For some patients presenting to the pelvic rehabilitation provider, vaginal yeast infections related to Candida are an ongoing issue, a prior causative factor in pelvic muscle tension, or a potential perpetuating issue in a patient's pelvic dysfunction. A recent research article discussing candida as a chronic disease aims to propose a definition of and diagnostic criteria for women who have chronic vulvovaginal candidiasis (CVVC). This was a prospective study involving 50 women presumed to have CVVC and 42 controls. Women with CVVC were found to have the following characteristics when compared to the control group: history of a positive vaginal Candida swab, discharge, dyspareunia, soreness, swelling, cyclicity, and worsening of symptoms with antibiotics. The authors proposed that CVVC diagnosis can be made confidently utilizing 5 or more of the following: soreness, dyspareunia, positive vaginal swab (current or past prior response to antifungal medication, exacerbation with antibiotics, cyclicity, swelling, and discharge.

The authors stated reasons for wanting to categorizing and address this issue is that they had frequently observed patients with vulvovaginal candidiasis who did not present with acute or recurrent episodes, but rather with a continuous issue. The symptoms in this population tend to improve during menstruation and ease with antifungal therapy. An interesting observation made in this article is that vaginal swab test may be negative even in the presence of other symptoms. There are several proposed theories as to why patients with chronic VVC may not have positive cultures (which is required for a diagnosis of acute or recurrent VVC) including that a woman may have treated herself with anti fungal medication prior to testing, that CVVC is a hypersensitivity reaction, or that bowel Candida is what sets off the vaginal reaction. The authors also assert that a complaint of itching is not in and of itself a sensitive marker that should be used for diagnosing any type of VVC.

With issues of high cost and self-medication available over the counter (often used without proper diagnosis awareness of symptom differentiation can be useful in the pelvic rehabilitation environment. If a patient is self-medicating with topical vaginal anti fungal medication, yet presents with symptoms more consistent with chronic vulvovaginal candidiasis, the article asserts that oral medications (a daily dose for up to or more than 6 months rather than a weekly dose) is less likely to cause irritation to the involved tissues, is less expensive, and is more effective.

The diagnostic criteria used in the study for CVVC is that a patient would need to have one major and 5 minor criteria, while a presumptive diagnosis would require 1 major and 3-4 minor criteria. Major criteria includes having chronic, nonerosive, nonspecific vulvovaginitis. Minor criteria includes positive vaginal swab (present or prior soreness, cyclicity, dyspareunia, prior positive response to anti fungal therapy, worsening with antibiotics, swelling, and discharge. While medical providers are left to diagnose and prescribe the appropriate medical treatment, pelvic rehabilitation providers are able to ask appropriate questions and communicate with the patient and provider(s) about suspected symptoms and concerns. Awareness of varying causes of vaginal soreness, skin irritation, and chronic VVC adds to our level of expertise in directing patients towards efficient healing.

Chronic vulvar pain and differential diagnosis are topics covered in our Pelvic Floor Series Level 3 class. Fortunately, if you sign up quickly you may still catch one of the remaining seats in our San Diego PF3 at the end of this month!

Maureen Brennan, PT, PRPC graduated from the University of Illinois at Champaign with her Bachelor of Science degree in Kinesiology, 2001 and then completed her degree in Physical Therapy from the Chicago campus in 2003. She achieved her Pelvic Rehabilitation Practitioner Certification in 2014.

Maureen has enjoyed treating patients at Rush University Medical Center for over a decade where she established a Women’s Health program and then expanded it to also include men and children. She is delighted to be part of the hospital’s Program for Abdominal and Pelvic Health which is a true multidisciplinary team that meets monthly to collaborate about challenging cases and offer continuing education opportunities for other health care professionals with an emphasis on the importance of teamwork.

In addition, she enjoys instructing a number of educational classes at the medical center that include prenatal education and pelvic floor health for employees and community members. She also presents talks focusing on a physical therapist’s perspective of pelvic floor dysfunction to Rush residents and physicians of neighboring hospitals.

In the clinic, she focuses on patient education and empowerment. She has real-time ultrasound and biofeedback machines available to support patient education. She is also certified in functional dry needling which has shown to be an invaluable modality to use with many of her patients in addition to her other manual skills such as visceral mobilization.

During the postpartum period, not only is a new mother adjusting to the needs of her infant, she is also recovering mentally, physically, and emotionally. Physical challenges can include fatigue, back pain, and healing abdominal or perineal wounds. Emotionally, women are also at increased risk for depression and anxiety which may negatively impact health of the mother and infant.

Recent research evaluated 6 clinical guidelines from the United Kingdom, Australia, and the United States for the postpartum period. (The authors point out that maternity care in these countries varies.) The guidelines fit into four main themes: maternal health, maternal mental health, infant health, and breastfeeding. Only 1 of the guidelines was deemed to have enough detail to provide data about both the mother and the infant that would guide the provider regarding care. The article states that "…scarcity of comprehensive guidelines for mothers and infants is a concern because of the stress many women experience at this time, the high burden of maternal morbidity postpartum and the significant interplay between the health of the mother and infant."

This information is valuable to the rehabilitation provider as we work with women in the postpartum period. We can initiate conversations about a woman's energy levels, sleep, and nutrition. We can inquire politely about her infant, about breastfeeding and support that she has at home. Our patients can be encouraged to discuss any concerns or anxieties about her healing or about parenting. If we do not know the answer, we can seek resources or recommend that the patient consult her healthcare team. Many women are not sure how they should be feeling, physically or emotionally, and the new mother should be reassured that any concerns she has are valuable issues to discuss. If she knows that you care about her symptoms and questions, she is more likely to express concern or share information that can help guide care, including referrals to appropriate providers.

The Peripartum series is designed to help the therapist learn about prenatal and postpartum care. Join faculty member Allison Ariail at Houston in June.

Herman & Wallace Pelvic Rehabilitation Institute would like to express thanks to the following therapists who participated in the development of our new certification, the Pelvic Rehabilitation Provider Certification, or PRPC. There were many stages of development in the rigorous process required to create a certification. Expertise was needed to provide input about examination content, format, and scope. Item writers were needed to create the 450 items needed for our test bank. Teams of reviewers volunteered time to revise items prior to the first exam offering, and raters spent many hours in team web conferences following the exam so that a cut score could be created.

Each of the following therapists contributed in some way to this process, and we are grateful for their time and expertise. (If I have forgotten to list anyone, let me know- we want to give credit where credit is due!) The PRPC is the only certification available that recognizes pelvic rehabilitation providers treating men and women across the lifespan. Congratulations to the first group of PRPC!

Dustienne Miller

Allison Ariail

Peter Philip

Karen Vande Vegte

Elizabeth Hampton

Lila Abbate

Holly Tanner

Nari Clemons

Heather Rader

Deanna Dreier

Joyce Steele

Michelle Lyons

Susannah Haarmann

Christine Cabelka

Brandi Kirk

Sagira Vora

Teri Elliott-Burke

Holly Herman

Pamela Downey

Genne DeHenau-McDonald

Tina Tyndall

Rachel Kilgore

Tina Allen

Kristina VanNiel

Megan Kranenburg

Rachel Brandt

In our blog, we have highlighted the importance of recognizing and screening for postpartum depression. What relationships exist between a person's posture and depression in the postpartum period? Prior research reporting on four studies of posture (Riskind & Gotay, 1982) noted that subjects placed in a slumped physical posture appeared to develop helplessness more easily than those placed in an upright posture. These authors also stated that physical posture was a valuable clue for an observer who attempted to identify states of depression. Results of the fourth study include that "…subjects who were placed in a hunched, threatened physical posture verbally reported self-perceptions of greater stress than subjects who were placed in a relaxed position."

A recent study addressed depression, back pain and postural alignment in eighty women between 2 and 30 weeks postpartum. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS). Pain scales included a visual analog scale (VAS) and the Nordic Musculoskeletal Questionnaire (NMQ while posture was assessed with visual observation. Findings of the study include that VAS pain scores were elevated in the women who were depressed. Back pain intensity and postpartum depression were also strongly associated. The authors suggest that back pain may be a risk factor for postpartum depression as well as a comorbidity. The article further states that physical therapists "…should be prepared to identify depressive symptoms as a comorbidity associated with posture changes and recurrent symptoms, signs of remission and recurrence that generate difficulties for treatment progression."

Can we look at this issue as a chicken and egg discussion, as in, is poor posture causativeto depression, or vice versa? And,if smiling has been determined to have the ability to improve happiness, can improved posture positively affect symptoms of depression? We know that postural dysfunction and pain can be a vicious cycle in our patients. Is screening for depression an equally important aspect of postural correction? Could postural taping, support, or re-training positively affect postpartum depression, and if so, should we be assessing and re-assessing our patients for depression as a means to document therapy benefits? The fun thing about reading research results is that the studies often lead to more questions, further hypotheses, and curiosity in relationship to how we interact with our patients. Can patients understand the relationship between postural correction and emotional health? Sounds like an opportunity for more research, and for dialoging with our patients!

If you are interested in learning more about postpartum health, click here for more information about the second course in our Peripartum series, Care of the Postpartum Patient. The next opportunities to take this class are June in Houston, and Chicago in September!

A qualitative study based in patient interview aimed to identify the reasons that survivors of gynecologic cancer do not seek help for pelvic floor dysfunction (PFD). Interviews of 15 patients by a medical provider asked both open-ended questions and provided a list of reasons why a patient may not seek care for PFD. (These reasons were compiled by the researchers based on clinical experience and on literature reviews.) Reasons for not seeking care for PFD were separated into four categories: that the pelvic floor symptoms in comparison to cancer diagnosis seemed bearable, the specialists did not make any recommendations about the PFD, the patient did not want to go to the doctor or hospital, and the patient or provider was unaware of treatment options. Of the women included in this study, cancer diagnoses included cancer of the cervix, endometrium, and vulva, and types of pelvic floor dysfunction included urinary and/or fecal incontinence, overactive bladder, constipation, painful bladder, or obstructed voiding.

One of the primary reasons women did not seek care for PFD was lack of knowledge about potential treatments. Another frequent statement from the 15 women interviewed is that the pelvic floor symptoms, when compared to dealing with cancer, were "bearable." The authors in this research suggest that the medical community needs to consistently give attention to PFD following cancer treatment. In addition to screening for PFD, the medical community should provide "…timely referral to pelvic floor specialists."

In regards to the first category of reasons for not seeking referral, women made statements such as feeling "lucky" to only have PFD rather than the cancer, or that the PFD symptoms were not as severe as other symptoms related to cancer diagnosis and treatment. Other women reported that they had symptoms prior to cancer treatment and were "used to them." Reasons women reported for not wanting to visit the doctor or hospital included fear that the symptoms meant that the cancer had returned or that the symptoms were too embarrassing. When discussing the lack of awareness about treatment for PFD, some women assumed that the physician would have referred for treatment if therapy was warranted or needed, and others did not not know where to go for help. Some women even reported that the oncologist stated that there was no treatment available to help with symptoms of PFD.

This information begs a reaction from pelvic floor therapists everywhere. How can we best interface with both these patients and the physicians? How can we infiltrate the journals, community lectures, national conferences, and also educate our peers about available options? While women who have suffered from cancer and pelvic floor dysfunction are not unique in the lack of awareness about treatment for PFD, common treatments for cancer can create increased tissue dysfunction, fatigue, and comorbid issues such as lymph dysfunction which complicate recovery. If you would like to work more with patients who have dealt with cancer diagnoses, but have a lot of questions about how to appropriately direct treatment, the Institute has new coursework developed by Michelle Lyons, who brings her expertise to this patient population. The next opportunity to take Oncology and the Pelvic Floor A: Female Reproductive and Gynecologic Cancers is this June in Orlando.

While the literature is clear that childbirth is a risk factor for pelvic floor dysfunction, how does a first childbirth affect the pelvic floor muscles? Does a vaginal delivery, instrumented delivery, or cesarean delivery affect the muscles differently? These questions were addressed in a prospective, repeated measures study involving 36 women. Outcomes included pelvic muscle function via vaginal squeeze pressure and questionnaires, prior to and following childbirth. The women were first evaluated between 20-26 weeks gestation and again between 6-12 weeks postpartum. All participants were primiparas, meaning that they had not given birth previously, and were found to have a significant decrease in strength and endurance after their first childbirth.

Pelvic floor muscle strength and endurance testing included maximum voluntary contraction (3 repetitions for up to 5 seconds) , sustained contraction, and repeated contractions at least 15 times. Ability to correctly contract the pelvic muscles was assessed via vaginal digital testing (with one examining finger) and perineal observation. A Myomed device was utilized with a vaginal sensor to more accurately measure strength. At the time of postpartum measurement, 33 of the 36 women were breastfeeding, the instrumented deliveries were completed with vacuum extraction, and all episiotomies were performed as right mediolateral procedures. Although the women in the study were asked if they completed pelvic muscle exercises- they were not instructed in any specific exercises.

Prior to childbirth, there were no significant differences in pelvic muscle strength and endurance between the three delivery groups. Following vaginal delivery (assisted or unassisted) pelvic muscle strength was significantly reduced, but endurance was not significantly influenced by delivery mode. While in this study, patients who had a cesarean procedure had decreased pelvic muscle dysfunction, the authors also point out that cesarean "…performed for obstructed labor or after the onset of labor has been reported to be ineffective in protecting the pelvic floor."

This study aimed to document the effect of a first childbirth on pelvic muscle strength. The authors acknowledge that controlled studies with larger sample sizes are needed to make further claims about pelvic muscle health postpartum. Ideally, even though pelvic muscle strength is reduced, we can utilize this information to establish connections about labor and delivery, and more importantly, how to minimize the impact or maximize the healing of pelvic muscles following childbirth. To further discuss postpartum issues, join us for Care of the Postpartum Patient in Houston (June) or Chicago (September)!

This post was written by H&W instructor Brandi Kirk, PT, BCB-PMD. Brandi teaches Pelvic Floor Level One and Pelvic Floor Level 2A. You can catch Brandi teaching PF2A in Maywood, IL later this month!

Recently, I was lucky enough to attend a 3-day frozen cadaver (no formaldehyde) dissection course that sparked an inquiry in my ever-inquisitive mind. While we were working on our cadaver, the coroner who was working on the other side of the complex invited us over. She wanted to show us what Crohn’s disease looks like. She had small intestines on the table and they were dissected in order to show the inside lining. The terminal ileum, where the Crohn’s disease was located, had patches of red inflamed tissue in it. The coroner proceeded to say that there was a significant amount of adhesions along the cecum, around the ileocecal valve and into the terminal ileum stemming from a prior appendectomy. Of course my mind cannot just let this information go by without some analysis…. could the appendectomy have contributed to the development of Crohn’s disease?

Travel along this thought process with me for a moment. The field of science has, to date, not found the actual cause of Crohn’s disease. With the new information I gained at my dissection course, I began to formulate a theory. My theory? Maybe the adhesions and scar tissue created by the appendectomy began to cause issues in the terminal ileum, ileocecal valve and cecum. One issue could be a decreased flow in undigested or digested food particles/chyme that causes stagnation in the terminal ileum, and over time irritation and then an inflammation of the inner mucosa. The second issue could be that the adhesions could additionally cause a decrease in circulation and lymphatic flow in the area, which also could cause an inflammatory condition.

Evidently, I’m not the only one with an inquisitive mind in the medical community! When I got home from the course, I did a search on “appendectomy and Crohn’s disease.” There is actually research that has already been completed on the topic. Some of my findings were: Appendix surgery cause Crohn’s disease? This article discusses the January 2003 issue of Journal Gastroenterology where it was found that people who had their appendix removed were 47% more likely to develop Crohn’s disease than those who did not have surgery. Badgut.org: “ IBD and Appendectomy” This article discusses the appendix having an influence over the immune system and thus appendicitis increasing the risks of Crohn’s disease. IBD and Your Appendix: This article discusses two studies on this topic. The first one showed an increase risk of Crohn’s disease within the first 20 years after an appendectomy and that women were at a higher risk than men. Unfortunately, the article did not share why the women were at higher risk than men. The second study showed a hypothesis that the original attack of appendicitis may actually be the first flare of Crohn’s disease. Potentially the patient always had Crohn’s, which went undiagnosed until the disease progressed enough. It was stated that more research is definitely needed on this correlation.

So what does this mean for practicing therapists, who are treating patients who are suffering from Crohn’s disease? If the patient has had an appendectomy, we should start there. Use all of your manual therapy skills such as visceral manipulation, myofascial release, scar massage and connective tissue manipulation in that area. In my clinical experience, which is correlated to research findings, the pelvic musculature in patients with Crohn’s disease tends to be hypertonic. These muscles need to be treated, but only after you address all of the abdominal restrictions. Through my dissection course, I was able to expand my vision about how connected the human body is. I’m afraid that as “pelvic therapists,” we tend to get tunnel-vision and we tend to blame those poor little pelvic muscles that are usually just doing their job. Yes, in the patient with Crohn’s disease they will be hypertonic, but why? They are just trying to guard and protect! They will still have to be released, but maybe not as the first step in your treatment plan. Once you release some of the fascial restrictions and improve the movement of the intestines and improve the circulation and lymphatic flow, then the pelvic muscles will not have a reason to become hypertonic again after you release them.

So let’s try to keep in mind the correlation between appendectomies and Crohn’s disease and treat those fascial restrictions first before you treat the compensatory pelvic muscles.

While hysterectomy is the second most common surgery performed on women; hysterectomy rates in the US have been declining as awareness improves about minimally invasive alternatives. According to the National Women's Health Network (NWHN hysterectomy may be associated with increased risk of heart attack, surgical complications, urinary dysfunction, fistula, UTI's, sexual dysfunction, depression, and hormonal deficiencies. The NWHN describes medical necessity for hysterectomy as occurring in cases of invasive cancer, unmanageable infection or bleeding, and uterine rupture or other serious peripartum complications.

What can a woman do as an alternative to surgery? For fibroids, medication, laser ablation, cryosurgery, and myomectomy may be options available to a woman. For precancerous cells or non-cancerous growths, a LEEP procedure or cryosurgery can be performed, or a partial rather than a complete hysterectomy can be completed. Endometrial ablation or dilation and curettage (D&C) can be used to remove the lining of abnormal tissue. Endometroisis may be managed with laparoscopy, pain medication, and hormone therapy, and symptoms of a uterine prolapse may be aided by a pessary, suspension surgery, or by pelvic rehabilitation. (Hysterectomy, 2005)

In an article by Solnik and Munro (2014) indications and alternatives to hysterectomy are discussed. The authors emphasize that the physician must make every effort to determine the true etiology of the patient's pain, and they caution that women who have chronic pelvic pain "…should be counseled against hysterectomy…" In the clinical practice of the pelvic rehabilitation provider, there is value in being aware of the alternatives to the extent that we can present the current options available to a patient. Directing women to discuss alternatives to hysterectomy with their medical providers may be helpful, and directing women to websites such as the National Women's Health Network or womenshealth.gov can allow the patient to explore options for herself.

If you are interested in learning more about advanced concepts in pelvic rehabilitation such as clinical reasoning regarding patients who are candidates for hysterectomy or conservative care for symptom management, the PF3 Course in the pelvic floor series is an excellent class. Click here to find out when you can sign up for this popular course!

References

Hysterectomy. (2014). Retrieved April 16, 2014 fromhttps://nwhn.org/hysterectomy.

SOLNIK, M. J., & MUNRO, M. G. (2014). Indications and Alternatives to Hysterectomy.Clinical obstetrics and gynecology,57(1 14-42.

This post was written by H&W faculty instructor Peter Philip, PT, ScD, COMT. Peter instructs the Differential Diagnostics of Chronic Pelvic Pain and the Sacroilliac Joint Evaluation and Treatment courses.

Have you ever palpated “marbles” - rolling masses along the SIJ that just don’t seem to go-away? Let’s take into consideration that you are a competent clinician, and that your patient is compliant with all of your requests. Clinical testing is negative for lumbar involvement, and both provocation and movement tests alike indicate involvement of the SIJ. Despite countless treatments directed at core training, and pelvic stabilization, the “marbles” persist.

Clinically speaking, often what is seen is that the innominate structures attain a more neutral alignment, where the sacrum maintains its hyper-nutated position. As a synovial joint, the SIJ is prone to swelling and subsequent scarring when placed under mechanical stress - hence the “marbles”. With great sincerity, the patient and clinicians alike focus on core strengthening, which often produces the correction of the innominate, but for reasons “unknown” to many clinicians and patients alike, the relative angle of the sacrum remains unchanged. Why would this be, how could this occur?

As a clinician, have you ever considered evaluating, and subsequently treating the anterior SIJ ligament? Running obliquely across from the sacrum to the innominate, the anterior SIJ ligaments have been found to be an underlying cause of chronic lower back pain, and sacroiliitis. As ligaments will do under mechanical stress, the anterior SIJ ligaments will stretch and scar, forming fibrous unions that limit their flexibility and hinder your manual techniques to improve SIJ osteokinematic motion. Akin to other ligaments of the body, once the origin of the mechanical insult has been addressed, the ligament can be directly treated via cross fiber massage, and to the surprise of many clinicians and patients alike heal in an expedient fashion; regardless of symptom duration. To best serve their patients, it would behoove the clinicians to take into consideration the concepts of central sensitization and knowledge that the anterior portion of the SIJ is innervated by segments L4 to S3! These and other strategies are discussed and implemented in both the Differential Diagnostics of Pelvic Pain, and The Evaluation and Treatment of the Sacroiliac Joint & Pelvic Ring courses.

Want more from Peter? You can catch him teaching his course on the SI Joint in Baltimore in July and the Differential Diagnostics course in New Canaan, CT in October.