As we head into the New Year, we commonly reflect on the past year and plan for the next 12 months. I wanted to share with you a tool that I have found to be useful not only in my personal life, but also in assisting patients with choices. This is a tool that I first read about in a book about neurolinguistic programming, and one that I understand many life coaches use when assisting people who want to assess various aspects of self or of life categories.
First, make a large circle on a piece of paper. Then divide it into "pie pieces" and label each piece of pie with a category. For example, if you wanted to get a sense of your personal satisfaction with your life, you might choose: spiritual practice, fitness, primary relationship, work, finances, and home improvement. List numbers from the center of the circle outward along the lines separating the category, you can use any range of numbers such as 1-5 or 0-10. Then score your rating for each category with the higher number being a positive rating. Let's say you self-score at least an 8 on all categories except for finances. If that is the case, you can then list a few tangible goals that relate to financial health with dates for achieving those goals. This type of wheel can be completed very quickly and in my experience it does not take much thought to score your sense of happiness within the various categories. If you focused this wheel on work/career, you might label the pieces as various aspects of evaluation, treatment, perhaps body parts, or even categories such as managerial tasks versus documentation. We are often balancing so many domains in our life that it is challenging to stay at a "10" with any one category for long; we are often giving of our energies to patients, to employers, to our families and children, and this leaves little time for our own self-care.
Many patients who present to our clinics our facing similar challenges. You may have met the patient who reports he or she is "falling apart" and does not know where to start, or who suffers from pain that limits sleep, work, and self-care, making it difficult to complete the 3 exercises we instructed last session. Perhaps your patient can be given a wheel of life assignment for a home activity, or it can be completed in the clinic. Once areas of dissatisfaction are identified, the patient can set goals towards improvement. If the wheel was designed to represent various environments that support or impair a patient's healing process, perhaps it could be sorted out that the work environment is where the patient feels resistance to follow-through with therapy concepts. This would allow you to help develop strategies towards improving that work environment in relation to rehab (such as an ergonomic eval, for example.) It may give another patient the opportunity to identify that her primary relationship is really struggling, therefore she does not truly want to return to intercourse with her partner due to these issues. If your home program of self-stretching or breathing, etc, is aligned towards physical intimacy with her partner, she may sabotage her home program and fail to progress. If she is able to make these connections as part of her pelvic rehabilitation, perhaps she will recognize that she wants to attend some counseling before continuing the physical rehabilitation process. My example is hypothetical, yet most of you could share similar stories about patients who are either overwhelmed by their life, or who are subconsciously resistant to your best efforts at rehabilitation because they are struggling with other more important issues.
I hope that you find this exercise useful in your own life. Sometimes I simply share the idea verbally with a patient, friend, or colleague and it is simple enough that the person can make a mental note to try it at a later time. I have found it very valuable to save the wheels in a notebook, re-assess and then see where progress has been made. Of course, the progress is usually made because goals were identified and efforts were made towards completing the goals. On behalf of the Herman & Wallace Pelvic Rehabilitation Institute, I wish you a very Happy New Year, and happy goal setting as well.
Can you list the three components of the female athlete triad? In an article published in a physical therapy sports journal 205 physical therapists were asked this same question, and only 21% of the therapists could list all components. These components are disordered eating (not to be confused with "eating disorder" because that is a more narrow description), menstrual dysfunction, and lowered bone density. The study further describes the strategies that surveyed physical therapists utilize to treat and/or prevent the female athlete triad.
Pantano, the author of this study, points out that "...therapists must be responsible for recognizing, treating and preventing the female athlete triad." Nearly 25% of the respondents surveyed described involvement in treatment via education (to include the patient, family, physician, or coach) or referral of the athlete, screening of the athlete, and nearly 50% reported efforts at prevention of the disorder. It is interesting to note that the surveys were sent to members of either the Orthopedic or the Sports Physical Therapy Specialty groups of the American Physical Therapy Association (APTA), and many of the PT's who participated in the study were also certified in athletic training and interfaced often with female athletes.
Regardless of how often we work with athletes, it is crucial for pelvic rehabilitation providers to be globally aware of the signs, risks, and treatments for female athlete triad. In the National Athletic Trainers' Association (NATA) position statement on the management of disordered eating in athletes, it is pointed out that disordered eating (DE) can not only impair health and function, but DE can be fatal. This article that you can access in full text contains excellent screening tools, advice for referrals to nutrition experts, and information about current treatment.
At a minimum, we must be aware that adolescent females can suffer from disordered eating that leads to poor energy availability in the body, with increased risk of menstrual dysfunction, and decreased bone density and risk for fractures in athletes. Knowing how to ask the right questions, provide education and communicate with a team of providers can improve the lives of athletes who are at risk for female athlete triad symptoms. The NATA guidelines suggest that female athletes should be evaluated within the first 3 months of amenorrhea so that aggressive screening and treatment can be implemented. It is common for an athlete to have one or two of the components, such as disordered eating and amenorrhea without bone loss. The guidelines also point out that males can suffer equally from disordered eating and a high suspicion should be in place for male athletes who are reluctant to discuss their eating patterns, regardless of the sport in which he participates.
Most of us, regardless of treatment setting, can make use of this information to maximize our awareness of the profound affects that athletics and improper diet can have on our female patients. Opportunities are available in our communities as well as in the clinical setting for educating others about the risks and about the available treatments.
The Bladder and Bowel Foundation (B&BF), a non-profit organization in the UK, has recently published an educational brochure for teenagers that teaches them about the pelvic floor muscles. The publication was also written in part by teenagers, and it has a look and feel that is appropriately "younger." If you click here, and then scroll through the announcement about the leaflet, you can view it on-line. You will note that many topics are covered, such as the where and why of pelvic floor muscles, and even the how to contract and exercise them. Conditions or habits that can interfere with pelvic floor health are described, including childbirth, smoking, coughing, and underactive abdominal and pelvic muscles.
Teenagers are struggling with pelvic pain, bladder, bowel, and sexual dysfunctions, and may feel uncertain about with whom they can discuss the issues. We know from the adult pelvic floor literature that in general, physicians don't ask and the patient is embarrassed to tell. What would make a teenager any more likely to share such private information? Teenagers may experience painful sexual encounters, bowel issues such as constipation or fecal incontinence, and bladder issues including urgency, pain, or leakage. (Have you noticed how many teens stop at Starbucks on the way to school now? Who is educating them about bladder irritants?) Athletes may also have increased risk of leakage, especially when engaged in high-impact sports.
I have often wondered how we can better impact the health of children and young adults if we discussed their pelvic floor as well as bowel, bladder, and sexual health beginning at younger ages. In this country, we certainly come up against the controversy of discussing the pelvic floor as it relates to sexual health, as well as the challenge of speaking about bodily functions that are not typically discussed. It may not be possible at this time to have pelvic floor education taught throughout middle and high schools, but it may be possible for pelvic rehab providers to improve the knowledge of parents and teens in our own communities. Perhaps offering a program at a local community center, with a session for adults and one just for teenagers would work. To better inform the parents, each adult could be given a detailed outline of what will and will not be included in the teen session. Better yet, the adults could be instructed in the same information so that the chances of dialog between parent and child may be more likely.
You may find the new teen pelvic floor resource useful in designing a brochure or a handout that could be offered in your own clinic or at a local event. As we continue to educate our colleagues, referral sources, and patients about pelvic floor health and function, we may be able to broaden the age base and improve the help that is offered to teenagers.
Researchers in the UK recently asked this question: For women in the UK who have given birth, what is the risk for pelvic floor surgery and for repeat surgery? Surgery for pelvic organ prolapse (POP), urinary incontinence (UI), and rectal prolapse or fecal incontinence (RP-FI) were included in the study. The research also addressed re-operation rates and the length of time between repeat surgery for prolapse and incontinence.
From the national registry in Scotland, 34,630 health records of women were accessed. The lifetime risk for women (up to age 80) having pelvic floor surgery was just over 12%. Re-operation rate was 19%; women who had a mid-urethral sling (MUR) versus a retropubic operation had reduced rates of re-operation.The average time between repeat surgeries for prolapse or incontinence was 2.8-3 years. A woman who gave birth to a first child when she was less than 20 years old, or women who had all births via c-section had reduced lifetime rates of surgery. Conversely, increased body mass index (BMI), having one perineal laceration, or having 1 birth that involved forceps for delivery increased rate of surgery. (Sustaining a third degree perineal tear was a risk factor for rectal prolapse-fecal incontinence.)
The bottom line: in the UK, more than 1 in 10 parous women will undergo pelvic floor surgery. This is a general population study, therefore the authors express confidence that these rates should hold true for the general UK or for the European communities. The authors also compare their findings to several other epidemiological studies completed in the US, Australia, and France, and it is interesting to read the discussion related to comparison of populations in these studies. As in all the studies addressing pelvic floor surgery rates, the numbers are sufficiently high to warrant increased national attention towards prevention, including pelvic rehabilitation. The average time interval between surgeries struck me as being relatively short, and it would be valuable to have more research that compares repeat surgeries in those patients who have had pelvic rehabilitation versus those who have not been educated about pelvic floor functional use and/or strengthening. If you are interested in reading the full, free-access article, please click here.
A recent Johns Hopkins Health Alert reflects a current issue in the family practice and urology clinics. For decades, men who presented to their medical care provider with symptoms of perineal aching and malaise were diagnosed with prostatitis, or inflammation of the prostate gland, and then they were given antibiotics. It is not uncommon to meet men who have been on multiple courses of antibiotics over a period of years. Due to research that has emerged over the past decade, the prescribing of antibiotics has been questioned since most men do not actually have an infection.
Jeanette Potts, urologist, has written several articles and presented research about this issue. You can read an article about prostatitis by Dr. Potts by clicking here. The article describes the importance of classifying patients accurately into true infection versus chronic pain or neuromuscular dysfunction. The general population estimate for prevalence of prostatitis is 5-10%, and the estimated number of patients diagnosed with prostatitis who actually have an infection (bacterial prostatitis) is also 5-10%.
As pointed out in the Johns Hopkins alert, " ...the impact of CPPS on a man's quality of life is often devastating." In addition to pain and discomfort, patients may also suffer from urinary frequency that interferes with work and home activities. This NIH public access article describing the life impact of urologic pain syndromes also lists fatigue, sexual dysfunction, limited social roles and negative emotional changes as concerns for patients.
It can be challenging for physicians (and the patient) to modify the habit of prescribing antibiotics for prostate region pain. Increased awareness about the condition and about the change in focus (from prostate alone to consideration of the pelvic muscles and the neurologic systems as well) can help the pelvic rehab provider to share knowledge with both referral sources and patients. You can learn more information about the treatment of prostatitis in the Institute's Level 2A course as well as in the Male course.
Although hand washing is clearly the easiest, and most effective way to practice preventive health in the clinics, it appears that the act of wearing gloves gives providers a sense of safety that is not healthy. In an article titled "The dirty hand in the latex glove: a study of hand hygiene compliance when gloves are worn", researchers looked within 15 hospitals in England and Wales at 7578 physician interactions with patients. Hand washing occurred 47.7% of the time, and when gloves were used, this number dropped to 40%.
One problem identified in the article is that gloves are not impermeable to pathogens, so having dirty hands inside the gloves can create a contamination issue for patients. Another concern is that doctors, when wearing gloves, failed to wash hands after removing the gloves 40% of the time. The researchers also found that gloves were often worn when not indicated, and forgotten when indicated.
The criticality of this practice certainly increases when medically fragile patients are involved and when conditions such as MRSA are lurking. However, it is best practice to wash (and dry) before donning gloves, and then to wash following glove removal. It becomes very important to have easy access to a sink near patient care, and to choose gloves when appropriate. Options of using non-latex gloves, and at a minimum non-powder latex gloves can reduce risk of developing latex allergies or giving a patient who is allergic to latex a reaction. Many outpatient clinics avoid latex gloves altogether and use alternatives such as gloves made from synthetic latex.
The problem for clinicians when washing so frequently is that soaps can be very drying, and skin can quickly become irritated, cracked, and even further at risk for infection. Having a quality skin care lotion and using this daily can help avoid such breakdown. The bottom line in this study is that when gloves are used, handwashing fequency decreases. Being aware of this tendency that may be related to a psychological protection from the gloves can help pelvic rehab therapists to maximize patient and provider safety practices.
In the patient who presents with urinary incontinence (UI), it is always important to find out what co-morbidities are present in her history. When a patient who has UI is dealing with diabetes, the pelvic rehabilitation provider needs to ask several questions related to the management of diabetes. Some of the questions that I have found to be useful include: "Are your blood sugars well-managed at this time?", and, "If your blood sugars are unstable, what symptoms should I look for?" The second question allows me to be alert to changes in patient behavior that might mean a blood sugar level should be tested or a quick-acting sugar might need to be consumed by the patient. Some patients have very obvious reactions to changes in blood sugar levels and some patients have very subtle reactions. A therapist can also inquire how often the patient tests her blood sugar levels and if she brought a testing kit to the clinic. A "diabetic kit" should be available in every clinic setting so that a patient can have immediate access to readily available sugar such as candy, glucose tablets, or soda.
Urinary incontinence has been found to co-exist at higher levels in patients with diabetes (Type 1 or Type 2) than in patients who do not have diabetes. The reference that discusses this issue also states that physicians need to be aware of and ask questions about incontinence in the patients who have diabetes because patients tend to not bring it up independently. Denise Elser, MD, reports in this article on the National Association for Continence (NAFC) website that over 50% of men and women with diabetes also suffer from UI. She describes issues that occur within the scope of diabetes that can cause incontinence for patients. For example, if blood sugars are not managed well, sugars can get into the urine (glycosuria) and irritate the bladder, creating urinary urgency, frequency, and incontinence. These symptoms can be mistaken for a urinary tract infection, leaving the patient to over-treat with repeat antibiotics.
Dr. Elser also points out that patients who have diabetes are more prone to urinary tract infections, often with chronic bacteria in the bladder that irritates the tissues and creates symptoms of overactive bladder (OAB). The neurologic dysfunction that accompanies diabetes can lead to impaired ability of the bladder to empty well, creating opportunities for urinary leakage as well as urinary tract infection due to poor emptying. Lastly, fluid retention can create urinary issues for the patient who has diabetes, as heart conditions may co-exist. When a patient lies supine, the extra fluid volume in the lower extremities can now more easily be moved through the patient's system to be voided out, usually leading to night time voiding frequency. This can interrupt a patient's sleep, and more alarmingly, create unsafe situations because the tired patient (who may have vision loss due to diabetes) is now frequently walking in darkened surroundings, leading to increased fall risk.
One home program strategy that is taught in the Institute's Level 1 course is to ask the patient to elevate the lower extremities and do ankle pumping towards evening but prior to bedtime so that fluids are encouraged to move out of the legs. This might increase voiding prior to bedtime, but it may allow the patient to have less interruption to her sleep hours. Many patients with increased swelling in the limbs are also taking diuretics, and if taken in the evening, may lead to frequency of voiding at night. The pelvic rehab therapist can encourage the patient to talk to her prescribing medical provider (or the therapist can contact the provider directly) to discuss the option of having the diuretic dose or timing reviewed. Many patients have been taking the same dose for years and, once reviewed by an appropriate medical provider, may be adjusted with improved outcomes for the patient.
When all of these puzzle pieces are put together, it is clear that our patients who have urinary incontinence as well as diabetes may require a very thorough history-taking and an equally comprehensive treatment strategy. If your patient is not managing blood sugars well, it is important to explain the above issues and encourage the patient to be more adherent to her diabetic home management program, or to return to her medical provider for further counseling and required care. The National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) can be a wonderful resource for patients as well as pelvic rehabilitation providers.
Check out this 8 minute video update on use of topicalsfor pain management on MedScape today. Dr. Charles Argoff, Professor of Neurology at Albany Medical College, shares updates in research from the American Academy of Pain Management meeting that took place in September. In the video, Dr. Argoff discusses various types of topical agents that have been tested for relief of acute and/or chronic pain. A topical agent, he points out, has a more local effect, with less systemic uptake than an oral medication, and ideally less side effects because of the decrease in general uptake.
Some of the topicals are anti-inflammatory, such as Voltarin, which can be used for osteoarthritis. Pennsaid and the Flector patch also have an anti-inflammatory action. Pennsaid has research to support its use for knee osteoarthritis, and the Flector patch is applied for muscle sprain/strain type injuries.The lidocaine patch, which has FDA approval for post-herpetic neuralgia, has also been reported to be useful for chronic musculoskeletal pain or complex regional pain syndrome. The Qutenza patch (with 8% capsaicin, extracted from chili peppers) has been demonstrated to be helpful for reducing pain of post-herpetic neuralgia. This patch works on a specific receptor that is in the skin, thereby reducing local pain. Whereas the lidocaine patch can be applied by the patient, the Qutenza patch must be applied carefully in an office setting.
Dr. Argoff concludes that the skin (and therefore topical, local applications to skin in painful areas) may be "...far more important than we ever thought in helping people control their pain." This is due to the important role that skin (an organ) plays in the initiation, maintenance, and modulation of the pain experience.
So how can topicals be useful to our patients with pelvic pain?When working as a team with medical providers, we can advocate for our patients to have the option of trying some pain patches over tissue that can tolerate such an application. Perhaps coccygeus pain, ischial bursitis pain, or other sites of neuropathic pain in the inguinal area, gluteal regions, or abdominals would respond favorably to the application of topicals. An example of research supporting use of topicals is thisCanadian studythat describes the benefits of a mixture of amitriptyline, ketamine, and lidocaine for neuropathic pain caused by radiation dermatitis. As with most modalities for pelvic pain, we need more research.In the world of pelvic pain, any option that assists the patient in healing the pain experience can be positive.
Vaginal diazepam has been used by patients who have pelvic pain as an "off-label" drug option yet there has been little research to support its use. Recognizing that conditions such as painful bladder syndrome (PBS)/interstitial cystitis (IC) may be complicated by pelvic muscle dysfunction, the use of diazepam (brand names include Valium) aims to target the muscle overactivity.
In the September/October issue of Urologic Nursing, Donna Carrico, MS, WHNP, and Kenneth Peters, MD, report on the effects of vaginal diazepam on 21 women (mean age of 40) who were diagnosed with urogenital pain. Women completed assessment scores at baseline and at one month after being treated with vaginal diazepam. 2-10 mg ("...as needed for symptom relief...") was prescribed to be used up to every 8 hours. Most women started at 5 mg unless they reported high sensitivity to most medications. Although patients had the option to have the medication compounded into a cream or suppository, all patients chose to utilize the oral tablet inserted vaginally. (It was either inserted whole or crushed and mixed with vaginal lubricant to be inserted into the vagina.) The women recorded weekly their dose, usage, and pain score on 0-10 Visual Analog Scale (VAS) as well as any adverse effects that occurred over the month. A serum diazepam level was recorded at the end of the 4 weeks for the 15 women who were using vaginal diazepam at least daily, and these levels were found to be in the normal range.
VAS scores decreased on average from 4.8 to 3.4, average vulvar Q-Tip level decreased from 3.3 to 1.2, and vulvar pain levels decreased at one month follow-up as well. Only 1/3 of the women reported a side effect of drowsiness, otherwise no side effects were reported.Interestingly, some patients found it helpful to insert the medication vaginally 1 hour prior to engaging in intercourse so that pain was reduced.
The authors are quick to point out that this research was not conducted as a controlled trial, and there is no proposed protocol for the use of vaginal diazepam. What this research does assist with is establishing that the off-label use of diazepam vaginally in those suffering with urogenital pain may have few side effects and may offer benefits. Because pelvic pain often does not have a target organ as a cause, and because pelvic muscles are involved in most urogenital pain cases, it makes sense to address the involved muscles. Of course, pelvic rehab practitioners are well-trained to address the muscles via direct releases as well as through the use of other modes, yet having assistance of pharmacology may be a useful tool for the patient.
Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here.
Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.
The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy.
If you have a biofeedback unit (for surface EMG, or sEMG, one type of biofeedback) and know how to use it, you can apply this wonderful skill in the care of children who need your help. Many of the computer programs do have animations included in the software. If you would like to learn more about treating children who have bowel and bladder dysfunction, the Institute offers a course in pediatric pelvic rehabilitation with faculty member Dawn Sandalcidi. The next course is scheduled in May in Texas. Click here to see more information about the class.