I recently found this article from the Psychology Research and Behavior Management Journal. I found myself curious about how other healthcare disciplines treat a diagnosis that often presents in conjunction with pelvic floor dysfunction. Irritable bowel syndrome, or IBS, affects nearly 35 million Americans. It is considered a ‘functional’ condition meaning that symptoms occur without structural or biochemical pathology. There is often a stigma with functional diagnosis that the symptoms are “all in their heads”, and while there are many theories about what predisposes individuals to IBS, the experts now think of IBS as a “disorder of gut brain interaction”. Generally, there are 3 subtypes of IBS where people note either constipation dominant, diarrhea dominant or mixed. In order to be diagnosed an individual must report abdominal pain at least 1 day per week in the last 3 months which is related to stooling and a change in frequency or form. Other symptoms that are common are bloating, nausea, incomplete emptying, and urgency.
The author suggests a biopsychosocial framework to help understand IBS. An interdependent relationship between biology (gut microbiota, inflammation, genes), behavior (symptom avoidance, behaviors), cognitive processes (“brain-gut dysregulation, visceral anxiety, coping skills”), and environment (trauma, stress). The brain-gut connection by a variety of nerve pathways is how the brain and gut communicate in either direction; top down or bottom up. Stress and trauma can dysregulate gut function and can contribute to IBS symptoms.
Stress affects the autonomic nervous system that contributes to sympathetic (fight/flight) and parasympathetic (rest/digest). Patients with IBS may have dysfunction with autonomic nervous system regulation. Symptoms of dysregulated gut function can present as visceral hypersensitivity, visceral sensitivity, and visceral anxiety. Visceral hypersensitivity is explained as an upregulation of nerve pathways. The author sites studies that note that IBS patients have a lower pain tolerance to rectal balloon distention than healthy controls. Visceral sensitivity is another sign of upregulation where IBS patients have a greater emotional arousal to visceral stimulation and are less able to downregulate pain. The author notes that the IBS population show particular patterns of anxiety with visceral anxiety and catastrophizing. Visceral anxiety is described hypervigilance to bowel movements and fear avoidance of situational symptoms. For example, fear of not knowing where the bathroom is located.
Cognitive behavioral therapy (CBT) has been shown to be an effective treatment to decrease the impact of IBS symptoms. CBT is focused on modifying behaviors and challenging dysfunctional beliefs. CBT can be presented in a variety of ways, however most include techniques consisting of education of how behaviors and physiology interplay for example the gut and stress response; relaxation strategies, usually diaphragmatic breathing and progressive relaxation; cognitive restructuring to help individuals see the relationship between thought patterns and stress responses; problem-solving skills with shift to emotion focused strategies (“acceptance, diaphragmatic breathing, cognitive restructuring, exercise, social support”) instead of problem focused strategies, and finally exposure techniques to help the individual slowly face fear avoidance behaviors. So much of the techniques are similar to what pelvic floor therapists try to educate our patients in. It is reassuring to me that through we may be different disciplines we are on the same team are moving towards the same goal. The author recommends a 10 session treatment duration, and notes that may be a barrier for some. Integrated practice with other healthcare professionals is also recommended. The more we can know about what our other team members are doing to help support patients the more effective we all are.
Kinsinger, Sarah W. “Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights” Psychology research and behavior management vol. 10 231-237. 19 Jul. 2017, doi:10.2147/PRBM. S120817
Most clinicians will agree that stress can amplify a patient’s pain and slow recovery. Mindfulness training provides patients with the ability to self-regulate their stress reaction and has been shown to reduce pain and depression and improve quality of life in patients with chronic pain conditions.1 The growing popularity of meditation training to manage stress has led to an increased interest in the physiological mechanisms by which meditation influences the body’s stress reaction. A systematic review and meta-analysis examined the results of randomized controlled trials that compared the impact meditation interventions to active control groups on stress measures. 2 Forty-five studies were included. Meditation practices examined were focused attention, open monitoring and mantra repetition. Outcome measures studied were cortisol, blood pressure, heart rate, lipid and peripheral cytokine expression. Studies had diverse participants including healthy adults, undergraduate students, army soldiers, veterans, cancer survivors, and individuals with chronic pain conditions, cardiovascular disease, depression and hypertension.
When all meditation forms were analyzed together, meditation reduced blood cortisol, C-reactive protein, resting and ambulatory blood pressure, heart rate, triglycerides and tumor necrosis factor-alpha. The effect of meditation on:
Authors report the primary reason for downgrading the grade of evidence when analyzing meditation practices individually was the limited number of studies available and small sample sizes. They conclude overall, when compared to an active control (relaxation, exercise or education) meditation practice leads to decreased physiological markers of stress in a range of populations.
Carolyn will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and again in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into pain treatment and the field of physical therapy. Hope to see you there!
1. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
2. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.
Pain demands an answer. Treating persistent pain is a challenge for everyone; providers and patients. Pain neuroscience has changed drastically since I was in physical therapy school. This update comes from the International Spine and Pain Institute headed by the lead author Adriaan Louw, PT, PhD. If you are interested in reading more about persistent pain, I suggest reading the article in its entirety.
This article brings together several comorbidities that pelvic physical therapists often encounter; fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and chronic Lyme disease. The authors argue that all of these syndromes have many common symptoms and might be dependent on the provider that the individual goes to as to which diagnosis the individual receives. Often, once an individual has a diagnosis, he or she (more often she) then identifies with this label. The authors reason that once medical pathologies have been ruled out, then a more holistic, biopsychosocial approach may create better outcomes.
Pain neuroscience education is a way to explain pain to patients, often with analogies, with a focus on neurobiology and neurophysiology as it relates to that individuals pain experience. To be able to educate our patients, we as providers, must be able to understand neuromatrix, output, and threat. Moseley states “[p]ain is a multiple system output activated by an individual’s specific pain neuromatrix. The neuromatrix is activated whenever the brain perceives a threat”. If that sounds like gibberish, consider watching this TEDx talk by Lorimer Moseley on YouTube (the snake bite story is a favorite of mine):
What is a neuromatrix? Essentially, it is a pain map in the brain; a network of neurons spread throughout the brain, none of which deal specifically with pain processing. The way I visualize it is to think about what goes on when you think of your grandmother. There isn’t a grandmother center in the brain, but there are sights and smells (sensory), feelings (emotional awareness), and memories that all come up when you think about her. When we are overwhelmed with pain, those regions become taxed and the individual may have difficulty concentrating, sleeping, and/or may lose his/her temper more easily. Just as each person’s grandmother is different so is a person’s pain and the neuromatrix is affected by past experiences and beliefs.
Pain is an output. It is a response to a threat. When a person is exposed to a threatening situation, biological systems like the sympathetic nervous system, endocrine system, immune system, gastrointestinal system, and motor response system are activated. When a stress response occurs, these systems are either heightened or suppressed to help cope, thanks to the chemicals epinephrine and cortisol.
What is a threat? Threats can take a variety of forms; accidents, falls, diseases, surgeries, emotional trauma, etc. Tissues are influenced by how the individual thinks and feels, in addition to social and environmental factors. The authors propose that when individuals live with chronic pain, their body reacts as though they are under a constant threat. With this constant threat the system reacts and continues to react, and the nervous system is not allowed to return to baseline levels. This can create a patient presentation with immunodeficiency, GI sensitivity, poor motor control, and more. This sounds like most patients who walk into my clinic. The authors suggest that one system may be affected more and that can influence what the patient is diagnosed with even though the underlying biology is the same for many conditions. There are theories for why that happens; genetics, biological memory, or it could be the lens of the provider that the patient sees. There is a table in the article that shows symptoms, diagnosis, and current best evidence treatment for the conditions of fybromyalgia, chronic fatique syndrome, irritable bowel syndrome, and chronic Lyme disease which is worth a look. The treatments all work to calm the central nervous system.
The authors go on to question the relationship between thyroid function and these conditions as changes in cortisol and the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is fascinating, and confusing. Luckily, the Pelvic Floor Series Capstone course does a great job breaking it down.
Now that this hypothetical patient is in our treatment room what do we do? The authors suggest seeing these conditions for what they are: chronic pain conditions. They recommend that physical therapists see past the label that a patient may have picked up with a previous diagnosis, and keep the following in mind when treating these patients:
These people need the following from their medical providers:
With empathy and understanding therapists can use skills in education, exercise and movement with the intent to improve system function (immune, neural, and endocrine), rather than fixing isolated mechanical deficits.
Louw, Adriaan PT, PhD; Schmidt, Stephen PT ; Zimney, Kory PT, DPT ; Puentedura, Emilio J. PT, DPT, PhD Treat the Patient, Not the Label: A Pain Neuroscience Update.[Editorial] Journal of Women's Health Physical Therapy. 43(2):89-97, April/June 2019.
Leg length discrepancy (LLD) is when there is a noticeable difference in length of one leg to the other. LLD is common and can be found in 70% of the population (Gurney, 2002). LLD can be structural or functional. Structural LLD is when a long bone in the leg is longer or shorter than the other. Structural LLD is often the result of congenital or boney damage of epiphyseal plate. Functional is when there is an apparent LLD from higher in the chain such as scoliosis. Generally as pelvic floor therapists we are orthopedic based therapists. In physical therapy school we learned that a leg length discrepancy had to be >1 cm to be considered significant, and based off of recent research that is still the case. Research in the last few years has focused on whether LLD has an effect on age related changes with osteoarthritis, posture & gait, and pain. Physiopedia suggests differential diagnosis of sacroiliac dysfunction, scoliosis, low back pain, iliotibial band (ITB) syndrome, stress fractures, and pronation. It can often feel like a chicken or egg question.
In the clinic I typically screen for a leg length discrepancy during my initial evaluation. A LLD may be noticed upon observation of gait assessment, standing posture, or part of the pelvic obliquity screen in standing and then in supine.
During gait, a LLD will create bilaterteral gait impairments. Khamis et al did a systematic review of LLD and gait deviations in 2017. They narrowed the search down to 12 articles and found that LLD >1cm was significantly related to gait deviations. These deviations occurred bilaterally, and while initially compensations occurred in the sagittal plane, as the LLD increased so did the gait deviations, and then affected frontal planes of motion as well. Resende et al (2016) agrees that even mild LLD should not be overlooked. They found that the most likely gait deviations were also in the sagittal planes and consisted of rearfoot and ankle dorsiflexion and inversion, knee flexion and adduction, hip adduction and flexion, and pelvic trendelenburg.
The sagittal, or right/left plane, and frontal, or front/back, plane involvement is consistent with the differential diagnosis of sacroiliac dysfunction, low back pain, and pronation. Really, one could justify why a LLD could contribute to pain and dysfunction in most of the lower body. It is reasonable to think that these compensational moments in gait over a long period create boney changes in the lower extremities which may contribute to low back pain.
Clinically, a leg length discrepancy can be assessed directly with a tape measure or indirectly with a shoe lift. Badii (2014) found a higher interrater reliability with the indirect method of a shoe lift as opposed to measuring with a tape measure.
Rannisto et al (2019) looked at leg length discrepancy among meat cutters with low back pain. All participants had been working for 10 years and were greater than 35 years old. Participants needed to have a LLD of 5mm (5mm is 0.5 cm) or more and complain of low back pain of >2/10 on visual analog scale (VAS). They were all given insoles and randomized into 2 groups; the intervention group were given lifts to correct the LLD about 70%; for example a 10mm LLD was corrected to 3 mm. The LLD was measured with a laser ultrasound technique. Participants were followed for 12 months. The intervention group had improvement in low back pain intensity, sciatica intensity, and took less sick time. Possibly the most amazing part is that for those that wore the heel lift at work the compliance was good.
Leg length discrepancy can often be an underlying component contributing to complaints of pain and dysfunction. It may have more of an effect on the populations who stand or walk for most of their work, and I wonder as more people transition to standing desks if we will see more people come into the clinic with a previously undiagnosed LLD.
My biggest clinical pearls from this research is that:
- Heel lifts can be used to diagnose and then for treatment (yay! One less step of getting the tape measure out)
- The heel lift does not have to be perfect. Clinically, I will try a lift and have the person walk, and then we can make a team decision if this lift is enough and feels better
- The gait compensations are consistently adduction and internal rotation throughout the lower body chain. I will continue to work on the opposing muscle groups; lateral rotators, hip extensors and abductors.
Leg Length Discrepancy can be evaluated using various assessments. To learn orthopedic evaluative techniques for patients, consider joining Lila Abbate in her course Advanced Orthopedic Assessment for the Pelvic Health Therapist.
Maziar Badii, A Nicole Wade, David R Collins, Savvakis Nicolaou, B Jacek Kobza, Jacek A Kopec, Comparison of lifts versus tape measure in determining leg length discrepancy; Journal of Rheumatology 2014, 41 (8): 1689-94
Renan A. Resende, Renata N. Kirkwood, Kevin J. Deluzio, Silvia Cabral, Sérgio T. Fonseca. "Biomechanical strategies implemented to compensate for mild leg length discrepancy during gait" Gait & Posture, Volume 46, 2016; 147-153, https://doi.org/10.1016/j.gaitpost.2016.03.012
Sam Khamis, Eli Carmeli, Relationship and significance of gait deviations associated with limb length discrepancy: A systematic review, Gait & Posture, Volume 57, 2017, 115-123, https://doi.org/10.1016/j.gaitpost.2017.05.028
Burke Gurney, Leg length discrepancy, Gait & Posture, Volume 15, Issue 2, 2002, Pages 195-206, https://doi.org/10.1016/S0966-6362(01)00148-5.
Satu Rannisto, Annaleena Okuloff, Jukka Uitti, et al. Correction of leg-length discrepancy among meat cutters with low back pain: a randomized controlled trial. BMC Musculoskeletal Disorders. 2019;(1):1. doi:10.1186/s12891-019-2478-3.
Diagnosing sacroiliac joint (SIJ) dysfunction can be tricky. Therapists need to rule out lumbar spine and the hip, and sometimes there is more than one area causing pain and limiting functional mobility. Typically, ruling in SIJ dysfunction is done by pain provocation tests and load transfer tests. Once the SIJ has been ruled in, then therapists can use a variety of treatments. Often those treatments include therapeutic exercise, joint manipulation, and Kinesio tape. But which intervention is the most effective?
A recent study looked at three physical therapy interventions for treatment for SIJ (sacroiliac joint) dysfunction and assessed which was the most effective (Al-Subahi, M 2017). The authors did a systematic review of the literature. The articles were from 2004-2014, written in English, with male and female participants. This review included a variety of experiment types from randomized control trials to case studies. Of the 1114 studies, only 9 met the inclusion and exclusion criteria. Four of the nine studies used manipulation, three used Kinesio Tape, and the three used exercise. One study did both exercise and manipulation, and was looked at in both interventions. All categories had at least one randomized control trial.
For the manipulation intervention, all studies showed a decrease in pain and disability at follow up. The follow ranged from 3 to 4 days to 8 weeks. Disability was measured using the Oswestry Disability Index. One study did manual high velocity and low amplitude thrust manipulation to lumbar and SIJ manipulation and showed improvement with manipulation to SIJ or SIJ and lumbar. The review did not disclose the type of lumbar manipulation, but did state the SIJ manipulation was a side bend and rotation position with an inferior and lateral force to ASIS (anterior superior iliac spine). Another study did either a SIJ manual high velocity and low amplitude thrust manipulation or a mechanical force with manual assistance. One studied did manipulation and home exercises but did not record exercise interventions. The last study did the same SIJ manual high velocity and low amplitude thrust manipulation as in previous study combined with exercise. The exercises are mentioned below.
For the exercise intervention, the studies did primarily stabilization exercises that were either isometric or isotonic eccentric or concentric. Quick PT school review, in isometric exercises the muscle does not change length, while in isotonic eccentric exercises the muscle is being lengthened under load, and isotonic concentric is the muscle shortening under load. All three studies showed decrease in pain. The first study had 7 participants and combined manipulation and exercise. The exercises consisted of 12% max voluntary contraction and eccentric loading quads in supine with hips at 90 degrees, and concentrically loading hamstrings in prone. The second study was a case study and performed 8 lumbo-pelvic-femoral stabilization exercises for 8 weeks. Fun fact: this case study was written by my Therapeutic Exercise teacher in PT school who did a lot of Postural Restoration based exercises. The last study, had 22 participants and educated and provided exercises on deep abdominal and multifidus muscles and do complete these exercises during functional movements throughout the day. These participants were follow up a year later and had decreased pain compared to laser group.
For the Kinesio tape (Kinesio tape) intervention, the studies did not find that Kinesio tape was not an effective intervention, however the follow up ranged from immediately after applying tape to 4 weeks afterwards. In the first study, a randomized controlled trial with 60 participants, the Kinesio tape was applied in sitting with 25% tension of 4 strips making a star pattern over the point of maximal pain. The Kinesio tape was compared to placebo tape and showed equal improvement in pain and disability. The other two studies applied a different taping technique where the Kinesio tape was applied. One applied the tape over erector spinae and internal oblique muscles bilaterally and in the other study the Kinesio tape was applied with 25% tension over external obliques, a second strip was placed from ASIS to PSIS in side-lying, and then a third strip was placed along rectus abdominis muscle. In this same study the tape was applied for weeks (6x/week for 9 hours/day).
In summary, the authors note that all three interventions help decrease pain and disability in women and men with SIJ dysfunction. The authors suggest that manipulation may be the most effective. Kinesio tape showed no significant difference between placebo tape. Exercise was effective, but less so than manipulation.
This review has a lot of limitations. The variety of experiment types with varying degrees of evidence, small number of participants, and lack of blinding. Most studies had a limited follow up ranging from 3-4 days to 12 months. The outcome measures varied greatly. Most studies had pain scores as the outcome measure, though one study only used inclination meter of anterior pelvic tilt. Use of a consistent objective measure in addition to perceived pain and disability would have helped. Only 1 study did pain provocation tests and that study was a case study whose intervention focused on Kinesio-taping.
As physical therapists we want to provide effective evidence-based practice, and we want to provide individualized compassionate care. It is hard to make a direct line between this study’s recommendations and clinical application based on the numerous limitations. I agree with the authors that manipulation and exercise are bread and butter to physical therapists. I disagree about Kinesio tape not being an effective treatment. Is Kinesio tape going to create boney alignment changes? Likely not. Is Kinesio tape (or any other tape) going to give proprioceptive feedback and possibly help calm sensory pathways? Yes. If a patient likes being taped, and thinks it will help, then I will tape them. Even if taping is just placebo effect; it’s still an effect.
Al-Subahi, M., Alayat, M., Alshehr, M.A., et al. (2017) The effectiveness of physiotherapy interventions for sacroiliac joint dysfunction: A systematic review. J Phys. Ther. Sci. 29: 1689-1694.
Does cognitive self-regulation influence the pain experience by modulating representations of nociceptive stimuli in the brain or does it regulate reported pain via neural pathways distinct from the one that mediates nociceptive processing? Woo and colleagues devised an experiment to answer this question.1 They invited thirty-three healthy participants to undergo fMRI while receiving thermal stimulation trial runs that involved 6 levels of temperatures. Trial runs included “passive experience” where participants passively received and rated heat stimuli, and “regulation” runs, where participants were asked to cognitively increase or decrease pain intensity.
Instructions for increasing pain intensity included statements such as “Try to focus on how unpleasant the pain is. Pay attention to the burning, stinging and shooting sensation.” Instructions for decreasing pain intensity included statements such as “Focus on the part of the sensation that is pleasantly warm. Imagine your skin is very cool and how good the stimulation feels as it warms you up.” The effects of both manipulations on two brain systems previously identified in the literature were examined. One brain system was the “neurological pain signature” (NPS), a distributed pattern of fMRI activity shown to specifically track pain intensity induced by noxious inputs. The second system was the pathway connecting the ventromedial prefrontal cortex (vmPFC) with the nucleus accumbens (NAc), shown to play a role in both reappraisal and modulation of pain. In humans, the vmPFC tracks spontaneous pain when it has become chronic and potentially dissociated from nociception.2,3 In patients with sub-acute back pain, the vmPFC-NAc connectivity has been shown to predict subsequent transition to chronic back pain.4 In addition, the vmPCF is hypothesized to play a role in the construction of self-representations, assigning personal value to self-related contents and, ultimately, influencing choices and decisions.5
Woo and colleagues found that both heat intensity and self-regulation strongly influenced reported pain, however they did so by two differing pathways. The NPS mediated only the effects of nociceptive input. The self-regulation effects on pain were mediated by the NAc-vmPFC pathway, which was unresponsive to the intensity of nociceptive input. The NAc-vmPFC pathway responded to both “increase” and “decrease” self-regulation conditions. Based on these results, study authors suggest that pain is influenced by both noxious input and cognitive self-regulation, however they are modulated by two distinct brain mechanisms. While the NPS encodes brain activity closely tied to primary nociceptive processing, the NAc-vmPFC pathway encodes information about evaluative aspects of pain in context. This research is limited in that the distinction between pain intensity and pain unpleasantness was not included and the subjects were otherwise healthy. Further research is warranted on the effects of this cognitive self-regulation model on brain pathways in patients with chronic pain conditions.
Even with the noted limitations, this research invites the clinician to consider the role of both nociceptive mechanisms and cognitive self-regulatory influences on a patient’s pain experience and suggests treatment choices should take both factors into consideration. Mindful awareness training is a treatment that contributes to cognitive self-regulatory brain mechanisms.6 When mindful, pain is observed as and labeled a sensation. The term “sensation” carries a neutral valence compared to “pain” which may reflect greater alarm or threat to an individual. The mind is recognized to have a camera lens-like quality that can shift from zoom to wide angle. While pain can draw attention in a more narrow focus on the painful body area, when mindful, an individual can deliberately adopt a wide angle view, focusing on pain free areas and other neutral or positive states. In addition, when mindful, the unpleasant sensation rests in awareness not characterized by fear and distress, but by stability, compassion and curiosity. Patients may not have control over the onset of pain, but with mindfulness training, they can take control over their response to the pain. This deliberate adoption of mindful principles and practices can contribute to cognitive self-regulatory brain mechanisms that can ultimately impact pain perception.
I am excited to share additional research and practical clinical strategies that help patients self-regulate their reactions to pain and other symptoms in my 2019 courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland OH, April 6 and 7 and Mindfulness-Based Pain Treatment in Houston TX, October 26 and 27 and Portland OR May 18 and 19. Hope to see you there!
1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self-regulation on pain. PLoS;2015;13(1):e1002036.
2. Baliki MN, Chialvo DR, Geha PY, Levy RM, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain.J Neurosci. 2006;26(47):12165-73.
3. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(pt9):2751-68.
4. Baliki MN, Peter B B, Torbey S, Herman KM, et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat Neurosci.2012;15(8):1117-9.
5. D’Argembeau. On the role of the ventromedial prefrontal cortex in self-processing: The Valuation Hypothesis. Front Human Neurosci. 2013;7:372.
6. Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016 Jun;1373(1):114-27.
Dustienne Miller MSPT, WCS, CYT is a Herman & Wallace faculty member, owner of Your Pace Yoga, and the author of the course Yoga for Pelvic Pain. Join her in Columbus, OH this April 27-28, to learn how yoga can be used to treat interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. The course is also coming to Manchester, NH September 7-8, 2019, and Buffalo, NY on October 5-6, 2019.
How does a yoga program compare to a strength and stretching program for women with urinary incontinence? Dr. Allison Huang1 et al have published another research study, after publishing a pilot study2 on using group-based yoga programs to decrease urinary incontinence. Well-known yoga teachers Judith Hanson Lasater, PhD, and Leslie Howard created the yoga class and home program structure for this research study and the 2014 pilot study. The yoga program was primarily based on Iyengar yoga, which uses props to modify postures, a slower tempo to increase mindfulness, and pays special attention to alignment.
To be chosen for this study, women had to be able to walk more than 2 blocks, transfer from supine to standing independently, be at least 50 years of age, and experience stress, urge, or mixed urinary incontinence at least once daily. Participants had to be new to yoga and holding off on clinical treatment for urinary incontinence, including pelvic health occupational and physical therapy.
28 women were assigned to the yoga intervention group and 28 women were assigned to the control group. The mean age was 65.4 with the age range of 55-83 years of age.
The control group received bi-weekly group class and home program instruction on stretching and strengthening without pelvic floor muscle cuing or relaxation training.
The yoga program met for group class twice a week for 90 minutes each and practiced at home one hour per week. The control group met twice a week for 90 minutes with a one-hour home program every week. Both groups met for 12 weeks.
Both groups received bladder behavioral retraining informational handouts. The information sheets contained education about urinary incontinence, pelvic floor muscle strengthening exercises, urge suppression strategies, and instructions on timed voiding.
The yoga program included 15 yoga postures: Parsvokonasana (side angle pose), Parsvottasana (intense side stretch pose), Tadasana (mountain pose) Trikonasana (triangle pose), Utkatasana (chair pose), Virabhadrasana 2 (warrior 2 pose), Baddha Konasana (bounded angle pose), Bharadvajasana (seated twist pose), Malasana (squat pose), Salamba Set Bandhasana (supported bridge pose), Supta Baddha Konasana (reclined cobbler’s pose), Supta Padagushthasana (reclined big toe pose), Savasana (corpse pose), Viparita Karani Variation (legs up the wall pose), and Salabhasana (locust pose).
Women in the yoga intervention group reported more than 76% average improvement in total incontinence frequency over the 3-month period. Women in the muscle stretching/strengthening (without pelvic floor muscle cuing and relaxation training) control group reported more than 56% reduction in leakage episodes.
Stress urinary incontinence episodes decreased by an average of 61% in the yoga group and 35% in the control group (P = .045). Episodes of urge incontinence decreased by an average of 30% in the yoga group and 17% in the control group (P = .77).
The take away? We know behavioral techniques have been shown to improve quality of life and decrease frequency and severity of urinary incontinence episodes.3 Couple this with our clinical interventions, and our patients have a way to reinforce the work we do in the clinic by themselves, or socially within their community. Yoga can be another tool in the toolbox for optimizing pelvic health.
1) Diokno AC et al. (2018). Effect of Group-Administered Behavioral Treatment on Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern Med.1;178(10):1333-1341. doi: 10.1001/jamainternmed.2018.3766.
2) Huang, Alison J. et al. (2019). A group-based yoga program for urinary incontinence in ambulatory women: feasibility, tolerability, and change in incontinence frequency over 3 months in a single-center randomized trial. American Journal of Obstetrics & Gynecology. 220(1) 87.e1 - 87.e13. doi: 10.1016/j.ajog.2018.10.031
3) Huang, A. J., Jenny, H. E., Chesney, M. A., Schembri, M., & Subak, L. L. (2014). A group-based yoga therapy intervention for urinary incontinence in women: a pilot randomized trial. Female pelvic medicine & reconstructive surgery, 20(3), 147-54.
Ask just about anyone on the street what one should do for osteoporosis and the typical answer is- weight bearing exercises. And they would be partially right. Weight bearing, or loading activities have been shown to increase bone density.1 But that’s not the whole story.
Regarding weight bearing exercises, the million-dollar question is, “How much weight bearing is enough to stimulate bone growth and how much is too much to compromise bone at risk for a fracture? We know that there are incidents of individuals fracturing from just their own body weight upon standing. Recently patients have been asking about heel drops and stomping, and whether they should do them. One size does not fit all.
An alternative is to focus on “odd impact” loading. A study by Nikander et al 2 targeted female athletes in a variety of sports classified by the type of loading they apparently produce at the hip region; that is, high-impact loading (volleyball, hurdling), odd-impact loading (squash-playing, soccer, speed-skating, step aerobics), high magnitude loading (weightlifting), low-impact loading (orienteering, cross-country skiing), and non-impact loading (swimming, cycling). The results showed high-impact and odd-impact loading sports were associated with the highest bone mineral density.
Morques et al, in Exercise Effects on Bone Mineral Density in Older Adults: A meta-analysis of randomized controlled trials, found that odd impact has potential for preserving bone mass density as does high impact in older women. Activities such as side stepping, figure eights, backward walking, and walking in square patterns help “surprise the bones” due to different angles of muscular pull on the hip. The benefit, according to Nikander, is that we can get the same osteogenic benefits with less force; moderate versus high impact. This type of bone training would offer a feasible basis for targeted exercise-based prevention of hip fragility. I tell my osteoporosis patients that if they walk or run the same route, the same distance, and the same speed that they are not maximizing the osteogenic benefits of weight bearing. Providing variety to the bones creates increased bone mass in the femoral neck and lumbar spine.4
Dancing is another great activity which combines forward, side, backward, and diagonal motions to movement. In addition, it adds music to make the “weight bearing exercises” more fun. Due to balance and fall risk many senior exercise classes offer Chair exercise to music. Unfortunately sitting is the most compressive position for the spine and is particularly problematic with osteoporosis patients. Also the hips do not get any weight bearing benefit. Whenever safely possible, have patients stand; you can position two kitchen chairs on either side, much like parallel bars, to hold on to while they “dance.”
Providing creativity in weight bearing activities using odd impact allows not only for fun and stimulation; it also offers more “bang for the buck!”
Andrea Wood, PT, DPT, WCS, PRPC is a pelvic health specialist at the University of Miami downtown location. She is a board certified women’s health clinical specialist (WCS) and a certified pelvic rehabilitation practitioner (PRPC). She is passionate about orthopedics and pelvic health. In her spare time, you can find her enjoying the south Florida outdoors.
Inflammatory bowel disease (IBD) includes the two diagnosis of Crohn’s Disease and Ulcerative Colitis. While both can cause similar health effects, the differences of the disease pathologies are listed below:1
|Ulcerative Colitis||Crohn’s Disease|
|Pattern of Damage||
Common complications experienced by patients with IBD include fecal incontinence, fecal urgency, night time soiling, urinary incontinence, abdominal pain, hip and core weakness, pelvic pain, fatigue, osteoporosis, and sarcopenia. In a sample of 1,092 patients with Crohn’s Disease, Ulcerative Colitis, or unclassified IBD, 57% reported fecal incontinence. Fecal incontinence was reported not only during periods of flare ups, but also during remission periods.2 One common factor affecting fecal incontinence is external anal sphincter fatigue. External anal sphincter fatigue has also been shown to be present in IBD patients who are not experiencing fecal incontinence or fecal urgency. IBD patients have been shown in studies to have similar baseline pressures versus healthy matched controls, thus indicating the possibility that deficits in endurance versus strength can play a larger role in fecal incontinence.3 Other factors contributing to fecal incontinence include post inflammatory changes that may alter anorectal sensitivity, anorectal compliance, neuromuscular coordination, and cause visceral hypersensitivity. Visceral hypersensitivity may be caused by continuous release of inflammatory mediators found in patients with IBD. It is also important to screen properly for incomplete bowel emptying and stool consistency to rule out overflow diarrhea or fecal impaction. Reports of need to splint digitally for full evacuation may indicate incomplete bowel emptying and defaectory disorders such as paradoxical contraction of the puborectalis muscle or rectocele. Anorectal manometry testing may be highly useful in identifying patients likely to improve from biofeedback therapy.4
Urinary incontinence can also be another secondary consequence to IBD. In a sample of 4,827 patients with IBD, 1/3 of responders reported urinary incontinence that was strongly associated with the presence of fecal incontinence. Frequent toilet visits for defecation may stimulate overactive bladder. Women were more likely to experience fecal incontinence versus men. One possible mechanism for increased fecal incontinence in women is men often have a longer and more complete anal sphincter that may be protective of fecal incontinence.5
Physical activity has been shown to be lower in patients with IBD versus healthy controls. 6, 7 Guiding IBD patients in proper exercises programs can have great benefits. Exercise may reduce inflammation in the gut and maintain the integrity of the intestines, reducing inflammatory bowel disease risk.8 It can also help increase bone mass density, an important factor in IBD patients who are at greater risk for osteoporosis. It has also been shown to help general fatigue in IBD patients. Patients with Crohn’s disease who participate in higher exercise levels may be less likely to develop active disease at 6 months. Treadmill training at 60% VO2 max and running three times a week has not been shown to evoke gastrointestinal symptoms in IBD patients. An increase of BMI predicts poorer outcomes and shorter time to first surgery in patients with Crohn’s disease.6
Conservative physical therapy interventions for treating IBD symptoms can include the following:
|Symptoms resulting from IBD||Physical Therapy Interventions|
|Fecal Incontinence (FI)||
Surgical interventions for IBD are dependent upon what type of disease the patient has and what areas of the intestines are affected the most. Surgery may be considered once the disease has become non responsive to medication therapy and quality of life continues to decline. A colectomy involves removing the colon while a proctocolectomy involves both removal of the colon and rectum. For ulcerative colitis patients, options include total proctocolectomy with end ileostomy or a restorative proctocolectomy with ileal pouch anal anastomosis. Restorative proctocolectomy eliminates the need for an ostomy bag making it the preferred surgery of choice if possible and gold standard for ulcerative colitis patients.10 For patients with Crohn’s disease, options include resection of part of the intestines followed by an anastomosis of the remaining healthy ends of the intestines, widening of the narrowed intestine in a procedure called a strictureplasty, colectomy or proctocolectomy, fistula repair, and removal of abscesses if needed.11
1. Crohn’s and Colitis Foundation. 2019. What is Crohn’s Disease. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/
2. Vollebregt PF, van Bodegraven A, Markus-de Kwaadsteniet T, et al. Impacts on perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease. Ailment Pharmacol Ther. 2018; 47: 1253-1260
3. Athanasios A, Kostantinos H, Tatsioni A et al. Increased fatigability of external anal sphincter in inflammatory bowel disease: significance in fecal urgency and incontinence. J Crohns Colitis (2010) 4: 553-560.
4. Nigam G, Limdi J, Vasant D. Current perspectives on the diagnosis and management of functional anorectal disorders in patients with inflammatory bowel disease. Therap Adv Gastroenterol. 2018 Dec 6: doi: 10.1177/1756284818816956
5. Norton C, Dibley L, Basset P. Faecal incontinence in inflammatory bowel disease: Associations and effect on quality of life. J Crohn’s Colitis. (2013) 7, e302-e311.
6. Biliski J, Mazur-Bialy A, Brzozowski B et al. Can exercise affect the course of inflammatory bowel disease? Experimental and clinical evidence. Pharmacological Reports. 2016 (68): 827-836.
7. Tew G, Jones K, Mikocka-Walus A. Physical activity habits, limitations, and preditors in people with inflammatory bowel disease: a large cross-sectional online survey. Inflamm Bowel Dis. 2016; 22(12): 2933-2942.
8. Vincenzo M, Villano I, Messina A. Exercise modifies the gut microbiota with positive health effects. Oxidative Medicine and Cellular Longevitiy. 2017: Article ID 3831972.
9. Cramer H, Schafer M, Schols M. Randomised clinical trial: yoga vs written self care advice for ulcerative colitis. Aliment Pharmacol Ther. 2017; 45: 1379-1389.
10. Cornish J, Wooding K, Tan E, et al. Study of sexual, urinary, and fecal function in females following restorative proctocolectomy. Inflamm Bowel Dis. 18 (9) 2012. 1601-160
11. Crohn’s and Colitis Foundation. 2019. Surgery Options. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/surgery-options.html
Today's guest post comes from Kelsea Cannon, PT, DPT, a pelvic health practitioner in Seattle, WA. Kelsea graduated from Des Moines University in 2010 and practices at Elizabeth Rogers Pilates and Physical Therapy.
Many studies done on pelvic floor muscle training largely have subjects who are Caucasian, moderately well educated, and receive one-on-one individualized care with consistent interventions. This led a group of researchers to investigate the occurrence of pelvic floor dysfunction, specifically pelvic organ prolapse (POP), in parous Nepali women. These women are known to have high incidences of POP and associated symptomology. Another impetus to perform this research: the discovery that there was a major lack of proper pelvic floor education for postpartum women. These women were commonly encouraged to engage their pelvic floor muscles via performing supine double leg lifts, sucking in their tummies/holding their breath/counting to ten, and squeezing their glutes. These exercises would be on a list of no-no’s here in the United States. In 2017, Delena Caagbay and her team of researchers discovered that in Nepal, no one really knew the correct way to teach proper pelvic floor muscle contractions, preventing the opportunity for women to better understand their pelvic floors. The team then set out to investigate the needs of this population, with the eventual goal of providing effective pelvic floor education for Nepali women.
Caagbay and her team first wanted to know what baseline muscle activity the Nepali women had in their pelvic girdle. Physical examinations and internal pelvic floor muscle strength assessments revealed that surprisingly there was a low prevalence of pelvic floor muscle defects, such as levator avulsions and anal sphincter trauma. Uterine prolapses were most common while rectoceles were comparatively less common. Their muscles were also strong and well-functioning, often averaging a 3/5 on the Modified Oxford Scale. It was hypothesized that these women had low prevalence of muscle injury because instruments were not commonly used during childbirth, they had lower birth weight babies, and the women were typically younger when giving birth (closer to 20-21 years old). But they had a high prevalence of POP even with good muscle tone? Researchers suggested that their incidence of POP is likely stemming from their sociocultural lifestyle requirements, as women are left to do most of the daily household chores and caregiving tasks while men often travelled away from the home to perform paid labor. Physical responsibilities for these women commonly begin at younger ages and while it helps promote good muscle tone, the heavier loading places pressure on the connective tissue and fascia that support the pelvic organs. Because of the demands of their lifestyles, Nepali women are often forced to return to their physically active state within a couple weeks after giving birth.
After assessing the current needs, cultural norms, and prevalence of POP in Nepali women, Caagbay et al created an illustrative pamphlet on how to contract pelvic floor muscles as well as provided verbal instruction on pelvic floor muscle activation. Transabdominal real time ultrasound was applied to assess the muscle contraction of 15 women after they received this education. Unfortunately, even after being taught how to engage their pelvic floor muscles, only 4 of 15 correctly contracted their pelvic floors.
This study highlighted that brief verbal instruction plus an illustrative pamphlet was not sufficient in teaching Nepali women how to correctly contract their pelvic floor muscles. Although there was a small sample size, these results can likely be extrapolated to the larger population. Further research is needed to determine how to effectively teach correct pelvic floor muscle awareness to women with low literacy and/or who reside in resource limited areas. Lastly, it is important to consider the significance of fascial and connective tissue integrity within the pelvic floor when addressing pelvic organ prolapse.
1 Can a leaflet with brief verbal instruction teach Napali women how to correctly contract their pelvic floor muscles? DM Caagbay, K Black, G Dangal, C Rayes-Greenow. Journal of Nepal Health Research Council 15 (2), 105-109.
2 Pelvic Health Podcast. Lori Forner. Pelvic organ prolapse in Nepali women with Delena Caagbay. May 31, 2018.
3 The prevalence of pelvic organ prolapse in a Nepali gynecology clinic. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Napean, University of Sydney.
4 The prevalence of major birth trauma in Nepali women. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Nepean, University of Sydney.