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Herman & Wallace Blog

Are you Suffering From Compassion Fatigue?

After reading a Medscape article about compassion fatigue and cancer care, it seemed appropriate to bring up the topic for pelvic rehab therapists and providers. In the article, burnout is described with phrases such as overwhelming exhaustion, detachment from job, and a sense of ineffectiveness. Compassion fatigue, while being associated with burnout, is related more directly to being in a role of helper to those in distress, thereby creating tension and distress for the one giving care. Health care workers are believed to be a vulnerable group for this compassion fatigue.

Many of the pelvic rehab therapists I have met over the last decade describe the challenges of working with this rewarding, yet challenging population. Patients with chronic pelvic pain are particularly in need of a listening ear and also require a significant amount of case management, hands-on rehabilitation, and encouragement. All of these factors can lead to increased work task burden for the therapist as well as psychological burden from carrying the weight of the patient's suffering. It then becomes important to "heal the healer" as described in this family practice article.

There are some resources in place at various work sites, such as employee assistance programs that provide a few visits to a counselor, and these should be used readily as the visits are usually free to an employee. The life skill of self-care does become the responsibility of the care provider, however, and in order to take care of ourselves the basic (but difficult to achieve) balance can be maintained by good nutrition, breaks from work (not documenting through lunch), having our own social support, and getting sleep and exercise.

You can take a Compassion Fatigue self- test, or the Professional Quality of Life (ProQOL) testhere.There are resources to combat burnout, one of the latest that I've seen is a book by Joan Borysenko, PhD. Check out her book Fried: Why You Burn Out and How To Revive.Another book that is clear in practical suggestions is The Art of Extreme Self-Care by Cheryl Richardson. You may also find support within the pelvic rehab community, as the therapists who have similar jobs truly understand some of the challenges as well as the rewards of our meaningful work. It is the hope of the Pelvic Rehab Institute that therapists continue to look towards the Institute to provide such support and a sense of community.

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Irritable Bowel Syndrome Correlated to Decreased Quality of Life and Increased Pelvic Floor Disorders

In a study that was originally published in Alimentary Pharmacology and Therapeutics, researchers correlated self-reported irritable bowel syndrome (IBS) with symptoms of urinary incontinence, pelvic organ prolapse (POP), sexual function, and quality of life (QOL.)

In a population of more than 2100 female patients, the reported incidence of IBS was nearly 10%. Within these women, an increased risk of bother from prolapse and sexual dysfunction was reported as well as a decrease in quality of life scores. The authors point out the hypothesis that frequent bouts of constipation may lead to weak pelvic floor muscles, and therefore increased pelvic prolapse, but this remains to be proven in the literature.

This study is meaningful not only because it evaluates information about a large group of women, but also because the population is a diverse group between the ages of 40 and 69. As IBS according to the ROME III can be further divided into constipation-dominant, diarrhea-dominant, or both, it makes sense that pelvic floor dysfunction is correlated to the diagnosis. Many patients who experience loose stool with IBS may unknowingly tighten the pelvic floor chronically to avoid leakage, and this in itself could lead to pelvic muscle tension and dysco-ordination as we see in many of our patients. Those patients who experience constipation and straining may also interfere with healthy muscle activity and create prolonged stress on the supporting tissues in the pelvis and pelvic floor.

The relationships pointed out in this study remind rehabilitation experts that it is important to ask detailed questions about all aspects of a patient's pelvic health, from sexual function to bladder or bowel function. This study is now available in PubMed Central, where you can find free, full-access articles.


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New research supports visceral mobilization to reduce post-operative adhesions.

Abdominal adhesions following surgeries can lead to pain with bowel function or general movement. This study aimed to assess whether or not a specific manual therapy approach could reduce the prevalence of such painful adhesions.

Researchers using an experimental animal model did in fact report benefits from applying post-operative visceral mobilization (VM). 3 groups of 10 rats were examined post-mortem at 7 days following an adhesion-producing surgery. The rats in the Lysis group were treated (unsedated) on day 7 only, while the Preventive group animals were treated daily beginning the day after surgery.

The severity and the number of adhesions were significantly lower in the Preventive group. Clear signs of disrupted adhesions were noted in both the Preventive and Lysis groups. The authors in this study conclude that pending further studies, “…visceral mobilization could readily be implemented into post-surgical care and patient education.” They propose that VM could aid in preventing and/or treating abdominal adhesions.

This is a very well cited study that describes the available literature in reference to abdominal surgery and adhesions. Although an animal model was utilized, the authors believe that the assessment and treatment to the animals creates an environment that encourages tissue mobility and discourages fibroblast invasion of the peritoneal tissues in the same manner as human tissues would react.

You can check out coursework that the Institute offers that focuses on visceral mobilization for patients with pelvic issues.

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How Bothersome is Urinary Incontinence?

In an effort to answer this question, 15,000 enrollees in AARP Medicare supplement plans (insured by United Healthcare) were asked this question in the form of a survey. Of the more than 5000 members who responded, over 35% of them described urinary incontinence as a condition that affected not only physical, but mental health as well.The researchers in this study also found that urinary incontinence affected perceived quality of life more than diabetes, arthritis, and some forms of cancer.



AsBurgio et alreported previously, many adults do not report incontinence to their medical providers, so the likelihood of incontinence creating significant bother is high when the chances of acquiring treatment are decreased. If health care providers and the insurance companies can help patients identify impairments caused by urinary leakage early on, send the patients to the most appropriate conservative care versus surgeries, perhaps patients will report enhanced quality of life as well as save health care dollars."

As reported onEnhanced Online News, Dr. Richard Migliori of the Business Initiatives and Clinical Affairs at UnitedHealth Group describes an "...opportunity for the health care system to develop treatment programs that can enhance not [the patients] physical health, but their mental and emotional health as well." We as rehab professionals can continue to educate the public and the health care system regarding our role in treating bladder issues so that fewer patients suffer decreased life quality due to urinary incontinence.
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Can Patients Use Internal Trigger Point Devices Safely?

The team associated with what was formerly called "The Stanford Protocol" for pelvic pain has evaluated the use of an internal wand by patients. This trigger point wand was designed to help the patient apply appropriate amounts of pressure as it has in its design an algometer for measuring pressure. 113 of 157 enrolled (mostly male) patients completed 6 months of wand use, the authors point out that those who dropped out of the study did not withdraw due to adverse affects from using the wand. Patients were instructed in use of the wand and carefully supervised prior to using the device on their own. They were instructed to use the wand several times per week. Visual analog scale measurements were taken at baseline and at 6 months. The baseline median sensitivity was 7.5 and decreased to 4 at 6 months. Over 95% of the patients reported that the wand was very or moderately effective in relieving pain.

This pilot study addresses some very important concerns. Although it is a pilot study, this work addresses the need for research to support aspects of pelvic pain therapy programs. Very importantly, it addresses the issue of how much pressure patients are using when applying self-trigger point releases with a device. We have all met patients who, despite our best coaching, apply so much pressure with any self-treatment that the symptoms meant to be alleviated are worsened, usually accompanied by the phrase, "I don't know what you did last time, but..."

Until such a device used in this study is available to clinicians, it will be difficult to gauge how much pressure a patient is applying with a device such as a wand. As in this study, patients who wish to use a trigger point tool should be carefully instructed in safe techniques for use of such a device. These trigger point tools may continue to be helpful in self-care and home program participation by the patient.

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Improving Urinary Continence Improves Sexual Function

As reported in Female Pelvic Medicine & Reconstructive Surgery, women who were successfully treated for stress urinary incontinence also noted improvements in sexual function. Women in the study were treated with a pessary, with behavioral therapy for incontinence,  or with a combination of these treatments. Behavioral therapy included pelvic muscle strengthening and continence strategies. At 3 months, sexual function was assessed using short forms of both the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12) and the Personal Experiences Questionnaire (SPEQ).

The researchers found that in those women who experienced improved urinary continence, sexual activity was one of the activities in which a reduction of urinary leakage occurred. Patients also reported less restricted sexual function due to fear of leakage.

Interestingly, patients who experienced both urge incontinence and stress incontinence (versus stress incontinence alone) reported a lower level of sexual function at baseline.
It is well documented in the literature that urinary incontinence impairs quality of life in women, and this includes sexual health. The American Urological Association (AUA) recommends that medical providers ask questions about urinary incontinence and about level of bother of symptoms. The AUA also recommends that providers use validated surveys to assess a patient's function. As physical therapists, we can include screening questions on our intake forms, provide more detailed continence questionnaires, and discuss these sensitive issues with our patients to ensure that we are getting the best information about our patient's function.

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Leaking? Drink more green tea

Behavioral modification training for patients who have urinary issues commonly involves education about dietary triggers. The IC-Network lists green tea as "probably problematic" for triggering increased symptoms. Researchers in Japan, however, have reported an inverse relationship between urinary incontinence and drinking green tea.

Researchers at Curtin University in Western Australia and at the University of Tokyo completed dietary intake questionnaires for 300 Japanese community dwelling women aged 40-75 years. A urinary continence questionnaire was also completed (International Consultation on Incontinence Questionnaire- Short Form).

In the 27.5% of women who experienced urinary incontinence, less green tea was consumed on a daily basis versus those who did not leak. Average consumption of green tea for those who did not report incontinence was over 3 cups (757 ml). This relationship was not identified to be in effect for coffee, black or oolong tea.

Perhaps an important message to take from this research is that in our clinical experiences patients rarely respond equally to the same dietary factors. Some of our patients cannot, despite vigorous logging of food and beverage intake, find a consistent association between certain foods or fluids and their bladder symptoms. Even though some of our patients may benefit from reducing coffee and teas, we can appreciate that at least in Japan, where this information was gathered, a diet that includes green tea may not necessarily contribute to bladder issues.
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Recently published JAMA article on the effectiveness of physical therapy and Biofeedback in treating post-radical prostatectomy male urinary incontinence

In a study from the Center for Aging at the University of Alabama, Birmingham and the Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, researchers determine that physical therapy, bladder control strategies, and biofeedback significantly reduced the incidence of urinary incontinence in post-radical prostatectomy males when compared to a control group.

Check out the abstract of the study here.

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Radio Show on Interstitial Cystitis and Pelvic Pain

The Institute is sponsoring a radio show hosted by Dr. Melanie Barton and featuing Amy Stein, MPT, BCB-PMD. Amy will talk about Interstitial Cystitis and Pelvic Pain and the role of physical therapy in treating these problems

Tune in on April 28th or visit Dr. Melanie's site to download the podcast.

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Internet Scam Targeting Physical Therapists

Recently, the Institute was made aware of an internet scam that is targeting physical therapists, including members of our teaching faculty. A bogus website called ComplaintsBoard has listed many PTs, including several respected Herman & Wallace faculty members, on a list of convicted sexual abusers. This site contains a similar list of doctors and lawyers that it claims have criminal records, meaning that patients or clients seeking professionals may find false and damning histories on internet search engines. The site then invites those whose names are posted to pay money through a different website to clear their records.

Clearly, this is the work of scam artists that are tarnishing the reputations of physical therapists. It is unclear who these perpetrators are, but they have targeted a number of respected professionals, including members of our faculty. Herman & Wallace is dismayed to see the character of professionals with whom we work and respect being attacked for profit. The APTA has been made aware of this, and is seeking legal action. If you find your name on such a list, please contact the APTA.

The Institute would like to make our community aware of this problem and to show our support of our faculty and our colleagues.

Please understand that, because we do not want to increase the web traffic to these scam sites, thereby increasing their efficacy, we will not be posting direct links to these sites.

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Upcoming Continuing Education Courses

Jan 10, 2020 - Jan 12, 2020
Location: Dominican Hospital - Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Spooner Physical Therapy

Jan 17, 2020 - Jan 19, 2020
Location: Banner Physical Therapy and Rehabilitation

Jan 17, 2020 - Jan 19, 2020
Location: Our Lady of the Lake Children's Hospital

Jan 24, 2020 - Jan 26, 2020
Location: Nova Southeastern University

Jan 24, 2020 - Jan 26, 2020
Location: UCLA Health

Feb 1, 2020 - Feb 2, 2020
Location: Evergreen Hospital Medical Center

Feb 1, 2020 - Feb 2, 2020
Location: Ochsner Health System

Feb 7, 2020 - Feb 9, 2020
Location: FunctionSmart Physical Therapy

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Feb 22, 2020 - Feb 23, 2020
Location: Huntington Hospital

Feb 28, 2020 - Mar 1, 2020
Location: Inova Physical Therapy Center

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Feb 28, 2020 - Mar 1, 2020
Location: Rex Hospital

Feb 28, 2020 - Feb 29, 2020
Location: Rex Hospital

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mar 6, 2020 - Mar 8, 2020
Location: Spectrum Health System

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Mar 13, 2020 - Mar 15, 2020
Location: Franklin Pierce University

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services