In 2007, after only speaking on the phone and never meeting in person, my new friend and colleague Stacey Futterman and I presented at the APTA National Conference on the topic of male pelvic pain. It was a 3 hour lecture that Stacey had been asked to give, and she invited me to assist her upon recommendation of one of her dear friends who had heard me lecture. I still recall the frequent glances I made to match the person behind the voice I had heard for so many long phone calls.
Upon recommendation of Holly Herman, we took this presentation and developed it into a 2 day continuing education course, creating lectures in male anatomy (we definitely did not learn about the epididymis in my graduate training), post-prostatectomy urinary incontinence, pelvic pain, and a bit about sexual health and dysfunction. Although it truly seems like the worst imaginable question, we asked each other “should we allow men to attend?” As strange as this question now seems, it speaks volumes about the world of pelvic health at that time; mostly female instructors taught mostly female participants about mostly female conditions.
Make no mistake- women’s health topics were and are deserving of much attention in our typically male-centered world of medicine and research. Maternal health in the US is dreadful, and gone are the days when providers should allow urinary incontinence or painful sexual health to be “normal”, yet it is often described as such to women who are brave enough to ask for help. Times have changed for the better for us all.
The following is the first in a series of posts by Erica Vitek, MOT, OTR, BCB-PMD, PRPC. Erica joined the Herman & Wallace faculty in 2018 and is the author of Neurologic Conditions and Pelvic Floor Rehab.
A well-respected colleague of mine brought something to my attention. My desire to learn everything possible about Parkinson disease and pelvic health was a unique passion, a combination of expertise not seen in many rehabilitation clinics.
Looking back, being passionate about how to physically exercise a person with Parkinson disease to produce the best functional outcome actually became a passion of mine when I was offered my first job. I was thrown into treating people with Parkinson disease in an acute care setting. I had very limited knowledge about Parkinson disease at the time, but I learned quickly from the vast opportunity that was offered to me through my place of work, which was the regions sought after Parkinson disease center of excellence. At the same time, I was eager to further advance my skills as a pelvic floor therapist, which I developed a substantial interest in when I was in college.
You have been treating a highly motivated 24-year-old woman with a diagnosis of Interstitial Cystitis/Painful Bladder Syndrome (IC/BPS). The plan of care includes all styles of manual therapy, including joint mobilization, soft tissue mobilization, visceral mobilization, and strain counterstrain. You utilize neuromuscular reeducation techniques like postural training, breath work, PNF patterns, and body mechanics. Your therapeutic exercise prescription includes mobilizing what needs to move and strengthening what needs to stabilize. Your patient is feeling somewhat better, but you know she has the ability to feel even more at ease in their day to day. Is there anything else left in the rehab tool box to use?
Kanter et al. set out to discover if mindfulness-based stress reduction (MBSR) was a helpful treatment modality for (IC/BPS). The authors were interested in both the efficacy of a treatment centered on stress reduction and the feasibility of women adopting this holistic option.
The American Urological Association defined first-line treatments for IC/PBS to include relaxation/stress management, pain management and self-care/behavioral modification. Second-line treatment is pelvic health rehab and medications. The recruited patients had to be concurrently receiving first- and second-line treatments, and not further down the treatment cascade like cystoscopies and Botox.
The expression, “the canary in the coal mine” comes from a long ago practice of coalminers bringing canaries with them into the coalmines. These birds were more sensitive than humans to toxic gasses and so, if they became ill or died, the coalminers knew they had to get out quickly. The canaries were a kind of early warning signal before it was too late. Even though the practice has been discontinued, the metaphor lives on as a warning of serious danger to come.
Osteoporosis, which means porous bones, has been called a silent disease because often an individual doesn’t know he or she has it until they break a bone. The three common areas of fracture are the wrist, the hip, or the spine. Osteoporosis fractures are called fragility fractures, meaning they happen from a fall of standing height or less. We should not break a bone just by a fall unless there is an underlying cause which makes our bones fragile.
Wrist fractures typically happen when a person starts to fall and puts his or her arms out to catch themselves. They often are seen in the Emergency Department but seldom followed up with an Osteoporosis workup. According to the International Osteoporosis Foundation’s Capture the Fracture program, 80% of fracture patients are never offered screening and / or treatment for osteoporosis. As professionals working with patients who often have co-morbidities, we can be the ones to screen for osteoporosis and balance problems, particularly if our patients have a history of fractures. These screens include the following:
EMG is a helpful tool to observe pelvic floor muscle activity and how it is influenced by everything from regional musculoskeletal factors and mucosal health, to client motor control, awareness, and comfort.
In this post I will discuss the case of one client who was referred for dyspareunia treatment, and whose SEMG findings are outlined in Figures 1-3. She had validated test item clusters for right hip labral tear as well as femoral acetabular impingement, in addition to right sided pelvic floor muscle overactivity and sensitivity with less than 3 ounces of palpation pressure.
The figures below demonstrate peri-anal SEMG response of pelvic floor muscles within a single treatment session, which included sacral unloading in supine as well as hip joint mobilization to demonstrate the relationship between her pelvic floor and her hips. Our focus for this SEMG downtraining treatment was to enable her to understand the connection between her pelvic floor muscle holding patterns and her body’s preferences to remain out of ranges of motion that impinged and irritated her hip.
It’s St Valentine’s day this week – you may have noticed hearts and flowers everywhere you look and a general theme of love and romance. For many women going through cancer treatment, sex may be the last thing on their mind…or not! Women who are going through treatment for gynecologic cancer are often handed a set of dilators with minimal instruction on how to use them, or as one patient reported, they are told to have sex three or four times a week during radiation therapy ‘to keep your vagina patent’. As a pelvic rehab practitioner with a special interest in oncology rehab, I know that we can (we must!) do better, in helping women live well after cancer treatment ends.
As Susan Gubar, an ovarian cancer survivor, writes in the New York Times ‘…It can be difficult to experience desire if you don’t love but fear your body or if you cannot recognize it as your own. Surgical scars, lost body parts and hair, chemically induced fatigue, radiological burns, nausea, hormone-blocking medications, numbness from neuropathies, weight gain or loss, and anxiety hardly function as aphrodisiacs…’
Although sexual changes can be categorised into physical, psychological and social, the categories cannot be neatly delineated in the lived experience (Malone at al 2017). The good news? Pelvic rehab therapists not only have the skills to enhance pelvic health after cancer treatment and are ideally positioned to be able to take a global and local approach to the sexual health difficulties women may face after cancer treatment ends, but there is also a good and growing body of evidence to support the work we do. Factors to consider include physical issues leading to dyspareunia, including musculo-skeletal/ orthopaedic, Psychological issues, including loss of libido and other pelvic health issues impacting sexual function such as faecal/ urinary incontinence, pain or fatigue.
As brain research in pain processing suggests, pain engages overlapping cortical networks responsible for nociception, cognition, emotion, stress and memory, a treatment model targeting nociceptive mechanisms alone can be inadequate to address the complexities of a patient’s pain experience.1 To help physical therapists understand and more effectively address multiple factors influencing a patient’s pain, the APTA, Orthopaedic Section and Pain Management Special Interest Group have brought together 10 physical therapists and a physician from around the country to present an informative and dynamic 2-day pre-conference course, Keep Calm and Treat Pain, Feb 21 and 22 at CSM 2018 in New Orleans. Presentation topics include the Science of Pain, Pain Education, Pain Psychology, Motivational Interviewing and Sleep and Pain. In addition, I will present An Introduction to Mindful Awareness Training and Its Role in Pain Treatment, and my colleague at Herman and Wallace, Megan Pribyl, PT, MSPT, will present Pain and Nutrition: Building Resilience Through Nourishment.
As we are in the midst of the opioid crisis, this programming could not come at a better time. In this regard, I am especially excited to share information on how mindfulness training has been shown to help patients who are reducing opioid medications to increase positive affect, decrease pain interference and reduce opioid craving.2, 3 I will also describe how mindful awareness training helps address a patient’s fears and fear avoidant behavior and will guide mindfulness exercises.4, 5
I am honored to be a part of this pioneering program that combines didactic presentations with experiential exercises and lab practice to offer participants the latest science of pain and practical skills to more successfully treat pain. In addition, I am presenting an Educational Session sponsored by the Federal Section on the topic Mindful Awareness Training for Veterans with Comorbid Pain and PTSD based on my research experience at the Puget Sound VA in Seattle. I hope to see you at CSM!
Interstitial cystitis is a chronic pain condition characterized by both pelvic pain and urinary symptoms. It’s diagnosed by unexplained pain or pressure that is perceived to be related to the bladder, and affects more than 12 million Americans. It’s often described as the sensation of a urinary tract infection, but without any bacterial infection. Many patients report severe pain, often more intense than that associated with bladder cancer, and up to 85% of patients have accompanying pelvic floor dysfunction.
Pelvic floor physical therapy is the most proven treatment for interstitial cystitis. It’s recommended by the American Urological Association (AUA) as a first-line medical treatment in their IC Guidelines, and is the only treatment given an evidence grade of ‘A’. Furthermore, it’s the sole intervention that provides sustained relief; bladder treatments and oral medications must be continued indefinitely to provide benefit, if they work at all.
Research has demonstrated that at least 85% of patients with interstitial cystitis also have pelvic floor dysfunction. In fact, many of the symptoms of IC can only be explained by the pelvic floor. The majority of patients report painful intercourse, low back pain, hip pain, or constipation accompanying the condition; symptoms that have nothing to do with the bladder.
I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).
From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).
People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.
Curing cancer but not addressing life-altering complications can be compared to feeding the homeless on Thanksgiving but turning your back on them the rest of the year. We love hearing positive outcomes of a surgery, but we are not always aware of what happens beyond that. Colorectal cancer is often treated by colectomy, and sometimes the survivor of cancer is left with urological or sexual dysfunction, small bowel obstruction, or pelvic lymphedema.
Panteleimonitis et al., (2017) recognized the prevalence of urological and sexual dysfunction after rectal cancer surgery and compared robotic versus laparoscopic approaches to see how each impacted urogenital function. In this study, 49 males and 29 females underwent laparoscopic surgery, and 35 males and 13 females underwent robotic surgery. Prior to surgery, 36 men and 9 women were sexually active in the first group and 13 men and 4 women were sexually active in the latter group. Focusing on the male results, male urological function (MUF) scores were worse pre-operatively in the robotic group for frequency, nocturia, and urgency compared to the laparoscopic group. Post-operatively, urological function scores improved in all areas except initiation/straining for the robotic group; however, the MUF median scores declined in the laparoscopic group. Regarding male sexual function (MSF) scores for libido, erection, stiffness for penetration and orgasm/ ejaculation, the mean scores worsened in all areas for the laparoscopic group but showed positive outcomes for the robotic group. In spite of limitations of the study, the authors concluded robotic rectal cancer surgery may afford males and females more promising urological and sexual outcomes as robotic.
Husarić et al., (2016) considered the risk factors for adhesive small bowel obstruction (SBO) after colorectal cancer colectomy, as SBO is a common morbidity that causes a decrease in quality of life. They performed a retrospective study of 248 patients who underwent colon cancer surgery, and 13.7% of all the patients had SBO. Thirty (14%) of the 213 males and 9 (12.7%) of the 71 females had SBO; consequently, they found patients being >60 years old was a more significant risk factor than sex regarding occurrence of SBO. The authors concluded a Tumor-Node Metastasis stage of >3 and immediate postoperative complications were found to be the greatest risk factors for SBO.