Nancy Cullinane PT, MHS, WCS is today's guest blogger. Nancy has been practicing pelvic rehabilitation since 1994 and she is eager to share her knowledge with the medical community at large. Thank you, Nancy, for contributing this excellent article!
Clinically valid research on the efficacy and safety of therapeutic exercise and activities for individuals with osteoporosis or vertebral fractures is scarce, posing barriers for health care providers and patients seeking to utilize exercise as a means to improve function or reduce fracture risk1,2. However, what evidence does exist strongly supports the use of exercise for the treatment of low Bone Mineral Density (BMD), thoracic kyphosis, and fall risk reduction, three themes that connect repeatedly in the body of literature addressing osteoporosis intervention.
Sinaki et al3 reported that osteoporotic women who participated in a prone back extensor strength exercise routine for 2 years experienced vertebral compression fracture at a 1% rate, while a control group experienced fracture rates of 4%. Back strength was significantly higher in the exercise group and at 10 years, the exercise group had lost 16% of their baseline strength, while the control group had lost 27%. In another study, Hongo correlated decreased back muscle strength with an increased thoracic kyphosis, which is associated with more fractures and less quality of life. Greater spine strength correlated to greater BMD4. Likewise, Mika reported that kyphosis deformity was more related to muscle weakness than to reduced BMD5. While strength is clearly a priority in choosing therapeutic exercise for this population, fall and fracture prevention is a critical component of treatment for them as well. Liu-Ambrose identified quadricep muscle weakness and balance deficit statistically more likely in an osteoporotic group versus non osteoporotics6. In a different study, Liu-Ambrose demonstrated exercise-induced reductions in fall risk that were maintained in older women following three different types of exercise over a six month timeframe. Fall risk was 43% lower in a resistance-exercise training group; 40% lower in a balance training exercise group, and 37% less in a general stretching exercise group7.
In manual therapy training, we do not learn just one position to mobilize a joint, so why should pelvic floor muscle training be limited by the standard training methods? There is almost always at least one patient in the clinic that fails to respond to the “normal” treatment and requires a twist on conventional therapy to get over a dysfunction. Thankfully, classes like “Integrative Techniques for Pelvic Floor and Core Function” provide clinicians with the extra tools that might help even just one patient with lingering symptoms.
In 2014, Tenfelde and Janusek considered yoga as a treatment for urge urinary incontinence in women, referring to it as a “biobehavioral approach.” The article reviews the benefits of yoga as it relates to improving the quality of life of women with urge urinary incontinence. Yoga may improve sympatho-vagal balance, which would lower inflammation and possibly psychological stress; therefore, the authors suggested yoga can reduce the severity and distress of urge UI symptoms and their effect on daily living. Since patho-physiologic inflammation within the bladder is commonly found, being able to minimize that inflammation through yoga techniques that activate the efferent vagus nerve (which releases acetylcholine) could help decrease urge UI symptoms. The breathing aspect of yoga can reduce UI symptoms as it modulates neuro-endocrine stress response symptoms, thus reducing activation of psychological and physiologic stress and inflammation associated with stress. The authors concluded the mind-body approach of yoga still requires systematic evaluation regarding its effect on pelvic floor dysfunction but offers a promising method for affecting inflammatory pathways.
Pang and Ali (2015) focused on complementary and alternative medicine (CAM) treatments for interstitial cystitis (IC) and bladder pain syndrome (BPS). Since conventional therapy has not been definitely determined for the IC/BPS population, CAM has been increasingly used as an optional treatment. Two of the treatments under the CAM umbrella include yoga (mind-body therapy) and Qigong (an energy therapy). Yoga can contribute to IC/BPS symptom relief via mechanisms that relax the pelvic floor muscle. Actual yoga poses of benefit include frog pose, fish pose, half-shoulder stand and alternate nostril breathing. According to a systematic review, Qigong and Tai Chi can improve function, immunity, stress, and quality of life. Qigong has been effective in managing chronic pain, although not specifically evidenced with IC/BPS groups. Qigong has also been shown to reduce stress and anxiety and activate the brain region that suppresses pain. The CAM gives a multimodal approach for treating IC/BPS, and this has been recommended by the International Consultation on Incontinence Research Society.
Dr. Dischiavi is a Herman & Wallace faculty member who authored and teaches Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System, available this August in Boston, MA.
STEM is an acronym for science, technology, engineering, and math. These fields are deeply intertwined and taking this approach could potentially be a way to facilitate the physical therapist’s appreciation of human movement.
Science: I would bet most physical therapists would agree that science is the cornerstone of our profession. It is time to look across all the landscapes of science to better understand the physical principles that govern movement. Biotensegrity is a great example of how science from a field such as cellular biology can help possibly explain how we maintain an erect posture when the rigid bony structure of our skeleton is only connected from bone to bone by soft tissues . The brain and central nervous system regulates muscle tone, and it is resting muscle tone that give our bodies the ability to be upright. Without resting muscle tone, we would crumple to the ground as a heap of bones within a bag of skin. Since the CNS can either up or down regulate muscle tone, this allows us to create the rigidity we need to accomplish higher level movements such as sport, and then return to a resting state after the movements are performed (see running skeleton picture below). This theory of organismic support was bred within the scientific field of cellular biology, and can potentially be applied effectively to the human organism. As physical therapists, I agree we need to be skeptical of new ideas, but we also need to embrace the idea that the physical sciences have applied to nature for centuries, and it is possible these various scientific fields can help us unlock new ideas and allow us to look at things through a different lens.
Today's blog is a contribution from Kristen Digwood, DPT, CLT, of the Elite Pelvic Rehab clinic in Wilkes-Barre, PA.
Urgency urinary incontinence (UUI), which is the involuntary loss of urine associated with urgency, is a common health problem in the female population. The effects of UUI result in limitations to daily activity and quality of life.
Current guidelines recommend conservative management as a first-line therapy in urinary incontinence, defined as "interventions that do not involve treatment with drugs or surgery targeted to the type of incontinence".
Vaginal wall thinning associated with menopausal changes can cause vaginal burning and pain, limitations in sexual function, and vaginal redness or even changes in discharge. Because these symptoms can mimic many other conditions such as pelvic floor muscle dysfunction or an infection, it is necessary for the pelvic rehabilitation therapist to be alert to identifying vaginal atrophy as an issue to rule out so that patients can access appropriate medical care when needed.
Atrophic vaginitis (AV) is a condition of the vaginal walls associated with tissue thinning, discomfort, and inflammation. The tissue changes often extend into the vulvar area as well. Atrophic vaginitis may also be called vaginal atrophy, vulvovaginal atrophy, urogenital atrophy, or genitourinary syndrome of menopause. Although we tend to associate menopause with women who are in their 40’s or 50’s, any woman who has stopped having her menstrual cycles or who has had a significant reduction in her cycles may be at risk for vaginal atrophy. Any woman who has had a hysterectomy may also be at risk of this thinning of the vaginal walls. Common symptoms of vaginal wall thinning include vaginal dryness, tissue irritation, redness, itching, and a “burning” pain. Interruption in sleep, limitations in activities of daily living, and changes in mood and temperament have also been reported.
One common pharmacological intervention for vaginal and vulvar atrophy is the topical application of hormone creams such as estrogen. A recent study examined the effects of low dose estrogen therapy on bacteria that populates the vaginal walls.Shen et al., 2016 This bacteria may be causal or correlated to vaginal health, and also appears related to estrogen levels. Sixty women diagnosed with atrophic vaginitis were treated with low dose estrogen therapy and followed for four weeks to assess the vaginal microbiotia via mid-vaginal swabs. Following are highlights from the linked study’s findings,
Spending the past 5 years watching a lot of Disney Junior and reading Dr. Seuss, professional journal reading is generally reserved for the sanctuary of the bathroom. When patients ask if I’ve heard of certain new procedures or therapies, I try to sound intelligent and make a mental note to run a PubMed search on the topic when I get home. Making the effort to stay on top of research, however, makes you a more confident and competent clinician for the information-hungry patient and encourages physicians to respect you when it comes to discussing their patients.
A 2016 article in Translational Andrology and Urology, Lin et al., explored rehabilitation of men post radical prostatectomy on a deeper level, trying to prove that brain-derived neurotrophic factor (BDNF) promotes nerve regeneration. In many radical prostatectomies, even when the nerve-sparing approach is used, there is injury to the cavernous nerves, which course along the posterolateral portion of the prostate. Cavernous nerve injury can cause erectile dysfunction in 60.8-93% of males postoperatively. The authors discussed Schwann cells as being vital for maintaining integrity and function of peripheral nerves like the cavernous nerve. They hypothesized that BDNF, a member of the neurotrophin family that supports neuron survival and prevents neuronal death, activates the JAK/STAT (Janus kinase /signal transducer and activator of transcription) pathway in Schwann cells, thus facilitating axonal regeneration via secretion of cytokines (IL-6 and OSM-M). Through scientific experiment on a cellular level (please refer to the article for the specific details), the authors were able to confirm their hypothesis. Schwann cells do, in fact, produce cytokines that contribute to the regeneration of cavernous nerves.
From a different cellular perspective, Haahr et al., (2016) performed an open-label clinical trial involving intracavernous injection of “autologous adipose-derived regenerative cells” (ADRCs) in males experiencing erectile dysfunction (ED) after radical prostatectomy. Current treatments with PDE-5 inhibitors do not give satisfactory results, so the authors performed a human phase 1, single-arm trial to further the research behind the use of adipose-derived stem cells for ED. Some limitations included the study was un-blinded and had no control group. Seventeen males who had ED after radical prostatectomy 5-18 months prior to the study were followed for 6 months post intracavernosal transplantation. The primary outcome was safety/tolerance of stem cell treatment, and the secondary was improvement of ED. The single intracavernosal injection of freshly isolated autologous adipose-derived cells resulted in 8 of 17 men regaining erectile function for intercourse; however, the men who were not continent did not regain erectile function. The end results showed the procedure was safe and well-tolerated. There was a significant improvement in scores for the International Index of Erectile Function-5 (IIEF-5), suggesting this therapy may be a promising one for ED after radical prostatectomy.
In case you’ve been under a rock (or maybe studying for the Pelvic Rehabilitation Provider Certification (PRPC) exam, the latest Netflix series starring Maria Bamford is out, and it is, as the kids say, amazeballs. We have Maria Bamford and team, and Lady Dynamite, to thank for getting the term vaginismus out in the public as the title of Season 1, Episode 8. The episode is named “A Vaginismus Miracle.” In this episode Maria is answering the question of when she last had sex. She answers that is was a year ago, which reminds her that the annual date of "Vaginismus" must be coming up. Maria further explains that she must have sex once per year because then everything is good "under the hood", and if she doesn't have sex once a year, her "vagina could close up." It's a nail biter of an episode as Maria's assistant has messed up the schedule, and Maria finds out that "Vaginismus" is that very night, and she must find a partner before midnight.
As a pelvic health provider, I knew that neither myself nor my colleagues would be able to sit back and worry about Maria suffering through another year with “Vaginismus” on her calendar, a looming deadline when we all know that with a little bit of rehabilitation, the issue could be much, much better, or maybe resolved altogether. The episode inspired me to write an open letter to Maria. Feel free to share and tag your friends who you think would love to watch a smart, funny show that puts real life issues including mental health in the spotlight.
Dear Lady Dynamite,
Yoga offers a compelling mind-body approach to maternal care that is forward thinking and aligns with the World Health Organization and Institute of Medicine’s recommendations for patient-centered care. But let’s take a look at WHY postpartum care MUST change in order to establish need for the entry of yoga into postpartum care. Maternal Health Track Record The United States and similarly developed countries have a very poor track record for postpartum care. The record is so poor that the problem in the US has been labeled a “human rights failure.”1 On its own, the US has the worst track record for not only postpartum care, but for maternal and infant mortality and first-day infant death rate in the developed world (Save the Children 2013). Between 1999-2008, global mortality rates decreased by 34% while the US’s rates doubled for mothers.1 Patient satisfaction also suffers under the current model of care, with many more mothers experiencing postpartum depression, a significant risk factor for both mother and baby during and after pregnancy. The increase in mortality and poor outcomes can, in part, be attributed not to underuse, but overuse of medical intervention during pregnancy and birth. 2,3,4 Countries that have “access to woman-centered care have fewer deaths and lower health care costs”; and, hospital system reviews in the US show that reducing medical interventions are both reducing cost and improving outcomes.1,4,5 The notorious lack of accountability (reporting system) in maternal health care also plagues the US and suggests that maternal deaths are even higher than currently reported, leading to Coeytaux’s conclusion that the “United States is backsliding.”1 Improving Postpartum Outcomes with Integrated Physical Therapy Care In After the Baby’s Birth, maternal health advocate Robin Lim writes, "All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six-week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive, particularly to women suffering from painful physical and/or psychological disorders following childbirth." Physical therapists can be instrumental change agents in improving current postpartum care, especially through the integration of contemplative sciences like yoga. Yoga can be the cornerstone of holistically-driven, person-centered care, especially in comorbid conditions such as pelvic pain and depression, where pharmacological side effects, stigma, can severely diminish adherence to biomedical interventions.6 Coeytaux, as well as other authors, clearly correlate the reduction of maternal mortality with improved postpartum care. The World Health Organization recommends that postpartum checkups should include screening for:Back painIncontinence (stress)HemorrhoidsConstipationFatigueBreast painPerineal painDepressionPainful or difficult intercourseHeadachesBowel problemsDizziness or fainting
A physical therapist is a vital team member in not only screening for many of the listed problems above, but in managing them. It is important to note that other countries, like France, deliver high quality postpartum rehab care plus in-home visits, all while spending far less than the US on maternal care. The World Health Organization, however, clarifies the vital importance of postpartum care delivery by making a significant recommendation for a paradigm shift in biomedical care.7 Yoga as a “Best Care Practice” for Postpartum Care The WHO recommends the use of a biopsychosocial model of care, which yoga is ideally suited to provide via its ancient, multi-faceted person-centered philosophy. Medical Therapeutic Yoga is a unique method of combining evidence-based rehabilitation with yoga to emerge with a new paradigm of practice. MTY:Addresses the mother as a person, not as a condition or diagnosis.Empowers mothers with self-care strategies for systems-based, not just musculoskeletal or neuromuscular, change.Addresses all domains of biopsychosocial impairment.Teaches interdisciplinary partnership-based theory, which is integral to creative collaborative discourse and innovation in postpartum care.Equips clinicians with business service, website development, practice paradigm, and social media campaign tools to fully develop the new clinical niche of Professional Yoga Therapy practice. Promotes patient advocacy, health promotion, and public health education via mainstreaming yoga into rehabilitative and medical services.Provides the gender context for prescription that traditional yoga is lacking.Evolves yoga for use in prenatal and postpartum care.
Physical therapy screening and intervention in the postpartum is vital, but the addition of yoga can optimize postpartum care and has enormous potential to be a “Best Care Practice” for postpartum care in rehabilitation. As a mind-body intervention, yoga during pregnancy can increase birth weight, shorten labor, decrease pre-term birth, decrease instrument-assisted birth, reduce perceived pain, stress, anxiety sleep disturbances, and general pregnancy-related discomfort and quality of life physical domains.8-9 In addition to the typical physical therapy intervention for postpartum physical therapy, the MTY paradigm provides:
Danielle is among the latest class of Certified Pelvic Rehabilitation Practitioners! Her experience treating patients and owning Core 3 Physical Therapy prepared her to pass the exam in flying colors. Read her bio here and check out our interview below. Congratulations, Danielle! What/who inspired you to become involved in pelvic rehabilitation?A patient was the first one to inspire me to improve my knowledge and treatment abilities in pelvic rehabilitation. I was working with a postpartum patient, while carrying my first child, and she felt that my guidance had been so helpful in her care that it made me interested learning more about the pelvic floor. Most of my fellow colleagues could discuss my orthopedic questions but I didn’t have any mentors that could offer advice in more advanced pelvic floor cases so I started attending the Herman and Wallace classes. They have been an invaluable at improving my ability to care for patients with pelvic pain which has even improved my treatment of orthopedic patients with low back pain and sacroiliac dysfunction.
What patient population do you find most rewarding in treating and why?I enjoy working with chronic pelvic pain patients because it's rewarding to be able to bring relief to someone who has been living with pain, limited quality of life or even social anxiety and has not received any benefit with other treatment options. Being able to help this patient population understand the pelvic floor muscles and function as well as providing justification to why they are in pain and then help them progress through various treatment approaches makes my job rewarding.
If you could get a message out to physical therapists about pelvic rehabilitation what would it be? PT's are uniquely trained to provided internal pelvic floor muscle release. This is something that no other health care professional is licensed or has the schedule/time to perform. This technique can provide relief and feedback to your patients that is possible in no other way. If you do not want to address this region or feel comfortable providing this treatment, find a therapist local to you who has experience with pelvic floor and refer when appropriate. Additionally, we as physical therapists are often the first line of defense in recognizing and educating patients about the ability to address a wide variety of symptoms that they believe is "just a normal part of life". Asking the in-depth questions and providing a multimodal approach to their symptoms is not only a boon to the patient but to our profession.
More than a year ago, after working on updating the pelvic floor series courses PF1, 2A and 2B, the Institute turned our attention to the final course in our popular series, PF3. To determine what content our participants wanted to learn about in the last continuing education course of the series, we asked that exact question. From a large survey of therapists who had taken all or most of the courses in the pelvic core series, we collected detailed data from therapists about what was needed to round out their comprehensive training. The results of that survey guided hundreds (and hundreds!) of hours of work completed by a team of instructors. This month, in the beautiful city of Denver, the three instructors who created the Capstone course will share their wisdom, clinical experiences, as well as their thoughtfully-designed lectures and labs. You will have an opportunity to learn in depth about topics covered in the prior courses in the series.
Such topics include lifespan issues and health issues common to different ages, conditions of polycystic ovarian syndrome, endometriosis, infertility, pelvic organ prolapse and surgeries, pelvic fascial anatomy, pharmacology and nutrition. Lab components are detailed and comprehensive for working with specific common implications from conditions in pelvic dysfunction or surgery. This course focuses on the female pelvis, including diving into the complexities of female pelvic health issues. The instructors have all worked in the field for many years, are experienced in working with complex patient presentations, and all excel at manual therapies. I asked each of them to briefly share thoughts about the Capstone course that they each dedicated the last year in developing; following you can read their thoughts.