In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Michele Syska, PT, PRPC

Describe Your Clinic:

Orthopedic manual based.  I love figuring out how mechanical issues may be affecting the current presentation.   I would also characterize my practice as open.  I’m up for trying new ideas either from course work, other therapists or patients.  I enjoy learning from the experience of others and have an open mind to many techniques.

What/who inspired you to become involved in pelvic rehabilitation?

I spoke with the therapist who had started the program at my clinic.  She helped to bring knowledge and understanding to the world of pelvic floor dysfunction.  She helped me gain motivation to attend my first course.  Upon attending Herman and Wallace level 1, I can truly say that it was Holly and Kathe’s unique and passionate teaching that solidified my decision.

What population do you find most rewarding in treating and why?

Male chronic pelvic pain.  For the most part, women are used to the medical profession “messing” with them.  After having several paps and babies, most women don’t arrive with the embarrassment and anxiety that more often is associated with male pelvic pain.  It’s rewarding to be able to bring comfort and relief to these patients through education and understanding.  The progression from start to finish is typically more dramatic in the way they improve their overall comfort in talking about the dysfunction and the re-integration into their work and social lives.

What Role do you See Pelvic Rehab Playing in Overall Patient Health?

One’s ability to be continent, have normal sexual function and go through their day without pain, play a large role in general well-being.  Looking for a restroom at every turn does not make for a very pleasant day.  An unhealthy pelvic floor can be extremely debilitating.  It can get in the way of basic daily activities and significantly affect ones social and work life.

Learn more about Michelle Syska, PT, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also read more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

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.

Research into the surgical and nonsurgical management of acetebaular labral tears is young, but growing fast. Physical therapy is considered an integral part of nonoperative management of acetabular labral tears, with a trial of therapy also serving as the newest standard in preoperative and postoperative care. Conservative care becomes even more important in young dancers.

A critical concern in all individuals is hip joint preservation and prevention of premature joint degeneration and development of osteoarthritis. Especially in young females, who start with a higher risk of labral tears, sports like figure skating, dancing, and gymnastics further increase risk and prevalence of tears.

There are several reasons young women can experience a labral tear, but in general the etiology will fall under five possible categories: 1) congenital, 2) traumatic, 3) degenerative (far less likely with a young population), 4) capsular laxity, and/or 5) idiopathic causes such as femoral acetabular impingement. There are many more causes that fall under each category, but early intervention is repeatedly found in the literature to be perhaps the most important variable in long-term hip joint preservation and outcomes. Duke University physical therapist and orthopaedic surgeon, Michael Reiman and Chad Mather, respectively, authored a 2014 article with colleagues from Ohio that outlines the five major etiological categories, discussing the increasing prevalence of labral tears in high-risk populations and underscoring the need for early intervention. Citing diagnosis of labral tears as “continuously challenging”, the article emphasizes that a battery of tests and screening, rather than a single diagnostic viewpoint, are requisite in identifying an acetabular labral tear.

For young dancers, early intervention is of utmost importance. A case study currently in press (April 2014) reports success with a 12-year-old skeletally immature figure skater with a diagnosis made within the first month of the onset of pain and impairment. A six-week trial of physical therapy began immediately on consensus of three pediatric orthopaedic surgeons specializing in arthroscopic management of the acetabular hip labrum. At the 4-week follow-up, progress in PT was being objectively made with pain levels diminishing and functional performance improving (with no return to skating yet). After a continuation of therapy for an additional 6 weeks, the figure skater was able to return to skating and perform single jumps and double Lutz at 75% of her normal jump height without pain. At that time, PT was decreased to 1x/day weekly while continuing her normal home therapy program. After another month of therapy, she returned to her full training schedule. At the four-month visit she had returned to full competition with full spins and jumps (double axels) without pain. The one-year follow-up found the young patient pain-free and competing at local and national competitions.

The importance of physical therapy cannot be underestimated in young athletes, especially females, due to their inherently increased risk of labral injury. Further, multiple studies cite the importance of a multi-disciplinary, integrated approach in managing the hip labrum.

My Hip Labrum Injury course will focus on this biopsychosocial and integrated approach, including both conventional and integrative techniques in order to obtain the best outcomes for patients.

You can read some of my previous posts on evaluating risk and prevalence of hip labral injury:

• Lady Gaga’s Hip Labral Tear: Are you at Risk?

• The Postpartum Hip and Labral Tear Risk

• The Importance of Early Intervention in Labral Tears

• Implicating the Iliopsoas in Acetabular Labral Tears: Focus on Anatomy

Want to learn more from Ginger? Join us in June!

This post was written by H&W instructor Lila Abbate PT, DPT, MS, OCS. Lila will be instructing Pelvic Floor Level 3 with Institute founder Holly Herman in San Diego at the end of this month! Sign up for the few remaining seats left in this popular course!

When treating your patient who has undergone a pelvic reconstruction in the not-so-distant past, does the mesh controversy come to your mind?Is the effect of the mesh causing your patient this dysfunction and is she complaining of urinary urgency, urinary frequency, or pelvic pain? Understanding pelvic muscle dysfunction, as pelvic rehabilitation providers do, can put us in a good position to help our patients, as well as to help our physicians with this oftentimes litigious issue.

Urogynecologists, gynecologists, urologists, or any surgeon who deals in the business of female sexual medicine and pelvic reconstruction seems to have been put in a position to defend their stance on the use of mesh when working with patients who present with any degree of pelvic organ prolapse (POP), be it complicated or simple.The decision to utilize mesh is now made with greater emphasis on education for the patient who is undergoing the procedure.

The Food and Drug Adminstration (FDA) has released a proposal on April 29, 2014 in order to address the potential reclassification of surgical mesh for transvaginal POP from a class II (moderate risk) to a class III (high risk) device and would “require manufacturers to submit a premarket approval (PMA) application for the agency to evaluate safety and effectiveness.” ¹ A similar proposal was put in place with breast implants in 1992 in order to create more awareness of safety concerns with the use of breast implants. ²

While older mesh kits (demonstrated to be more likely to cause complications) have been pulled from the market, any mesh surgery can create complications. As the body heals, scar tissue forms and contracts which is part of the normal healing process, and for some patients, this process can wreak havoc as the tissues and the mesh shrink. Muscles are bypassed, pressed upon, and ligaments are used as supportive measures for the mesh arms, and this can set up the pelvic floor muscles for edema, weakness, or even muscle over-activity. We know that different patients heal in different ways; just as a patient who has had a total hip replacement experiences muscle swelling, soreness, weakness, and scarring, a mesh surgery will necessarily create temporary dysfunction. However, physical therapists are skilled and well-versed in palpating and treating muscle dysfunction, scar tissue and adhesions, and we can educate our patients on the symptoms of mesh complication that may in fact be a muscle problem. Not every patient who has had mesh placement is suffering from mesh erosion, and physical therapists can help patients improve or resolve their symptoms over time through treatment.

Pelvic Floor Level 3 is an advanced course offered by the Institute that covers surgical procedures, pharmacology including hormone replacement, and other medical interventions that address pelvic muscle over-activity, tissue dysfunction, and surgical complications. Lab activities include manual techniques to downtrain (decrease muscle over-activity) such as Strain-Counterstrain of the pelvic floor muscles.

1.http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm395192.htm. Accessed on May 5, 2014.

2. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm064461.htm. Accessed on May 5, 2014.

During a pelvic muscle assessment, patients who have pelvic pain or other dysfunction that includes pelvic floor muscle tenderness will often ask the pelvic rehabilitation practitioner the following question: "Doesn't everyone have tenderness if you push on the muscles like that?" The answer should be "no," and we have research to support this claim. While it may seem incredibly simple to a pelvic rehabilitation provider that a "healthy muscle does not hurt" and that in order to optimize muscle function, the length-tension curve should be optimized, this knowledge is not universally understood by most patients. Tenderness, especially if severe or if the intensity of the discomfort inhibits a healthy muscle contraction, can be eased so that a patient can learn to appropriately contract and relax the pelvic floor muscles.

While logical to rehabilitation providers, the concept that healthy muscles are typically devoid of significant tenderness must be well-established if we wish patients, providers, and payor sources to join in our belief that diminishing such tenderness can be a marker of progress. (Of course we keep in mind that function trumps tenderness, especially when a person has no functional limitations despite presenting with muscle tension or tenderness.) Researchers have aided our profession in establishing that significant muscle tenderness is not present in young, healthy, asymptomatic patients.

In research published last year, Kavvadias and colleagues assessed pelvic floor muscle tenderness in 17 asymptomatic, nulliparous female volunteers (mean age 21.5 years with results indicating low overall pain scores. The authors also aimed to examine inter-rater and test-retest reliability of specific muscle tenderness testing using a visual analog scale (VAS) and a muscle examination method recommended by the International Continence Society (ICS) over 2 testing sessions. This study used a cut-off score of 3 or less on the 0-10 VAS to determine clinically non-significant pain. Inter-rater and test-retest reliability was reported as good to excellent for palpation to the posterior levator ani, obturator internus, piriformis muscle, and for pelvic muscle contraction, yet found to be poor to fair for pelvic floor muscle tone and anterior levator ani palpation. Resulting scores on the VAS were less than 3 for all muscles tested, leading the investigators to conclude that in nulliparous women aged 18-30 who have no lower urinary tract (LUT) symptoms or history of back or pelvic pain, tenderness "…should be considered an uncommon finding."

While this research is in moderate contrast to some research cited in the report, the authors point out that the exclusion criteria and the ages of the women were more narrow in their studied population. Other authors such as Montenegro et al. (2010) have also reported a low prevalence of pelvic muscle tenderness in healthy volunteers (4.2%) whereas Tu et al. reported a high prevalence of tenderness (75%) in women who present with chronic pelvic pain. For male patients, Hetrick et al. concluded that patients with chronic pelvic pain syndrome, or CPPS, have more pain and tension in pelvic and abdominal muscles than men without pain.

The value of research that establishes markers of health in tissues relating to function cannot be underestimated within the realm of pelvic rehabilitation. If we propose or document that reducing tender points, tension and muscle dysfunction is valuable for our patients, research that creates a baseline of non tenderness in patient populations is needed. The research from Kavvadias and colleagues assists our cause, as we can put this information together with other valuable modes of intervention to address pelvic muscle dysfunction within a holistic model of care. If you are interested in discussing further research about pelvic muscle tension, tenderness, and muscle releases, check out faculty member Ramona Horton's Myofascial Release for Pelvic Dysfunction, taking place next in Dayton, Ohio, this June.

How the concepts of stigma and taboos affect bowel function is the focus of a recent article by Chelvanayagam, a lecturer in mental health in England. The author establishes that previously taboo subjects are becoming less hidden in the media, such as sexual function or urinary incontinence, but that in the UK, bowel function is still considered taboo. When people are not given language and social permission to discuss health concerns, conditions go underreported or unrecognized and under treated.

The author points out that patients with bowel dysfunction such as irritable bowel disease, fecal incontinence, and stomas feel stigmatized and are hesitant to discuss concerns with heath care providers or loved ones. The social implications of bowel disorders can lead to socially isolating behaviors including difficulty going out to eat, participating in physical activities, or taking sick leave from work.

Because pelvic rehabilitation providers discuss intimate issues including bowel function with patients, communication skills are very important in order to allow the patient to feel comfortable about the topic. Both verbal and non-verbal techniques will be observed and responded to by the patient. Various stigma-reducing strategies are described in the article. At the interpersonal level, cognitive-behavioral and empowerment strategies are recommended, and at the community level, education and advocacy are listed. Each of these strategies are ones that the pelvic rehabilitation provider is capable of providing.

If you have been wanting to learn more about bowel dysfunction and pelvic rehabilitation, the Institute added to our offeringsa bowel course that is next offered in June in Minneapolis, and November in Los Angeles area.

This post was written by H&W instructor Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Care of the Postpartum Patient course in Houston in June.

As Mother’s day weekend approaches, I take time to think about the dramatic changes in life that occur with the birth of a baby! No one is quite prepared for how much their life will change with the birth of their child, especially their first child! There are numerous changes that occur in a woman’s life during the pregnancy and into the postpartum time, both emotionally and physically. Any woman who has had a baby knows our bodies do not revert back to the exact body we had prior to pregnancy. New moms may be left with changes in their body that can greatly affect their function. Physical therapy in the postpartum time can greatly improve a woman’s well-being and function. We can treat a woman for back pain, diastasis rectus separations, incontinence, thoracic outlet syndrome, nerve damage that occurred during delivery, and many more issues a woman may present with. We also are a listening ear for the new mom going through many changes and hormonal upheaval. It is important to stay open and listen in a non-judgmental way. New moms are inundated with unsolicited advice in a way that no other patient population is. Having a safe place to come and get treated physically can help her emotionally as well.

During pregnancy and the postpartum time many habits are formed that if not changed can influence and shape how a woman lives the rest of her life. For example, night time voiding is common for pregnant women. If a woman continues to void every time she gets up with the baby in the middle of the night once she delivers, she may continue or even worsen her habit, thus creating an issue that will greatly affect her overall sleep health and well-being for the rest of her life. Having an objective person educate a woman about some of these habits can be very enlightening for an individual!

Receiving therapy in the postpartum time can influence a woman’s overall health in the immediate future as well as down the road. There are special things to consider when treating a postpartum woman and a women’s health therapist is the best person to treat her.

You can learn about special topics that affect a postpartum woman in Care of the Postpartum Patient course. The next time this course is being offered is June7-8 in Houston, Texas. So as mother’s day comes upon us, let’s celebrate the amazing journey we and other moms take in becoming a mom. Let us embrace the remarkable changes that occur physically and emotionally and thank our own mothers, as well as ourselves, for being willing to undergo these changes!

A recent MedScape articlewarns that "no amount" of alcohol is safe in terms of avoiding cancer risk. Although the mechanisms between alcohol and cancer are not well understood, according to the article, alcoholic beverages can contain at least 15 ingredients that are carcinogenic, such as acetaldehyde, acrylamide, aflatoxins, arsenic, benzene, cadmium, ethanol, ethyl carbamate, formaldehyde, and lead. Potential causative mechanisms for alcohol-related cancer include that alcohol interferes with folate metabolism, and that in relation to breast cancer, alcohol can increase estrogen levels and stimulate mammary cell growth. Hard liquor can affect the oral cavity, the esophagus (especially hard liquor and the colon, rectum, and liver.

According to the author, patients who have health issues related to cancer should be warned to stop using alcohol and should be referred to cessation programs. Pregnant women and youth should be counseled not to drink at all. Alcohol consumption is recommended to be limited to 1 drink per day in women and 1.5 drinks per day for men. Alcohol screening is recommended as a "routine" part of an office visit. Whether the screening is completed on a written or electronic intake, or as part of the verbal history, patients should be asked to report the number of drinks per day, week, or month. Validated screening tools and referral resources that are helpful for patients are listed in this article written by Dr. Friedan.

Smoking in combination with alcohol can worsen the risk for detrimental health effects, especially in the oral cavity, the pharynx, larynx, and esophagus. Physical therapist intervention as a part of smoking cessation education can be an important and effective part of health management. Bladder health is also negatively impacted by smoking, as described in an earlier blog post. As physical therapists and other pelvic rehab providers become more involved in wellness education and integrate smoking and alcohol consumption into their clinical practice, increased knowledge about cancer-related lifestyle issues can be helpful. The Institute offers our Oncology series including a Female and Male focused course on cancer and the pelvic floor. The next opportunity to take Oncology and the Pelvic Floor: Female Reproductive and Gynecologic Cancers is June in Orlando. If you are interested in hosting one of our oncology courses, contact the Institute!

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.