Prostate Cancer and the Male Pelvic Floor

The Border Mail, an Australian newspaper, published an article today following Brian Costello, a man who underwent a prostatectomy.? Surgery for prostate cancer often leaves patients suffering with erectile dysfunction and incontinence.? However, Brian?s physicians did not send him into outpatient rehab, leaving him and his wife Jill, ?on their own.?

The piece titled ?Sex and Secret Men?s Business,? outlines how important pelvic floor and penile rehabilitation is, as well as how few hospitals are prepared to treat outpatients who survive prostate cancer.

Brian?s wife and daughter Leah started ManUp!, an advocacy organization meant to promote better prostate care in Australia.? All too often they hear stories like Brian?s; physicians who show ?no interest in what happens to their patients after prostate cancer treatment.? One man left impotent and incontinent after his robotic surgery[, and] was told the doctor?s job was simply to deal with the cancer.?

One of the many reasons that erectile dysfunction and incontinence are under-serviced conditions though is that patients frequently do not bring it up: ?it?s hard for busy practitioners to keep up to date with the recently developed erection treatments.? It?s also a two-way street, with some men finding it difficult to talk about these issues,? says Prem Rashid, a urologist and associate professor at the University of NSW.? ?Issues surrounding erectile dysfunction following prostate cancer treatment are complex and multi-factorial and often require the help of a multidisciplinary team,? - a team in which pelvic PTs play an important role.

Herman & Wallace will be offering a course on The Male Pelvic Floor in Minneapolis this September.? Participants in this two-day course will learn how to treat conditions such as sexual dysfunction, pelvic pain, and incontinence.

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Chicken or Egg: Dyspareunia and Body Image

A recent article examines the relationship between sexual dysfunction and body image. The authors note that little is known about the relationship between dyspareunia (painful intercourse) and body image and genital self-image. Could it be that body image issues link to the fact that women who report dyspareunia also complain of overall sexual impairment, anxiety, and feelings of sexual inadequacy?

The research included an on-line survey of 330 premenopausal women, and 58% reported dyspareunia, 42% were pain-free controls. The women with dyspareunia reported more distress about their body image and more negative genital self-image. This study presents an excellent literature review related to the myriad of challenges a woman faces when dealing with pain limiting intercourse. Such examples include decreased sexual desire, feelings of guilt, shame, failure, and a sense of being incomplete. Women will frequently describe their genital area as a "dead" part of the body. These intense thoughts and feelings are rarely addressed in studies of dyspareunia, and in the treatment of the condition, according to the authors. In studies using the Female Genital Self-Image Scale (FGSIS) in a sample of young college women, women reporting impaired sexual function also reported negative genital self image.

How do we help? In addition to providing caring pelvic rehabilitation, how can the medical community offer a more comprehensive approach that encompasses body image? As discussed in the article, if health care providers view dyspareunia as a chronic pain syndrome rather than only as a sexual dysfunction, patients may benefit from addressing how their "sense of self" becomes negative in relation to the pain. Interestingly, body image and sexuality are intertwined, as a positive body image may "...facilitate the subjective experience of sexuality..." while a negative body image can inhibit sexual health.

In our role as pelvic rehabilitation providers, we can discuss the potentially negative relationship between a woman's sexual dysfunction and her body image. As a minimal level of intervention, instructing in awareness of the problem, in use of positive self-talk, and in ways to evaluate self-worth as a "whole" person despite sexual health issues. Ideally, rehabilitation and medical management can alleviate sexual dysfunction, yet the patient may continue to struggle with anxiety, fears, and self-doubt. Through education, encouragement, rehabilitation, and further research, patients may continue to address issues of sexual health as well as body image. We may not know if decreased genital self-image causes decreased sexual dysfunction, or if having sexual dysfunction causes the poor body image, but this research creates an excellent, well-cited platform from which we can launch meaningful discussions with our patients. Referring providers can also be consulted when the patient may benefit from a consult with an expert in psychological health or counseling.

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Treating the Pelvic Floor with Biomechanics

Pelvic Rehabilitation is often incorrectly considered a women?s health issue. ?This is because, as this wonderful video from Aligned and WellTM demonstrates, ?childbirth often gets blamed for pelvic floor disorder.?? Male or female, hip and pelvic biomechanics play an important role in the functioning of the pelvic floor.

Tucking one?s pelvis while sitting or favoring one leg when you stand can have a tremendous effect on the strength of one?s hip and pelvic muscles.? Weakened pelvic floor muscles often correlate with or cause such common conditions as urinary/fecal incontinence and sexual dysfunction, as well as chronic lower back and pelvic pain.

However, as Jessica Powley, PT, DPT, WCS, says in a recent blog post on Pelvic Guru, "rehabilitation for the pelvis is much more involved than simply strengthening a muscle group. It involves restoring function?improving muscular support around the pelvis, improving behavioral/dietary habits, and re-training body movements to allow for optimal organ and structural function"(emphasis added). ?In short, by focusing on the biomechanics, practitioners can better educate patients on treatment.

This August, Herman & Wallace will be presenting a course on the Biomechanics of the Hip & Pelvis. In the course, instructor Steve Dischiavi will demonstrate how one?s biomechanics affect the pelvis and hip, enabling clinicians to better instruct patients on treatment.

This course is less than one month away - register today!

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Painful Pelvic Conditions Need Pelvic Therapy Treatment

The Great Falls Tribunepublished a piece Tuesday about McKenna Fromm, an eighteen-year-old girl who suffers from interstitial cystitis, pudendal neuralgia, and levator ani syndrome. Alone, each of these conditions can be debilitating, leaving patients in pain. Often each of these conditions is coupled with urinary or fecal incontinence. This piece, titled ?Great Falls Teen Fighting Three Painful Pelvic Conditions,? elucidates the struggle of patients who suffer from these conditions.

Each of these conditions is known to be difficult to diagnose, particularly interstitial cystitis which has ?[n]o specific diagnostic tests.?? Sometimes these conditions require surgery.? Other times, treatment includes ?a ?cocktail? of medications that include topical anesthesia or anti-inflammatory.?

However, one aspect of this article fails to truly emphasize is the role of physical therapy in treatment.? Stephanie Prendergast, president of the International Pelvic Pain Society, demonstrated this point well in a Facebook post about the Tuesday article.

?More often than not, pelvic pain syndromes are driven by the musculoskeleture of the pelvic floor. That said, when something goes amiss with the pelvic floor all of the many systems that make up this unique part of the body will most likely become involved--the muscles, nerves, organs, and derma of the area become locked in a vicious pain cycle that needs to be broken. Physical therapy has an important role to play in the unwinding of this pain cycle. That's because a PT is in the best position to uncover and treat any musculoskeletal impairments that are contributing to a patient's pain/symptoms?

??What often happens in these cases is that the patient's pelvic floor muscles guard in response to the pain of the infection; however, once the infection clears, the muscles remain in this tight, guarded state causing a lack of blood flow to the area and the formation of trigger points, both of which can cause the symptoms that McKenna presents with. What a PT can do in such a case is to manually relax any tight muscles, and treat any trigger points or other musculoskeletal impairments contributing to the patient's pain. That said, to date, there is no standard of care when it comes to pelvic floor PT. It is my opinion that manual, hands-on treatment under a multidisciplinary setting is the best approach to treating pelvic pain for a patient like McKenna. I am hoping that this is the kind PT that McKenna is currently receiving.?

Well said, Stephanie.? We completely agree.? The more people know about these conditions and realize the role PTs have in treatment, the better off patients will be.

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Scientists Discover Protein for Diagnosing Crohn's Disease

Scientists at the National University of Ireland in Maynooth reported the detection of a protein, Pellino3 that may stop Crohn's disease from developing. The Irish Times article, University breakthrough in fight against Crohn's disease, described the benefit as diagnostic: [Researchers] will now use the protein as a basis for new diagnostic for Crohn's and as a target in designing drugs to treat the illness.

Researchers noticed that levels of Pellino3 are dramatically reduced in Crohn's disease patients. Prof. Paul Moynagh, who led the researchers, believes that identifying Pellino3s role in Crohn's disease may lead to better treatments for other inflammatory bowel diseases.

In the United States, more than a half-million people suffer from Crohn's disease and more than a million suffer from some type of inflammatory bowel disease. Symptoms often include abdominal pain and diarrhea. These symptoms are often debilitating and even life-threatening. There is neither a known cause nor cure for Crohn's disease.

Therapy has been known as one of the few treatments that can reduce symptoms and even lead to remission.

Hopefully, this discovery will lead to further advancements in treating Crohn's disease: The findings by Prof Moynagh and his team have the potential to impact positively on many lives.

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Treating Ulcerative Colitis: Generic vs. Brand-Name Medicine

Erin Matlock, who struggles with ulcerative colitis, one day opened her Delzicol capsule to find her pervious medication inside.

The Bulletin, a newspaper in Central Oregon, published a piece about Matlock?s change in medication titled, ?Blocking generics.?? This piece examines the financial benefits pharmaceutical companies gain from patenting new prescriptions just before they face competition from generic manufacturers: ?With no new clinical trials, the company secured an expedited review from the FDA and got Delzicol approved six months before Asacol was due to go off-patent. ?By pulling Asacol from the market, they could get doctors to begin writing prescriptions for Delzicol and patients established on it well before a generic Asacol arrived.?

For years, Matlock took Asacol to help treat her condition.? Until it stopped being manufactured.? Her doctor told her about a new prescription from the same manufacturer called Delzicol.? Now she has the choice between taking twelve Delzicol pills (which she finds more difficult to digest) a day and spending $25 a month or taking four Apriso pills (another mesalamine-based medicine) a day while paying $125 dollars a month.

Matlock?s struggles are not uncommon.? Many patients who suffer from ulcerative colitis require medication, and even surgery, to treat their symptoms.

Although there is no known cure, correctly applied therapy has been known to markedly reduce symptoms and even lead to long-term remission.

Herman & Wallace offered their first on Bowel Pathology and Function in Stony Brook, NY last April and is in the midst of confirming dates for another course in 2014.? Keep a look out for updates!

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Meet the Instructor for our New Course: "Lymphatic Drainage for Pelvic Pain!"

This November, Herman & Wallace is excited to bring a new course, Manual Lymphatic Drainage for Pelvic Pain, to Houston, TX!  This course will be taught by Debora Hickman, DPT, WCS.

Susannah Haarmann

Pelvic Rehab Report sat down with Debbie to learn more about her upcoming course.

What can you tell us about this continuing education course that is not mentioned in the course description and objectives that are posted on-line?

This course is a must for physical therapists performing women’s health physical therapy.  I have found there is a need to reduce inflammation in pelvic pain patients either prior to beginning intravaginal treatment or following intravaginal treatment. In both cases, inflammation is prevalent.  Patients who are in an acute state of pain will be more tolerant of intravaginal treatment and those who flair up following treatment will have less discomfort and inflammation.

What inspired you to create this course?

I developed treatment protocols for a variety of diagnoses in women’s health that included MLD for patients with pelvic pain and inflammation.  A physical therapy expert on pelvic pain,who is a colleague of mine from Herman and Wallace, intimated other therapists attending her courses expressed an interest in learning techniques to treat inflammation in pelvic pain patients.  Her high regard for Herman and Wallace and the apparent need for a course motivated me to develop this program.

What resources and research were used when writing this course?

During my Klose Lymphedema Training Course, I learned the benefits of MLD included decreasing inflammation and pain.  Additionally, as I researched treatment for pelvic pain, I frequently observed that the primary treatment goals were to decrease pain and inflammation.  With my extensive knowledge of the lymphatic system combined with the current research on pelvic pain, I connected the idea that to improve the patient out come and decrease the duration of physical therapy treatment, manual lymphatic drainage needs to be apart of the treatment protocol.

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

The clinical treatment approach, following a comprehensive women’s health physical therapy evaluation, includes how to decrease pain and inflammation.  You will be able to apply MLD for the pelvis and genitals to your current treatment protocol for your pelvic pain patients.  The seminar will cover emptying lymph node groups to receive additional lymph, making path ways to transport lymphatic fluid, and transporting lymph fluid from the pelvis, genitals and thighs to the terminus. When you have completed this course, you will have a general understanding of the lymphatic system, know when to use manual lymph drainage, and demonstrate how  to perform manual lymph drainage for the pelvis and genitals.

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

You will want to take this course to improve quality care and decrease pain and inflammation in your pelvic pain patients.  It is effective and gentle to use as a stand  alone treatment if needed due to patients in ability to tolerate more aggressive therapy.  Following this course you will be able to return to your clinic and begin   using MLD on your pelvic pain patients.

This course is a must for clinicians who wish to expand their knowledge of treating pelvic pain.  Seats are limited – register today!

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Doctors Increasingly Ignoring Guidelines for Treating Back Pain Patients

The JAMA Internal Medicine recently published a study that illustrated how physicians are suggesting physical therapy and over-the-counter medicine less and less frequently. According to PT in Motion, the JAMA study illustrates that, ?[d]espite published guidelines that call for physical therapy or medications such as ibuprofen or acetaminophen for first-line management of most back pain, other treatments such as imaging, narcotics, and referrals to other physicians have increased.?

The study also concluded that ?Early physical therapy following a new primary care consultation was associated with reduced risk of subsequent health care compared with delayed physical therapy.?

This report appeared on the JAMA website yesterday.? The study, identifying ?23,918 visits for spine problems,? demonstrated that both treatment with narcotics and physician referrals have grown drastically since 1999, while ?[n]onsteroidal anti-inflammatory drug or acetaminophen use per visit decreased from 36.9% to 24.5%?. During this time, the percent of therapist referrals has remained roughly the same.

Herman & Wallace instructor, Ginger Garner, articulated the problem clearly in her blog: ?What was startling about the study was that while narcotic prescription, referrals for diagnostic tests, and other physician referrals all increased, patient quality of care and back pain outcomes decreased.?? Sometimes PTs are better suited to treat patients than physicians.

The study concluded that, ?[b]ecause more than 10% of visits to primary care physicians relate to back and neck pain, and the treatments recommended by guidelines generally are less costly than those being used increasingly, the financial implications in the health care market are significant.?

Patients now have direct access to PT in all 50 states, but it is important to get the word out to patients and referring physicians that PT is supported as the standard of clinical care for typical low back pain management.

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Percy Harvin Suffers Hip Labrum Tear

Yesterday, star athlete and Seahawks wide receiver, Percy Harvin, suffered a hip labrum tear.? His injury may require surgery, as one of his physicians has suggested.

The labrum is vital in such basic functions shock absorption and joint lubrication.? As described on the Mayo Clinic?s website, ?The labrum acts like a socket to hold the ball at the top of your thighbone (femur) in place.?? It?s easy to see why hip labrum tears are not uncommon among athletes.

Percy Harvin received a $67 million dollar contract when he was traded to Seattle from the Minnesota Vikings last spring.? His career has been hampered by injuries.? Frequently missing games because of migraine headaches, Harvin missed most of last season with an ankle injury.

Of course, you don?t have to be a star football player to suffer from labral tears, and acetabular labral tears are reported to be a major cause of hip dysfunction in young patients and a primary precursor to hip osteoarthritis. Herman & Wallace offers a course on Extra-Articular Pelvic and Hip Labrum Injuries.? The next course-event will be offered next year? Stay tuned for our 2014 schedule!

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Inflammatory Bowel Disease

Inflammatory bowel disease (IBD) is an idiopathic disease estimated to affect 1.4 million people in the United States. The two main types of IBD are Chrohn's disease and ulcerative colitis (UC). Chronic inflammation occurs in all or part of the digestive tract. Symptoms related to chronic bowel inflammation include diarrhea, rectal bleeding, bowel urgency, abdominal pain, constipation and incomplete emptying of the bowels. Constitutional symptoms such as fever, weight loss, fatigue, night sweats, and changes in menstrual cycle can also be reported. To read more about the symptoms, treatment, and research updates about IBD, the Crohn's and Colitis Foundation of America (CCFA) is an excellent resource. The CCFA has a variety of events aimed towards support, education, and fundraising, and you can look for events in your part of the world by going to this page on their website.

Other resources for increasing your own knowledge and awareness and for patient education purposes are listed below.

These conditions are different from Irritable Bowel Syndrome primarily due to the inflammation that occurs. While the etiology of IBD is still unclear, what is known is that the body's immune system response is abnormal. The condition is more common in patients who are caucasian, and there is also a familial link. Structural abnormalities including inflammation, lesions, ulcers or tearing are common. While Crohn's can affect any part of the gastrointestinal tract, ulcerative colitis affects the lining of the colon. If a patient of any age presents with symptoms of bowel dysfunction, a worsening of or lack of improvement of bowel complaints, he or she should be referred to an appropriate medical provider to rule out inflammatory conditions of the bowel. In children, IBD can affect growth and development, so the sooner the condition is managed, the better for overall health. The presentation of IBD can be cyclical, with flare-ups that occur, and while pelvic rehabilitation providers are a valuable part of the team treating the symptoms and functional bowel dysfunction related to IBD, we also must be astute in recognizing when a patient requires the evaluation of a medical provider.

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