As therapists are increasingly immersed in understanding of mechanisms of chronic pain and central nervous system phenomena, a question persists: what should we do with the peripheral tissues? As is usual in discussions that can take an either/or approach, the answer may lie somewhere in the middle. A recent article discussing myofascial trigger points (TrP) discusses the hypotheses surrounding this phenomena as a peripheral versus central mechanism. In a very well-cited summary of the issue, the authors come to some very helpful conclusions that you may find useful in your clinical practice.

If a trigger point, by definition, is a hyperirritable spot in a taut band of skeletal muscle that may or not have referred pain, what then, is driving the soft tissue dysfunction? Some authors argue that the peripheral nervous system is at fault, while others point to the central nervous system as the driver. Peripherally, nociceptive input may sensitize dorsal horn neurons. Centrally, patients who have chronic pain will have larger areas of pain, described as being a result of higher central neural plasticity. This is a controversial topic, and the authors are quick to point out that experimental evidence is "sparse." While there is support in the literature for peripheral trigger points creating central sensitization, the article states that "…preliminary evidence suggests that central sensitization can also promote TrP activity."

While this study does an excellent job describing various clinical and experimental research, hypotheses, and strength of evidence to support the hypotheses, the summary points are that trigger points may be both a central and peripheral phenomena, and that chronicity of the condition may drive the focus of rehabilitation efforts. Specifically, the authors state that when a patient presents with peripheral sensitization, treatment should be directed towards inactivation of the trigger point, mobilizing joints and nerves, and functional activity. Patients who present with persistent pain may require more attention directed to the central system utilizing a multidisciplinary approach such as medications, medical and physical therapy management, and psychological therapy. Fear, anxiety, and the neuroscience approach to pain should be addressed.

These issues are discussed throughout many the Institute's courses, but if you hope to get an earful about connective tissue and chronic pain research AND add tools to your toolbox, Institute faculty member Ramona Horton offers Myofascial Release for Pelvic Dysfunction. Join Ramona in June in Ohio, the last chance to take the course in 2014!

This post was written by guest-blogger, H&W faculty member Michelle Lyons. You can catch Michelle teaching our Pregnancy and Postpartum series courses, Pelvic Floor Series courses, as well as our new courses on Oncology and the Pelvic Floor and the Athlete and the Pelvic Floor. Michelle lives in Ireland and was an integral part of bringing Institute founder, Holly Heman, to the UK to teach two courses this spring.

Two weeks ago, Institute founder Holly Herman took London by storm and presented Pelvic Floor Level 3 to an enraptured audience. Twenty one unsuspecting British and Irish physiotherapists gathered in the Chelsea and Westminster Hospital for an unprecedented weekend of pelvic health assessment and treatment techniques. They may have been surprised at the breadth and width of topics covered, from orthopaedics, hormones and surgery, but they weren’t the only ones who got a surprise that weekend.

The night before we started, Holly and I were at the hotel, preparing slides and tweaking the schedule, when a very familiar head popped around the corner – Diane Lee! To say that Holly was surprised would be something of an understatement (I had been sworn to secrecy for months beforehand – dire threats had been issued!) The hilarity and bonhomie that ensued set the tone for the rest of the weekend.

We had a mix of clinicians – physiotherapists who just treated women, those who specialised in all areas of pelvic health and a couple of brave musculoskeletal physios for whom this was their first pelvic floor course! We were lucky to have a great presentation by Jenny Burrell, of Burrell Education, the UK’s leading provider of continuing education to fitpro’s, who highlighted how her profession works with pelvic floor issues with an entertaining and dynamic presentation, and the legendary Diane Lee also gave a presentation on her latest work and research on diastasis. Diane was generous with her time and knowledge throughout the course and I think gained a new insight into the world of pelvic rehab!

Holly also gave a three hour presentation during her time in London, to a large audience containing physiotherapists, doctors, midwives and fitpro’s, including a very dynamic theraband demonstration of the role of the pelvic floor in all aspects of health and function. Special mention must go to Mr Gerard Greene, who played the role of the clitoris with aplomb!

Holly worked tirelessly throughout the weekend to make sure that everyone left on Sunday evening enthused and excited about pelvic rehab and our role as part of the multi-disciplinary team. While British and Irish physiotherapists have traditionally enjoyed more autonomy in the private practice setting (there is a long history of direct access), there is common ground between US therapists and their Irish & English counterparts when it comes to highlighting the broad role of pelvic rehab providers to our medical colleagues and our communities – a great deal of enthusiasm for the international roll out of the PRPC process was observed.

Compliments were flowing throughout the weekend, not only regarding Holly’s fantastic teaching style but on the hugely beneficial resource that the PF3 manual was sure to become. Plans are already afoot for future HW courses on this side of the pond.

This post was written by H&W instructor, Ginger Garner, PT, MPT, ATC, PYT, who teaches the Yoga as Medicine for Pregnancy and Labor & Delivery and Postpartum courses, and is teaching her brand new course, Extra-Articular Pelvic and Hip Labrum Injury, in June in Akron, OH.

Pregnancy brings with it a bevy of physiological and hormonal changes, both of which greatly influence orthopaedic health, not to mention psychoemotional well-being. However, what has historically been overlooked is the risk at which the acetabular hip labrum and related structures are placed during pregnancy, labor, delivery, and the postpartum. Hip labral tears are debilitating and painful, preventing normal ambulation, ADL completion, or participation in any recreational activity, including sex. Tears can also lead or contribute to pelvic pain, with the average time of injury to diagnosis being an average of 2.5 years. This delay in diagnosis can put mothers at high risk for developing chronic pelvic pain.

Several theories have been posited as to why pregnancy brings increased risk of hip labral pathology. Increased joint laxity has been widely debated but is generally accepted as a plausible mechanism in back pain, sacroiliac joint dysfunction, pubic symphysis dysfunction, or related pain. Increased (axial) loading through the joint combined with joint laxity are thought to be compounding factors. These changes alone could explain the presence of a prenatal tear, says researchers Brooks et al (2012).

Unavoidable changes in joint structure and function during labor and delivery also place mothers at higher risk, which means screening for hip joint intra-articular pathology is vital in the clinical setting. Further, forces applied externally during labor can be responsible for hip labral tears. Brooks et al (2012) found 4 of 10 women (all with labral tears) reported a specific incidence during labor, such as a pop, twist, or sudden sharp pain in the hip, that led to their diagnosis of hip labral tear. The range of motion that is most often forced in the hip during labor is flexion and internal or external rotation, combined with abduction. This is a common mechanism of injury that applies torque at the hip joint and can commonly be delivered by a birth assistant (husband, relative, or health care professional). Birth biomechanics education is an important aspect of hip labrum preservation that should be included in interdisciplinary care.

Screens to identify mothers at highest risk for hip joint pathology and special tests to target the hip labrum and related structures should be considered a regular part of prenatal and postpartum care in women’s health physical therapy. Hunt et al (2007) raises the importance of interdisciplinary interaction in maternal health care since “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.”

Finally, pre-existing conditions of the hip and pelvis, such as femoral torsion, femoracetabular impingement (FAI), hip dysplasia, shallow acetabulum, and lumbopelvic instability or failed load transfer can all contribute to the incidence of, and increased risk for, hip labral tears. Since over 80% of women give birth in the United States during their lifetime, the vast majority of women are at risk for hip labral tears. Universal screening and education for hip joint preservation should be made available, through women’s health PT, as part of national agenda to improve birth and maternal health outcomes.

A discussion of postpartum risk, screening, and education are offered in the new Hip Labrum Differential Diagnosis course. This course emphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. My courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. At the course, I will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip.

Want more from Ginger on this topic? Join us in June!

This post was written by H&W faculty member Elizabeth Hampton, who will be debuting her course, Finding the Driver in Pelvic Pain, in May at Marquette University. 

Your client presents with a referral from an OBGYN for evaluation and treatment of vulvodynia. During your evaluation, you confirm that she has pubic symphysis instability and that her vulvar pain reduces by 90% with use of a pelvic compression belt. How do you screen for musculoskeletal dysfunction as well as specific urogyn/colorectal and pelvic floor issues in these complex clients? How do you develop the clinical reasoning methods to prioritize evaluation and treatment interventions? If you send a report back relating her pain to pubic symphysis instability, will the physician think that they sent this client to a PT who doesn’t understand the pelvic floor?

Your next client presents with stress urinary incontinence during box jumps and running, however she has no pelvic floor laxity and her strength is 4/5 bilaterally. She denies leaking with coughing, sneezing, lifting, bending. You notice that she has failed load transfer with jumping, weak abductors and marked anterior pelvic tilt that becomes more exaggerated with jumping. Her thorax is rigid and her habitual breathing method is with full abdominal wall relaxation. She demonstrates that a ‘core contraction’ means to her and she holds her breath and bears down. Is this an unstable urethra due to fascial incompetence, poor motor control or is it driven by her poor shock absorbtion with plyometrics?

Part of the joy of working with clients with pelvic floor dysfunction is the ability to sleuth out musculoskeletal dysfunctions as a contributor and (at times) the primary driver of pelvic floor dysfunction. How do you assess a client who may have much co-morbidity that contributes to her pain? It can feel like there is so much to do and it is hard to know where to start.

The good news is that Herman Wallace has many educational resources to fill your toolbox relating to this topic. In the new course I am debuting through H&W, Finding the Driver in Pelvic Pain, fundamental screening tests for spine, pelvic ring, hip tests are integrated with direct PFM assessment to determine all factors in the evaluation of pelvic floor dysfunction.

Clinical Reasoning is an essential tool in the evaluation and treatment of clients with pelvic floor dysfunction as it enables differential diagnosis and prioritization of treatment interventions. The majority of clients with pelvic floor dysfunction have associated co-morbidities which may include labral tear, femoral acetabular impingement (FAI), discogenic low back pain (LBP), altered respiratory patterns, nerve entrapments, fascial incompetence or coccygeal dysfunction. These complex clients require the clinician to have a comprehensive toolbox to screen both musculoskeletal as well as pelvic floor dysfunctions in order to design an effective treatment regimen. This intermediate- level, 3-day course is designed for rehabilitation professionals treating pelvic pain and elimination disorders who seek additional skills in the evaluation and treatment of musculoskeletal co-morbidities as well as clinical reasoning with prioritization of interventions. Participants will be provided with differential diagnosis and clinical reasoning that can be applied to their clients immediately. Internal and external pelvic floor assessment is critical for evidence based evaluation and treatment of pelvic pain and elimination disorders. This data, along with the musculoskeletal screening, can determine if the pelvic floor dysfunction is the outcome or the cause of the problem. This intermediate level course is an excellent adjunct for clinicians interested in learning how to evaluate and prioritize the treatment interventions of clients with pelvic floor associated musculoskeletal dysfunction.

Want more from Elizabeth? Join us at Marquette University in Milwaukee, WI in May!

This post was written by guest-blogger, H&W faculty member Michelle Lyons. You can catch Michelle teaching our Pregnancy and Postpartum series courses, Pelvic Floor Series courses, as well as our new courses on Oncology and the Pelvic Floor and the Athlete and the Pelvic Floor. Michelle lives in Ireland and was an integral part of bringing Institute founder, Holly Heman, to the UK to teach two courses this spring.

As a longtime fan of Holly Herman's work, it has been my pleasure to help bring her depths of knowledge and unforgettable teaching style first to London to teach Pelvic Floor Level 3 and then on to Dublin to allow us Irish PT’s the honor of being the first to attend her new course, Sexual Medicine for Women & Men.

We had 26 therapists travel to Dublin from all over Ireland, Northern Ireland, Scotland and England as well as one intrepid PT who flew to us from Saudi Arabia!

This is a course unlike any other I have attended – over the course of two intense days, we explored our own sexual perceptions and biases and how by challenging those notions, we can provide even better healthcare to our patients as part of a multi-disciplinary team dealing with sexual health issues.

It is an enormously practical course, not only in exploring the anatomy and physiology of sexual function and dysfunction but also in looking at the essential role therapists must play if we want optimal outcomes for all of our patients.

This course provides the framework for all aspects of assessment and treatment of sexual health issues, all the way from interviewing skills, to building awareness and acceptance of alternative lifestyle choices, and a strong influence on the role of orthopaedic concerns in sexual health. Gender specific issues such as hormonal changes in postpartum and perimenopasual women, and erectile dysfunction and Peyronie’s disease in men were also covered in depth. Participants will leave this course well equipped to understand the different sexual health issues that present to women and men throughout the lifespan, as well as an understanding of transgender, LGBT and heterosexual practices and preferences.

Of course we had to show Holly some Irish hospitality during her visit – a substantial number of us went out to Temple Bar in Dublin’s city centre for feasting and frolics and we introduced Holly to Irish dancing – a true functional test of our pelvic floor integrity! In the late 19th century, Benjamin Jowett said ‘What I don’t know isn’t knowledge’ and the same can be said of Holly Herman. She brings not only an engaging and insightful teaching style, but an incredible depth of knowledge in orthopaedics, pelvic health and sexual function, knowledge which she generously shares with all of her class attendees. Don’t miss the first opportunity to experience this course in the US is coming up soon in Rhode Island – as one of the participants in Dublin commented in her feedback form: ‘it is a life altering course!’

If you would like to catch the Sexual Medicine course in the US, it will be offered in Newport, RI on April 5-6. We hope we can look forward to having you there!

Psychological distress and cognitive impact are common sequelae of a cancer diagnosis, even once a patient is considered disease-free. Fear of cancer recurrence or progression is a significant issue for many patients, and can have severe impacts on a patient's well-being and function. Research published in August of last year describes predictors of this fear of recurrence, or FOR, in almost 1300 patients who completed a range of validated measures. The study reports that patients within a lower social class, this with skin cancer, colon or blood cancer, palliative treatment intention, pain, an increased number of physical symptoms, depression, and decreased social support were at higher risk of having fear of cancer.

Fear and psychological distress could potentially impact a patient's life in many ways, and also may have an effect on a patient's ability to maximally participate in recommended rehabilitation. If a patient is experiencing anxiety and/or depression, getting out of the house, making it to appointments on time, and participating in health programs may be very difficult. Cognitive impact from treatment or from psychological stress can also make remembering a home program or other instruction from you very challenging. What are things we can do to support a patient who has been impacted by a diagnosis of prior cancer? We can ask some simple questions…

What if we, as rehabilitation experts, acknowledged this research and simply asked the patient if fear of cancer recurrence or progression was creating any struggles for him or her? We already inquire about pain and physical symptoms, so can we link a reduction in physical symptoms to reduced psychological distress? Reducing pain and improving function is a logical way for us to have a positive impact. We can also screen a patient for the FOR risk factors mentioned in the literature, and ask if the patient has noticed some changes in the way information is processed or retained since having treatment for cancer. Knowledge that the patient experiences quick mental fatigue is valuable when designing home programs or when teaching important concepts; a therapist could use brief, repeated instruction rather than one long explanation. If a patient describes significant distress, discussing referral options is another way in which rehabilitation providers can serve our patients.

A Cochrane summary that was updated last in 2012 confirmed that a regular physical examination and annual mammogram are as effective as "more intense methods" of exam in detecting a cancer recurrence. If fear of recurrence prevents a patient from wanting to schedule a medical follow-up, we can encourage a patient to make any recommended medical appointments so that changes in health status are caught as early as possible. For further discussions in caring for patients who have experienced cancer, the Pelvic Rehab Institute offers Rehabilitation for the Breast Oncology Patient as well as Oncology and the Pelvic Floor, Parts A and B. The breast oncology course is taking place next month in San Diego, and the pelvic floor oncology (female) course is scheduled for June in Orlando!

This blog post was written by faculty member Bridgid Ellingson, DPT, MPT, OCS, BCB-PMD. Bridgid is a private practice owner in the Chicago area and she is an instructor for the Institute's pelvic floor course series Level 2B course.

For years I resisted taking a physical therapy student into my clinic for their final rotation. The traditional physical therapy curriculum does not adequately prepare a student for the experience and I do not believe that physical therapy for the pelvic floor is entry level work. However, I recently had a particularly motivated student convince me to give it a try and I’d like to share my experience to help prepare other clinicians interested in taking students.

I first reached out to physical therapists in the community for advice- there were very few in the private clinic setting who had taken students. I was advised to interview the student to make sure she was a good fit. I was also advised to set realistic expectations with the student and the advisor- I could not guarantee how much hands-on experience she would get in my clinic. In the end, we agreed to a split clinical with the student in my clinic two days per week for ten weeks. This student had displayed entry level skills in previous clinicals and her advisor was not concerned that she would not be working independently or even with just supervision.

The next step was to prepare her for the clinical. The ideal scenario would have been to have her attend Pelvic Floor Function, Dysfunction and Treatment (Level 1) prior to the clinical, but the logistics did not work out for her. Instead she took two online continuing education courses: Functional Applications in Pelvic Rehabilitation Part A and B. She studied anatomy extensively and utilized many other internet resources. In my clinic, I prepared my clients by telling them that a special PT student with a strong interest in learning about pelvic floor rehabilitation would be working with me for the next ten weeks but that their care would not change and they always would have a choice as to whether to allow the student to observe or participate in treatment.

In the end, I feel that the clinical went quite well for me, the student, and my clients. The student was well prepared, respectful, professional, and had a good rapport with my clients. She was able to participate in history taking, health screening, orthopedic assessment, treatment planning, and documentation. Her ability to analyze data and formulate hypotheses and prognoses progressed well over the ten weeks. While she did not perform a pelvic floor examination on a client, she did bring in a “model” and I talked her through a complete pelvic floor examination. She did learn a variety of external treatment techniques and was exposed to the use of visceral manipulation, craniosacral therapy, trigger point dry needling, biofeedback, and rehabilitative ultrasound imaging specific to the pelvic floor. I believe that the after she gains hands-on experience by taking the Herman Wallace Pelvic Floor Series courses, she will be adequately prepared to start her career as a physical therapist specializing in pelvic floor disorders.

As rehabilitation providers move towards primary care for musculoskeletal dysfunction, the privileges bring responsibilities. Regardless of our level of training and degree attainment, screening for underlying medical conditions is at the forefront of our work at all times. During the postpartum period, it is understandable that a new mother may report fatigue, aches and pains, as she tends first to the needs of her newborn. Many pelvic rehabilitation providers love working with new mothers because we have such a powerful opportunity to serve, support, educate, and nurture our patients.

One important health risk to keep in mind in the postpartum period is blood clots, or thrombosis. Changes in a woman's physiology during the peripartum period alter her risk factors for experiencing blood clots, a topic that is discussed in our pregnancy and postpartum courses. A deep vein thrombosis, or DVT, often occurs in the calf area, but the upper extremity can also develop clots. While local injury can result from a DVT, a major risk of a DVT is the progression to a pulmonary embolism, when a blood clot travels through the blood stream to the lungs- this is a life threatening condition. An article in the New England Journal of Medicine reports that the most significant risk period is within the 6 weeks postpartum. Let's get to the heart of this issue: how do we screen for a DVT or pulmonary embolism?

According to the Mayo clinic, in about 50% of cases of DVT, symptoms are not noticeable. When they are, they include:

Symptoms

• Swelling in the affected limb
• Pain in the leg, like a charley horse
• Warmth over affected area
• Changes in skin color (blue, pale, or red)

Warning signs of a pulmonary embolism:

• Sudden shortness of breath
• Chest discomfort that increases with deep inspiration
• Faintness, lightheadedness, dizziness
• Rapid heart rate
• Sweating
• Coughing up blood
• Anxiety or nervousness

If a patient is screened for the above, and you suspect a DVT, what should you do? If the first thought that comes to mind is the clinical test known as "Homans's Sign," unfortunately, that is not a current response. The best thing to do is to contact an appropriate provider (perhaps the referring provider, primary care provider, emergency room provider, etc) and report on the findings of Wells criteria. Providers can base further diagnostic testing upon this clinical prediction rule for DVT screening. To read an article about application of Wells criteria in the clinical setting, click here. If you google "Wells criteria" you will also find many reliable sites that calculate the test for you.

If you are already working with women in peripartum periods, please join us in our Peripartum Course Series! The next opportunity to take Care of the Pregnant Patient is April in Illinois and Care of the Postpartum Patient happens at the end of this month in California!

xPop Quiz

1. Can a pelvic rehabilitation provider help a male patient who has erectile dysfunction (ED)?
2. Is there research to support a claim that rehab helps with ED?
3. Are there any medical conditions a pelvic rehab provider should suspect when a patient complains of ED?
4. Are there any screening tests a pelvic rehab provider can complete to rule out medical causes of ED?
5. Are there any pelvic rehabilitation courses that discuss ED in men?

If you answered "yes" to all of the above questions, well done. A pelvic rehabilitation provider can indeed help a patient who presents with complaints of erectile dysfunction, and the highest level of evidence (randomized, controlled clinical trial) has been completed to support this claim. Medically, a patient with ED may be suffering from heart disease, diabetes, metabolic syndrome, or even multiple sclerosis and should be screened by a medical provider prior to working with a pelvic rehabilitation provider. Skilled listening, and screening tests such as blood pressure, balance, and medication screening can be utilized in the clinic to alert the therapist to a medical issue.

As many of our readers are members of the APTA Section on Women's Health, you may have seen a recent email inviting interest in a men's health subgroup. Hooray! As we know intimately, both men and women are underserved in the world of pelvic rehab. In our training programs, it was rare to learn about the specific pelvic floor muscles, let alone the male versus female sexual health dysfunctions. If you are interested in learning more about the clinical reasoning process, the anatomy, and the research behind erectile dysfunction, join Holly Tanner and Stacey Futterman in California at the end of the month in Torrance!

Male Pelvic Floor Function, Dysfunction, & Treatment not only covers male sexual health, but covers in depth the topics of urinary incontinence and male chronic pelvic pain. As many therapists are already working with patients following prostate cancer surgery, these topics are very applicable in current practice. The course is only a couple weeks away, and it's in sunny California near the ocean. The men in your care will thank you!

This blog was written by H&W faculty member Jenni Gabelsberg DPT, MSc, MTC, WCS, BCB-PMD. You can catch Jenni teaching Care of the Postpartum Patient later this month in Oakland, CA.

Physical Therapists specializing in Women’s Health are in a unique position to help guide and inspire women during their perinatal years, affecting both the health of the woman, as well as the long-term health of any unborn children.

In a recent study published in The Journal of Perinatal and Neonatal Nursing, early onset childhood obesity was determined to be one of the leading pediatric health concerns in the US. Women in their peripartum years need to be educated on what the risk factors for childhood obesity are, and how their personal health decisions can affect their children even before they are conceived. These risk factors are stated as being: maternal obesity at time of conception; excessive weight gain during pregnancy; smoking before, during, and/or after pregnancy; and bottle-feeding the infant after birth.

If a child is born of an obese mother, it has been shown that by four years of age, 24% of children were already obese (and only 9% of children born to mothers of normal weight during first trimester of pregnancy). If a mother gained more than the recommended amount of weight during her pregnancy, it has been shown that there is a 6 times increased risk of that child being overweight or obese by preschool. According to the WHO, an obese mom who gains more than the WHO recommended 11-20 pounds during pregnancy has a 48% increased risk of having an overweight or obese child by age 7. Children who are exposed to smoke in utero were both higher risk of being obese in childhood, and also being of shorter stature. And finally, infants who were fed by bottle were shown to have three times greater risk of rapid weight gain compared to those breast-fed in the first three years of life.

These risk factors not only affect the infant’s birth weight, but can also influence their weight as toddlers and preschool ages. According to the WHO, “Childhood obesity is one of the most serious public health challenges of the 21st century. “ The prevalence of childhood obesity globally is increasing at a rapid rate and has serious implications into adulthood. If children begin life as overweight or obese, they are much more likely to remain obese into adulthood, and also more likely to develop lifelong chronic conditions such as diabetes and heart disease.

More information about childhood and adult obesity can be obtained by watching the HBO series “Weight of the Nation”, which has interviews of many researchers who are focusing their studies on the secondary complications of obesity and how we can fight them. As physical therapists treat women during their childbearing years, it is critical that we use that time to educate women on the long term impact of their health choices and inspire them to make positive changes that will impact both their health and their children’s health for the long term.