudendal neuralgia, particularly when pudendal entrapment is to blame. After all, entrapment, by medical standards, describes a peripheral nerve basically being caught in between two surrounding anatomical structures.
Ploteau et al., (2016) presented 2 case studies highlighting the warning signs when pudendal nerve entrapment does not follow the Nantes criteria. A brief summary of those 5 criteria follows:
The case studies of a 31 and a 68 year old female revealed endometrial stromal sarcoma and adenoid cystic carcinoma in the ischiorectal fossa, with night pain was noted in both patients, as well as no pain with sitting or defecation, respectively. Clinicians must always be mindful to resolve red flags in patients.
In 2016, Florian-Rodriguez, et al., studied cadavers to determine the nerves associated with the sacrospinous ligament, focusing on the inferior gluteal nerve. Fourteen cadavers were observed, noting the distance from various nerves to the sacrospinous ligament (from a pelvic approach) and to the ischial spine (from a gluteal approach). The S3 nerve was closest to the sacrospinous ligament, and the pudendal nerve was the closest to the ischial spine. In 85% of subjects, 1 to 3 branches from S3/S4 nerves pierced or ran anterior to the sacrotuberous ligament and pierced the inferior part of the gluteus maximus muscle. The authors concluded the inferior gluteal nerve was less likely to be the source of postoperative gluteal pain after sacrospinous ligament fixation; however, as the pudendal nerve branches from S2-4, it was more likely to be implicated in postoperative gluteal pain.
A study by Ploteau et al. (2017) explored the anatomical position of the pudendal nerve in people with pudendal neuralgia. In 100 patients who met the Nantes criteria, 145 pudendal nerves were surgically decompressed via a transgluteal approach. At least one segment of the pudendal nerve was compressed in 95 of the patients, either in the infrapiriform foramen, ischial spine, or Alcock’s canal. In 74% of patients, nerve entrapment was between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants were found in 13% of patients, often with a transligamentous course of the nerve.
When the pudendal nerve is caught in the narrow space between ligaments in the pelvis, diagnosing the source of pain is paramount. Research supports a gluteal approach in releasing the entrapped nerve. Post-surgical care falls into the hands of pelvic floor therapists, so taking “Pudendal Neuralgia and Nerve Entrapment: Evaluation and Treatment” may be something to consider in order to provide optimal care.
Ploteau, S, Cardaillac, C, Perrouin-Verbe, MA, Riant, T, Labat, JJ. (2016). Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician. 19(3):E449-54
Florian-Rodriguez, ME, Hare, A, Chin, K, Phelan, JN, Ripperda, CM, Corton, MM. (2016). Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study. American Journal of Obstetrics and Gynecology. 215(5):646.e1-646.e6. doi: 10.1016/j.ajog.2016.06.025
Ploteau, S, Perrouin-Verbe, MA, Labat, JJ, Riant, T, Levesque, A, Robert, R. (2017). Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia. Pain Physician. 20(1):E137-E143
In the dim and distant past, before I specialised in pelvic rehab, I worked in sports medicine and orthopaedics. Like all good therapists, I was taught to screen for cauda equina issues – I would ask a blanket question ‘Any problems with your bladder or bowel?’ whilst silently praying ‘Please say no so we don’t have to talk about it…’ Fast forward twenty years and now, of course, it is pretty much all I talk about!
But what about the crossover between sports medicine and pelvic health? The issues around continence and prolapse in athletes is finally starting to get the attention it deserves – we know female athletes, even elite nulliparous athletes, have pelvic floor dysfunction, particularly stress incontinence. We are also starting to recognise the issues postnatal athletes face in returning to their previous level of sporting participation. We have seen the changing terminology around the Female Athlete Triad, as it morphed to the Female Athlete Tetrad and eventually to RED S (Relative Energy Deficiency Syndrome) and an overdue acknowledgement by the IOC that these issues affected male athletes too. All of these issues are extensively covered in my Athlete & The Pelvic Floor’ course, which is taking place twice in 2018.
How can we ensure that pelvic floor muscle dysfunction is on the radar for a differential diagnosis, or perhaps a concomitant factor, when it comes to athletes presenting with hip, pelvis or groin pain? Gluteal injuries, proximal hamstring injuries, and pelvic floor disorders have been reported in the literature among runners: with some suggestions that hip, pelvis, and/or groin injuries occur in 3.3% to 11.5% of long distance runners.
In Podschun’s 2013 paper ‘Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report’, the author explored the case of a 45-year-old female distance runner who was referred to physical therapy for proximal hamstring pain that had been present for several months. This pain limited her ability to tolerate sitting and caused her to cease running. Examination of the patient's lumbar spine, pelvis, and lower extremity led to the initial differential diagnosis of hamstring syndrome and ischiogluteal bursitis. The patient's primary symptoms improved during the initial four visits, which focused on education, pain management, trunk stabilization and gluteus maximus strengthening, however pelvic pain persisted. Further examination led to a secondary diagnosis of pelvic floor hypertonic disorder. Interventions to address the pelvic floor led to resolution of symptoms and return to running.
‘This case suggests the interdependence of lumbopelvic and lower extremity kinematics in complaints of hamstring, posterior thigh and pelvic floor disorders. This case highlights the importance of a thorough examination as well as the need to consider a regional interdependence of the pelvic floor and lower quarter when treating individuals with proximal hamstring pain.’ (Podschun 2013)
Many athletes who present with proximal hamstring tendinopathy or recurrent hamstring strains, display poor ability to control their pelvic position throughout the performance of functional movements for their sport: along with a graded eccentric programme, Sherry & Best concluded ‘…A rehabilitation program consisting of progressive agility and trunk stabilization exercises is more effective than a program emphasizing isolated hamstring stretching and strengthening in promoting return to sports and preventing injury recurrence in athletes suffering an acute hamstring strain’
If you are interested in learning more about how pelvic floor dysfunction affects both male and female athletes, including broadening your differential diagnosis skills and expanding your external treatment strategy toolbox, then consider coming along to my course ‘The Athlete and the Pelvic Floor’ in Chicago this June or Columbus, OH in October.
The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S), Mountjoy et al 2014: http://bjsm.bmj.com/content/48/7/491
‘DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT’ Podschun A et al Int J Sports Phys Ther. 2013 Aug; 8(4): 462–471. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812833/
‘A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains’ Sherry MA, Best TM J Orthop Sports Phys Ther. 2004 Mar;34(3):116-25. https://www.ncbi.nlm.nih.gov/pubmed/15089024
The expression, “the canary in the coal mine” comes from a long ago practice of coalminers bringing canaries with them into the coalmines. These birds were more sensitive than humans to toxic gasses and so, if they became ill or died, the coalminers knew they had to get out quickly. The canaries were a kind of early warning signal before it was too late. Even though the practice has been discontinued, the metaphor lives on as a warning of serious danger to come.
Osteoporosis, which means porous bones, has been called a silent disease because often an individual doesn’t know he or she has it until they break a bone. The three common areas of fracture are the wrist, the hip, or the spine. Osteoporosis fractures are called fragility fractures, meaning they happen from a fall of standing height or less. We should not break a bone just by a fall unless there is an underlying cause which makes our bones fragile.
Wrist fractures typically happen when a person starts to fall and puts his or her arms out to catch themselves. They often are seen in the Emergency Department but seldom followed up with an Osteoporosis workup. According to the International Osteoporosis Foundation’s Capture the Fracture program, 80% of fracture patients are never offered screening and / or treatment for osteoporosis. As professionals working with patients who often have co-morbidities, we can be the ones to screen for osteoporosis and balance problems, particularly if our patients have a history of fractures. These screens include the following:
1. Check for the three most common signs of osteoporosis:
a. History of fractures
b. Hyper-kyphosis of the thoracic spine
c. Loss of height equal or greater than 4 cm.
2. Grip Strength
Low grip strength in women is associated with low bone density1
3. Rib-pelvic distance- less than two fingerbreadths.
With the patient standing with their back to you, arms raised to 90 degrees, check the distance from the lowest rib to the iliac crest. Two fingerbreadths or less may be indicative of a vertebral fracture.
A prior fracture is associated with an 86% increased risk of any fracture based on a 2004 meta-analysis by Kanis, Johnell, and De Laet in Bone 2. Fracture predicts fracture. It is our duty as professionals and as human beings to intervene by screening and referring out even if this is not the primary reason we are treating this patient. Fractures from osteoporosis can be devastating, resulting in increased risk of mortality at worst and a diminished quality of life at best. Look for the canaries in the coal mine. Our patients deserve to live the quality of life they envision.
Deb Gulbrandson, PT, DPT, CEEAA teaches the Meeks Method for Osteoporosis Management seminars for Herman and Wallace around the country.
1. Dixon WG et al. Low grip strength is associated with bone mineral density and vertebral fracture in women. Rheumatology 2005;44:642-646
2. Kanis JA, Johnell O, De Laet C, et al. (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35:375