The American College of Obstetricians and Gynecologists and the American Urogynecologic Society recently published recommendations for medical evaluation of women who have uncomplicated stress urinary incontinence (SUI). The following steps are recommended for evaluation: history, urinalysis, physical examination, demonstration of SUI, urethral mobility assessment, and a post void residual. For women who have complicated SUI, urodynamic testing may be appropriate, according to the article, whereas in women with uncomplicated SUI, urodynamics testing may not affect treatment outcomes.

Uncomplicated urinary incontinence is defined within this article as including the following:

• • UI with loss of urine on effort, physical exertion, sneeze or cough
• • Absence of recurrent UTI
• • No prior major pelvic surgery including surgery for SUI
• • Absence of voiding symptoms such as urinary hesitancy, straining to void, spraying of stream, dysuria, sense of incomplete emptying, postmicturition leakage
• • Absence of medical conditions affecting lower urinary tract
• • Absence of vaginal bulge beyond the hymen, absence of urethral abnormality
• • Presence of urethral mobility
• • *<150 mL postvoid residual
• • Negative urinalysis

Recommended nonsurgical approaches include pelvic muscle strengthening (with or without physical therapy), behavioral modification, pessaries, and urethral inserts. The document also includes an example list of validated urinary incontinence questionnaires. The paper makes the point clear that "…counseling should begin with conservative options." However, for those women who wish to have a sling surgery, and "in whom conservative treatment has failed…" is a phrase used in the article, leaving us to wonder: what constitutes failed conservative care? Does this mean that a patient who has failed a pessary trial is a viable candidate for surgery? Or that someone who has completed pelvic muscle strengthening (and perhaps no behavioral modification therapy) should be considered a "failed" patient? Does it mean that a patient who was given a handout about completing Kegel exercises has completed a conservative bout of care?

Further guidelines can best be made when the research describing components of pelvic rehabilitation are included. Clearly the burden of responsibility falls on the shoulders of the pelvic rehab therapists to fill in this knowledge and/or research gap. Clinical guidelines are increasingly inclusive of pelvic rehabilitation approaches, which is a terrific improvement, and yet we should not like to see (with or without physical therapy) following pelvic muscle strengthening, particularly when clinically we see such a wide variety of pelvic dysfunctions limiting appropriate strengthening techniques.

For foundational information about evaluation and treatment of urinary incontinence, a therapist can begin with the Pelvic Floor level 1 training, and then continue through the pelvic floor series continuing education courses in which urinary incontinence is continually addressed as a topic.

This fall, Herman & Wallace will be debuting a brand new course, Integrating Meditation and Neuropsych Principles to Maximize Physical Therapy Interventions, in Winfield, IL. We sat down with the course instructor, Nari Clemons, PT, to learn more about this brand new offering.

What inspired you to create this course?

There is so much more to pain management than just manual techniques, and with meditation we can help patients with a mental shift to facilitate healing. Everyone is always telling patients to work on stress management, but so few people are really able to give patients usable, practical, useful tools to do so. We all know those patients who come in so keyed up or so caught up in playing the same tape in their heads, that we are not sure what we can do to help them. I meditate every day, and it has helped my life (and my patients) beyond measure. I know how many times I use meditation as a way for patients to benefit more from their treatment. In most of the Herman Wallace courses, we talk about using down training and stress management for conditions like overactive pelvic floor, constipation, urinary urge, dyspareunia etc. (even for Interstitial cystitis, the first line of treatment is now relaxation training) but, so few practitioners have access to these tools or this knowledge, so how are they able to help patients? I want to help bridge that gap.

What can you tell us about this course not mention in the description and objectives?

This course is, above all, extremely practical. It takes away the mystery and lack of approachability of meditation, by taking the idea of centering, self-care, healing, and balancing the mind from something esoteric, vague and mystical to step-by-step tools that therapists can use. I hope attendees will use these simple techniques in their own lives and with their patients to help manage conditions of pain, tension, and anxiety. Because the aspects of health for this course border on both the realm of mental health and physical therapy, this course will be co-instructed by Dr. Shawn Sidhu, psychiatrist and meditator, who will provide info on current mental health perspectives.

Can you describe the clinical/treatment approach/techniques covered in this course?

These are all techniques that the clinician can use with the patient and the patient can use on their own. This is the piece you can give a patient to do at home. Most of these techniques can also be used as a part of treatment (ther act or neuro re-ed) to retrain muscle resting levels. I will have a CD that comes with the course that can also be used for patients at home, if the patient needs more guidance. There will be a variety of techniques, all within the realm of mind/body. Centering, observation, visualization, using mantras, affirmations, grounding, breath counting, breath control will all be addressed in a very practical and usable format.

What resources and research were used when writing this course?

I have been meditating: both learning and practicing techniques for decades, as has Shawn. I can’t tell you how many meditation and yoga workshops, books, videos and classes I have experienced over the years. I pulled heavily from that experience and my experience in the clinic and as a yoga teacher. I also bought a book that had 20 plus years of catalogued research in the fields of health and meditation to find the most clinically relevant research for PT’s. Also, I used the typical sources: pub med, medical journals. Finally, I bought all kinds of cd’s to see what was currently available. Again, I chose what I found most practical, usable (not annoying), and clinically relevant, as well as choosing a variety of styles to match different personality types/mind types.

Why should a therapist take this course? How can these skill sets benefit his/her practice?

I feel any therapist can benefit from this course because of the strength of the mind/body connection. Research has shown us that pain perception is not directly correlated with degree of injury or dysfunction. By helping your patient be in the present, rather than reacting to the past or anticipating future issues, your outcomes with your already existing manual skill set will be maximized. Similarly, as a therapist, if you can be in the present, really hear your patients, notice more with your hands, and be fully present, your interventions are certainly more directed than when you are distracted or stressed yourself. Above all, as a therapist practicing these skills, you may find yourself leading a more balanced life and less stressed by work. Certainly, not “taking our patients home with us” benefits our own health and our own families. Staying in the present moment in our own work days and our own lives ( as providers), allows us to enjoy our own lives and work days more…and who of us does not want to enjoy life more?

Want to learn more from Nari and Shawn? Join us in September for this cutting-edge course!

Research by Wong and colleagues published by the American College of Obstetricians and Gynecologists reported on the incidence of postpartum lumbosacral and lower extremity injuries. Of 6048 women who were interviewed, 56 had a new injury, confirmed by physiatrist evaluation. The researchers noted that "Women with nerve injury spend more time pushing in the semi-Fowler-lithotomy position than women without injury." The researchers also noted that women who were nulliparous (had not given birth previously who had an assisted (forceps or vacuum) birth, or who experienced a prolonged second stage of labor, were at increased risk of nerve injury.

The most common nerves involved included the lateral femoral cutaneous nerve, followed by the femoral nerve. Radiculopathies occurred at the L4, L5, and S1 levels. The authors make the following recommendations: changing positions frequently during the pushing phase, avoiding prolonged thigh flexion, avoiding extreme thigh abduction and external rotation. Other labor-related perineal nerve injuries have been documented by Sahai-Srivastava et al. to occur due to prolonged squatting or to prolonged pressure from birth attendants at the knees.

The research by Wong and colleagues highlights the important of interviewing patients about past and current symptoms, birth histories including length of time spent pushing and in what positions a woman was pushing. Teaching a woman and her birth assistants about providing support to the birthing woman's body can be very helpful; a birthing woman may welcome support of a limb, yet avoiding over-compression or sustained positions without intermittent breaks may reduce risk of nerve injury. Because the authors also noted a correlation between nerve injuries and maternal pushing at higher fetal stations (the fetus had not descended as far into the birth canal they recommend attempting to shorten active pushing time by allowing the fetus to descend further prior to pushing. (This concept in itself is a very interesting topic to be followed-up on in another post!)

To discuss issues of postpartum evaluation and nerve dysfunction, you can sign up for the Care of the Postpartum Patientor our Postpartum Special Topicsin which we dedicate an entire lab to this topic.

This November, Herman & Wallace is thrilled to be offering a brand-new course instructed by Carolyn McManus, PT, MS, MA, called Mindfulness-Based Biopsychosocial Approach to Chronic Pain. This course will be offered November 15-16, 2014 in Seattle, WA. We sat down with Carolyn to learn more about her course.

What inspired you to create this course?

I want to improve the lives of people with chronic pain and help my colleagues be successful in providing care to this often challenging patient population. With my academic training in both PT and psychology, my longstanding mindfulness meditation practice and over 25 years specializing in the care of people with chronic pain, I have a wealth of information and a wide range of practical skills to share with my colleagues.

Among my co-workers at Swedish Medical Center, I learned that those who liked working with patients with persistent pain felt they had something to offer that would help. Those who did not like this patient population felt there was nothing they could do to make a difference in the lives of these patients. I want physical therapists to have the skills and confidence to make a difference and improve the lives of people with chronic pain. I want others to know the same feeling of reward I feel when I have made that difference.

I have had colleagues comment to me that although they understand the basic principles of chronic pain, they do not feel confident to explain pain to patients or talk about the role of stress, cognitions and emotions in amplifying pain. I want to give my colleagues the language to do just that. I do not mean stepping beyond our comfort zone or scope of practice, but rather to offer patients a basic framework for the mind body relationship, based in neuroscience, that can change a patient’s attitude and belief system about pain.

I also want to introduce my colleagues to mindfulness. Mindfulness is the ability to rest the mind in the present moment with an open, friendly, curious attitude. This skillful way to pay attention has made an enormous difference in my personal and professional life and in my patient’s lives. Although it takes years of training to teach mindfulness meditation, any healthcare provider can draw on the basic principles of mindfulness to support a patient’s well being and healing.

What resources and research were used when writing this course?

I track the pain literature closely and am especially interested in how the brain changes with chronic pain and the role of stress, emotions and cognitive variables in contributing to chronic pain conditions. PTs are highly skilled to address the nociceptive component of a patient’s pain complaints. As our understanding of chronic pain has broadened to include principles of central sensitization, structural and functional brain changes and the cognitive modulation of nociceptive input, we need to have the training and skills to address these multiple and complex components that give rise to chronic pain conditions. I draw from literature in physical therapy, pain, psychology and mindfulness meditation.

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

If you ever feel overwhelmed, frustrated or challenged by patients with persistent pain conditions, this is the course for you. You will learn the about the exciting new science of pain, the amazing ways stress and cognitive modulation impacts the pain system, and how to apply mindfulness to help manage your own stress during your workday. In addition, you will be able to explain pain, the role of stress in amplifying pain, the mind-body connection and mindfulness to your patients to help empower them to maximize what they can do for themselves to promote healing and well being.

Want to learn more from Carolyn? Join us in November in Seattle!

This blog was written by Carolyn McManus, PT, MS, MA, who will be presenting at the APTA's Virtual NEXT conference in North Carolina. Carolyn is instructing a new course with Mindfulness-Based Biopsychosocial Approach to Chronic Pain. This course will be offered November 15-16, 2014 in Seattle, WA.

Last fall, I was honored to receive an invitation from the APTA’s National Conference team to contribute to this year’s Virtual NEXT programming. Virtual NEXT offers live and on-demand streaming of annual conference's signature lectures and select educational sessions, worth up to 1.6 CEUs. New this year, you can purchase presentations individually. For the price of one registration, you and your colleagues can get together and be part of a worldwide Virtual NEXT viewing party!

The title of my presentation, to be delivered on Thursday, June 12th, is “The Pain Puzzle: Empowering Your Patients to Put the Pieces Together.” I will highlight basic chronic pain neurophysiology, and briefly discuss the brain in chronic pain, stress-induced hyperalgesia and the cognitive modulation of pain. I will describe how this current evidence affects our clinical practice and suggest evidence-based treatment strategies. These will include therapeutic pain neurophysiology education and mindful awareness training. I will close with a case study that demonstrates how our treatment choices must be based on an understanding of underlying pain generating mechanisms in order to achieve success with this complex patient population.

If you cannot join me in Charlotte, North Carolina for APTA’s NEXT conference, I hope you can make an online date! For more information, go to the APTA’s NEXT Conference website:

Want to learn more from Carolyn? Join us in November in Seattle!

This post was written by H&W instructor Lila Abbate PT, DPT, MS, OCS. Lila will be instructing the course that she wrote on "Coccyx Pain" in New Hampshire in September.

“Sit up tall, stand up straight” were comments we heard from our teachers and our caregivers. Do you find that you are saying that now to your patients? Postural correction can go beyond just preventing neck and low back pain. For a women’s health therapist, improved posture may help our patients prevent uterine prolapse or reduce coccyx pain.

Lind, Lucente and Kohn published a study back in 1996 titled Thoracic Kyphosis and the Prevalence of Advanced Uterine Prolapse. They determined that, in patients with uterine prolapse, the degree of thoracic kyphosis was about 13 degrees higher than in the 48 matched controls.¹ Hodges, in the chapter titled “Chronic Low Back and Coccygeal Pain” in Clinical Reasoning for Manual Therapists, presents a case of a 39 year old woman with poor posture who has reproducible coccygeal pain, despite a coccygectomy, with palpation of her L4 segment. This poor posture perpetuates nerve and muscle dysfunction along with decreased and inappropriate muscle firing patterns that have created this long-term condition.

Whether our patients present with pelvic organ prolapse, chronic low back or coccygeal pain, it is important to step back and look at their overall posture. Decreasing thoracic kyphosis, or improving thoracic mobility, can help change an entire system. If you are looking for a course that takes you back to the basics and then enhances it with a twist of advanced techniques think about taking the Institute’s 2-day Coccydynia course.

References:

1. Lind LR, Lucente V, Kohn N. Thoracic Kyphosis and the Prevenlence of Advanced Uterine Prolapse. Obstet Gynecol. 1996 Apr; 84 (4): 605-609.

2. Hodges P. Clinical Reasoning for Manual Therapists, Chapter 7, Chronic Low Back and Coccygeal Pain. Elsevier.2004; 103-122.

In a recently published study, an anti-inflammatory diet (AID) for inflammatory bowel disease (IBD) was offered to 40 patients as an adjunctive regimen. Retrospective medical chart review was utilized to assess dietary adherence and outcomes. Of the 40 patients who were offered the program, 13 patients did not attempt the diet. Of the remaining 27 patients who did attempt the AID, 24 of them had a good or very good response, 3 of them had a "mixed" response. After following the diet, all patients were able to discontinue 1 or more IBD medications, and all patients reported decreased symptoms such as improved bowel frequency. Interestingly, of the 3 patients who had an ambivalent or negative response to the AID, 2 of them were diagnosed with C-difficile, a very challenging condition to resolve.

Inflammatory bowel disease can include the diagnoses of Chrohn's disease and ulcerative colitis, and each are characterized by periods of relapse. Patients are often reliant upon medications such as corticosteroids or immunomodulators during flare-ups, and surgical interventions including colectomy. As medical theories have evolved, the authors of this study point out that the gut microbiome is believed to play an importnant role in IBD, and therefore treatments directed at improving intestinal microbiome have increased.

The IBD anti-inflammatory diet (AID) includes lean meats, poultry, fish, omega-3 eggs, particular carbohydrates, specified fruits and vegetables, flours from nuts and legumes, a few limited cheeses, cultured yogurt, kefir, miso and other foods rich in certain probiotics, and honey. Bananas, oats, blended chicory root, and flax meal are also included. Additional suggestions are given based on the acuity of patient symptoms such as pureeing food or avoiding food with seeds. The diet is detailed into "phases" that progress from Phase I+ to Phase IV, to be followed when the patient is in remission and without dietary restrictions.

As this study is a case series, the authors are hesitant to extrapolate findings beyond stating that "some of our patients with inflammatory bowel disease can benefit.." from an anti-inflammatory diet, with respect to decreased symptoms and a resultant decrease in medication usage. In the study, patients were primarily seen by a nutritionist. As the mechanism for the improvement noted with an AID is still theorized but not known, the article describes different proposed mechanisms for improved symptoms, such as changes in the gut flora, or gut mucosal healing due to decreased irritants.

As pelvic rehabilitation providers, we have a responsibility, not to counsel our patients in detailed nutritional regiments aimed at curing disease, but in educating our patients about the potential benefits of nutritional counseling and attention to diet. Many patients are not offered nutritional counseling, or need support in order to initiate or maintain dietary changes. We can play an important role in guiding our patients to help and in supporting them in their efforts to make lasting changes. If you find that you are working with more patients who have bowel dysfunction, and wish to increase your knowledge beyond the PF2A course, you still have time to register for the Bowel Pathology and Function course, taking place in June in Minneapolis, which addresses many factors specific to bowel health and pelvic rehabilitation approaches.

Prostate removal via open, laparoscopic or robotic surgical techniques has been a treatment of choice for patients with prostate cancer. Historically, patients have been keen to inquire about "nerve-sparing" procedures for prostatectomy with a goal of reducing erectile dysfunction or urinary incontinence, two common unwanted side effects of prostate surgery. Research published in Prostate International journal proposes that exquisite knowledge of fascial anatomy is a key to minimizing negative impact from surgery caused by damage to the prostatic neurovascular bundles. The authors in this paper point out that anatomical controversy exists in the literature and that the anatomy is still being investigated, increasing the surgical challenge for those physicians who aim to identify the structures.

The pelvic organs are covered by pelvic, also called endopelvic, fascia, that is commonly divided into two layers: that which covers the viscera (wrapping around each organ structure and the parietal component which covers the medial levator ani, obturator internus, and piriformis. Access to the prostate gland is gained by an anterolateral incision through the endopelvic fascia at the fusion of the visceral and parietal fascia, according to the article. Layers of prostatic fascia and the endopelvic fascia attach laterally at the tendinous arch of the pelvic fascia, and these structures attach to the puboprostatic ligaments. The puboprostatic ligaments anchor the prostate to the pubic bone, creating an important aspect of continence through fascial tension and support.

While nerve-sparing techniques have focused on preserving pelvic plexus autonomic nerve fibers, the authors argue that there is not a definite anatomy of the periprostatic nerve fibers, possibly contributing to the variability in surgical outcomes reporting for nerve-sparing procedures. Various approaches have been detailed in the literature, and are described in this article, with emphasis on dissection plane and intra- and interfascial techniques utilized.

This is a full access article with images and details beyond what most pelvic rehabilitation providers need. What is of great interest across professions is the recognized need for acute anatomical knowledge with application of skilled techniques with such anatomy in mind. The authors conclude that "…the relation of the periprostatic fascial layers on the anterior, lateral, and posterior sides of the prostate should be of great interest. A better understanding of the relation between nerve fibers and pelvic fascial layers is crucial…" Most of us were never introduced to detailed pelvic anatomy, male or female, in school. To learn more about male pelvic anatomy, you can attend either the pelvic floor series course that introduces male pelvic health, called PF2A, offered in October in St. Louis- this is the only PF2A with open seats this year. You can also attend the Male Course, offered again this year in October in Tampa.

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!