IPPS Highlight: Dry Needling for Pelvic Pain

Herman & Wallace faculty member Dawn Sandalcidi and Dr. Nel Gerig, who is in urology practice in the Denver area, gave a clear presentation at the most recent International Pelvic Pain Society (IPPS) Meeting about the treatment modality of dry needling for pelvic pain. Following a clear explanation of trigger points and the high prevalence of trigger points in the population of men and women who have chronic pelvic pain, the techniques of using needles in the muscles of the perineum was demonstrated by excellent images. The treatment can certainly include other portions of the body, such as the low back or thighs, as we know that these areas often become tense and painful during the course of pelvic pain.

Dry needling, called "dry" because there is no injectable such as lidocaine or cortisone used, is a technique that allows placement of a very small needle into the skin, muscle, or connective tissue of a hyper-irritable area in the soft tissue. This is done for the purpose of reducing the tension, pain, and connective tissue restrictions in the local area. In addition to the mechanical effect that the needle has, there are also neurophysiologic effects and chemical effects from the needle placement. Dry needling is commonly practiced in many other countries and is increasingly offered by physical therapists in many states. You need to check your state practice act to find out the current status of dry needling. Kinetacore is one continuing education provider that lists current states on their website who have either allowed or who have restricted dry needling.

Dawn Sandalcidi reported during her lecture that she finds the patient's muscles significantly decreased in tension, pain, and that patients report a significant decrease in pain levels following treatment that includes dry needling. She also noted that the technique allows her to "save her hands" as the needles can treat the trigger points very effectively. In states where dry needling is not practiced by physical therapists, it may be very helpful for the pelvic rehab provider to team up with someone such as a physician who is allowed to use needles. When a pelvic rehab provider and a medical provider work together to treat the patient, it is always the patient who benefits from such coordinated care. Increased research is needed to support dry needling for pelvic pain, and as Institute co-founder Holly Herman is known to say at courses, "What a great research project- you should do it!" The more "sharp" tools that are in our toolbox that are supported by patient outcomes and by research, the better we can serve our patients.

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IPPS Highlight: Neuroplasticity for the Clinician

At this year's International Pelvic Pain Society (IPPS) meeting held in Las Vegas last weekend, I found myself wishing that I had reviewed neuroanatomy prior to the conference. Many speakers addressed portions of the brain such as the insular cortex as the brain continues to be a prominent piece of the puzzle in chronic pain anywhere in the body. Dr. Alain Watier, a Canadian gastroenterologist who specializes in treatment of pelvic pain, gave a lecture that included research based on chronic pain as well as practical advice for the clinician. He states in his lecture that a provider should be familiar with the neurobiology of pain. Functional brain imaging studies have identified that the brain can be activated simply by anticipating pain relief, and that the brain can then activate pathways that modulate a patient's pain experience. There is significant anatomy and physiology involved in the modulation of pain, and reduction in pain can be achieved through pharmacology as well as through the brain.

How do we encourage our patients to maximize the ability to use the brain for pain reduction? Here is a practical suggestion based on the idea that the brain must re-learn "normal" pain perception. The patient can be taught to actively engage the brain in soothing thoughts, feelings, memories, touches, smells, and new beliefs. When a patient experiences an increase in pain, she should "...flood the brain with memories of how they felt and who they were before pain." Patients can be taught to use mindfulness meditation, many forms of biofeedback (thermistor for skin temperature, mirror therapy, heartbeat regulation, and blood pressure. ) Cognitive behavioral therapy can be helpful in reducing anxiety as well as gastrointestinal disorders.Other techniques that can help a patient heal were discussed such as EMDR, hypnosis, art therapy, massage, and acupuncture.

When patients are dealing with chronic pain, according to Dr. Watier, is is critical to engage a multidisciplinary approach and to focus on changing the brain/body patterns of pain perception. The pelvic rehab therapist can play an important role in explaining that the brain can physically change during chronic pain experiences, and that to heal, the brain must be addressed in addition to the peripheral pain. The patient can be guided back to gentle, graded movements so that moving can again become a positive experience, even in small doses.

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A new resource for patients.

(A blog directing your patient to the computer should not ideally follow a post about avoiding the computer, however, this is a potentially very positive resource for both patients and pelvic rehab providers alike.) As a founding sponsor, Boston Scientific has funded through an educational grant the development of a new website called "Take the Floor: Voices for PFD" (pfd = pelvic floor dysfunction). You can access the new website here.It is developed by the American Urogynecologic Society (AUGS) and the AUGS Foundation.

Patients will find helpful information about urinary incontinence, bladder dysfunction, and bowel dysfunction including definitions, incidence, symptoms, prevention and treatment. Regarding treatment, the site recommends a medical examination to determine the best course of treatment. I especially think the resource page for caregivers is really useful, and the How To Talk About PFD page is excellent and gives some "conversation starters" that are really nice openers to discussing the potentially sensitive topics.

As a pelvic rehab provider you might also appreciate the Find A Provider link. Many rehabilitation professionals find that Urogynecologists have a head start on understanding the role of conservative care, pelvic floor strengthening or manual therapy techniques. You can also register to join the website community and follow contributions to the interactive portion of the site.

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Step away from the computer, Mrs. Jones!

While the internet can provide amazing resources and connections for patients, the internet is also a place where our patients can find frightening, anxiety-producing information. How often do our patients post in "I was healed" chat rooms? One thing we often have to do is ask our patients who suffer from chronic pain to "stop checking the internet." Research published in the Journal of Urology addresses the question of quality of internet informationavailable regarding female pelvic floor disorders (PFD). Of the number of websites sharing health information about female PFD, there were few that were certified by the NGO Health on the Net. For urinary incontinence, pelvic organ prolapse, and overactive bladder, certification rates were between 27-29%. 44% of the sites were sponsored by for-profit entities. Whether a website is "certified" (a voluntary process) may be an interesting concept for our patients when they are looking for information on the net.

Also in relation to internet use by patients, researchers at the University of Washington wanted to know how information provided as "patient-expertise" differed from clinician expertise when advice was offered to patients going through breast cancer. Here is the full text article. The authors conclude that when patients give other patients advice (through chat rooms or books) they do not categorically try to doctor other patients. Instead, advice available from patient expertise included primarily medical or personal advice. Patients shared strategies for making medical choices, managing the daily challenges of life, as well as dealing with the emotional response to having cancer. The article also outlines suggestions for builders of health websites that can best serve patients.

In summary, the internet can be seen as an incredibly valuable tool. Patients who are immersed in the internet and come away with a fear-based approach to their illness or chronic pain may be best advised to limit their time spent on the computer. As a practical suggestion, here is a blog post about how to step away from your computer. After you read your H&W blog posts, of course.

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Menopause at work.

In Menopause: The Journal of the North American Menopause Society, an article addressing the effects of menopausal symptoms that affect work is discussed. A cross-sectional sample of 208 Dutch women aged 44 to 60 years were evaluated using the Work Ability Index and the Greene Climacteric Scale. The conclusion of the study is this: "Menopausal symptoms are negatively associated with work ability and may increase the risk of sickness absence." When symptoms of menopause include hot flashes, sleep disturbances, mood swings, depression and anxiety, it is easy to consider how this could affect a woman's ability to perform her tasks with maximal success or to feel rested enough to attend work.

I found it very interesting to read a study about "menopausal interventions" at a newspaper company in Japan. This company has 907 employees, and 98 of them are women. The employee's health is managed by 2 occupational health nurses (full-time) and an industrial medicine physician (part-time.) A gynecologist was consulted to assist in improving the workplace for women who reported menopausal symptoms. Not only were women included in some of the cases described in this study, but a male employee with concerns about his wife's health was brought to the attention of the nurse and physician. While I cannot comment with any authority about healthcare in Japan, I appreciate the fact that menopause was identified as an issue, and then the workplace was educated about the effects of menopausal symptoms (not simply in terms of work output reduction but also in terms of mental stress and depression) and then interventions were applied with success reported.

What many healthcare advocates in the US have been hopeful towards is the development of a more proactive approach, and with healthcare dollars shrinking, shifting towards workplaces that assist in health management of employees may prove to be a part of that process. While the healthcare system is not a can of worms I aim to open, I would like to point out that many women suffering from menopausal symptoms are not getting the support needed to manage adverse symptoms. One of my favorite questions for a patient (this comes from Holly Herman, founding member of the Pelvic Rehab Institute) is, "Who is managing your hormones with you?" I recall the 56 year-old patient (who had a hysterectomy at 27!) saying, "well, I tried Premarin once after the surgery, and it didn't really help, so I stopped taking it." That was the extent of her assistance with hormonal management. Although hormone therapy is certainly not in the scope of practice of many therapist-rehab providers, asking such a question most certainly is. The patient can be encouraged to discuss any symptoms with her primary care or gynecologist, naturopath, or other provider who can discuss options for treatment.

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Fiber Tips

If you are dealing with patients who eat the "standard american diet," also known as "SAD," then you may find yourself sharing basic nutritional advice. With regards to bowel health, a topic that is covered in the 2A course, many patients have questions about amount and types of fiber. Johns Hopkins has issued a helpful health alert titled, "What's so great about fiber?"Fiber is helpful in balancing digestive health so that stool form is moderate versus too loose or too hard. Many patients lives are significantly affected by having difficulty emptying the bowels or by having difficulty avoiding bowel leakage due to poor stool form.

Some helpful tips in the health alert include getting the right amount of fiber. Most people who track the amount of fiber in a daily diet find that they think they are getting more fiber than they really are. For men and women the range of recommended fiber is 21-30 grams. Keep in mind that an average apple may have 5 grams, and you start to see that you really do need a healthy dose of fruits and vegetables to get to an ideal number. Check out this list from the mayo clinic to see some high fiber foods and the content levels. You will note that legumes such as lentils, split peas, or black beans really pack a large amount of healthy fiber per serving.

It is recommended that we eat both soluble and insoluble fibers for dietary health, and the way to achieve that is to eat a variety of foods including "whole" foods, or items that are less processed. Adding fiber gradually to the diet and drinking a healthy amount of water helps to avoid excessive gas and bloating. At the grocery store we also see increased foods that are supplemented with extra fiber. The Johns Hopkins health alert advises that whole foods such as grains and fruits, vegetables are superior to supplements. The alert also states that most Americans get only 40% of the recommended fiber in the diet. The National Fiber Council has a fiber chart so you or your patient can keep track of your intake. For your clinic needs you can also check out the Prolapse/Colorectal Care Manual available on this website as it has fiber logs, fiber charts, and information for patients about bowel health and dietary fiber.

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To PSA or not to PSA?

The United States Preventive Services Task Force has recommended against routine PSA tests for prostate cancer screening. This is noted as a "Level D" recommendation, meaning that "There is moderate or high certainty that the service has no net benefit or that harms outweigh the benefits." You can read the task force draft report by clicking here. The official recommendation will be published next week.

A PSA (prostate specific antigen) testis commonly utilized in conjunction with a digital rectal exam for screening of prostate cancer in men 50 years or older. If the PSA level is high or is rising in relation to prior tests, a biopsy of the prostate is usually recommended. It is thought that over diagnosis occurs in many men who have a slow-growing tumor that will not be the cause of death. In terms of potential harm, the task force cites the research indicating that false positive results can lead to psychological distress, and that risk of biopsies such as infection, fever, bleeding, or transient urinary issues is moderate.

The New York Times published an article recently addressing this issue. Highlighted in this article is the fact that the panel who recommended against PSA testing is the same panel who advised against routine mammograms, creating quite a controversy. Will the advice against routine PSA testing be met with as much disagreement? The disease is reported to be rare in men under age 50, and with most deaths from prostate cancer occurring in men over age 75. Even so, many men credit the PSA test as having "saved their life." It remains to be seen how insurance providers, medical practitioners, and patients will respond to the advisement against PSA testing.

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Does surgery for post-prostatectomy urinary incontinence improve sex life?

While it is well-documented that prostatectomy surgery negatively impacts sexual and urinary function in a significant portion of men, this case series asks if correcting the surgery-related incontinence can improve sexual function. This article looks at a group of men who were all treated by the same surgeon for radical prostatectomy (RP) surgery. 15 men who experienced urinary incontinence after the RP were then surgically treated with an anti-incontinence surgery, either a male sling or an artificial urinary sphincter(AUS) . 11 of these 15 men were sexually active and they completed post-surgical outcomes for both urinary and sexual function.

Of the 11 men described in the study, 4 of them had the AUS and the remaining 7 had the sling surgery. All of the men reported significant improvements in urinary incontinence (the goal of the surgery.) Most of them also reported a significant increase in their sexual quality of life. It was noted that the 4 men treated with the AUS reported a marked improvement, and in the group of 7 men who had the sling procedure, more than half of them reported marked improvements.

This is encouraging information for men who are suffering from the effects of prostate surgery. Could it be that overall sense of wellness and virility improved because urinary incontinence in general was improved, or that urinary leakage during sexual activity was improved? The authors acknowledge that more research is needed to determine if a UI surgery would be beneficial for men who have UI only with sexual health.

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Psychological Factors in Female Pelvic Pain

An article addressing the fear-avoidance model (FAM) of chronic pain as it relates to female pelvic pain appears in the October issue of Physical Therapy. The FAM, in simple terms, aims to aid understanding of why some people recover from an injury, whereas others may respond with "exaggerated pain perception." Patients who develop chronic pain, according to the model, are in a state of fearful avoidance of the pain which leads to decreased mobility and further challenges in perceiving the pain appropriately. Fear, anxiety, and catastrophizing of the pain can lead the patient to thoughts and behaviors that reduce the patient's ability to recover from the injury.

The authors cite a recent survey of physical therapists who treat pelvic pain and it was noted that these therapists did not employ any specific coping strategies for pain. The authors further recommend that therapists who work with women who have chronic pelvic pain should offer patients education about the psychological components of the pain. This can include teaching the patient that hypervigilance of pain response is not a helpful coping strategy, and that the fear and anxiety related to the pain are important pieces of the therapeutic puzzle. Options for helping the patient reduce anxiety can include relaxation training and helping the patient modulate the return to potentially painful activities.

Screening tools can be utilized as part of the pelvic rehab professionals intake forms, and referral to the appropriate provider for psychological support can be made if needed. The pelvic rehab provider can also include in her treatment plan strategies such as education, relaxation training, activity modification, and coping skills (components also included in cognitive behavioral therapy per the authors.) The study concludes that physical therapists can provide valuable screening of women who have chronic pelvic pain who may also present with fear and avoidance of the pain. This may lead the therapist to modify her treatment plan to include strategies to help the patient reduce the fear-anxiety-avoidance and/or to refer the patient to an appropriate professional for psychological support.

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Common Vulvar Skin Conditions

A recent blog post discussed the importance of looking for skin dysfunctions near the vulva during pelvic muscle examinations. The logical question might be, "what would it look like if the tissue was unhealthy?" I was able to locate a very helpful article for illustrating some variances in tissues. Catherine Drummond, Australian dermatologist, has written a succinct article that includes excellent images to help the reader understand the various clinical presentations of vulvar skin disorders. (The article can be found by clicking here.) Specifically the article discusses inflammatory vulval dermatoses that present as rashes.

Presentations of vulvar dermatoses discussed include those that are erythematous, those with pallor, and those presenting as erosions or ulcers. Hopefully we are not the first person to notice an ulceration or disease process, yet many patients are referred for "pelvic pain" without having a thorough assessment or pelvic examination. In this article there is a chart listing common vulval irritants such as detergents, urinary or fecal discharge, hair removal, lubricants or condoms, pads, tight clothing (including thong underwear), cycling, and swimming. You will also find a list of common corticosteroids used for vulvar care. I found this list helpful as I had a patient last week asking me if she should be applying hydrocortisone cream to her vulvar area. (I deferred the question to her provider.) Keep in mind that unless you ask, you might not know what a patient is applying to the tissues. This same patient found another topical recommended "on the internet" that she started using, without first checking with her medical care providers.

Although some of the article is most relevant for the practicing gynecologist or dermatologist, much of the information is very helpful to us in our role of pelvic rehabilitation provider. The bottom line is that if we do not look, we won't see it. And if we do see something of concern, the more information that we can document, or provide to the provider and to the patient, the more we can be of value when working as part of a team.

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