Recently, a note was left at my doorstep by the wife of an older gentleman who had chronic male pelvic pain. His pain was so severe, he could not sit, and he lay in the back seat of their idling car as his wife, having exhausted all other medical channels available to her, walked this note up to the home of a rumored pelvic floor physical therapist who also treated men. The note opened with how she had heard of me. She then asked me to contact her about her husband’s medical problem. It ended with three words that have vexed me ever since…we are desperate.
Unlike so many men with chronic pelvic pain, he had at least been given a diagnostic cause of his pain, pelvic floor muscle dysfunction, rather than vaguely being told it was just a prostate issue. However, the therapists that had been recommended by his doctor only treated female pelvic dysfunction.“We are desperate”: A Call to Action for All Therapists to become Pelvic Floor Inclusive
My first thought after reading the note was, “I bet shoulder or knee therapists don’t get notes like this on their doorstep.” My next thought, complete with facepalm, “THIS HAS TO STOP! Pelvic floor rehab has got to become more accessible”.
After my Dad’s 3rd trip to the emergency room not being able to breathe because of his sleep apnea and congestive heart failure, his cardiologist recommended he ”just relax” when his suffocating feelings occurred. Of course, not being able to catch his breath would always heighten anxiety, which made it even more difficult to inhale and exhale. Ultimately, what my Dad needed to learn was mindfulness to deal with his relatively benign inability to breathe, since the focus of mindfulness is acceptance of rather than control over your circumstances.
The concept of mindfulness has been studied in adults, but it is gaining popularity among the pediatric population. Ruskin et al., (2017) used a prospective pre-post interventional study to assess how children with chronic pain respond to mindfulness-based interventions (MBI’s). For 8 weeks, 21 adolescents engaged in group sessions of MBI. Before, after, and 3 months post-treatment, the authors collected self-report measurements for a variety of factors such as disability, anxiety, pain quality, acceptance, catastrophizing, and social support. Subjects were highly satisfied with the treatment, and all would recommend the group intervention to friends. From baseline to 3-month follow-up, pain acceptance, body awareness, and ability to cope with stress all improved in the subjects. Further randomized controlled studies are needed, but the initial conclusion was MBI’s were received well by adolescents.
A feasibility study performed by Anclair, Hjärthag, and Hiltunen in 2017 considered the effect of mindfulness and cognitive behavioral therapy for the parents of children with chronic conditions, looking at Health-Related Quality of Life (HRQOL), measured with Short Form-36 (SF-36), and life satisfaction. Ten parents received group-based cognitive behavioral therapy (CBT), and 9 participated in a group-based mindfulness program (MF). Treatment was implemented for 2-hour weekly sessions over the course of 8 weeks. The CBT treatment was based on the Acceptance and Commitment Therapy, focusing on changing thoughts and emotions about stressful issues as well as behaviors. They avoided the acceptance aspect, as it would overlap the MF intervention. The MF therapy used the Here and Now Version 2.0 (including daily themes on knowing your body, observing breathing, acceptance, meditation, coping, understanding thoughts versus facts, and self-care reinforcement). The parents in each group significantly improved their Mental Component Summary (MCS), Vitality, Social functioning, and Mental health scores. The MF group even showed notable improvement in Role emotional and some of the physical subscales (Bodily pain, General health, and Role physical). The CBT group showed improved satisfaction with Spare time and Relation to partner, and CBT and MF groups improved life satisfaction Relation to child. The authors conclude CBT and MF may positively affect HRQOL and life satisfaction of parents with chronically ill children.
Consider combing long, curly hair. Untangling the top layer is not so bad, but once half the hair is tamed, there is often a mangled mess lurking underneath. Sometimes the lumbar spine gets all the primping to relieve pain, but the sacroiliac joint is harboring the knots, such as when a lumbar rhizotomy leaves a patient’s satisfaction a little fuzzy.
A 2017 study by Rimmalapudi and Kumar investigated the incidence of sacroiliac (SI) joint dysfunction being diagnosed in patients after undergoing lumbar radiofrequency rhizotomy of the medial branches of lower lumbar dorsal rami for chronic facet-mediated low back pain. The authors used a retrospective chart review of 96 patients who had the procedure performed, and 50 subjects responded to the 2 follow ups and were included in the study. Their choice of control was a limitation in this study, as they compared the results to a different study (DePalma et al., 2011) with a similar population that did not have the lumbar rhizotomy performed. Of the 50 patients (66% female, 34% male), 35 (70%) were subsequently diagnosed with SI joint pain; whereas, in the comparison study, only 18% of the patients had SI pain. The assessment of SI dysfunction in this study was by clinical exam, and the DePalma et al. study used diagnostic tests. The authors concluded the following: clinicians should suspect underlying SI joint pain post-lumbar rhizotomy; careful evaluation of the SI joint should be performed pre and post procedure; and, diagnostic joint blocks should be performed to confirm SI dysfunction. They suggested using criteria of 80-100% relief as opposed to the currently accepted >50% after a diagnostic facet block because residual pain from an underlying condition may arise after lumbar rhizotomy.
Stelzer et al., (2017) published another retrospective study on lumbar neurotomy or SI joint lateral branch cooled radiofrequency (RF) neurotomy, looking at pain reduction and medication decrease, depending on BMI, gender, and sports. Facet-mediated pain is accountable for 31-45% of low back pain, and 18-30% is SI joint mediated. The study started with 160 patients who had undergone procedures, and Visual Analog Scale (VAS) pain scores, quality of life, BMI, medication use, and pain management satisfaction were assessed before, 1 month after (n=160), 6 months after (n=73), and 12 months (n=89) after treatment. Group 1 (n=43) had neurotomy of the medial branch of L4-5 and L5-S1 facet joint, medial branch L3 and L4, and dorsal ramus L5. Group 2 (n=109) received cooled RF treatment of the SIJ, SIJ lateral branch of the posterior rami S1–S3, and rami dorsalis of L5. Group 3 (n=8) had various areas treated according to their disease process. The authors determined from these treatments that a 95% probability of significant pain reduction could last 12 months; medication usage decreased; lower BMI had slightly better results than >30BMI; no significant difference between males and females; and, involvement in sports 1-3 times a week for 30 minutes showed improvement in quality of life.
An 80 year old lady who had seen a physical therapist where I once worked in Naperville, IL, just completed a marathon and a 5k race in one weekend. She is undoubtedly one woman who can change our perception of the “elderly,” but we all know her strength and ability are not the norm. The geriatric patients coming to therapy for pelvic floor disorders are more likely to be too frail to have run a mile this century, and they are most likely struggling with functional ADLs, as research suggests.
A study by Erekson et al., (2015) looked into the prevalence of frailty, cognitive impairment, and functional disability among women over 65 years of age looking for the best treatment for their pelvic floor dysfunction (PFD). A major concern was the presence of frailty being equated with poorer surgical outcomes. The 150 women in the study were tested with the Fried Frailty Index to measure frailty, the Saint Louis University Mental Status Score for cognitive screening, and the Katz ADL score for functional status. Pelvic organ prolapse was present in 65.3% women, urinary incontinence in 20.7%, overactive bladder in 9.3%, and anal incontinence in 0.7%. Sixteen percent of women were considered frail and 42% were “prefrail.” Dementia was determined in 21.3% of women, and functional disability in 30.7%. Pelvic floor dysfunction in women with frailty caused a significantly greater life-impact than in normal and pre-frail women. Forty-six percent of the subjects opted for surgery, but only women with functional disability, not impaired cognition nor frailty, were less likely to choose non-surgical intervention. The authors concluded that being able to identify women with PFD with risk factors of frailty, cognitive impairment, and functional disability may help predict the risk of complications before surgery and help encourage behavioral changes and provide the appropriate pre and post-operative care for each woman.
Silay et al., (2016) published a review on urinary incontinence (UI) in elderly women, relating its association with other geriatric conditions. Sixty-four females aged 65 and older were evaluated using the Turkish version of the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) to assess UI and quality of life. Activities of daily living (ADL) and instrumental activities of daily living (IADL) were used to evaluate functional status, and the Mini Mental State Examination was used for cognitive assessment. The comorbidities, pharmaceuticals, falls, and body mass index (BMI) of patients were also recorded. Results showed the subjects’ rate of urinary incontinence was 40.6%, and 28.1% of the women had their quality of life impacted. There was a statistically significant association using logistic regression between UI and quality of life, functional status, and comorbidity. Sadly, 50% of patients thought UI was normal with aging, 34.6% had been embarrassed to tell anyone about it, and 15.3% said they did not know UI was something for which medical treatment could be given.
When my 6 year old daughter ran to the bathroom 3-4 times before she got on the school bus every morning, I wasn’t too concerned, but I definitely took note. The day she was in tears and wouldn’t get off the toilet because she felt like she was still wet, I got worried (although slightly intrigued). No matter how much she wiped, she still felt wet. When she stood up, she felt like she was going to pee herself, making my sweet-natured girl slip into hysterics. After eliminating small amounts of urine 8 separate times in 3 hours and saying it burned, I assumed she had a urinary tract infection (UTI). A simple urine test ruled out UTI or diabetes (thankfully!). So then, what was my daughter’s diagnosis? The pediatrician simply referred to it as “a phase;” however, I had researched the symptoms before the visit.
In 2014 Arlen et al. described a condition called “phantom urinary incontinence.” This refers to the situation when children experience the sensation of being wet (a presumptive urinary incontinence) when they are objectively dry. They considered 20 children (18 females, 2 males) referred to their pediatric urology clinic over a 5 year span, all who were all diagnosed with phantom urinary incontinence (PUI). The authors evaluated the concomitant diagnoses found among the boys and girls in the study. Lower urinary tract symptoms were present in 95% of the subjects. Associated bladder symptoms were found as well, with urgency in 75% and frequency in 50% of the children. Vaginitis occurred in 72% of the girls. Parents reported obsessive-compulsive disorder or obsessive-compulsive disorder personality traits in 70% of the children. In order to treat these patients, dietary modifications, timed voiding, and a bowel regimen were implemented to manage symptoms. A follow up at 14.4 months revealed 90% of the children’s bowel-bladder dysfunction improved and PUI resolved. The authors concluded children compliant with a rigid bladder-bowel regimen experience relief of their “phantom” incontinence as well as lower urinary tract symptoms, and a majority of PUI patients have obsessive-compulsive traits.
Oliver et al., (2013) studied how psychosocial comorbidities and body mass index relate to children with lower urinary tract dysfunction. Data on 358 patients with lower urinary tract dysfunction between 6 to 17 years old was collected, and the subjects’ parents completed questionnaires screening for lower urinary tract symptoms, stressful life events, and psychological comorbidities. Obesity was present in 28.5% of the children, 22.9% had a recent stress in life, and 22.9% had a psychiatric disorder. Under and overweight children, children with a recent life stressor, psychiatric disorder, or both, as well as the younger-aged children all had lower urinary tract symptom scores significantly higher than healthy weight subjects, those without psychosocial comorbidities, and older subjects. The results encourage screening for psychosocial issues and obesity in pediatric patients with lower urinary tract dysfunction.
Perhaps you have seen the Facebook post by Alan Naughton (March 5, 2015) where a horse with one zebra leg tells another horse, “I can’t say I’m entirely pleased with my hip replacement.” Although this post makes some people laugh, I imagine surgical candidates cringe at the thought of complications. Few people hop onto a surgeon’s schedule with great enthusiasm. While hip replacements are sometimes inevitable for quality of life, other hip pathologies can be successfully treated with more conservative measures.
A case report in Manual Therapy (Lewis, Khuu, & Marinko 2015) described how postural correction and alternation of movement patterns were able to reduce hip pain secondary to acetabular dysplasia. A 31-year old female acute care nurse developed anterior hip pain with no trauma, and acetabular dysplasia as well as a labral tear were found. She got temporary relief of her constant ache and occasional sharp, intense pain from an intra-articular injection of cortisone. Her functional complaint was the pain prevented her from returning to recreational running. Intervention involved correcting the subject’s slight hip and knee hyperextension and posterior pelvic tilt with swayback posture, cueing her to walk on the treadmill with slight anterior pelvic tilt and contraction of the abdominals. This decreased her pain while walking from 6/10 to 2/10. Correction of the swayback posture decreased the hip flexion moment, decreasing stress on the anterior hip. At three months and then one year after the initial visit, she was relatively pain free. She still had pain with running, so she was advised to decrease her stride length and take shorter steps as well as decrease her hip extension by pushing off her feet more to minimize anterior hip joint reaction forces. With these cues, she was able to run without pain. Luckily for her, she had declined the option of acetabular reorientation surgery.
MacIntyre et al., (2015) presented a case study on conservative management of femoroacetabular impingement (FAI) in a retired 22 year old elite ice hockey goaltender. A 4-year history of left anterior hip pain forced him into early retirement. He was diagnosed with longitudinal acetabular labral tears with a cam-type FAI. Before considering surgery, he had to undergo physical therapy, which he did 1-2 times per week for 6 weeks. Treatment consisted of Active Release Technique (ART)® and soft tissue therapy with tools directed to the affected gluteal , iliopsoas, and adductor muscles and fascial planes, spinal manipulation of the right sacroiliac joint, left hip capsule distraction/release using the Mulligan concept, contemporary medical electroacupuncture, and extensive rehabilitation exercises for lumbopelvic stability. After 8 visits, he had no pain at rest or with exercise. At 8 weeks he returned to playing ice hockey and now plays competitively again with no need for surgery.
Anxiety and depression are frequently encountered co-morbidities in the clients we serve in pelvic rehabilitation. This observation several years ago in clinical practice is one of many that prompted me down the path of exploring the connection between the gut, the brain, and overall health. In answering the question about these connections, I discovered many nutritionally related truths that are being rapidly elucidated in the literature.
A recent study by Sandhu, et.al. (2017) examines the role of the gut microbiota on the health of the brain and it’s influence on anxiety and depression. The title of the study, “Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry” gives us pause to consider the impact of our diets on this axis and in turn, on the health of our nervous system. The authors state:It is diet composition and nutritional status that has been repeatedly been shown to be one of the most critical modifiable factors regulating the gut microbiota at different time points across the lifespan and under various health conditions.
With diet and nutritional status being the most critical modifiable factors in the health of this system, it becomes our responsibility to seek to understand this system and its influencing factors. We need to learn how to nourish the microbiota-gut-brain axis.
In the comedy, Kindergarten Cop, Detective John Kimble may only have had a headache, not a tumor, but sometimes our patients do have a tumor. One of my patients was actually just diagnosed with a brain tumor after responding poorly to a cortisone injection for her neck pain. Tumors in other areas of the body, even in the pelvis, can be the source of symptoms that may seem like a nerve entrapment. This is a serious consideration to be given when diagnosing pudendal neuralgia.
In 2008, Labat et al. published the “Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment” in Neurourology and Urodynamics . A group in Nantes, France, established criteria in 2006, since the diagnosis is primarily clinical in nature. The results of this paper concluded the five essential diagnostic criteria (Nantes criteria) are as follows:Pain located in the anatomical region of the pudendal nerve.Pain worsened with sitting.Pain does NOT awaken the patient at night.Negative sensory loss upon clinical exam.Pain is relieved with an anesthetic pudendal nerve block.
A recent study by Waxweiler, Dobos, Thill, & Bruyninx explored the Nantes criteria as related to choosing surgical candidates for pudendal neuralgia from nerve entrapment. They looked at how a patient’s response to the anesthetic block corresponded to appropriate selection of patients for a successful surgical outcome. Six of 34 patients in the study had a negative anesthetic pudendal nerve block, and 100% of those patients had no symptom relief after surgery. In contrast, 64% of the patients who met all five of the Nantes criteria responded positively to surgery. The authors concluded confirmation of the 5th criteria as essential for predicting success of surgery for pudendal neuralgia by pudendal nerve entrapment.
In getting ready to teach my Menopause course in Minneapolis next month, I always like to do a review of the evidence, to see what’s new, or what’s changed. What has changed over the past few years – more and more evidence to support the role of skilled rehab providers, using evidence based assessment techniques to gauge the grade of pelvic organ prolapse and assess the risk of levator avulsion. What hasn’t changed enough – the level of awareness of the benefits of pelvic rehab in managing, or in some cases even reversing, the effects and symptoms of prolapse.
Dr Peter Dietz, from the University of Sydney, writes ‘…although clinical anecdote suggests some physiotherapists recognize other characteristics suggesting muscle dysfunction (e.g. holes, gaps, ridges, scarring) or pelvic floor dysfunction (e.g. width between medial edges of pelvic floor muscle) with palpation it is difficult to find any literature describing the techniques needed to do this or their accuracy or repeatability. Mantle (in 2004) noted that with training and experience a physiotherapist might be able to discern muscle integrity, scarring, and the width between the medial borders of the pelvic floor muscles, with palpation. It is not clear to what extent physiotherapists are able to do this reliably or how such characteristics are to be recorded.’
Dr Dietz describes a palpation technique to assess the integrity of the pubovisceral muscle insertion, by checking the gap between the urethra centrally and the pubovisceral muscle laterally. On levator contraction this gap should be little wider than your index finger, otherwise an avulsion injury is very likely.
Lee Sowada, PT, DPT, PRPC is a newly minted Certified Pelvic Rehabilitation Practitioner (PRPC) who treats patients in rural Wyoming. Within her community, she relishes the chance to bring pelvic rehab to a more rural environment and provide care that many people in the community didn't know existed. Dr. Sowada was kind enough to share her story with us. Thanks, Lee, and congratulations on earning your certification!
How did you get involved in the pelvic rehabilitation field? I fell into pelvic health rehab by accident as a student when I was placed in a “Women’s Health” rotation at the last minute. Initially I was disappointed as this was my last clinical rotation and among the longest. However, I fell in love with this line of work almost right away. It was evident from the start that pelvic rehab makes an enormous impact on a person’s life in a way that most outpatient rehab doesn’t. The impairments were private and sometimes embarrassing and they often resulted in social isolation and loneliness with the inability to share it and the assumption that nothing could be done. It was so rewarding to provide support, information and much needed treatment. After that, I never looked back.