Rarely does a patient with sacroiliac joint dysfunction come to see us with a goal of having surgery. Sometimes surgery winds up being the last resort for relief if our efforts and the patient’s commitment to physical therapy and prescribed exercises fail. Some of the most recent research shows positive results from minimally invasive surgery; however, the bottom line is to make sure the most educated, clinically accurate diagnosis has been made in implicating the SI joint as the source of pain.

Capobianco et al (2015) performed a prospective multi-center trial regarding SI joint fusion using a minimally invasive technique in women with post-partum pain in the pelvic girdle. Eligibility for the study required subjects to have 3 out of 5 positive SI joint stress tests and at least 50% relief with image-guided intra-articular SI joint block with a local anesthetic. Of the 172 subjects in the study, 20 of the 100 females had post-partum pelvic girdle pain, and 52 subjects were male. Significant improvements in pain, quality of life, and function were found for not only the post-partum group but all groups 12 months after surgery. Worth noting is one to three weeks after surgery, the subjects engaged in physical therapy, two times per week for six weeks.

Whang et al (2015) assessed the 6-month outcomes of SI joint fusion using triangular titanium implants versus non-surgical management in a prospective randomized controlled trial. Of the 148 subjects chosen based on similar diagnostic criteria as the study mentioned above, 102 underwent surgery, and 46 had non-surgical management. Non-surgical management involved appropriate pain medication administration, physical therapy, intra-articular SI joint steroid injections, and radiofrequency ablation of sacral nerve roots, all based on individual needs. The surgical group subjects in this study were also asked to have physical therapy two times per week for six weeks anywhere from one to three weeks post-op. The results in a six month follow up showed “clinical success” of >80% in the surgical group and <25% in the non-surgical management group.

The Journal of Neurosurgery: Spine presented an article in July 2015 by Zaidi et al with results of a systematic review of literature regarding the surgical and clinical effectiveness of SI joint fusion. The studies included open as well as minimally invasive surgery, and the causes of surgery included SI joint degeneration and arthritis, SIJ dysfunction, postpartum instability, posttraumatic, idiopathic, pathological fractures, and HLA-B27+/rheumatoid arthritis. A mean rate of satisfaction with open surgery was 54%; whereas, the mean was 84% with minimally invasive surgery. Ultimately, the authors concluded, “serious consideration of the cause of pain” is necessary before embarking on SI joint fusion as the evidence for the surgery’s efficacy is lacking.

So, who is responsible for making the definite diagnosis for SI joint dysfunction? As many patients get minimal time in doctor offices, we have a professional responsibility to competently perform a thorough evaluation for our patients. When the diagnosis is “SI joint dysfunction,” rule out the lumbar spine and hip; and, of course, when “low back pain” or “hip pain” fills the diagnosis line, rule out/in the SI joint. If you are confused about how, it is time to consider taking the Sacroiliac Joint Evaluation and Treatment course!

References:
Capobianco, R., Cher, D., & for the SIFI Study Group. (2015). Safety and effectiveness of minimally invasive sacroiliac joint fusion in women with persistent post-partum posterior pelvic girdle pain: 12-month outcomes from a prospective, multi-center trial. SpringerPlus, 4, 570. http://doi.org/10.1186/s40064-015-1359-y
Zaidi, Hasan A., Montoure, Andrew J., and Dickman, Curits A. (2015). Surgical and clinical efficacy of sacroiliac joint fusion: a systematic review of the literature. Journal of Neurosurgery: Spine. (23)1:59-66. DOI: 10.3171/2014.10.SPINE14516
Whang, P., Cher, D., Polly, D., Frank, C., Lockstadt, H., Glaser, J., … Sembrano, J. (2015). Sacroiliac Joint Fusion Using Triangular Titanium Implants vs. Non-Surgical Management: Six-Month Outcomes from a Prospective Randomized Controlled Trial. International Journal of Spine Surgery, 9, 6. http://doi.org/10.14444/2006

Exercise in pregnancy is a loaded topic. We commonly see images of women doing vigorous exercise in late pregnancy accompanied by judgmental statements about the safety of such activity not only for the woman, but also for the baby. Many myths persist about exercise in pregnancy, and it’s our role as health care specialists to educate women about what is known about exercising. Holly Herman, co-founder of the Herman & Wallace Pelvic Rehabilitation Institute, has been educating providers about this topic for most of her career. Anyone lucky enough to take a course on pregnancy and postpartum issues from Holly Herman knows that her style of teaching is effective and her passion is contagious. From Holly’s use of patient stories to wonderful humor, you can really “get it” when it comes to clinical concepts and strategies. One of Holly’s clinical pearls that really stuck with me after learning about exercise and pregnancy is the research completed by James Clapp in his book “Exercise in Pregnancy”. In short, the book dispels the myth that women shouldn’t exercise in pregnancy and in fact reports on the benefits of exercise to both Mom and baby for labor, delivery, and beyond. In signature style, Holly held this book up in front of the class and to great laughter said, “And this is the book you should buy for your mother-in-law.”

Another myth that has been perpetuated in relation to pregnancy, labor and delivery is the notion that exercising can make the pelvic floor muscles short, tight, and more narrow, making delivery more difficult. In an article we reported on previously about women being “too tight to give birth” the authors concluded that strong pelvic floor muscles do not lead to challenges with birthing. (Bo et al., 2013) In a more recent article that addressed this issue, Kari Bo and colleagues studied 274 women for levator hiatus (LH) width to see if exercising in late pregnancy did in fact narrow this space. At week 37 of gestation, the exercisers were measured to have a significantly larger LH than the non-exercisers. (Exercisers were defined as women who exercised 30 minutes or more 3 times per week versus the non-exercisers.) The authors conclude that there were not any significant differences in labor outcomes or in delivery outcomes between the groups. (Bo et al., 2015)

Without a doubt, the patient’s obstetrician gives primary direction to the patient when any high-risk issues are present. Most women however, are basing their exercise choices on experience, on misinformation, myths, or popular opinion. It is our responsibility to engage women in conversations about her health, wellness, and fitness, and to appropriately counsel on exercise during pregnancy and the postpartum period. Most of us lacked proper education about this important population in our primary graduate training, and therefore must seek out information to fill in the gaps. If you are interested in filling in any gaps, join us at one of our peripartum courses around the country. Your next opportunities to take these courses are:

Care of the Postpartum Patient - Seattle, WA
Mar 12, 2016 - Mar 13, 2016

Care of the Pregnant Patient - Somerset, NJ
Apr 30, 2016 - May 1, 2016

Care of the Pregnant Patient - Akron, OH
Sep 10, 2016 - Sep 11, 2016

Bø, K., Hilde, G., Jensen, J. S., Siafarikas, F., & Engh, M. E. (2013). Too tight to give birth? Assessment of pelvic floor muscle function in 277 nulliparous pregnant women. International urogynecology journal, 24(12), 2065-2070.

Bø, K., Hilde, G., Stær-Jensen, J., Siafarikas, F., Tennfjord, M. K., & Engh, M. E. (2015). Does general exercise training before and during pregnancy influence the pelvic floor “opening” and delivery outcome? A 3D/4D ultrasound study following nulliparous pregnant women from mid-pregnancy to childbirth. British journal of sports medicine, 49(3), 196-199.

Clapp, J. F., Cram, C. (2012) Exercising Through Your Pregnancy. Addicts Books

A few years ago, I was convinced my left hip pain was due to osteoarthritis. When my hip locked up after a 14 mile run, my manual therapist husband differentially diagnosed the pain as discogenic. Partly in denial and partly wanting to know the extent of the “damage,” I got an x-ray of my left hip, which was completely normal, and a lumbar MRI, which wasn't pretty. The source of my hip pain was a disc bulge at L3-4 and L4-5 with a Schmorl's node at L5-S1 to boot. Instead of riding the train of thought that we treat what hurts, therapists need to disembark and look further for the source, as suggested in the course, “Finding the Driver in Pelvic Pain.”

A case report published in the International Journal of Sports Physical Therapy by Livingston, Deprey, and Hensley (2015) documents the discovery of a deeper problem than the referring diagnosis of greater trochanteric pain syndrome. A 29 year old female had to stop running because of lateral hip pain that began 3 months after increasing the intensity and frequency of her running and low impact plyometrics. She had pain in sitting and while running. During the evaluation, she demonstrated a positive Trendelenburg, weak and painless hip abductors, and a positive single leg hop test on concrete. When the pain was not elicited with single leg hop on a foam surface, the patient was referred back to the physician for magnetic resonance imaging. The patient was later diagnosed with an acetabular stress fracture. The therapist’s thorough examination helped prevent possible avascular necrosis or a more traumatic fracture of the pelvis.

In a 2013 issue of the same journal, Podschum et al. presents a case report on deciphering the diagnosis in a female runner with deep gluteal pain with pelvic involvement. A 45 year old female marathon runner reported pulling her hamstring and complained of left ischial tuberosity pain with aching into the gluteal and pubic ramus regions that eventually forced her to stop running. She had pain in sitting and could not tolerate speed work. She had a history of low back and pelvic floor pain, with an MRI showing osteitis pubis, a lateral L3-4 bulge, and facet hypertrophy at L4-5. The physical therapist ruled out lumbar disc lesion, radiculopathy, sacroiliac joint dysfunction, and hip labral tear with special tests. Initial treatment focused on the differential diagnoses of hamstring syndrome and ischiogluteal bursitis based on subjective complaints and objective findings. After 4 visits, her deep ache shifted to the inferior pubic ramus in sitting as the ischial tuberosity pain diminished. A trained therapist then conducted a thorough pelvic floor exam. Pelvic floor hypertonic dysfunction was diagnosed and took over the “driver’s seat” as the focus for the rest of the treatment of this patient. Symptoms resolved and the patient returned to running marathons without any of her initial presenting symptoms.

If we let specific pain complaints guide our treatment, we will run out of steam with the lack of progress. Finding the true source of symptoms is critical in physical therapy. Sometimes so much is going on with our patients we have to sort through the weeds before we can access the actual road to recovery. The lumbar spine, hips, and pelvic floor create an intricate map of U-turns and two-way streets, so we need to deepen our understanding of how to navigate the regions. Only then will be able to confidently diagnose the “driver” and let the other areas call “shotgun.”

References:
Livingston, J. I., Deprey, S. M., & Hensley, C. P. (2015). DIFFERENTIAL DIAGNOSTIC PROCESS AND CLINICAL DECISION MAKING IN A YOUNG ADULT FEMALE WITH LATERAL HIP PAIN: A CASE REPORT. International Journal of Sports Physical Therapy, 10(5), 712–722.
Podschun, L., Hanney, W. J., Kolber, M. J., Garcia, A., & Rothschild, C. E. (2013). DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT. International Journal of Sports Physical Therapy, 8(4), 462–471.

Food, at its basic level, provides us with nutrition and sustenance to perform our daily activities. Populations in tune with nature’s cycles of food tend to eat what is available locally based on climate and growth seasons. When societies move beyond simply eating food for energy, but also for flavor, pleasure, and even status, the face of nutrition changes. Whereas some diseases come from a lack of nutrition, many diseases we are faced with in the United States also come from an overabundance of food, with too many calories or too much sugar making up common causes of lack of health. The knowledge within the field of disordered eating is vast, and patients struggling with disordered eating may be fortunate enough to work with a specialist to help recover healthier habits. Even without a diagnosis of disordered eating, many us can identify with unhealthy eating habits, often guided by stress, fatigue, or emotions.

Prior research has studied how we access willpower under different conditions of cognitive stress. In part of this research, participants were given a number to recall (either 2 digits or 7 digits) and then while walking to another location were offered a snack of either fruit salad or chocolate cake. The authors found that the participants who had to recall a 7 digit number more often chose the chocolate cake, leading the researchers to theorize about the role of higher-level processing and making choices. (Shiv et al., 1999) While we may be aware of a tendency to overeat (or make poorer food choices) during times of stress, fatigue, or emotional distress, changing the habits can be very challenging.

Resources that discuss improving our eating choices in the face of “emotional eating” offers many alternatives, or ways to soothe ourselves without eating. In her books about this topic, clinical psychologist Susan Albers offers advice that may be helpful for our own habit building and for offering basic advice for our patients who struggle with the issue. (While offering advice to patients about healthy eating and habits is within our scope of practice, if a patient has need for a referral to a counselor, psychologist, or nutritionist, we can coordinate such a referral with the patient’s primary care provider.) In her book titled “50 More Ways to Soothe Yourself Without Food: Mindfulness Strategies to Cope with Stress and End Emotional Eating”, Dr. Albers offers many strategies for altering our habits. Some of these ideas include using acupressure points, breathing, rituals, self-massage, yoga, writing, dancing, art, tea, or sex to defer ourselves from poor eating habits. While eating can be enjoyable and pleasurable, when our patients are struggling with over-eating or eating foods that don’t support nutritional or healing goals, having a discussion about these issues may be useful.

If you are interested in learning more about nutrition, consider joining your pelvic rehab colleagues at one of the two Nutrition Perspectives for the Pelvic Rehab Therapist courses this year! Your first chance to attend will be in Kansas City on March 5-6, and later on in Lodi, CA June 25-26.

Albers, S. (2015). 50 More Ways to Soothe Yourself Without Food: Mindfulness Strategies to Cope with Stress and End Emotional Eating. New Harbinger Publications.
Shiv, B., & Fedorikhin, A. (1999). Heart and mind in conflict: The interplay of affect and cognition in consumer decision making. Journal of consumer Research, 26(3), 278-292.

After menopause, more than half of women may have vulvovaginal symptoms that can impact their lifestyle, emotional well being and sexual health. What's more, the symptoms tend to co-exist with issues such as prolapse, urinary and/or bowel problems. But unfortunately many women aren't getting the help they need, despite a growing body of evidence that skilled pelvic rehab interventions are effective in the management of bladder/bowel dysfunctions, POP, sexual health issues and pelvic pain.

Vaginal dryness, hot flashes, night sweats, disrupted sleep, and weight gain have been listed as the top five symptoms experienced by postmenopausal women in North America and Europe, according to a study by Minkin et al 2015, and they also concluded ‘The impact of postmenopausal symptoms on relationships is greater in women from countries where symptoms are more prevalent.’ Between 17% and 45% of postmenopausal women say they find sex painful, a condition referred to medically as dyspareunia. Vaginal thinning and dryness are the most common cause of dyspareunia in women over age 50. However pain during sex can also result from vulvodynia (chronic pain in the vulva, or external genitals) and a number of other causes not specifically associated with menopause or aging, particularly orthopaedic dysfunction, which the pelvic physical therapist is in an ideal position to screen for.

According to the North America Menopause Society, ‘…beyond the immediate effects of the pain itself, pain during sex (or simply fear or anticipation of pain during sex) can trigger performance anxiety or future arousal problems in some women. Worry over whether pain will come back can diminish lubrication or cause involuntary—and painful—tightening of the vaginal muscles, called vaginismus. The result can be a vicious circle, again highlighting how intertwined sexual problems can become.’

The research has demonstrated that the optimal strategy for post-menopausal stress incontinence is a combination of local hormonal treatment and pelvic floor muscle training – the strategy of combining the two approaches has been shown to be superior to either approach used individually ^{(Castellani et al 2015, Capobianco et al 2012)} and similar conclusions can be drawn for promoting sexual health peri- and post-menopausally.

The pelvic rehab specialist may be called upon to screen for orthopaedic dysfunction in the spine, hips or pelvis, to discuss sexual ergonomics such as positioning or the use of lubricant as well as providing information and education about sexual health before, during and after menopause.

To learn more about sexual health and pelvic floor function/dysfunction at menopause, join me in Atlanta in March for Menopause: A Rehab Approach.

Prevalence of postmenopausal symptoms in North America and Europe, Minkin, Mary Jane MD, NCMP1; Reiter, Suzanne RNC, NP, MM, MSN2; Maamari, Ricardo MD, NCMP3, Menopause:November 2015 - Volume 22 - Issue 11 - p 1231–1238
Low-Dose Intravaginal Estriol and Pelvic Floor Rehabilitation in Post-Menopausal Stress Urinary Incontinence, Castellani D. · Saldutto P. · Galica V. · Pace G. · Biferi D. · Paradiso Galatioto G. · Vicentini C., Urol Int 2015;95:417-421

Occasionally, as pelvic rehab providers, we will encounter the question from our patients, “Do vaginal weights help with urinary incontinence and pelvic floor performance?” The premise behind the use of vaginal cones or balls is that holding them actively in your vagina with your pelvic floor muscles helps to increase the performance (strength and endurance) of the pelvic floor muscles, assisting in reduction of urinary incontinence.

A recent systematic review (Midwifery, 2015) explores this topic for a specific population of post-partum women with urinary incontinence. The question to be answered was “Does the vaginal use of cones or balls by women in the post-partum period improve performance of the pelvic floor muscles and urinary continence, compared to no treatment, placebo, sham treatment or active controls?”. This review had extensive search criteria. The types of participants in the studies analyzed were post-partum women up to 1 year (when starting interventions) of any parity, that underwent any mode of birth or birth injuries, and had or did not have urinary incontinence. Exclusion criteria were pregnant women, anal incontinence, and major genitourinary/pelvic morbidity. Any frequency, intensity, duration of pelvic exercises with the devices, and any form, size, weight, or brand of vaginal balls or cones were considered. Participants could undergo any type of instruction, either from a health care provider, or self-taught from written materials.

Of the searched studies, all were randomized or quasi-randomized controlled trials. The primary outcomes of the searched studies were pelvic floor muscle performance (strength or endurance) and/or urinary incontinence, both assessed with a valid or reliable method. 37 potentially useful articles were reviewed out of 1324 based on the search criteria, but only one article met all of the inclusion criteria and was included in this review with 192 relevant participants (Wilson and Herbison).

In the included study, the group that used vaginal cones (compared to control group) showed a statistically significant lower rate of urinary incontinence. However, when compared to the pelvic exercises group, the continence rates were similar at 12 months post-partum between the cone group and the exercising group. At 24-44 months post-partum, continence rates amongst all groups were similar, but follow-up rates were very low.

As pelvic rehabilitation providers, it is our job to promote pelvic health and assist our post-partum patients with their pelvic impairments, providing them with options to meet their goals. This review does not make a scientific statement of a preferred mode of pelvic exercise, however, it gives us one more option to consider when teaching patients about how to improve pelvic muscle performance to increase urinary continence following child birth. Pelvic exercise enhances pelvic performance, so if your patient would prefer to use vaginal cones or balls to do their pelvic exercise versus completing pelvic exercises without them, do what works best for the patient. One can argue that any pelvic exercise is better than none in improving performance. The use of vaginal cones or balls may be helpful for urinary continence in post-partum women, and provides us with one tool more when promoting pelvic health in our patients.

Oblasser, C., Christie, J., & McCourt, C. (2015). Vaginal cones or balls to improve pelvic floor muscle performance and urinary continence in women post-partum: A quantitative systematic review. Midwifery, 31(11), 1017-1025.
Wilson, P. D., & Herbison, G. P. (1998). A randomized controlled trial of pelvic floor muscle exercises to treat postnatal urinary incontinence. International Urogynecology Journal, 9(5), 257-264.

While working with a 71 year old lady one day, I asked her about her sleep habits, thinking she would describe her neck position, since that it was I was treating. She quickly commented she gets up one to two times every night to use the bathroom. Without any hesitation, she then declared her sister and her friends all do the same thing. No one she knows who is close to her age can sleep through the night without having to pee. Realizing this was more of an issue for my patient than her neck at night, I proceeded to look into the research behind these nighttime escapades of the elderly.

In the Journal of Clinical Sleep Medicine in 2013, Zeitzer et al. performed research regarding insomnia and nocturia in older adults. The introduction explains how 40-70% of older adults experience insomnia, and the greatest cause for sleep disturbance is the need to urinate in the middle of the night (nocturia). In epidemiological studies, between two-thirds and three-quarters older adults report disrupted sleep due to nocturia. The study performed by these authors involved men (average age of 64.3) and women (average age of 62.5) recording their sleep and toileting habits over the course of 2 weeks. The results showed over half the reported awakenings at night were secondary to nocturia. They had worse restfulness and efficiency of sleep associated with the log-reported need to get up to use the bathroom.

In a 2014 study by Tyagi, et al., the effect of nocturia on the behavioral treatment for insomnia in older adults was explored. The authors noted how nocturia being the primary reason for waking up at night increased proportionately with age with results ranging from 39.9% in people 18-44 years of age to 77.1% in the 65 years old or above population. The 79 participants in this study underwent brief behavioral treatment for their chronic insomnia or only received information. People with and without nocturia both demonstrated significant improvements in quality of sleep after receiving brief behavioral treatment versus the control group; however, the effect size was larger in the participants without nocturia. The authors concluded nocturia needs to be addressed first in order to experience the full benefit of behavior treatment for insomnia.

On a neurological level, a study from November 2015 by Smith, Kuchel, and Griffiths reported there could be a neural basis for voiding dysfunction in older adults. They found 3 separate neural circuits control voiding, and damage to the pathways feeding these circuits increases with age and can increase urge incontinence. Older adults experiencing neurological deficits may have difficulty discerning what to do when there is urgency and are susceptible to becoming incontinent. The authors recommend treatment of not just the bladder in older people but also therapies to address the structural and functional abnormalities of the neural circuits to provide the greatest results.

So, the next time I saw my patient, I explained to her she is definitely not alone in her nightly rendezvous to the bathroom when it comes to her age group. She has accepted this as “just how things are.” I would like to think there is something more we can do for the elderly population to keep them out of the nocturia “night club.” Taking the Geriatric Pelvic Floor Rehabilitation course by Heather S. Rader, PT, DPT, BCB-PMD, seems like an essential step in the right direction.

Tyagi, S., Resnick, N. M., Perera, S., Monk, T. H., Hall, M. H., & Buysse, D. J. (2014). Behavioral Treatment of Chronic Insomnia in Older Adults: Does Nocturia Matter? Sleep, 37(4), 681–687.
Zeitzer, J. M., Bliwise, D. L., Hernandez, B., Friedman, L., & Yesavage, J. A. (2013). Nocturia Compounds Nocturnal Wakefulness in Older Individuals with Insomnia. Journal of Clinical Sleep Medicine : JCSM : Official Publication of the American Academy of Sleep Medicine, 9(3), 259–262.
Smith, Phillip P., Kuchel, George A., Griffiths, Derek. (2015). Functional Brain Imaging and the Neural Basis for Voiding Dysfunction in Older Adults. Clinics in Geriatric Medicine. 31(4), 549–565.

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.

Within a pelvic rehabilitation setting, applying all orthopedic and specific pelvic rehabilitation skills is necessary for women cyclists who present with pelvic dysfunction. Because injury to the perineal area including the pudendal nerve can have negative impact on function such as bowel, bladder, or sexual health, skills in helping a patient heal from compressive or traumatic cycling injuries is very valuable. To learn more about pudendal nerve health and dysfunction, the Institute offers a 2-day course titled Pudendal Neuralgia Assessment, Treatment and Differentials: A Brain/Pain Approach. This course is offered next in Salt Lake City in April, so sign up soon!

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy. She will be presenting this course this February!

Endometriosis is a common gynaecological disorder, affecting up to 15% of women of reproductive age. Because endometriosis can only be diagnosed surgically, and also because some women with the disease experience relatively minor discomfort or symptoms, there is some controversy regarding the estimates of prevalence, with some authorities stating that as many as one and three women may have endometriosis (Eskenazi & Warner 1997)

There is a wide spectrum of symptoms of endometriosis, with little or no correlation between the acuteness of the disease and the severity of the symptoms (Oliver & Overton 2014). The most commonly reported symptoms are severe dysmenorrhoea and pelvic pain between periods. Dyspareunia, dyschezia and dysuria are also commonly seen. These pain symptoms can be severe and have been reported to lead to work absences by 82% of women, with an estimated cost in Europe of €30 billion per year (EST 2005). Secondary musculoskeletal impairments caused by may include: lumbar, sacroiliac, abdominal and pelvic floor pain, muscle spasms/ myofascial trigger points, connective tissue dysfunction, urinary urgency, scar tissue adhesion and sexual dysfunction (Troyer 2007) – all of which may be responsive to skilled pelvic rehab intervention.

Endometriosis can lead to inflammation, scar tissue and adhesion formation and myofascial dysfunction throughout the abdominal and pelvic regions. This can set up a painful cycle in the pelvic floor muscles secondary to the decrease in pelvic and abdominal organ/muscle/fascia mobility which can subsequently lead to decreased circulation, tight muscles, myofascial trigger points, connective tissue dysfunction and pain and possible neural irritation.

Abdominal trigger points and pain can be commonly seen after laparascopic surgery for diagnosis or treatment. We know that fascially, the abdominal muscles are closely connected with the pelvic floor muscles and dysfunction in one group may trigger dysfunction in the other, as well as causing associated stability, postural and dynamic stability issues.

The pain created by muscle tension and dysfunction, may lead to further pain and increasing central sensitisation and further disability. Unfortunately for the endometriosis patient, as well as dealing with the problems already associated with endometriosis, she may also develop a spectrum of secondary musculo-skeletal problems, including pelvic floor dysfunction – and for some patients this may actually be responsible for the majority of their pain (Troyer 2007).

The skilled pelvic rehab therapist has much to offer this under-served patient population in terms of reducing pain and dysfunction, educating regarding self-care and exercise and helping to restore quality of life. Interested in learning more? Join me for my new course: ‘Special Topics in Women’s Health: Endometriosis, Infertility & Hysterectomy’ in San Diego this February or Chicago in June.

Guidelines for the management of 3rd and 4th degree tears were updated and published last month by The Royal College of Obstetricians & Gynaecologists. The purpose of the guidelines are to provide evidence-based guidelines on diagnosis, management and treatment of 3rd and 4th degree perineal tears. These types of tears are also referred to as obstetric anal sphincter injuries, or OASIS. The authors acknowledge an increased rate of reported anal sphincter injuries in England that may in part be due to increased awareness and detection of the issue. In terms of classification of anal sphincter injuries, the following is recommended (note the different levels at grade 3:

- 1st degree tear: injury to the perineal skin and/or the vaginal mucosa
- 2nd degree tear: injury to the perineum involving the perineal muscles but not involving the anal sphincter.
- 3rd degree tear: injury to the perineum involving the the anal sphincter complex
- Grade 3a tear: Less than 50% of the external anal sphincter (EAS) thickness is torn.
- Grade 3b tear: More than 50% of the EAS thickness is torn.
- Grade 3c tear: Both the EAS and the internal anal sphincter (OAS) are torn.
- 4th degree tear: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and the anorectal mucosa.

Risk factors for anal injury are also outlined in the guidelines, although the authors point out that accurate prediction based on the risk factors is not reliable. The noted risk factors are as below:

- Asian ethnicity
- Nulliparity
- Birthweight greater than 4 kg (8.8 lb)
- Shoulder distocia
- Occipito-posterior position
- Prolonged 2nd stage labor
- Instrumented delivery

Recommendations worth noting include Level A evidence that warm compression during the 2nd stage of labor reduces the risk of OASIS. A noted best practice recommendation is that “Women should be advised that physiotherapy following repair of OASIS could be beneficial.” Guidelines such as these from The Royal College of Obstetricians & Gynaecologists can help in creating common language and in making recommendations that improve communication and expectations between patients and providers.

If you are interested in learning more about anal tears, Herman & Wallace offers several courses which cover the topic. For postpartum care specifically, check out Care of the Postpartum Patient.