Allison Ariail, PT, DPT, CLT-LAANA, BCB-PMD is one of the creators of the Herman & Wallace Oncology of the Pelvic Floor Course Series. Allison Ariail is a physical therapist who started working in oncology in 2007 when she became certified as a lymphatic therapist. She worked with breast cancer, lymphedema patients, head and neck cancer patients, and the overall oncology team to work with the whole patient to help them get better. When writing these courses, Allison was part of a knowledgeable team that included Amy Sides and Nicole Dugan among others.

March is Colorectal Cancer Awareness Month. Did you know that the incidence rate of colorectal cancers is increasing? According to the International Agency for Research on Cancer, 1.9 million new cases of colorectal cancer were identified worldwide in 2020. This number is expected to grow even more. It is predicted that by 2040 the number of new cases of colorectal cancer will rise to 3.2 million new cases a year, and 1.6 million annual deaths worldwide. Additionally, did you know due to the fact that the incidence rate is increasing and it is being diagnosed in younger individuals, the age for screening for colorectal cancer has lowered to 45? At age 45 individuals should begin regular screening for colorectal cancer either via stool-based testing or visual-based screening via a colonoscopy. If someone has risk factors they may need to begin screening at a younger age. 

Colorectal cancer can often be preventable through modifiable risk factors. Changing some of these risk factors, alongside the detection and removal of precancerous lesions can lower someone's risks.  However, if a diagnosis is made, treatment can help to prolong the life of the patient. The treatment can include various surgeries, chemotherapy, and radiation. All of these treatments can cause changes to a patient's body. A rehab professional that has knowledge about both the body and how the medical treatment of cancer causes changes, can make all the difference in the world for that patient returning to activities that they enjoy and love after treatment.

There are not many opportunities for rehab professionals to learn about these changes and how we can help these patients. However, Herman & Wallace has a series focused on helping oncology patients. In this series, techniques are learned that can help colorectal cancer patients recover from their diagnosis and the medical treatment they go through. The oncology series is online and offered several times a year. You can attend the upcoming oncology courses on: Oncology of the Pelvic Floor Level 1 scheduled for July 8-9 and December 2-3, Level 2A scheduled for May 20--21, and Level 2B scheduled for December 9-10.

Reference:

Morgan E, Arnold M, Gini A, et al.  Global burden of colorectal cancer in 2020 and 2040: incidence and mortality estimates from GLOBOCAN.  Colon. 2023; 72(2).

*Certified Lymphatic Therapists may skip Oncology of the Pelvic Floor Level 1 and move on to the Level 2A and Level 2B courses.*

Oncology of the Pelvic Floor Level 1 - no partner needed for registration
Price: $550.00          Experience Level: Beginner          Contact Hours: 17.5 hours

Oncology of the Pelvic Floor Level 2A - partner needed for registration
Price: $495.00          Experience Level: Intermediate          Contact Hours: 17.25 hours

This course was designed to build on the information that was presented in Oncology of the Pelvic Floor Level 1.

Information will be provided focusing on male pelvic cancers, colorectal cancer, and anal cancer including risk factors, diagnosis, and prognosis. The participant will also understand the sequelae of the medical treatment of cancer and how this can impact a patient's body and quality of life. Other topics include rehabilitation and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy.

Course Dates: May 20--21

Oncology of the Pelvic Floor Level 2B - partner needed for registration
Price: $600.00          Experience Level: Intermediate          Contact Hours: 19.25 hours

This course was designed to build on the information that was presented in Oncology of the Pelvic Floor Level 1.

Information will be provided focusing on gynecological and bladder cancers including risk factors, diagnosis, and prognosis. The participant will also understand the sequelae of the medical treatment of cancer and how this can impact a patient’s body and quality of life. Other topics include rehabilitation and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy.

Course Dates: December 9-10

In a 2018 article by Holly Tanner, she explains how managing a medical crisis such as a cancer diagnosis can be overwhelming for an individual. ‘Faced with choices about medical options, dealing with disruptions in work, home, and family life often leaves little energy left to consider sexual health and intimacy. Maintaining closeness, however, is often a goal within a partnership and can aid in sustaining a relationship through such a crisis.” Research shows that cancer treatment is disruptive to sexual health. Intimacy is a larger concept that may be fostered even when sexual activity is impaired or interrupted.

Prostate cancer treatment can change relational roles, finances, work-life, independence, and other factors including hormone levels. (1) Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido, and performance anxiety can create further challenges. (1, 3, 4) Recovery of intimacy is possible, and reframing of sexual health may need to take place. Most importantly, these issues need to be talked about, as a renegotiation of intimacy may need to take place after a diagnosis or treatment of prostate cancer. (2)

If a patient brings up sexual health, or the practitioner encourages the conversation, many research-based suggestions can be provided to encourage recovery of intimacy including:

• Redefining sex to include other sexual practices beyond penetration, such as massage or touching, cuddling, talking, use of vibrators, medication, aids such as pumps (5)
• Participation in couples therapy to understand their partner’s needs, address loss, be educated about sexual function (7)
• Participation in “sensate focus” activities (developed by Masters & Johnson in the 1970s as “touch opportunities”) with appropriate guidance (6)

Holly continues to share that “Within the context of this information, there is an opportunity to refer the patient to a provider who specializes in sexual health and function. While some rehabilitation professionals are taking additional training to be able to provide a level of sexual health education and counseling, most pelvic health providers do not have the breadth and depth of training required to provide counseling techniques related to sexual health - we can, however, get the conversation started, which in the end may be most important.”

Courses of Interest:

Oncology of the Pelvic Floor Level 2A Remote Course - Male Pelvic and Colorectal Cancers - April 2-3, 2022

• A colorectal or male pelvic cancer diagnosis has multiple systems that are affected by cancer treatment. The rehabilitation professional that works with the pelvic oncology patient needs to competently navigate treatment techniques for all of these systems, as well as be confident in treating a patient in a personal area. This two-day course will address specific cancer types including prostate cancer, penile cancer, and testicular cancer. Additional cancer types covered include colorectal cancer and anal cancer.

Trauma Awareness for the Pelvic Therapist - Remote Course - Apr 9-10, 2022

• Bring their increased awareness of trauma to the successful, holistic treatment of patients with pelvic pain, sexual dysfunction, bowel dysfunction, and bladder dysfunction.

Sexual Medicine in Pelvic Rehab - Remote Course - Apr 9-10, 2022

• This course provides a thorough introduction to pelvic floor sexual function, dysfunction and treatment interventions for males and females of all sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Male Pelvic Floor Function, Dysfunction, and Treatment - Satellite Lab Course - April 23-24 2022

• Discuss sexual anatomy and physiology, prostate issues, and look at the research describing models of intimacy and what worked for couples who did learn to renegotiate intimacy after prostate cancer. Participants will be able to describe the relationships between pelvic muscle function and men’s sexual health, including the evidence that demonstrates pelvic muscle rehabilitation's positive impact on erectile function.

1. Beck, A. M., Robinson, J. W., & Carlson, L. E. (2009, April). Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. In Urologic oncology: seminars and original investigations (Vol. 27, No. 2, pp. 137-143). Elsevier.
2. Gilbert, E., Ussher, J. M., & Perz, J. (2010). Renegotiating sexuality and intimacy in the context of cancer: the experiences of carers. Archives of Sexual Behavior, 39(4), 998-1009.
3. Hawkins, Y., Ussher, J., Gilbert, E., Perz, J., Sandoval, M., & Sundquist, K. (2009). Changes in sexuality and intimacy after the diagnosis and treatment of cancer: the experience of partners in a sexual relationship with a person with cancer. Cancer Nursing, 32(4), 271-280.
4. Higano, C. S. (2012). Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology, 30(30), 3720-3725.
5. Ussher, J. M., Perz, J., Gilbert, E., Wong, W. T., & Hobbs, K. (2013). Renegotiating sex and intimacy after cancer: resisting the coital imperative. Cancer Nursing, 36(6), 454-462.
6. Weiner, L., Avery-Clark, C. (2017). Sensate Focus in Sex Therapy: The Illustrated Manual. Routledge, New York.
7. Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., An, L., Palapattu, G., & Montie, J. E. (2014). Exploring the role of the partner in couples’ sexual recovery after surgery for prostate cancer. Supportive Care in Cancer, 22(9), 2509-2515.

A recent article in the Washington Post Health & Science section explored the wonders of dietary fibre in an article called ‘Fiber has surprising anti-aging benefits, but most people don’t eat enough of it’ The article discussed how ‘…Fiber gets well-deserved credit for keeping the digestive system in good working order — but it does plenty more. In fact, it’s a major player in so many of your body’s systems that getting enough can actually help keep you youthful. Older people who ate fiber-rich diets were 80 percent more likely to live longer and stay healthier than those who didn’t, according to a recent study in the Journals of Gerontology’

But what is fiber and why does it matter?

Before we jump in there, let me answer the perennial questions that arise when we, as pelvic rehab clinicians, talk about fiber…’Is it in our scope of practice to talk about food?!’ I think it is fundamental that if we are placing ourselves as experts in bladder and bowel dysfunction, that we also remember that we can’t focus on problems at one end of ‘the tube’ without thinking about what happens at the other end. Furthermore, let me quote the APTA RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. (June 2015): “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’’

Fiber plays a huge role in so many of the health issues that we as clinicians face daily – constipation is regarded as a scourge of a modern sedentary society, perhaps over-reliant on processed convenience food – this is borne out when we gaze upon the rows of constipation remedies and laxatives in our pharmacies and supermarkets.

Let's take a look at the effects of fiber on breast cancer recovery – what does the research say?

There is growing interest and evidence to suggest that making different food choices can help control symptoms of breast cancer treatment and improve recovery markers – avoiding food with added sugar, hydrating well and focusing primarily on plant based food. Fiber is of course beneficial for bowel health, but may also have added benefits for heart health, managing insulin resistance, preventing excess weight gain and actually helping the body to excrete excess estrogen, which is often a driver for hormonally sensitive cancers. Fiber may be Insoluble (whole grains, vegetables) or Soluble (oats, rice, beans, fruit) but both are essential and variety is best.

In their paper ‘Diets and Hormonal levels in Post menopausal women with or without Breast Cancer’ Aubertin – Leheudre et al (2011) stated that ‘…Women eating a vegetarian diet may have lower breast cancer because of improved elimination of excess estrogen’, but even prior to that, in ‘Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women.’ Golden et al (1982) concluded that ‘…that vegetarian women have an increased fecal output, which leads to increased fecal excretion of estrogen and a decreased plasma concentration of estrogen.’

Fiber may also be beneficial in the management of colorectal cancer, which is on the rise in younger women and men. A recent report by the World Cancer Research Fund International/American Institute for Cancer Research found that eating 90 grams of fiber-rich whole grains daily could lower colorectal cancer risk by 17 percent…and the side effects? A happier healthy digestive system, improved cardiovascular health and a lower risk of Type 2 Diabetes.

Your mother was right – eat your vegetables!

For more information on colorectal function and dysfunction, take Pelvic Floor Level 2A or for a deeper dive on the role of nutrition and pelvic health, why not take Megan Pribyl’s excellent course, Nutrition Perspectives for the Pelvic Rehab Therapist? Physical Therapy Treatment for the Breast Oncology Patient is also an excellent opportunity to learn about chemotherapy, radiation and pharmaceutical side effects of breast cancer treatment, as well as expected outcomes in order for the therapist to determine appropriate therapeutic parameters.

https://www.washingtonpost.com/national/health-science/fiber-has-surprising-anti-aging-benefits-but-most-people-dont-eat-enough-of-it/2018/04/27/c5ffd8c0-4706-11e8-827e-190efaf1f1ee_story.html?fbclid=IwAR0b-9VFUOCyUOgwe2BqV7-ahqwGzWs9rNpd1mscT75KNOGqnHm4ooFAu74&utm_term=.4d2784974ddc
Estrogen excretion patterns and plasma levels in vegetarian and omnivorous women. Goldin BR, Adlercreutz H, Gorbach SL, Warram JH, Dwyer JT, Swenson L, Woods MN. N Engl J Med. 1982 Dec 16;307(25):1542-7.
Diets and hormonal levels in postmenopausal women with or without breast cancer. Aubertin-Leheudre M1, Hämäläinen E, Adlercreutz H. Nutr Cancer. 2011;63(4):514-24. doi: 10.1080/01635581.2011.538487.

When a woman is given a cancer diagnosis, her entire world is turned upside down and inside out. There are so many things to think about; medical treatments, financial concerns, family concerns, and emotional upheaval. Sex may be the last thing that a woman may think about when she is actively going through treatment. However, at what rate are survivors having issues after treatment is complete?

A recent study published in the journal Cancer looked at just this. A 2-year longitudinal study was performed that tracked young adults (18-39 years old) through and after their cancer diagnosis. The most common cancers seen in the samples were leukemia, breast cancer, soft-tissue sarcoma, and non-Hodgkin lymphoma. The patients completed the Medical Outcomes Study Sexual Functioning Scale at 4 months, 6 months, and 24 months after diagnosis. At 2 years after diagnosis over 50% of the patients surveyed reported some degree of sexual dysfunction. Women that were in a committed relationship had an increased likelihood for experiencing sexual dysfunction; while men had increased rate of reporting sexual issues regardless of their relationship status.

Women that undergo cancer treatment have several reasons that could be influencing their sexual function. Fatigue is a complaint that is often expressed by cancer patients. Their body image is often altered due to surgeries that have been performed. Chemotherapy and hormonal therapy often push women into menopause which then leads to vaginal dryness. Additionally, radiation and surgical treatment can lead to scar tissue, fibrosis, and stenosis of the vagina and pelvic floor muscles.

This is where physical therapy can help! In the Pelvic Floor Series Capstone course we teach advanced techniques that help treat pelvic floor issues by working on both the muscles, and the fascia. We also cover techniques that decrease the tenderness in the muscles that then allow you to stretch the muscle with less discomfort.

All of the techniques taught in Capstone are gentle but effective. The cancer survivor is the perfect population to use these gentle techniques on! Think of how rewarding our job will be when we help relieve the pain that may be associated with intercourse, and therefore improve intimacy of a cancer survivor with her partner!

Come join us for Capstone and learn techniques that will take your treatment skills to the next level!

Acquati, Zebrack, Faul, et al. Sexual functioning among young adult cancer patients: A 2-year longitudinal study. Cancer. 2018; 124(2): 398-405.

Sara Chan Reardon, DPT, WCS, BCB-PMD is a pelvic floor dysfunction specialist practicing in New Orleans, LA. Sara was named the 2008 Section on Women’s Health Research Scholar for her published research on pelvic floor dyssynergia related constipation. She was recognized as an Emerging Leader in 2013 by the American Physical Therapy Association. She served as Treasurer of the APTA’s Section on Women's Health and sat on their Executive Board of Directors from 2012-2015. Today she was kind enough to share a bit about her course Post-Prostatectomy Patient Rehabilitation, which is taking place twice in 2018.

My name is Sara Reardon, and I teach the Post-Prostatectomy Patient Rehabilitation course, which I wrote and developed in the year 2015. At the time, I had been a pelvic health Physical Therapist for over 10 years. Earlier in my career, I had taken the Pelvic Floor 2A course by Herman and Wallace Institute, which was a fantastic and thorough introduction to treating a male patient.

Over the years, I started seeing more and more men with post-prostatectomy urinary incontinence and erectile dysfunction in my clinic. Urinary incontinence is the most common and costly complication in men following prostate removal surgery, and their quality of life is directly related to their duration of experiencing those symptoms. Evidence supports that pelvic floor muscle training started as soon as possible after surgery can help decrease incontinence and improve quality of life. I enjoyed being able to help men decrease their incontinence and improve their other symptoms after all they had been through following a cancer diagnosis and treatment.

No courses focused specifically on treating post-prostatectomy pelvic floor dysfunction were offered at the time, so I scoured the research, shadowed with physicians, observed surgeries, and attended urology conferences to understand how to effectively treat these individuals. Treating this population of men is fun, fulfilling, and rewarding, and I was inspired to help other pelvic health physical therapists dive deeper as I witnessed the impact pelvic health physical therapy can have on the quality of life of these patients. I love teaching this course, and I am excited to help other pelvic health professionals learn evidence based and effective treatment strategies to help these men navigate their recovery after prostatectomy.

Join Dr. Reardon in Philadelphia, PA on June 2-3, 2018 or in Houston, TX on November 10-11, 2018 to learn evaluation and treatment techniques for men recovering from prostatectomy surgery.