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Benefits of working with the breath


In his famous book Light on Yoga, B K S Iyengar describes pranayama as “extension of breath and its control”1.  Pranayama includes all aspects of breathwork: inhalation, exhalation, and breath retention.  As clinicians treating pelvic floor dysfunction, we emphasize the importance of breathing as a critical component of rehabilitation.  Physical therapists Paul Hodges (et al) and Julie Wiebe describe a piston-like relationship between the diaphragm and pelvic floor2,3.  Pranayama, or conscious breathing, can enhance this relationship, especially if there are holding patterns in the pelvis. On inhalation, the pelvic floor muscles and diaphragm move caudally. On exhalation, the pelvic floor muscles and diaphragm move cranially4.  As physical therapists, we instruct patients to use the breath in coordination with the pelvic floor muscles to obtain optimal stability and continence.  Pelvic organ prolapse and urinary/fecal incontinence are often caused by a lack of tonic support and muscular strength of the pelvic floor, core and surrounding pelvic girdle musculature5.  Optimal pelvic floor support from adequate strength, core stability, and neuromuscular control allows for continence and organ support. For optimal core stability, there must be coordination and strength of all components of the deep core musculature – pelvic floor muscles, transverse abdominals, multifidi, and diaphragm6. The “Soda Pop Can Model of Postural Control”, conceptualized by Mary Massery, illustrates how the pressure system of an aluminum soda can maintains the stability of the structure7. Loss of support can happen at the top (i.e. tracheotomy), front (i.e. diastasis recti abdominus), back (i.e. disc herniation), or bottom (i.e. pelvic organ prolapse or incontinence). A “leak” in the structural integrity could affect postural control, core stability, and continence.  This concept underlines the importance of breath retraining as one aspect of our treatment plan. Pranayama gives your patient a strategy to decrease sympathetic nervous system overactivity and encourages the parasympathetic response. According to Diane Lee, common areas of rigidity of movement/holding patterns include lateral and posterior-lateral expansion of the ribcage during inhalation8.  Mindful pranayama encourages the student to explore diaphragmatic breathing without gripping in the chest and ribcage.   Examples of pranayama DirghaDirgha is the Three-Part Breath. Inhale, allowing the belly to fill.  If your patient finds this challenging, try a book on the belly when supine or try breathing in quadruped. The second part of dirgha is expanding the ribcage, followed by the collarbones to floating up. After trying this for 10 breath cycles, stop and recognize any new sensations or softening in the body. I recommend my patients set an alarm to go off every hour to remind them to move and breathe. 

Ujjayi

Ujjayi is known as the Ocean breath. It sounds like you have one ear to a giant seashell. Raise one hand in front of the mouth and pretend to fog a mirror with an inhalation and exhalation.  Recreate the same action at the back of the throat, but now with the mouth closed. This breath should sound similar to the signature sound of the Star Wars villain Darth Vader.  Perform this breath with any warm-up or asana while layer this breath onto Dirgha.

 

Letting Go Breath

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Pelvic Organ Prolapse and Levator Avulsion


What's the evidence, and what's the answer?

In getting ready to teach my Menopause course in Minneapolis next month, I always like to do a review of the evidence, to see what’s new, or what’s changed. What has changed over the past few years – more and more evidence to support the role of skilled rehab providers, using evidence based assessment techniques to gauge the grade of pelvic organ prolapse and assess the risk of levator avulsion. What hasn’t changed enough – the level of awareness of the benefits of pelvic rehab in managing, or in some cases even reversing, the effects and symptoms of prolapse.

Dr Peter Dietz, from the University of Sydney, writes ‘…although clinical anecdote suggests some physiotherapists recognize other characteristics suggesting muscle dysfunction (e.g. holes, gaps, ridges, scarring) or pelvic floor dysfunction (e.g. width between medial edges of pelvic floor muscle) with palpation it is difficult to find any literature describing the techniques needed to do this or their accuracy or repeatability. Mantle (in 2004) noted that with training and experience a physiotherapist might be able to discern muscle integrity, scarring, and the width between the medial borders of the pelvic floor muscles, with palpation. It is not clear to what extent physiotherapists are able to do this reliably or how such characteristics are to be recorded.’

Dr Dietz describes a palpation technique to assess the integrity of the pubovisceral muscle insertion, by checking the gap between the urethra centrally and the pubovisceral muscle laterally. On levator contraction this gap should be little wider than your index finger, otherwise an avulsion injury is very likely.

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Synopsis of Current Research into Pelvic Organ Prolapse Surgeries using Mesh Products


The following comes to us from Felicia Mohr, DPT, a guest contributor to the Pelvic Rehab Report.

Vaginal mesh kits were used frequently early in the millennium as they led to high initial anatomic success rates with peak use between 2008 and 2010. Objectively they seemed to help elevate women’s pelvic organs to appropriate anatomical locations. Unfortunately there has been a high rate (10% according to a review of current literature on PubMedBarski 2015) of mesh erosion causing recurrent prolapse and/or stress urinary incontinence. Also there are cases when the mesh product perforates surrounding organs causing numerous dangerous complications. The rate of mesh-related complications according to current research is 15-25%. As a result, the FDA has reclassified the risk of synthetic mesh into a higher risk category so that the public has an increased awareness of the risk involved in these types of surgeries.

A systematic review and meta-analysis, published in 2015, reviewed the risk factors for mesh erosion following female pelvic floor reconstructive surgery (Deng, et al). They concluded the following factors increase risk of mesh erosion: younger age, more childbirths, premenopausal states, diabetes, smoking, concomitant hysterectomy, and surgery performed by a junior surgeon. Moreover, concomitant POP surgery and preservation of the uterus may be the potential protective factors for mesh erosion.

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Degree of prolapse symptoms


The following post comes to us from Herman & Wallace faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison authored "Use of transabdominal ultrasound imaging in retraining the pelvic-floor muscles of a woman postpartum" and is a leading expert in the use of ultrasound imaging for pelvic rehab. She is the author and instructor of the Rehabilitative Ultrasound Imaging: Women’s Health and Orthopedic Topics offered with Herman & Wallace.

In the pelvic floor series we learn how to perform examinations for cystoceles and rectoceles. It can be more difficult for therapists to examine and quantify the degree of uterine descent. In the last few years translabial ultrasound imaging has also been used to identify what is happening in the anterior compartment upon Valsalva and pelvic floor contraction, including the uterus. This is helpful when trying to determine the degree of uterine prolapse. Degree of pelvic organ descent visible on by ultrasound has been shown to have a near-linear relationship with measures on the POPQ.

Clinically we see that some patients with severe prolapses have few symptoms, while other patients with smaller prolapses will have more severe complaints of symptoms. This can be puzzling to the clinician who is trying to treat prolapse patients. Shek and Dietz performed a study to set cutoff measures of uterine descent that will predict symptoms of prolapse. Translabial ultrasound imaging was performed on 538 women with 263 women reporting prolapse symptoms. Seventy-five percent of the women presented with grade two or greater prolapse on the POPQ, with most of being cystoceles or rectoceles. The women with more complaints of symptoms of prolapse were more likely to have uterine prolapse. There was a strong association between degree of uterine descent and symptoms of prolapse. They determined that an optimal cutoff to predict symptoms of prolapse due to uterine descent is a cervix descending to 15 mm above the pubic symphysis.

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Rectal Prolapse: The Basics


The phrase “rectal prolapse” may be easily confused with the term “rectocele” yet they may be very distinct clinical presentations. A rectocele refers to a prolapse of the posterior wall of the vagina that allows the rectum to bulge forward towards the posterior vaginal wall. This condition occurs most often in women rather than men. A rectal prolapse is a protruding of the rectum itself outside of the anal verge or opening. An overview article published in 2013 in the Journal of Gastrointestinal Surgery provides information about the condition that may assist the pelvic rehabilitation provider with valuable clinical concepts. Prior to becoming a full external prolapse, an internal intussusception may occur (and observed on defecography) and progress to include an external mucosal prolapse. Rectal prolapse may occur with or without other conditions of pelvic organ descent such as a cystocele or uterine prolapse. Although the prevalence of complete rectal prolapse is low, and occurs more often in women or in elderly patients, interference with quality of life may be significant.

Symptoms can include pain, difficulty emptying the bowels, bloody and or mucous discharge, urinary incontinence, and fecal incontinence or constipation. Patients may also complain of a lump or a bulge in the rectum that may or may not improve following a bowel movement. A complete rectal prolapse can be described as a full-thickness protrusion of the rectum through the anus. A more serious consequence of this condition is strangulation of the bowel. Features of a rectal prolapse often include a redundant sigmoid colon, levator ani muscle diastasis, and loss of the vertical position of the rectum, according to the article.

Treatment of a rectal prolapse may include surgery. Prior to surgery, a physical exam, colonoscopy, anoscopy, and possibly manometry and defecography may be completed. The surgical goals are to correct the prolapse, improve any complaints of discomfort, and to resolve bowel dysfunction. Surgical approaches may include abdominal or perineal approaches, minimally invasive versus open surgery, and techniques can include posterior versus ventral and rectopexy with or without sigmoidectomy. For more details about the specific approaches for rectal prolapse repair, see the linked article. The authors of this overview article point out that because “…there is a paucity of data evaluating the effectiveness and appropriateness of the various surgical techniques…”, there is not one single management strategy for each patient.

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