The goals of a recent research article were to determine the degree to which lower urinary tract symptoms (LUTS) are related to quality of life (QOL) and also the reliability of parents to accurately report on QOL disturbance in children who have urinary incontinence (UI). Outcomes tools utilized in the study include the Dysfunctional Voiding Symptom Score (DVSS) and the Pediatric Urinary Incontinence QOL tool (PIN-Q). Parents of forty children ages 5-11 (10 males and 30 females) and diagnosed with non-neurogenic daytime wetting completed the outcomes tools and responded to open-ended questions about incontinence and QOL. All children had daytime wetting, more than 50% of them had recurrent urinary tract infections (UTI's), and 89% reported urinary urgency.

According to the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), night-time wetting affects 30% of children who are 4 years of age, with the condition resolving in about 15% of children each year. Additionally, wetting at night persists in about 10% of 7 year-old, 3% of 12 year-olds, and 1% of 18 year-olds. A summary handout about Urinary Incontinence in Children is available here.

The study found that parents were reliable in reporting quality of life and symptoms in their children, as the outcomes scores completed were not different between them. (I would point out that nearly all parents involved were the patient's mothers; and it may be interesting to know more information about how the responsibility of managing urinary incontinence in children is shared among parents or caregivers.) Confirmed in the research was the knowledge that urinary dysfunction in children causes significant quality of life impact.

The subjective complaints of how some of the children avoid activities such as sleepovers, or worry that classmates can see or smell leakage is heartbreaking. The parents' complaints of feeling frustrated and angry about the issue is also understandable as there is a variable amount of support and understanding that each family has about how to manage the incontinence. A child's teacher or friends will also display a wide variety of supporting or sabotaging reactions that can add dramatic increases in stress. The authors point out that there is a significant "…need to improve teacher education and make attempts to engage the educational system to help these children."

If you would like to learn how to be a part of the solution, you can attend the Pediatric Incontinence and Pelvic Floor Dysfunction continuing education course taking place in August in South Carolina. It's the last chance to take the course this year!

Sacroiliac joint pain can be a challenging condition to treat. One of the clinical pearls that I feel changed my practice for the better is the palpation and direct treatment of the dorsal sacral ligament. At a course many years ago, I listened to Diane Lee describing some ofAndry Vleeming's work addressing the potential role of the long dorsal sacral ligament (LDL) in pelvic pain. His valuable research was conducted in women who had complaints of peripartum pain, and it has been my experience that the information is easily extrapolated to other patient populations.

Vleeming and colleagues describe the long dorsal sacroiliac ligament anatomy as attaching to the lateral crest of the 3rd and 4th sacral segments (and sometimes to the 5th segment), and as having connections to the aponeurosis of the erector spine group, the thoracolumbar fascia, and the sacrotuberous ligament. Functionally, nutation in the sacroiliac joint will slacken the ligamentous tension in the LDL and counternutation will tension the ligament. This structure can be palpated directly caudal to the posterior superior iliac spine (PSIS).

The referenced study examined how many women had tenderness in the LDL who were also diagnosed with peripartum pelvic pain. Patients included in the study had pain in the lumbopelvic region, pain beginning with pregnancy or within 3 weeks of childbirth, were not pregnant at the time of the study, and were between the ages of 20-40. In patients with peripartum pelvic pain, 76% of the women reported tenderness in the LDL- this number increased to 86% when only patients scoring positively on the active straight leg raise test and posterior pelvic pain provocation (PPPP) test were included.

The study proposes that strain in the LDL may occur from a counternutated sacrum and/or an anterior pelvic tilt position. In my clinical experience and as instructed to many pelvic health therapists by expert clinicians such as Diane Lee, balancing the pelvic structures, activating stabilizing muscles of the inner core (pelvic floor, multifidi, transverses abdominis), and addressing soft tissue dysfunction in the ligament frequently resolve long standing localized pain in the sacroiliac joint area. The authors of the study conclude that "…knowledge of the anatomy and function of the LDL and the simple use of a pain provocation test…could be helpful in gaining a better understanding of peripartum pelvic pain." They also reported that combining tests such as the ASLR, the PPPP test, and the long dorsal sacral ligament palpation test "seems promising" in the differentiation of patients categorized as having pelvic pain versus lumbar pain.

To learn more about sacroiliac joint anatomy and function, diagnosis and treatment, come to Peter Philip's very popular continuing education course, Sacroiliac Joint Treatment, offered for the last time this year in Baltimore in July!

In the world of pelvic rehabilitation, brain morphology has been a hot topic for several years. Research has identified changes in various brain structures in patients who have specific conditions: irritable bowel syndrome, chronic pelvic pain, among others. (See prior blog about the brain, pain, and pelvic rehab by clicking here.) The research related to meditation is deep and rich, and the medical system continues to acknowledge the potential health benefits and cost savings from this simple technique that requires no equipment. The National Center for Complementary and Alternative Medicine (a division of the National Institutes of Health) states that meditation may work through effects on the autonomic nervous system. The nervous system in turn regulates functions such as breathing, heart rate, and digestion.

I had the opportunity in 2006 to take a course titled Mindfulness-Based Strategies for Relaxation and Stress Management from Carolyn McManus. In addition to discussing an abundance of research from a variety of disciplines, Carolyn taught us practical strategies and clinical approaches for patient care. She also instructed us in mindfulness techniques so that we increased our own skill set. Carolyn has instructed similar strategies to health care providers from many disciplines and to her patients, many of whom have tried years of other types of therapy. Since that time, I have constantly recommended the CD's that Carolyn created for patients, and with the many approaches she has (including contract-relax and autogenic retraining) I have found that there is something for everyone. The Institute is honored to host Carolyn's continuing education course, Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain this November in Seattle. Keep in mind that the course is open to many disciplines- would this be a great course to take your student to, or to invite a referral source to attend with you? Undoubtedly, this course will offer beneficial information not just for the patients, but also for the participants to use in their own daily self-care.

In addition to Carolyn's new offerings, we are thrilled to host a course that is taught by siblings who represent the fields of physical therapy and psychiatry. How wonderful it will be to hear from Nari Clemons, PT, and Shawn Sidhu, MD, expert clinicians who treat patients from their own perspectives, and to be able to receive information from these different view points. You can sign up for the Meditation and Pain Neuroscience continuing education course taking place in Illinois in September. You can also read about Nari and Shawn's new course in Nari's recent blog post.

Now, back to the title of this post. Researchers studied MR images of 25 male patients while they were practicing a type of meditation termed loving-kindness. 10 of the men were deemed experts with practice in the technique for more than 5 years. Compared to the novices, the right angular and posterior parahippocampal gyri had increased gray matter in the experts. The authors note that the regions identified as being larger are related to affective regulation associated with empathy, anxiety, and mood. Bottom line? We are still learning a lot about meditation and the potential implications towards health, and there is continual attention given to understanding how the changes are created in the body. If you want to learn practical and evidence-based information about mindfulness and meditation, please join us at our new courses! And if you want some increased gray matter in some seemingly really valuable parts of the brain, practice a lot!

Abnormal hip joint development causes 25-50% of all hip disease, according to an article by Goldstein and colleagues on hip dysplasia in the skeletally mature patient. An acetabulum that is dysplastic tends to be shallow and anteverted while the dysplastic femur tends to have a small femoral head and an increased neck shaft angle. These abnormalities cause increased joint contact pressures and lead to joint breakdown in the hip, and are associated with issues such as altered hip and knee biomechanics, hip instability, hip impingement, and labral or chondral dysfunction.

Developmentally, the altered joint surface contact also affects acetabular development: the well-formed contact pressure in healthy hip development helps to deepen the acetabulum. The shape and position of the acetabulum and femoral head will also influence the relative angle of the femoral neck, represented as retroversion or anteversion. Soft tissue changes occur in response to the altered bony mechanics that affect length-tension curves in the muscles and therefore affect muscle performance. Because of the primary and secondary dysfunctions that can occur with hip dysplasia, early recognition of hip dysfunction is important.

Measurements for hip position are easy to implement in the clinic and can include Craig's Test for femoral anteversion/retroversion. Treatment approaches focusing on hip abduction strengthening have been demonstrated to improve hip stability in patients with dysplastic hip. With shared structures including muscles between the hip and pelvis, pelvic rehabilitation providers must be able to assess the hip's influence on conditions of pelvic pain or other dysfunctions. To learn about detailed examination and treatment of the hip, there is still time to register for the Institute's upcoming continuing education course instructed by Ginger Garner.

The addition of the International Fascia Research Congress onto the scene of educational conferences has ignited an increased focus on understanding how fascia works in the body. Of course, we know fascia plays a role in compartmentalizing and separating various structures in the body, yet we also know that fascia must allow communication with the rest of the body. Is fascia simply a structural tissue that plays a mechanical role? Or does fascia hold memories, accessible during bodywork, as discussed in this article?

It may seem logical that fascia could contribute to compressive forces on the skeleton, on muscles and neurovascular structures, possibly contributing to musculoskeletal disease. Is myofascial tension sufficient to cause enough mechanical stress to create micro-damage and histochemical responses? Can this then lead to ankylosing spondylitis or axial spondyloarthritis, as discussed in this article published in Arthritis Research & Therapy? And if fascial thickness and tension is a proposed culprit of conditions such as compartment syndrome, why did these researchers find no correlation and in fact a negative correlation between fascial stiffness in patients with compartment syndrome?

Do we really know the implications of fascially-directed assessments and interventions at this time? Is the research on fascial therapy being interpreted correctly if science is still trying to figure out what fascia is, how fascia works, how fascial forces affect the body and body functions? If we don't yet understand the intricacies of the neurophysiological mechanisms that drive fascia, should we jump to conclusions about the science that may or may not be measuring the right variables? (To this end, is a test of the fascial strength meaningful if taken from a biopsy now that the tissue is disconnected from the nervous system?)

I am not a fascial researcher, and I appreciate those who do give their time and energy towards working on these questions. As a pelvic rehabilitation provider, I know that fascial relationships within the pelvis are multi-faceted and somewhat unique: the obturator internus (OI) attaches directly into a thick fascial line running between the OI and the levator ani muscles. The potential implications of this relationship on muscle strength and tension are constant clinical considerations, and ones that we hopefully will know more about as tools such as functional MRI lend improved data.

Clinicians who utilize myofascial assessments and treatment have more understanding of the role of substances such as hyaluronic acid in fascial health, yet we are still searching for accurate ways to describe how stretching and connective tissue manipulation can ease chronic pain. While we continue to explore the science behind the techniques, you can further your knowledge of fascia and fascial techniques at the continuing education course Myofascial Release for Pelvic Dysfunction, offered for the last time this year in Ohio this month.

Research led by Mei Fu, associate professor of Chronic Disease Management at New York College of Nursing, offers support for a preventive approach to lymphedema following breast cancer treatment. 140 women who were followed for 12 months were included in the study and outcomes included limb volume measurement from baseline (prior to surgery 2-4 weeks post-surgery, and at 6 and 12 months. Lymphedema was defined in the study as a 10% or greater increase in limb volume. 134 women completed the study, with 97% maintaining limb volume.

Of the subjects studied, axillary lymph node dissection was completed in almost 60%, and approximately 40% had sentinel lymph node biopsy. The self-care strategies in the research included shoulder mobility exercises, muscle-tightening deep breathing, muscle-tightening pumping exercises, and large muscle group exercise such as walking, swimming, yoga) to promote lymph health. The participants were also instructed in nutritional information aimed toward maintaining body mass index (BMI.) 97% of the women were also able to maintain BMI at the 12 month follow-up.

The majority of women in this pilot study also reported that the educational program helped in understanding of risk reduction for lymphedema, and also reduced their fear and anxiety about the condition. This type of research is very encouraging towards empowering patients following breast cancer. The authors note that a larger study population in a randomized, controlled trial will offer further information to guide clinical program development. While this study focused on participants with a diagnosis of breast cancer, is it likely that similar lifestyle and activity education would offer prevention of abdominopelvic and lower extremity lymphedema?

Within the Institute's Oncology series, you can learn more about these topics at several continuing education courses. To learn more about lymphedema, check out the Rehab for the Breast Oncology Patient, or the Oncology and the Pelvic Floor Courses (divided into male and female topics.) The next opportunity to take the Oncology for the Pelvic Floor Female: Reproductive and Gynecologic Cancers is June 21-22 in Florida. There a few seats left, so sign up soon!

The American College of Obstetricians and Gynecologists and the American Urogynecologic Society recently published recommendations for medical evaluation of women who have uncomplicated stress urinary incontinence (SUI). The following steps are recommended for evaluation: history, urinalysis, physical examination, demonstration of SUI, urethral mobility assessment, and a post void residual. For women who have complicated SUI, urodynamic testing may be appropriate, according to the article, whereas in women with uncomplicated SUI, urodynamics testing may not affect treatment outcomes.

Uncomplicated urinary incontinence is defined within this article as including the following:

• • UI with loss of urine on effort, physical exertion, sneeze or cough
• • Absence of recurrent UTI
• • No prior major pelvic surgery including surgery for SUI
• • Absence of voiding symptoms such as urinary hesitancy, straining to void, spraying of stream, dysuria, sense of incomplete emptying, postmicturition leakage
• • Absence of medical conditions affecting lower urinary tract
• • Absence of vaginal bulge beyond the hymen, absence of urethral abnormality
• • Presence of urethral mobility
• • *<150 mL postvoid residual
• • Negative urinalysis

Recommended nonsurgical approaches include pelvic muscle strengthening (with or without physical therapy), behavioral modification, pessaries, and urethral inserts. The document also includes an example list of validated urinary incontinence questionnaires. The paper makes the point clear that "…counseling should begin with conservative options." However, for those women who wish to have a sling surgery, and "in whom conservative treatment has failed…" is a phrase used in the article, leaving us to wonder: what constitutes failed conservative care? Does this mean that a patient who has failed a pessary trial is a viable candidate for surgery? Or that someone who has completed pelvic muscle strengthening (and perhaps no behavioral modification therapy) should be considered a "failed" patient? Does it mean that a patient who was given a handout about completing Kegel exercises has completed a conservative bout of care?

Further guidelines can best be made when the research describing components of pelvic rehabilitation are included. Clearly the burden of responsibility falls on the shoulders of the pelvic rehab therapists to fill in this knowledge and/or research gap. Clinical guidelines are increasingly inclusive of pelvic rehabilitation approaches, which is a terrific improvement, and yet we should not like to see (with or without physical therapy) following pelvic muscle strengthening, particularly when clinically we see such a wide variety of pelvic dysfunctions limiting appropriate strengthening techniques.

For foundational information about evaluation and treatment of urinary incontinence, a therapist can begin with the Pelvic Floor level 1 training, and then continue through the pelvic floor series continuing education courses in which urinary incontinence is continually addressed as a topic.

This fall, Herman & Wallace will be debuting a brand new course, Integrating Meditation and Neuropsych Principles to Maximize Physical Therapy Interventions, in Winfield, IL. We sat down with the course instructor, Nari Clemons, PT, to learn more about this brand new offering.

What inspired you to create this course?

There is so much more to pain management than just manual techniques, and with meditation we can help patients with a mental shift to facilitate healing. Everyone is always telling patients to work on stress management, but so few people are really able to give patients usable, practical, useful tools to do so. We all know those patients who come in so keyed up or so caught up in playing the same tape in their heads, that we are not sure what we can do to help them. I meditate every day, and it has helped my life (and my patients) beyond measure. I know how many times I use meditation as a way for patients to benefit more from their treatment. In most of the Herman Wallace courses, we talk about using down training and stress management for conditions like overactive pelvic floor, constipation, urinary urge, dyspareunia etc. (even for Interstitial cystitis, the first line of treatment is now relaxation training) but, so few practitioners have access to these tools or this knowledge, so how are they able to help patients? I want to help bridge that gap.

What can you tell us about this course not mention in the description and objectives?

This course is, above all, extremely practical. It takes away the mystery and lack of approachability of meditation, by taking the idea of centering, self-care, healing, and balancing the mind from something esoteric, vague and mystical to step-by-step tools that therapists can use. I hope attendees will use these simple techniques in their own lives and with their patients to help manage conditions of pain, tension, and anxiety. Because the aspects of health for this course border on both the realm of mental health and physical therapy, this course will be co-instructed by Dr. Shawn Sidhu, psychiatrist and meditator, who will provide info on current mental health perspectives.

Can you describe the clinical/treatment approach/techniques covered in this course?

These are all techniques that the clinician can use with the patient and the patient can use on their own. This is the piece you can give a patient to do at home. Most of these techniques can also be used as a part of treatment (ther act or neuro re-ed) to retrain muscle resting levels. I will have a CD that comes with the course that can also be used for patients at home, if the patient needs more guidance. There will be a variety of techniques, all within the realm of mind/body. Centering, observation, visualization, using mantras, affirmations, grounding, breath counting, breath control will all be addressed in a very practical and usable format.

What resources and research were used when writing this course?

I have been meditating: both learning and practicing techniques for decades, as has Shawn. I can’t tell you how many meditation and yoga workshops, books, videos and classes I have experienced over the years. I pulled heavily from that experience and my experience in the clinic and as a yoga teacher. I also bought a book that had 20 plus years of catalogued research in the fields of health and meditation to find the most clinically relevant research for PT’s. Also, I used the typical sources: pub med, medical journals. Finally, I bought all kinds of cd’s to see what was currently available. Again, I chose what I found most practical, usable (not annoying), and clinically relevant, as well as choosing a variety of styles to match different personality types/mind types.

Why should a therapist take this course? How can these skill sets benefit his/her practice?

I feel any therapist can benefit from this course because of the strength of the mind/body connection. Research has shown us that pain perception is not directly correlated with degree of injury or dysfunction. By helping your patient be in the present, rather than reacting to the past or anticipating future issues, your outcomes with your already existing manual skill set will be maximized. Similarly, as a therapist, if you can be in the present, really hear your patients, notice more with your hands, and be fully present, your interventions are certainly more directed than when you are distracted or stressed yourself. Above all, as a therapist practicing these skills, you may find yourself leading a more balanced life and less stressed by work. Certainly, not “taking our patients home with us” benefits our own health and our own families. Staying in the present moment in our own work days and our own lives ( as providers), allows us to enjoy our own lives and work days more…and who of us does not want to enjoy life more?

Want to learn more from Nari and Shawn? Join us in September for this cutting-edge course!

Research by Wong and colleagues published by the American College of Obstetricians and Gynecologists reported on the incidence of postpartum lumbosacral and lower extremity injuries. Of 6048 women who were interviewed, 56 had a new injury, confirmed by physiatrist evaluation. The researchers noted that "Women with nerve injury spend more time pushing in the semi-Fowler-lithotomy position than women without injury." The researchers also noted that women who were nulliparous (had not given birth previously who had an assisted (forceps or vacuum) birth, or who experienced a prolonged second stage of labor, were at increased risk of nerve injury.

The most common nerves involved included the lateral femoral cutaneous nerve, followed by the femoral nerve. Radiculopathies occurred at the L4, L5, and S1 levels. The authors make the following recommendations: changing positions frequently during the pushing phase, avoiding prolonged thigh flexion, avoiding extreme thigh abduction and external rotation. Other labor-related perineal nerve injuries have been documented by Sahai-Srivastava et al. to occur due to prolonged squatting or to prolonged pressure from birth attendants at the knees.

The research by Wong and colleagues highlights the important of interviewing patients about past and current symptoms, birth histories including length of time spent pushing and in what positions a woman was pushing. Teaching a woman and her birth assistants about providing support to the birthing woman's body can be very helpful; a birthing woman may welcome support of a limb, yet avoiding over-compression or sustained positions without intermittent breaks may reduce risk of nerve injury. Because the authors also noted a correlation between nerve injuries and maternal pushing at higher fetal stations (the fetus had not descended as far into the birth canal they recommend attempting to shorten active pushing time by allowing the fetus to descend further prior to pushing. (This concept in itself is a very interesting topic to be followed-up on in another post!)

To discuss issues of postpartum evaluation and nerve dysfunction, you can sign up for the Care of the Postpartum Patientor our Postpartum Special Topicsin which we dedicate an entire lab to this topic.

This November, Herman & Wallace is thrilled to be offering a brand-new course instructed by Carolyn McManus, PT, MS, MA, called Mindfulness-Based Biopsychosocial Approach to Chronic Pain. This course will be offered November 15-16, 2014 in Seattle, WA. We sat down with Carolyn to learn more about her course.

What inspired you to create this course?

I want to improve the lives of people with chronic pain and help my colleagues be successful in providing care to this often challenging patient population. With my academic training in both PT and psychology, my longstanding mindfulness meditation practice and over 25 years specializing in the care of people with chronic pain, I have a wealth of information and a wide range of practical skills to share with my colleagues.

Among my co-workers at Swedish Medical Center, I learned that those who liked working with patients with persistent pain felt they had something to offer that would help. Those who did not like this patient population felt there was nothing they could do to make a difference in the lives of these patients. I want physical therapists to have the skills and confidence to make a difference and improve the lives of people with chronic pain. I want others to know the same feeling of reward I feel when I have made that difference.

I have had colleagues comment to me that although they understand the basic principles of chronic pain, they do not feel confident to explain pain to patients or talk about the role of stress, cognitions and emotions in amplifying pain. I want to give my colleagues the language to do just that. I do not mean stepping beyond our comfort zone or scope of practice, but rather to offer patients a basic framework for the mind body relationship, based in neuroscience, that can change a patient’s attitude and belief system about pain.

I also want to introduce my colleagues to mindfulness. Mindfulness is the ability to rest the mind in the present moment with an open, friendly, curious attitude. This skillful way to pay attention has made an enormous difference in my personal and professional life and in my patient’s lives. Although it takes years of training to teach mindfulness meditation, any healthcare provider can draw on the basic principles of mindfulness to support a patient’s well being and healing.

What resources and research were used when writing this course?

I track the pain literature closely and am especially interested in how the brain changes with chronic pain and the role of stress, emotions and cognitive variables in contributing to chronic pain conditions. PTs are highly skilled to address the nociceptive component of a patient’s pain complaints. As our understanding of chronic pain has broadened to include principles of central sensitization, structural and functional brain changes and the cognitive modulation of nociceptive input, we need to have the training and skills to address these multiple and complex components that give rise to chronic pain conditions. I draw from literature in physical therapy, pain, psychology and mindfulness meditation.

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

If you ever feel overwhelmed, frustrated or challenged by patients with persistent pain conditions, this is the course for you. You will learn the about the exciting new science of pain, the amazing ways stress and cognitive modulation impacts the pain system, and how to apply mindfulness to help manage your own stress during your workday. In addition, you will be able to explain pain, the role of stress in amplifying pain, the mind-body connection and mindfulness to your patients to help empower them to maximize what they can do for themselves to promote healing and well being.

Want to learn more from Carolyn? Join us in November in Seattle!