Earlier this year, the Food and Drug Administration issued a warning about serious side effects of laxatives if not used according to the label or when used in the presence of certain comorbities. Sodium phosphate laxatives, according to the label, are to be taken as a single daily dose, and for no more than three days. In addition to the warning to contact a physician if the patient has kidney disease, cardiac conditions, or dehydration, the FDA advises patients to ask their physician before taking the drug with age older than 55, or when taking certain medications. These medications include: diuretics, angiotensin-converting (ACE) inhibitors, angiotensin receptor blockers (ARBs), and nonsteroidal anti-inflammatory drugs (NSAIDs).

Laxatives are grouped into different classes and have varied effects on a person's gastrointestinal system. The following is adapted from the Mayo Clinic's website and describes the main types of laxatives.

Because laxatives can interact with medications, asking about medication lists (including supplements and herbals) is important for pelvic rehabilitation providers. Even the teas available at the grocery store that are marketed to help with digestion and specifically, constipation, may work well and may interact with a patient's medications. If you are interested in learning more about laxatives, constipation, and promotion of bowel health with rehabilitation techniques, sign up for the Bowel Pathology and Function continuing education course. This course, written by faculty member Lila Abbate, has been well-received and aims to further the knowledge of therapists who are treating patients with bowel dysfunction. The next course is coming up next month in California!

What are the spontaneous mental images that women who have chronic pelvic pain report, and how might the positive or negative mental images relate to chronic pelvic pain? These questions are the focus of research published by authors from the UK in the journal Pain Medicine. Mental images are distinguished in this study from thoughts, or thinking in words, as mental images are "cognitions with sensory-perceptual qualities." These qualities are often visual, and may also be related to smell, touch, taste, and hearing. Ten women were interviewed, 8 of whom had a diagnosis of endometriosis or adenomyosis. The researchers explained that they wanted to learn more about the women's thoughts when in pain, and asked about any images that popped into their heads when in pain. Researchers asked other questions about images related to specific categories, while attempting to avoid offering any leading words during their interview. The patients' most significant mental image (chose by the patient) was then explored for content, triggers, related emotion, meaningfulness, activity impairment, and related behavioral changes.

Other data collected included the Brief Pain Inventory short form, the Pain Catastrophizing Scale, the Spontaneous Use of Imagery Scale, the Hospital Anxiety and Depression Score, and the Mini-International Neuropsychiatric Interview. The range of pain duration in the subjects was 3-20 years, with a mean age of 36.2. While every one of the ten women reported that pain was a trigger, other triggers for a negative mental image included movement, social gatherings, exercise, babies, anxiety, sex, sleep, talking about pain, and reminders of surgery or menstruation- in other words, common daily activities or experiences. The content of the most significant mental images included being raped, having "malicious demons" playing around the pelvis, bright lights in an operating room, being terrorized, feeling sad, helpless, anxious, angry, panicky, guilty, disgusted, horrified, and revulsed. The associated meanings were usually also quite negative in nature. The women reported active avoidance of the triggers when able, limiting activities such as social outings or physical activity. Positive or "coping" images were also reported, with images such as putting the pain into a box, mentally "rubbing pain" medication on the body, or imagining a loved one.

What does this information have to do with pelvic rehabilitation? This study utilized a cognitive-behavioral (CBT) framework, and aspects of CBT are tools that rehabilitation professionals utilize in daily practice. Simply put, a cognitive-behavioral approach addresses how a person's thoughts and feelings affect behavior. In rehabilitation, research studies have described how CBT is utilized in the physical therapy setting, and how therapists can be trained to use skills in CBT to help patients . We can engage patients in conversations about what negative images may be impacting movement, and what positive images may be utilized as healthy coping strategies. For more information about the mind and patient education, join us at Carolyn McManus's continuing education course Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain which takes place next month in Seattle.

Several researchers have contributed to foundational literature in trunk control including Richardson, Snijders, and Hull. One study of interest completed by these authors and other colleagues assessed sacroiliac joint stability with contraction of the transversus abdominis muscles compared to contraction of all the lateral trunk muscles.

In this experiment, 13 healthy subjects without a history of low back pain participated in the tests. Eight men and five women with a mean age of 26 and who were able to complete the required muscle activations participated in the study. The subjects were positioned in prone, and electromyographic recordings as well as ultrasound imaging were used to verify the muscle activation patterns. To measure sacroiliac joint stiffness or laxity, Doppler imaging of vibrations was utilized. The theory of using vibration to measure joint stiffness includes that a transfer of vibration across a joint is best when the joint is more stiff, according to the authors.

The results of the study include a decrease in laxity (or an increase in stiffness) in the sacroiliac joint when either muscle patterns were used, however, when the transversus only was activated, laxity was decreased more than during a more global contraction.

Research in trunk and pelvic control has typically divided the muscles into local or global muscles, with inclusion of the the more superficial, larger muscles that control trunk movement grouped into the global muscles. Local muscles in this study describe the deeper, smaller muscles more apt to act as stabilizers of the lumbar spine and sacrum such as the transversus abdominis and multifidus. While this description is not inclusive of all or of more recent models, for the purposes of this study, these descriptions may be found useful.

The authors acknowledge that the role of the pelvic floor in creating sacroiliac joint stiffness, having not been measured, is not known in this study. The research does support the body of work that describes use of specific training for treating patients with low back pain, rather than global exercises without an emphasis on local muscle activation.

Many of you are aware of the various "camps" and beliefs about trunk and pelvic rehabilitation and activation, and more than likely, as with most issues in life, the truth lies in the middle. Do some patients simply need to correct their breathing patterns, trunk alignment, or gait patterns? Sure, and other patients may require a focus on inhibiting a very painful muscle, bringing awareness to that area, and learning how to "turn on" the muscle and incorporate the muscle pattern into routine activities. Herein we find, in my opinion, the art of rehabilitation. Researchers and therapists will continue to work towards clinical prediction rules and guidelines for best practice, yet we are left with understanding the theories and tools that drive the research and clinical practice so that we can apply individual plans of care for patients. If you find yourself "stuck" with the same "core" exercises and feel that you would like to improve your skills in sacroiliac rehabilitation, therapists have been raving about Peter Philip's sacroiliac joint course, where you can learn very specific palpation, testing, and rehabilitation principles. The next opportunity to take this course is in January!

The Herman & Wallace Pelvic Rehabilitation Institute is excited to offer continuing education courses this year in mindfulness and in meditation, which are not necessarily one in the same. However, each has a relationship with the other, and may be combined into lovely practices. More importantly, you may be wondering, "How does mindfulness fit into pelvic rehab?" Mindfulness or meditation has been applied to many pain diagnoses, and even to pelvic rehab conditions such as bowel or bladder dysfunction, and pelvic pain. (For some interesting reading about mindfulness and meditation, check out the National Center for Complementary and Alternative Medicine's website by clicking here.

In this Canadian study, 14 women participated in four sessions of mindfulness and cognitive behavioral therapy tailored to women with provoked vulvodynia (PVD). The sessions were spaced 2 weeks apart, and each session was 2 hours in length. The program included education in PVD and in pain neurophysiology, cognitive behavioral skills ("identifying problematic thoughts"), progressive muscle relaxation (contract-relax), and mindfulness exercises. The mindfulness exercises included eating meditation, mindfulness of breath, body scan and mindfulness of thoughts. The goal of this particular research article was to describe the women's thoughts about participation in the study activities. The authors report on six major themes from the study:

1)Feeling more normal and part of a community in the group setting
2)Positive psychological outcomes
3)Impact of relationship (supportive versus unsupportive partner)
4)Feeling of gratitude for group facilitators
5)Concern about barriers to continuing their mindfulness practice
6)Feelings of self-efficacy in being able to exert control over their pain

One of the major themes expressed by the participants in this study is that of feeling more "normal" through finding out that other women have the same symptoms and knowing that there are a myriad of symptoms associated with vestibulodynia. By participating in the study, women reported having improvements in self-esteem and feeling more optimistic about their challenges with physical activities such as sexual relationships. Carloyn McManus, who has degrees in both physical therapy and psychology, shares her expertise in our new course: Mindfulness-based Biopsychosocial Approach to the Treatment of Chronic Pain. The next opportunity to take this mindfulness continuing education course, and learn skills that you can immediately apply in mindfulness is this November in Seattle.

Consider how many times we have worked with a patient who refuses to participate in rehabilitation or cancels an appointment because of constipation. Also recall the high number of patients we treat who are in chronic pain and who are also likely taking an opioid medication for pain management. A well-known side effect of opioids is constipation, which can create a viscous cycle: taking the medication can mean having to strain to pass stool, or being bloated which can aggravate an already painful state. Not taking pain medications can increase pain levels, potentially decreasing physical activity levels, another cause for poor bowel function. A recent research article sheds light on this problem, pointing out that, despite a failure of medications in positively treating their constipation, patients are willing to continue on the current course of treatment.

The on-going longitudinal study in the USA, Canada, Germany, and the UK aims to assess the burden of opioid-induced constipation (OIC) in patients who have chronic pain that is not cancer-related. Patients were using at least 30 mg of opioids per day for more than four weeks and had self-reported opioid-induced constipation. For the 493 patients who met the inclusion criteria, retrospective chart reviews, on-line patient surveys, and physician surveys were utilized. Outcomes tools included the Patient Assessment of Constipation-Symptoms, Work Productivity and Activity Impairment Questionnaire-Specific Health Problem, EuroQOL 5 Dimensions, and Global Assessment of Treatment Benefit, Satisfaction, and Willingness to Continue. 62% of the patients were female, mean age in males and females was 52.6.

Patients complained of bowel dysfunction including abdominal pain and bloating, painful straining to defecate and having flatulence, rectal pain and bleeding, headaches, and having hard stools that were difficult to pass. Most of the patients (83%) wanted to have at least one bowel movement (BM) per day, yet the mean reported BM was 1.4 per week without use of laxatives, and 3.7 BM with use of laxatives. Natural or behavioral therapies were used by 84%, and 60% of the patients used at least 1 over-the-counter (OTC) laxative, 24% used 2 or more OTC laxatives, and 19% used one or more prescription laxatives. Unfortunately, 94% of the patients reported inadequate response to laxative use.

Current employment rates for the sample population was 27%, and of these patients, the average reports of missed work due to constipation issues was 4.6±11.9 hours of work over the past 7 days. Even worse, from a pain-management perspective, 49% of the patients reported "…moderate to complete interference with pain management resulting from their constipation." The authors conclude the following: "The prevalence of these symptoms suggests that patients may be undertreating their OIC and/or that the currently utilized therapies for the treatment of OIC may be lacking in efficacy and tolerability." Can we conclude that the under-treatment applies to a lack of pelvic rehabilitation intervention? Granted, opioid-induced constipation by nature of its effects on the gut will in turn affect peristalsis and hydration of stool. However, if a patient learns techniques to stimulate bowel activity, how to manage abdominal bloating and pain, and how to affect the nervous system in a positive way, perhaps less work (and leisure) time would be lost.

If you are interested in learning more about constipation, we have one opening in the PF2A St. Louis course taking place in early October. If you have already taken PF2A, and want to expand your knowledge and your skill set, join faculty member Lila Abbate in her Bowel Pathology and Function continuing education course in California in early November. Course topics include over-the-counter products and medications affecting bowel health, constipation and fecal incontinence, internal vaginal and rectal muscle mapping, and a balloon-manometry lab- a lab that therapists are thrilled to have offered in an Institute course!

An article this year in Canadian Family Physician concludes that "…pregnant women should avoid practicing hot yoga during pregnancy." Have you ever had a pregnant patient ask you if she should use hot tubs, warm pools, use hot packs, exercise in the heat, or participate in hot yoga? As always, the answer to some of the questions may be "it depends," as many factors must be considered including the woman's age, fitness status, pre-pregnancy exercise routines, general health, level of risk, what part of the body she wants to expose to heat, and ability to modify the requested activity. And, most importantly, the biggest driving factors behind our response to our patients is this: is there any known risk for the mother and her baby, and what does her physician say? If there is any known risk to the mother and to the viability of her pregnancy, then we always want to err on the side of caution.

What about yoga? Can participating in a hot yoga class increase core temperature and put the growing fetus at risk? The linked clinical reference article above cites some of the following factors as potential reasons why a person should not participate in hot yoga during pregnancy.

•Elevated core temperatures can occur with fever, extreme exercise, saunas, and hot tubs

•First trimester hyperthermia may lead to neural tube defects, gastroschisis, esophageal atresia, omphalocele, and encephaly in the developing fetus

•Heat decreases time to exhaustion, potentially leading to over stretching, muscle and joint injuries

•High temperatures may increase the risk of dizziness or fainting due to effects on blood pressure

I can imagine the arguments from all sides of the story, and we know that, especially in a highly litigious society, a medical provider will always suggest the most conservative approach. When the stakes are inclusive of both a healthcare license and the maternal/fetal health of our clients, rehabilitation professionals must also be medically conservative and mindful of the most safe, and effective health practices. Several prior posts have discussed the benefits of yoga during pregnancy, and the article by Chan and colleagues acknowledges that for pregnant women participating in yoga the benefits can include increased quality of life, decreased stress and anxiety, decreased pain, and improved sleep. Is it reasonable, then, to suggest that a woman avoid hot yoga during pregnancy?

If you are wondering, "What would Ginger say?", you have another opportunity to learn yoga principles and techniques applied during pregnancy from our yoga expert, Ginger Garner. Ginger teaches from the perspective of a mother, a physical therapist, an athletic trainer, a community educator, a national-level speaker, and a professional yoga therapist. She will be teaching the continuing education course Yoga as Medicine for Pregnancy in November in New York.

Surgery for prostate cancer can impair urinary function, and in the case of persistent urinary incontinence, patients may progress to surgical interventions. In order for physicians to conduct optimal patient counseling and surgical candidate selection for post-prostatectomy urinary incontinence (UI), the records of 95 patients were reviewed in this study. The patients were retrospectively placed into "ideal", n = 72, or "non-ideal", n = 23, categories based on chosen characteristics, and the results of their outcomes and satisfaction were consolidated. Men in the "ideal" group had the following characteristics: mild to moderate UI, external urethral sphincter that appeared intact on cystoscopy, no prior history of pelvic radiation or cryotherapy, no previous UI surgeries, volitional detrusor contraction with emptying of the bladder, and a post-void residual of < 100 mL. Patients who did not meet all listed criteria for the "ideal" group were placed into the "non-ideal" classification.

A cure for the surgery was considered total resolution of post-prostatectomy incontinence with the sling. Of the patients fitting into the ideal classification, 50% reported cure, and of the non-ideal group, 22% reported a cure. Satisfaction rates within the ideal group for the procedure were 92%, whereas the non-ideal group reported a 30% satisfaction. Although uncommon, complications occurring in both groups included prolonged pelvic pain and worsened urinary incontinence. The authors describe the importance of placing the correct amount of tension through the sling, and of leaving as much of the external urethral sphincter in place as possible. Another complication that occurred more frequently is that of acute urinary retention. In the ideal cohort, the 11 cases of urinary retention resolved within 6 weeks of surgery. Of interest is that 12 of the 23 men in the "non-ideal" category had to undergo further surgery with an artificial urethral sphincter.

This information can assist surgeons in guiding and advising patients about operative procedures for post-prostatectomy incontinence. (Ideally, every patient would "fail" a trial of pelvic rehabilitation prior to progressing to a surgery!) If a patient wishes to proceed with a sling surgery despite being in a "non-ideal" category, he could be advised of the known potential outcomes. This article offers support for pre-operative investigation techniques such as urodynamics. Our role as pelvic rehabilitation providers may allow us to discuss such research with patients and providers, and participate in discussions about the role of rehabilitation pre-operatively or post-operatively. If you would like to learn more about working with men who have pelvic floor dysfunctions, you still have time to book a flight to Orlando for the Male Pelvic Floor Function, Dysfunction, & Treatment course, where you can learn about male pelvic pain, incontinence and BPH, and male sexual dysfunction. This is the last opportunity to take this course this year!

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy Robinson, PT, PRPC, CLT.

What/who inspired you to become involved in the pelvic rehabilitation field?:

I first learned about pelvic rehabilitation while I was a student at the Indiana University Physical Therapy program. The instructor brought in speakers for special topics sessions and I must admit I knew at that moment that pelvic rehab was an area of interest for me. However, I was hesitant to start in the area of pelvic health as I felt I needed to gain experience as a new graduate, and I also wasn’t sure I would feel comfortable performing pelvic examinations. I chose to work in a hospital setting for one year, a long term care setting for 2 years, and then transitioned into outpatient physical therapy. There were numerous times in each of those settings that it was apparent pelvic rehabilitation was the missing link in the patients’ treatment plan. In 1998 we had a physician, Dr. Scott Miles, approach the president of the rehabilitation company that I worked for and request that they train a women’s health physical therapist. This was my opportunity and I took my first course with Kathe Wallace, PT. I remember thinking that she was a wealth of knowledge and her enthusiasm allowed me to get over the trepidation of performing pelvic examinations. She allowed me to focus on the examination process itself, how to apply critical thinking to the patient symptoms and evaluation findings, and how to pick the appropriate treatments. I was hooked! I feel very blessed to have had the opportunity to participate in several continuing education courses all over the country from so many very talented Pelvic Health Practitioners and each and every one of them have inspired me in some way to continue to learn and perfect my skills as a pelvic practitioner.

What patient population do you find most rewarding in treating and why?

I truly enjoy treating patients who have a diagnosis of pelvic pain. There are so many different types of pelvic pain and the complexity of the cases fascinate me. I thrive on working together as a team with my client to identify the issues at the root of their pain. There are no two pelvic pain patients who are alike which allows me to create an individualized plan for each patient. It is always very rewarding when a patient who has been suffering with pain for years meets their therapy goals, has the knowledge to self treat, and can complete ADLs and work functions, all being done without pain limiting them.

What role do you see pelvic health playing in general well-being?

Pelvic health affects women and men across the life span. The core musculature must activate correctly in order to maintain function. I continually explain to my patients that the pelvis is similar to the foundation of a house. If the foundation is not laid correctly in a house, the doors and windows don’t open and close as they should and the floors will not be level. In the pelvis if the alignment is not correct, the musculature and ligamentous systems cannot function optimally which leads to injury, pain, and an overall decrease in function over time. Pelvic health should be addressed on the medical history portion of the intake paperwork for all patients who attend physical therapy. If the medical history identifies potential issues with pelvic health, a referral should be made to a qualified pelvic practitioner.

What motivated you to earn PRPC?

I think it is critical in today’s market to be able to identify yourself as a practitioner who has taken the time and made the effort to truly understand such a complex area of the human body. Several years ago when Women’s Health became the hot topic, I noticed there were several hospitals and therapy companies that were sending Physical Therapists to one course and then marketing that they had a Women’s Health program. Unfortunately, this issue continues today and there are so many women and medical practitioners who feel that pelvic rehabilitation is a waste of time and money due to the poor outcomes they have had while under the care of unqualified pelvic practitioners. There are many days in my practice that I evaluate patients who on average have seen 10 different physicians and two pelvic practitioners and still have experienced little to no relief of their symptoms. I feel earning PRPC allows medical practitioners and potential clients feel more confident in my skill set.

Learn more about Amy Robinson, PT, PRPC, CLT at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

An interesting study assessed the ability of fluorescence imaging to measure the benefits of manual lymphatic drainage (MLD a key component of complete decongestive therapy (CDT). Lymphatic dysfunction, often developing into lymphedema, affects a significant population of our patients who undergo treatment for breast cancer or pelvic cancer. Complete decongestive therapy includes manual lymphatic drainage, compression bandaging, therapeutic exercise, and specific skin care techniques. A theory describing the beneficial effects of MLD, as explained in this article, is that MLD stimulates a contractile or "pumping" mechanism within the superficial lymphatic system.

Although effects of MLD can be measured by limb volume assessment, this study aimed to investigate if in fact contractile function is improved. The investigators used near-infrared fluorescence, or NIR fluorescence, to measure "…the apparent propulsive lymph velocities..and…the period or time of arrival between successive propulsive events." Twelve subjects diagnosed with Grade I or II unilateral lymphedema and 10 controls were included in this research and were treated by a certified lymphedema therapist. The manual lymphatic drainage preparatory protocol for an involved upper extremity included lymphatic massage to the cervical lymph nodes x 5 minutes, then the neck, axillary region of the contralateral arm, and the ipsilateral inguinal region. Lower extremity MLD also started at the neck, then treatment was directed to the contralateral inguinal nodes and ipsilateral axillary nodes. The control subjects received massage to the neck for 3 minutes, bilateral axillary region massage x 5 minutes or bilateral inguinal regions, depending on if the upper or lower limb was imaged in the study. The appropriate limb was then treated with MLD massage techniques.

Prior to and after the treatment, images were collected that allowed the researchers to visualize the imaging contrast agent that was injected through intradermal route into the patient's upper or lower extremities. The results of the study, although limited by statistical power by the low number of subjects, demonstrated that after the manual lymph drainage, in subjects and in controls, treatment had the potential to improve lymph transport. Despite the overall evidence of potential for improvement, there were two subjects in the upper extremity lymphedema group who did not show an improved lymph transport after treatment. One of these subjects also did not respond to MLD and bandaging treatment that followed for six weeks after the fluorescence study. In the lower extremity treatment group, overall apparent lymph velocity and a decrease in the period between propulsive events was noted. The authors state that NIR fluorescence could be utilized to help predict patients who may benefit from manual lymph drainage. The imaging may also help identify functioning lymphatic vessels towards which the therapist can direct manual techniques for draining the limb effectively.

While this study was directed towards the lymphatic dysfunctions of the limbs, what does a pelvic rehabilitation therapist need to know when treating dysfunctions of lymph in the pelvis? Lymphatic function can easily be interrupted following surgeries, or radiation for pelvic cancers, or even following orthopedic injuries. Join Debora Hickman at her continuing education course Manual Lymphatic Drainage for Pelvic Pain in San Diego next month to learn technique in applying MLD for the pelvis!

A recent on-line survey queried fourty-four Obstetrician-Gynecologists (OB-GYNs) in British Columbia to learn more about the needs of physicians who treat women who have endometriosis and chronic pelvic pain (CPP). Physicians reported that women who present with endometroisis or chronic pelvic pain usually require more visits than other patients, for reasons including medical and pain management, lack of a clear diagnosis, and lack of improvement in condition. Evaluation techniques utilized by the physicians often included laparoscopy and ultrasound, and despite these practices, the OB-GYNS reported challenges in making a diagnosis or successfully treating their patients with CPP. In fact, survey results indicated that 5% of the respondents were able to diagnose a patient for a cause of pelvic pain in > 70% of patients. Most of the physicians reported that less than half of the women treated had a good response to interventions. Although the highest rate of referral for these providers was to another OB-GYN specializing in pelvic pain, nearly 60% of the time a referral to physical therapy was reported.

Although some of the narrative comments encountered in this survey were positive, including one physician's report of having "…good success with physiotherapy…", more often the providers expressed frustration and annoyance when faced with not only the challenges of diagnosis and treatment, but also the poor compensation and the longer visits required for counseling and teaching of patients. In addition to wanting more clear guidelines on diagnosis and management of female CPP, physicians expressed interest in having group educational sessions for patients, and more resources such as educational brochures on self-management for patients.

How can pelvic rehabilitation providers fill in this knowledge gap? I recall asking a referring provider if he was pleased with his patients' rehabilitation outcomes, and he expressed such a relief that I was taking the "dregs of the practice." He meant nothing disparaging about the patients themselves, he explained, just that when these patients walked in the door he felt a sinking feeling because he did not know what to do for them. Now, he reported, these same patients were returning from a pelvic rehabilitation referral and excitedly reporting on progress they had made. So many physicians and other referring providers still do not understand the scope of the patient populations that we can treat in pelvic rehabilitation. We can provide a necessary bridge between the challenge of diagnosing and medically treating chronic pelvic pain and the rehabilitation approach that addresses the chronic pain issues. Differential diagnosis of chronic pelvic pain from a rehabilitation standpoint is a skill set that every therapist must continually improve upon. If you are interested in learning more about these skills, sign up for faculty member Peter Philip's continuing education course Differential Diagnostics of Chronic Pelvic Pain next month in Connecticut.