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Herman & Wallace Blog

Topicals for pain relief

Check out this 8 minute video update on use of topicalsfor pain management on MedScape today. Dr. Charles Argoff, Professor of Neurology at Albany Medical College, shares updates in research from the American Academy of Pain Management meeting that took place in September. In the video, Dr. Argoff discusses various types of topical agents that have been tested for relief of acute and/or chronic pain. A topical agent, he points out, has a more local effect, with less systemic uptake than an oral medication, and ideally less side effects because of the decrease in general uptake.

Some of the topicals are anti-inflammatory, such as Voltarin, which can be used for osteoarthritis. Pennsaid and the Flector patch also have an anti-inflammatory action. Pennsaid has research to support its use for knee osteoarthritis, and the Flector patch is applied for muscle sprain/strain type injuries.The lidocaine patch, which has FDA approval for post-herpetic neuralgia, has also been reported to be useful for chronic musculoskeletal pain or complex regional pain syndrome. The Qutenza patch (with 8% capsaicin, extracted from chili peppers) has been demonstrated to be helpful for reducing pain of post-herpetic neuralgia. This patch works on a specific receptor that is in the skin, thereby reducing local pain. Whereas the lidocaine patch can be applied by the patient, the Qutenza patch must be applied carefully in an office setting.

Dr. Argoff concludes that the skin (and therefore topical, local applications to skin in painful areas) may be "...far more important than we ever thought in helping people control their pain." This is due to the important role that skin (an organ) plays in the initiation, maintenance, and modulation of the pain experience.

So how can topicals be useful to our patients with pelvic pain?When working as a team with medical providers, we can advocate for our patients to have the option of trying some pain patches over tissue that can tolerate such an application. Perhaps coccygeus pain, ischial bursitis pain, or other sites of neuropathic pain in the inguinal area, gluteal regions, or abdominals would respond favorably to the application of topicals. An example of research supporting use of topicals is thisCanadian studythat describes the benefits of a mixture of amitriptyline, ketamine, and lidocaine for neuropathic pain caused by radiation dermatitis. As with most modalities for pelvic pain, we need more research.In the world of pelvic pain, any option that assists the patient in healing the pain experience can be positive.



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Vaginal Diazepam

Vaginal diazepam has been used by patients who have pelvic pain as an "off-label" drug option yet there has been little research to support its use. Recognizing that conditions such as painful bladder syndrome (PBS)/interstitial cystitis (IC) may be complicated by pelvic muscle dysfunction, the use of diazepam (brand names include Valium) aims to target the muscle overactivity.

In the September/October issue of Urologic Nursing, Donna Carrico, MS, WHNP, and Kenneth Peters, MD, report on the effects of vaginal diazepam on 21 women (mean age of 40) who were diagnosed with urogenital pain. Women completed assessment scores at baseline and at one month after being treated with vaginal diazepam. 2-10 mg ("...as needed for symptom relief...") was prescribed to be used up to every 8 hours. Most women started at 5 mg unless they reported high sensitivity to most medications. Although patients had the option to have the medication compounded into a cream or suppository, all patients chose to utilize the oral tablet inserted vaginally. (It was either inserted whole or crushed and mixed with vaginal lubricant to be inserted into the vagina.) The women recorded weekly their dose, usage, and pain score on 0-10 Visual Analog Scale (VAS) as well as any adverse effects that occurred over the month. A serum diazepam level was recorded at the end of the 4 weeks for the 15 women who were using vaginal diazepam at least daily, and these levels were found to be in the normal range.

VAS scores decreased on average from 4.8 to 3.4, average vulvar Q-Tip level decreased from 3.3 to 1.2, and vulvar pain levels decreased at one month follow-up as well. Only 1/3 of the women reported a side effect of drowsiness, otherwise no side effects were reported.Interestingly, some patients found it helpful to insert the medication vaginally 1 hour prior to engaging in intercourse so that pain was reduced.

The authors are quick to point out that this research was not conducted as a controlled trial, and there is no proposed protocol for the use of vaginal diazepam. What this research does assist with is establishing that the off-label use of diazepam vaginally in those suffering with urogenital pain may have few side effects and may offer benefits. Because pelvic pain often does not have a target organ as a cause, and because pelvic muscles are involved in most urogenital pain cases, it makes sense to address the involved muscles. Of course, pelvic rehab practitioners are well-trained to address the muscles via direct releases as well as through the use of other modes, yet having assistance of pharmacology may be a useful tool for the patient.

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Biofeedback for Children with Dysfunctional Elimination

Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here.

Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.

The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy.

If you have a biofeedback unit (for surface EMG, or sEMG, one type of biofeedback) and know how to use it, you can apply this wonderful skill in the care of children who need your help. Many of the computer programs do have animations included in the software. If you would like to learn more about treating children who have bowel and bladder dysfunction, the Institute offers a course in pediatric pelvic rehabilitation with faculty member Dawn Sandalcidi. The next course is scheduled in May in Texas. Click here to see more information about the class.

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New Book Available: Healing Painful Sex

Dr. Deborah Coady and Nancy Fish, MSW, MPH, have collaborated to offer a book exclusively for women who have pain with sexual function. The book is called Healing Painful Sex: A Woman's Guide to Confronting, Diagnosing, and Treating Sexual Pain. Dr. Coady and Ms. Fish both work in a practice in New York serving women who have chronic pain. You can read more about them here. Their book explains how prevalent sexual pain is and for our patients who feel isolated in their pain, this concept in itself is a valuable thing to share. Medical treatments available for pelvic pain are included in this book so patients can be better prepared to discuss their concerns with a provider.

Healing Painful Sex is a very patient-centered book and includes many actual patient stories, allowing the reader to gain perspective about the various ways that pelvic pain can interfere with relationships, work, and typical activities. The reader also can gain insight into how to bring support into her life so that healing can take place.

This is a great book to add to your collection so that you can share with patients that there is a new resource available to help increase their knowledge and perhaps their level of hope. If you would like tolisten to an archived radio broadcast of the authors speaking with Dr. Melanie Barton on the Dr. Melanie Show, clickhere. The book is easily available from Amazon and Barnes and Noble and is very reasonably priced.

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Neutral Language in Patient Care

PT in Motion recently reported on a newfield guidecreated by theJoint Commissionthaturges US health care providers to create a more inclusive and safe environment for LGBT (lesbian, gay, bisexual, and transgender) individuals. The new guide points out that LBGT patients struggle with overall lowered health status, higher rates of substance abuse, higher risk for anxiety or depression, and decreased access to insurance and health care services. Additionally, LGBT patients are not treated equally, facing refusals of care or delayed care, leading to distrust of the health care system.

One of the strategies described in the guide that will help improve communication and inclusion is the use of neutral language on commonly used forms. In a hospital this may include admission forms, in a clinic, all intake forms can use the term "partner", or "parent/guardian" may be substituted for father or mother. Verbal communication should also be free of assumptions. For example, "are you married?" implies heterosexuality to most people. Instead of referring to husband or wife, the guide suggests that you can ask, "Who are the important people in your life?", or, "Who is family to you?" Listening to and reflecting the patient's choice of language can demonstrate inclusion and help your patient feel more able to reply honestly.

Other concepts are shared towards creating a welcoming environment.For example, does your health care setting have a non-discrimination policy? Perhaps it could be more prominently displayed to demonstrate that your work environment does not tolerate discrimination of any type. Images of or descriptions of "family" should include various structures of family, including same sex couples. Your clinic can also display LGBT-friendly symbols such as the rainbow flag, the pink triangle, or a "Safe Zone" sign. Having a unisex or a single stall restroom may also be more comfortable for a patient.

There is an incredible amount of information available in this new guide, it is nearly 100 pages long and can serve as an excellent resource in your work place. The guide summarizes that "...all patients, regardless of social or personal characteristics, should be treated with dignity ad respect...and should feel comfortable providing any information relevant to their care, including information about sexual orientation and gender identity."

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Fecal incontinence: Skin protection

According to a research review by senior staff nurse Julie Patrick-Heselton, fecal incontinence in critical illness “…is distressing, unpleasant and frequently socially disruptive to patients.” Because patients who require intensive care often have diarrhea, skin care and avoidance of infection are important for patient health. If bowel care is not made a priority, patients can additionally suffer from abdominal bloating, vomiting, dehydration, urinary issues, and bowel obstruction and perforation according to the article. Skin that is exposed to excess moisture from urine or stool becomes more fragile and at risk for breakdown. If a pressure ulcer occurs due to skin breakdown, infection becomes a major health risk.

If you are working with patients who are at risk for skin breakdown due to urinary or fecal incontinence, it is important to provide education about skin protection including barrier creams. These topics are discussed in the Herman & Wallace course series, and handouts are available in the Urinary Incontinence and the Prolapse and Colorectal Care Manuals. This study refers to Cavilon Durable Barrier Cream, and describes its use with incontinence pads for maximizing protection. For most patients, anything that contains zinc oxide or other water-repelling substance can assist in keeping the skin less moist and therefore less susceptible to breakdown.

Another resource described in this article is the Flexi-Seal FMS (Fecal Management System). It is a device that uses a tube to divert loose or liquid stool into a bag so that skin is protected. Although this is not something that most patients in outpatient rehab would utilize, I can think of a few patients who may have been able to use such a device during periods of diarrhea and skin irritation. (One patient I recall had to periodically go through a medical procedure and take antibiotics, which always increased her fecal incontinence for several weeks. One strategy we also implemented was having her talk to a pharmacist about changing the form of antibiotic that she used from a broad spectrum to a narrow spectrum antibiotic, which was very helpful.)

While fecal incontinence may resolve in patients following a bout of critical care at hospital, I have worked with several patients who suffer from long-term diarrhea or from chronic infection of C. difficile. Diarrhea is not normal, and patients must be sure to be evaluated medically to reveal the cause of the issue. Many patients we meet in the clinic have been suffering from bowel issues for years, some for decades. Patients can routinely be screened by all providers (pelvic rehab providers or not) for bowel and bladder issues so that appropriate referral can be provided. Protecting perianal skin as well as reducing the psychosocial impact of fecal leakage is a goal that we can all work towards for the sake of our patients.

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H&W faculty talks BBGOSO

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Last weekend Herman and Wallace faculty met in Florida to work on the Pelvic Therapy Practitioner Certification(PTPC) development. The team was led fearlessly by Patricia Young of Kryterion, who assists the Institute in creating a test of the highest quality. Working within the framework of the patient/client management model that appears in the Guide to Physical Therapist Practice (APTA), faculty worked on exhaustive lists of concepts with which a pelvic rehab therapist must be competent. The work completed this past weekend allows Kryterion to create the practice analysis that will be foundational for all other elements of the test development.

The intent of the PTPC is to recognize expertise in treatment of pelvic floor and pelvic girdle dysfunction. Some of the topics that will be included on the certification exam will be pelvic anatomy, pathophysiology, medical and rehabilitative interventions, outcomes measurement, and ethics. If you currently receive the Herman & Wallace newsletter, you will be notified when Certification information is updated. If you are not currently receiving newsletters, click hereif you wish to sign up.

While the faculty worked hour after hour to move the certification process forward, there was also a lot of sharing of knowledge, learning of new vocabulary words such as "criticality" and eating of excellent food such as the kale ceasar salad made by Institute administrator Siv Prince.The letters "BBGOSO" were substituted whenever someone wanted to refer to bowel, bladder, gynecologic, obstetric, sexual, and orthopedic conditions (I even heard a rumor about a t-shirt being created). Theweekend was a great opportunity to spend quality time with other people who are passionate about their work, and who all have unique contributions that he or she is willing to share. The next step of the PTPC process will involve many pelvic rehabilitation providers as a survey involving job tasks will be sent out to those on the Herman & Wallace list. Please consider participating in the survey when you see that e-mail.The Institute looks forward to having the Pelvic Therapy Practitioner Certification available as a means of recognizing the specialized care that you provide to your patients.

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InterStim for Fecal Incontinence

Appearing in the September issue of Diseases of the Colon and Rectum, an article was published regarding the long-term efficacy of using chronic implantation of the InterStim device made by Medtronic.120 patients (110 of them female) were given the surgically implanted treatment after a positive test period with external stimulation was utilized. (Even though the external stimulation was used in the test trial, an electrode was placed surgically in the foramen of S2,3 and/or 4.) The mean duration of fecal incontinence (FI) was 7 years. The mean length of follow-up that is reported on in this study is just over 3 years, and 83 of the 120 patients completed all or a portion of the follow-up. At the time of follow-up, 86% of the patients reported at least 50% improvement in the number of incontinence episodes per week. The mean rate of episodes of FI at baseline was 9.4 per week and this reduced to 1.7 per week. Full continence was achieved by 40% of the patients. Quality of life measures including the Fecal Incontinence Quality of Life Scale were also improved from baseline.

Patients who had fecal staining were not included in this research, instead the patients in this study had at least 2 episodes of frank fecal incontinence per week for at least 6 months. At baseline 60% of the patients experienced passive anal incontinence (leaking without being aware of leaking stool), and at follow-up this number was reduced to approximately 10%. The two highest etiologies for fecal incontinence reported was for obstetrical injury (55 of the patients) and post-surgical injury (25). The majority of those in the study reported significant improvements within 3 months of beginning the InterStim treatment.

Any such procedure is not free of risk, and in this study, complications included pain at site of implant, paresthesia, change in sensation of the stimulation, and infection.It seems that for pelvic rehab providers, our first instinct is to believe that every patient can benefit from rehabilitation and thus avoid surgery. While it is often the case that conservative treatment provides benefit, there are also patients who will not make progress for various reasons. For these patients, we can provide excellent education towards improving neuromuscular function and therefore continence, we also can improve a patient's knowledge when we are aware of other options such as InterStim. For patients who fail all other rehabilitative efforts, some type of surgery or other intervention may be required.

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IPPS Highlight: Fascia and Pain

At the most recent International Pelvic Pain Society Meeting in Las Vegas, Thomas Findley, MD , PhD, discussed the continuously emerging science of fascia and the mechanisms that can produce pain when fascial tissues are dysfunctional. He described the fascial cells in the body as similar to tents, bearing compression or creating structure. It is the microtubules that bear compression in living cells. The fascial connective tissue "connects and disconnects." If you have seen the Bodies exhibit, you may recall the bodies that had everything removed except fascia, yet the structure still looked very much like a body.

Fascia covers every muscle, every nerve, every vessel, every fascicle of muscle. Dr. Findley explained that while muscle fibers have been found to be 7-8 cm long, fascicles can be found in the body that are 35 cm long. The concept of muscles that stop and start at an origin and an insertion is an illusion according to Dr. Findley, because the amount of connectivity from the muscle to the tendon and to nearby fascia create continuity that allows for functionality. One function of these fascial connections is to take part in dynamic compression of joints and loading of tissues. He gave the example that 85% of the gluteus medius muscle fibers attach into the fascia lata, not the muscle attachment itself. It is this connectivity that can help transmit force along the length of the thigh.

In relationship to pain, there is a layer of hyaluronic acid within the fascia that creates glide by acting as a lubricant. This acid can also act as an irritant and a "glue" when there is too much compression or dysfunction in the tissue. Fascia contains fibers for both nociception and proprioception. Some fiber elements of fascia turn over every 24 hours according to Dr. Findley. Within the pelvis, there are many layers of fascia with connections from the abdomen, the buttocks, trunk, and the thighs. We must continue to take into account these important fascial structures when treating those who have pelvic pain. We must also continue to take part in and look for research that expands the scientific knowledge as well as the clinical experiences of providers treating conditions such as pelvic pain.

Dr. Findley is the Executive Director of the Third International Fascia Research Congress to be held in Vancouver, BC, in March of 2012. For more information about how emerging fascial research can influence your practice, join the multidisciplinary gathering of clinicians and scientists at the meeting. The Institute incorporates myofascial treatment techniques in many of the courses offered, including a new course created by Ramona Horton, called Myofascial Release for the Pelvis.

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IPPS Highlight: Dry Needling for Pelvic Pain

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

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

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

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