It seems safe to say that if you are currently working with patients who have pelvic pain, you are familiar with the phrase "trigger point." Yet, what is a trigger point? This question has proved elusive for quite some time, given that there is not always a palpable structure or a visible change in the tissue that produces the pain.
Travell and Simons, in their 2 volume classic work on myofascial paindescribe the concepts of active and latent trigger points, with an active trigger point being a location in the tissue that when palpated, reproduces the patient's symptoms, often at a site distant to the one being palpated.
In a very interesting article, Hong-You Ge, MD, PhD, and colleagues describe a possible mechanism for a local pain site (trigger point) creating more global and chronic pain via central sensitization. The authors explain the concepts of spontaneous electrical activity (SEA) at the myofascial trigger point (MTP) via research over the last decade. Some of the article (which you can read full-text thanks to PubMed Central access) will bring you back to physiology class as you do your best to recall gamma motor units within the muscle spindles or extrafusal motor endplate potential (yeesh).
While the authors admit that the "how" in formation of a taut band in a muscle is still under debate, the evidence they cite as explanation to many of the tissue responses is very enlightening and interesting. Dr. Ge also describes how motor control strategies are impaired by active trigger points. We may observe this in the clinic through the patient who reports that her urinary leakage control improves following muscle tension release techniques to the pelvic floor that were administered due to pelvic pain.
As the scientific community continues to give attention to the physiology behind connective tissue dysfunction, we should hope to better explain why some of our interventions are helpful in alleviating impairments. If you feel like nerding out and catching up on some of the interesting research related to trigger points, read this article. And then, be sure to use the phrase "membrane depolarization" in your next conversation.
Pregnancy related pelvic girdle pain is a considerable issue for women that creates significant loss of function. An update on pelvic girdle dysfunction from Kanakaris et alcan be found here by opening the link to the free full access text to the right of the Pubmed abstract. They report that the incidence of pregnancy pelvic girdle pain ranges from 4-76% in the literature depending on the definition utilized.
Britt Stuge, PhD, PT, of Norway and colleagues recently published an article in the Physical Therapy Journal. The article includes a new tool that physical therapists can utilize to assess function in female patients who have pelvic girdle pain.
The tool is called the "PGP" for "pelvic girdle pain" and was designed for use in the pregnancy and post-partum period.20 of the questions refer specifically to activities and 5 questions are about symptoms. This is a rather specific tool and it was designed for use in the clinic or for research.
You can access this tool on the Herman Wallace website and you can use it in your practice. This is very valuable to therapists as not all tools can be used freely in the clinic or in research without specific permissions or fees paid.
In a cross-sectional study in The Netherlands, standardized surveys of 1380 women between the ages of 45-85 years were completed for urinary and bowel distress. The women also answered questions about prior pelvic floor surgery.
Prior pelvic floor surgery was recorded by approximately 8.6% of the participants. The likelihood of surgery taking place increased with age, and there was identified greater than 20% chance of prior pelvic floor surgery in the women aged 76-85 years. Higher rates of urinary and defaecatory distress were noted in women who had gone through prior surgery as well.
The factors associated with previous surgery were age, higher body mass index (BMI), pelvic organ prolapse symptoms during pregnancy and prior hernia surgery. The lifetime risk for pelvic organ prolapse surgery is estimated at 20% in The Netherlands.
In the US by the year 2050, research has estimated that pelvic organ prolapse will increase in women by 46% (WU JM 09). Rehabilitation efforts must continue to advance so that women can avoid surgery when possible, and so that women can be offered pre-surgery rehabilitation as well as follow-up post-surgically.
Researchers in Taiwan have reported on a clinical trial investigating the effects of pelvic muscle strengthening for urinary incontinence on bladder neck mobility.
23 female participants completed a pelvic muscle strengthening program for 4 months. Bladder neck position was measured by transperineal ultrasonography at rest, during a cough, and during a Valsalva maneuver. The interventions included instruction in pelvic muscle contraction confirmed by digital palpation and by use of pressure feedback. Participants were instructed to perform 6 near-maximal contractions holding up to 10 seconds, 3-5 sets/day, along with 6 sets of quick (1 second hold, 1 second rest) contractions. Study participants were also allowed but not required to make follow-up appointments with a physical therapist to assess exercise.
Results demonstrated that after the 4 month period, ability to elevate the bladder neck with a contraction improved. However, at rest or with a Valsalva, the bladder neck "stiffness" did not improve. All participants did report lessened urinary incontinence, and they had increases in pelvic floor muscle strength and in maximal vaginal squeeze pressure.
This study appears in the July edition of Physical Therapy journal.
Mindfulness meditation has been demonstrated in research trials to alter perceived pain, reduce depression, and decrease stress. Results of a pilot study were recently published in support of mindfulness meditation for women with chronic pelvic pain.
The mindfulness program the women participated in was 8 weeks long and assessment tools included (but were not limited to) daily pain scores, the SF-36, and a depressive scale. For the women who completed the program, significant improvements were noted in daily pain scores, physical function, mental health, and social function. Only 12 of 22 women enrolled completed the study, which may indicate that this type of program may not have global appeal or it may be difficult for women with chronic pain to commit to a daily regimen for 8 weeks.
This pilot study is encouraging in its outcomes and demonstrates that meditation can serve as another option for women dealing with chronic pain. There is significantly more research investigating the changes in the brain function of those who meditate. One such study describes increased brain connectivity in those who have practiced meditation long-term. Functional MRI has been used to describe mechanisms that allow pain modulation to occur for those in a meditative state.
It is helpful for us to be aware of the increased attention the scientific community has given to the potential benefits of meditation, and to be able to share mindfulness meditation as an option for our patients. You may find it helpful to have a few relaxation or meditation CD's in your practice space that a patient can listen to while on heat or electrical stimulation. That way a patient might better decide if it is something he or she would like to purchase for home use. You can find an example of various relaxation and meditation CD's available at the website of Carolyn McManus,a physical therapist in Seattle.
In the British Journal of Urology International a new study was published that addresses older men's fall risk in relation to urinary issues. The histories of 5872 male patients were investigated to determine if having urinary symptoms were independently associated with a risk for fall within the following 12 months.
The men who reported moderate (39% of men at baseline) or severe (7%) urinary symptoms had a significantly higher incidence of falls over a period of one year than those men who reported mild symptoms. Symptoms that were most associated with falls were urinary urgency, difficulty initiating urine, and nocturia (getting up at least 4x/night to urinate.) The authors reference other studies that reported urinary incontinence as a risk factor for increased fall risk in men as well.
Since benign prostatic hypertrophy (BPH), which causes difficulty initiating the urine stream, and overactive bladder both increase with age, the above urinary issues are understandably of concern when assessing fall risk.
It is also well-known in the orthopedic literature that falls in the elderly increase risk for hip fracture, and 1 year mortality rates are known to be significantly higher for those who have had a hip fracture. Many rehab providers have assisted these patients in their fall recovery, and many factors are at play in making such a recovery challenging. Oftentimes a patient who has suffered a fall and a significant injury have to spend time away from their home, enter environments in which iatrogenic illnesses can occur, and experience the effects of being bed-bound or of having reduced physical activity.
It is valuable to keep such research information in mind when we are educating our colleagues, patients, providers, and community members about the risks of urinary dysfunction. Helping a person maintain healthy bladder function may not only be helping to maximize a person's dignity, but also his level of independence, health, and longevity.
In a recent Johns Hopkins Health Alertthe signs and symptoms of colorectal cancer are discussed. Some of the symptoms of colorectal cancer include a change in bowel status such as diarrhea, constipation,or narrow stools that last for a few weeks. Bloating, cramping, a feeling of incomplete emptying of the rectum, or inability to pass stool for a week can also be the first signs of cancer. Unfortunately for pelvic rehabilitation providers, the above symptoms can describe many of our patients who we are treating for bowel dysfunction.
To better screen for concerning symptoms, you can ask if the patient has had bright red blood in the stools or a black stool, abdominal tenderness that does not improve, loss of appetite, loss of weight, vomiting, and/or persistent fatigue. Hopefully some of above symptoms are included on your medical conditions intake form. I am always amazed that we meet patients who are dealing with bloody stools for months, or unexplained weight changes, who do not find these changes compelling enough to share with a medical provider.
A couple of great textbooks to keep on hand for medical screening purposes are Goodman and Snyder's Differential Diagnosis in Physical Therapyor William Boissonnault's Primary Care for the Physical Therapist.
We must continually challenge ourselves to be alert to changes in the patient's health status. Keeping in mind that a patient who is in the early stages of having colorectal cancer may have primary complaints of changes in bowel habits, the medical providers who trust our care may be quick to refer for pelvic rehabilitation. Develop the habit of constantly asking questions and if you are not sure what questions to ask, acquire one or both of the above mentioned texts which are designed to lay out useful questions.
Once you get the summer vacations booked and begin to look ahead to the fall and the "school year" beginning, be sure to get scheduled for important courses and conferences before they book up!
The International Pelvic Pain Society conference will happen on October 21-22, 2011 in Vegas, baby. The American Physical Therapy Association (APTA) Combined Sections Meeting (CSM) is taking place in February in Chicago(brrr!) and will no doubt feature interesting lectures that can update your practice knowledge.
Some other opportunities for increasing your knowledge include the Third International Fascia Research Congress. It will take place in the beautiful city of Vancouver, BC, in March of 2012. The Society of Urologic Nurses and Associates will hold its annual conference in October 2011 in San Antonio, Texas.
For those of you itching for some international travel, the World Congress on Low Back and Pelvic Pain is happening in Dubai in 2013!
You may have also noticed that the Herman & Wallace Pelvic Rehab Institute website continues to add new courses. Be sure to sign up early as some classes book up many months in advance.
The Vulvar Pain Functional Questionnaire (V-Q) is provided to help patients quantify the extent that pelvic pain is affecting their lives and helps the practitioner devise a treatment strategy based on the patient's account of her symptoms.
To score the VQ: add numerical values assigned to each response. These appear next to the check-boxes. The higher the score the greater the functional limitation. A diminishing score represents improvement.
Wendy Sword, Professor in the School of Nursing at McMaster University, and her colleagues have recently published a study in which they looked at the relationship between mode of delivery and risk for post-partum depression. An interesting correlation that the authors found shows that having urinary incontinence in the first 6 weeks after childbirth doubles the risk for having post-partum depression. In McMaster University's post about this research, it is pointed out that up to 20% of new mothers experience post-partum depression, and this can interfere with the mother's self-care, with bonding between the mother and child, and with the care needed by the infant. Early detection and treatment of post-partum depression is critical.
In this research, 1900 new mothers were studied, up to 1/3 of them had c-sections as the mode of delivery. At 6 weeks post-partum, nearly 8% of the mothers had post-partum depression. The depression was not identified as being related to one mode of child delivery over another. The 5 strongest predictors of post-partum depression were identified as: 1) mother's age less than 25, 2) mother requiring hospital readmission, 3) non-initiation of breast-feeding, 4) good, fair, or poor self-reported health by the mother, and 5) urinary incontinence.
Dr. Sword recommends that providers ask patients about continence status early in the post-partum period, as patients may be embarrassed to bring it up, and also because incontinence is often dismissed as a common issue post-partum that will likely improve. When patients are referred to rehabilitation for continence issues, we often find that the symptoms have persisted for years, sometimes decades, unfortunately. During our marketing visits and education of the community, we can also encourage patient providers to send the patients to rehabilitation as early as possible. It is often at the 6 week appointment that the patient can be screened for such concerns, and this is when many of our referrers are comfortable sending a patient in for a check of the pelvic muscles.