As pelvic rehab practitioners, it is common for our patients to ask us dietary questions pertaining to their unique pelvic floor symptoms. We often counsel on fluid consumption, bladder irritants, and fiber intake. At times, we even give our patients a bladder or bowel diary to better monitor nutritional status and habits. However, how often do we ask about vitamin D status? It is common knowledge that vitamin D deficiency contributes to osteoporosis, fractures, and muscle pain and weakness, but what is the role of vitamin D in overall health of the female pelvic floor. Is vitamin D supplementation something we as health care providers need to at least discuss? An article published in the International Urogynecology Journal (Parker-Autry) explores this topic. This interesting paper reviews current knowledge regarding vitamin D nutritional status, the importance of vitamin D in muscle function, and how vitamin D deficiency may play a role in the function of the female pelvic floor.
Vitamin D affects skeletal muscle strength and function, and insufficiency is associated with notable muscle weakness. Vitamin D has been shown to increase skeletal muscle efficiency at adequate levels. The levator ani muscles and coccygeus pelvic floor muscles are skeletal muscle that are crucial supporting structures to the pelvic floor. Pelvic floor musculature weakness can contribute to pelvic floor disorders such as urinary or fecal incontinence and pelvic organ prolapse. Pelvic floor muscle training for strengthening, endurance, and coordination, are first line treatment for both stress and urge urinary incontinence, fecal incontinence, pelvic organ prolapse, and overactive bladder syndrome. The pelvic floor muscles are thought to be affected by vitamin D nutrition status. Additionally, as women age, they are more prone to vitamin D deficiency and pelvic floor disorders.
This article reviews several studies, including small case and observational, that show an association between insufficient vitamin D and pelvic floor disorder symptoms and severity of symptoms. The recommendation from this review is that more studies of high quality evidence are needed to fully understand and demonstrate this relationship between vitamin D deficiency and pelvic floor disorders. However, the authors feel that vitamin D supplementation may be a helpful adjunct to treatment by helping to optimize our physiological response to pelvic floor muscle training and improving the overall quality of life for women suffering from pelvic floor disorders.
The Institute of Medicine has only made recommendations for dietary allowance for vitamin D and calcium for bone health. There is no consensus for adequate vitamin D levels for a condition specific goal (other than bone health), and the levels of vitamin D varied throughout the reviewed studies. It has been shown that very high levels of vitamin D are tolerated well, so supplementation of vitamin D seems to be very safe in low and very high doses.
As pelvic rehabilitation providers, it is our job to assess the whole person, however, we are not dieticians. As physical therapists we are musculoskeletal specialists and vitamin D affects muscle function. What our patients put in their bodies (wholesome nutritious food vs nutrient lacking artificial food) affects the quality of the cells they produce and tissues that are made, which can influence their healing. When reviewing health history, maybe consider discussing vitamin D status and possible supplementation with the patient, or with the patients’ primary care provider or naturopathic doctor. This team approach may provide more comprehensive health care, hopefully yielding more successful outcomes.
Parker-Autry, C. Y., Burgio, K. L., & Richter, H. E. (2012). Vitamin D status: a review with implications for the pelvic floor. International urogynecology journal, 23(11), 1517-1526.
Megan Pribyl, MSPT is the author and instructor for Nutrition Perspectives for the Pelvic Rehab Therapist. Megan is passionate about nutritional science and manual therapy. Megan holds a dual-degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) from Kansas State University, and has actively sought to fill in missing links between orthopedics and nutrition.
APTA Landmark Motion Passes
RC 12-15: The Role of the Physical Therapist in Diet and Nutrition
Is nutrition within our scope of practice? As the instructor for “Nutrition Perspectives for the Pelvic Rehab Therapist” offered through Herman & Wallace, I hear this question frequently! To me, the answer has always been a clear “yes*!”; now the APTA is endorsing this view. It’s an exciting time to be a rehab professional, especially for those looking to broaden clinical perspectives and scope of services to include basic nutrition and lifestyle information.
At the APTA House of Delegates in early June 2015, a landmark motion passed - RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. As our profession advances towards a more integrative model, this motion symbolizes an acknowledgement of the rehab professional’s broader role as a health care provider. We, as physical therapists, are uniquely positioned to offer patients more comprehensive lifestyle-related education including discussion of nutrition. Both the World Health Organization (WHO, 2008) and the Physical Therapy Summit on Global Health (Dean, et.al, 2014) have called upon all health care providers to stand in unity to help the public with epidemics of lifestyle-related diseases; the APTA has given it’s nod of approval as well.
The motion states: “as diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patient, clients, and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist*.” Further, “this motion clearly incorporates the intent of the new Vision Statement for the Physical Therapy Profession by transforming society and improving the human experience.” (APTA, 2015)
This powerful development provides us with both challenge and opportunity. How can we, as pelvic rehab professionals, be armed with the most cutting edge nutritional information available? What nutrition information lies within our scope of practice? How can we apply this information to our pelvic rehab patient population? For the answer to these pressing questions and much more, plan now to attend Nutrition Perspectives for the Pelvic Rehab Therapist” March 5 & 6, 2016 in Kansas City, MO. It is my passion to share this information and I welcome you to join me for this timely CEU opportunity. It is designed to help you obtain the skills needed to confidently identify nutritional correlates in pelvic rehabilitation.
ATPA (2015) http://www.apta.org/uploadedFiles/2015PacketI.pdf
Dean, E., de Andrade, A. D., O'Donoghue, G., Skinner, M., Umereh, G., Beenen, P., . . . Wong, W. P. (2014). The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract, 30(4), 261-275. (http://www.ncbi.nlm.nih.gov/pubmed/24252072)
World Health Organization. (2008). 2008-2013 Action plan for the global strategy for the prevention and control of non communicable diseases. Geneva, Switzerland: WHO. (http://www.who.int/mediacentre/news/releases/2015/noncommunicable-diseases/en/)
This post was written by Megan Pribyl MSPT, who teaches the course Nutrition Perspectives for the Pelvic Rehab Therapist. You can catch Megan teaching this course in June in Seattle.
Convalescence and mitohormesis…really big words that in a scientific way suggest “BALANCE”. In our modern world, there are many factors that influence the pervasive trend of being “on” or in perpetual “go mode”. We see the effects of this in clinical practice every day. The sympathetic system is in overdrive and the parasympathetic system is in a state of neglect and disrepair. And so we reflect on that word “balance” through the concepts of convalescence and mitohormesis.
“In the past, it was taken for granted that any illness would require a decent period of recovery after it had passed, a period of recuperation, of convalescence, without which recurrence was possible or likely.
Convalescence fell out of favor as powerful modern drugs emerged. It appeared that [antibiotics] and the steroid anti-inflammatories produced so dramatic a resolution of the old killer diseases… that all the time spent convalescing was no longer necessary.” (Bone, 2013)
How many of us take the time to convalesce after even a minor cold or flu? “Convalescence needs time, one of the hardest commodities now to find.” (Bone, 2013) We live in a culture where getting well FAST typically takes priority over getting well WELL.
On the flip-side of convalescence lies mitohormesis, or stress-response hormesis. Simply put, hormesis describes the beneficial effects of a treatment (or stressor) that at a higher intensity is harmful. Without mitohormesis, the driving, adaptive forces of life might lie dormant or find dysfuction. In a recent article (Ristow, 2014) mitohormesis is discussed: “Increasing evidence indicates that reactive oxygen species (ROS) do not only cause oxidative stress, but rather may function as signaling molecules that promote health by preventing or delaying a number of chronic diseases, and ultimately extend lifespan. While high levels of ROS are generally accepted to cause cellular damage and to promote aging, low levels of these may rather improve systemic defense mechanisms by inducing an adaptive response.”
Relevant to nutritional trends, Tapia (2006) suggests this perspective: “it may be necessary…to engender a more sanguine perspective on organelle level physiology, as… such entities have an evolutionarily orchestrated capacity to self-regulate that may be pathologically disturbed by overzealous use of antioxidants, particularly in the healthy.” Think of mitohormesis as the cellular-level forces that spur change. Motivation….drive….exhilaration. These life-sprurring stressors include physical activity and glucose restriction among other interventions.
The natural world is full of contrasts; day and night, winter and summer, land and sea, sun and rain. These contrasts are not only essential in creating rhythm to our existence, but necessary as driving forces of life. But what happens when there is not a balance of activity and rest? What happens when our energy systems go haywire? What nutritional factors play a role in whether a client of yours will have a healing and helpful course of therapy or may struggle with the healing process? How might we frame our understanding of the importance of balance through the lens of nourishment?
March is “National Nutrition Month”! It’s a perfect time to register for our brand new continuing education course Nutrition Perspectives for the Pelvic Rehab Therapist to learn more about how nutrition impacts our clinical practice. To register for the course taking place in June in Seattle, click here.
Bone, K. Mills, S. (2013) Principles and Practice of Phytotherapy; Modern Herbal Medicine. Second Edition. Churchill Livingstone Elsevier.
Gems, D., & Partridge, L. (2008). Stress-response hormesis and aging: "that which does not kill us makes us stronger". Cell Metab, 7(3), 200-203. doi: 10.1016/j.cmet.2008.01.001
Ristow, M., & Schmeisser, K. (2014). Mitohormesis: Promoting Health and Lifespan by Increased Levels of Reactive Oxygen Species (ROS). Dose Response, 12(2), 288-341. doi: 10.2203/dose-response.13-035.Ristow
Tapia, P. C. (2006). Sublethal mitochondrial stress with an attendant stoichiometric augmentation of reactive oxygen species may precipitate many of the beneficial alterations in cellular physiology produced by caloric restriction, intermittent fasting, exercise and dietary phytonutrients: "Mitohormesis" for health and vitality. Med Hypotheses, 66(4), 832-843. doi: 10.1016/j.mehy.2005.09.009