The eve of my daughter’s 5th birthday has me reminiscing about my first pregnancy. I had recently surrendered my ACL on a ski slope and was contemplating surgery when I got confirmation I was pregnant. A seasoned surgeon had told me if I just wanted to return to running and not ski or do cutting sports (without a brace, anyway), I would probably be fine; so, I chose to forego the surgery and was running again 7 weeks later. Being my first pregnancy, I was not sure how hormones would affect my knee stability without an ACL or if the impact was safe for me and the baby or if my doctor would approve of my exercise choice of running. After all, pending ligamentous laxity from hormonal changes made running without an ACL seem risky while pregnant; but, runners tend to be, well, stubborn, when it comes to being able to run.

Deghan et al (2014) discuss the hormone relaxin and its effect on bone, muscle, tendon, ligaments, and cartilage. Interestingly, relaxin actually plays a role in the healing and remodeling of certain tissues in the body such as muscle and bone. However, the article also emphasizes how relaxin has been shown to reduce the integrity of the ACL and put female athletes at risk for injury. Lucky for me, that hormone couldn’t have its way with my knee since the ACL was already gone!

A study in the British Journal of Sports Medicine just published online October 4, 2015, encourages running and other high-impact sports before pregnancy to decrease the risk of pelvic girdle pain. The patients engaging in such exercises prior to being pregnant showed a 14% lower risk of having pelvic girdle pain during pregnancy. Out of 4069 women, 12.5% of the 10.4% of women who experienced pelvic pain were non-exercisers pre-pregnancy. The women who exercised 3-5 days per week and participated in high-impact aerobic exercise prior to being pregnant had less pelvic pain while pregnant.

Tenforde et al (2015) investigated the habits of competitive runners during pregnancy as well as breastfeeding. Out of 110 female runners, 70% continued to run during their pregnancy; however, only 31% continued into their 3rd trimester. Only 3.9% of the women got injured while running pregnant. In general, the competitive runners reduced their intensity and volume and ran primarily for fitness and health. The 84.1% of the women who ran during breastfeeding reported less postpartum depression and no negative impact on breastfeeding.

Looking back at my running log, I ran 3 miles under 10-minute pace two days before going into labor, and my daughter was even 9 days late. I continued to run because I love it and, quite simply, because I could. Personally, my blood pressure, weight, and glucose levels stayed healthy throughout the pregnancy. Even without an important stabilizing ligament in my knee and some extra pounds, I never experienced joint pain while running. On the trail where I ran, I got mixed responses from people coming the other way - mostly encouragement, but also some looks of disappointment or disgust (I didn’t say it was pretty) and an occasional know-it-all “warning.” Ultimately, any woman who has been running prior to pregnancy should be able to continue some level of running through the trimesters until her own body, the obstetrician, or a hard-kicking baby gives a reason to stop.

Dehghan, F., Haerian, B. S., Muniandy, S., Yusof, A., Dragoo, J. L., & Salleh, N. (2014). The effect of relaxin on the musculoskeletal system. Scandinavian Journal of Medicine & Science in Sports, 24(4), e220–e229. http://doi.org/10.1111/sms.12149
Owe KM, Bjelland EK, Stuge B, Orsini N, Eberhard-Gran M, Vangen S. (4 October 2015). Exercise level before pregnancy and engaging in high-impact sports reduce the risk of pelvic girdle pain: a population-based cohort study of 39,184 women. British Journal of Sports Medicine. pii: bjsports-2015-094921. doi: 10.1136/bjsports-2015-094921. [Epub ahead of print]
Tenforde AS, Toth KE, Langen E, Fredericson M, Sainani KL. (2015 Mar). Running habits of competitive runners during pregnancy and breastfeeding. Sports Health.;7(2):172-6. doi: 10.1177/1941738114549542.

Commonly in physical therapy we treat patients with osteopenia or osteoporosis, however, they are usually in our office for another diagnosis such as back, hip, or pelvic pain as the primary complaint and we learn about the osteoporosis from health history review. Physical therapy is an opportunity to provide them with not just relief from their primary complaint, but a chance to learn from a professional how to move in a more healthy way and learn the right ways to exercises to make a regular routine that can help them to protect their body and even slow or stop bone mineral density loss. This is important as the primary concern for a patient with the diagnosis of osteoporosis is risk of fracture (especially of the hip or spine) due to minimal trauma because of low bone mineral density. So let’s make sure we are giving patients comprehensive exercise programs that address their primary complaint, however be comprehensive and include exercise modes that may reduce fractures and may improve bone mineral density.

An interesting article by Palombaro et al¹ in 2013 from Physical Therapy discusses a Cochrane review by Howe et al² and applies the findings from this review to an example patient similar to the participants reviewed in the study. The goal of the article is to link evidence in the literature with how we practice as PT’s. The topic explored in the systematic review by Howe et al was exercise for the management of osteoporosis in women postmenopause and which exercise approaches reduce the loss of bone mineral density or reduce chance of fractures in women who are healthy postmenopause. The systematic review² included 43 randomized controlled studies of postmenopausal women age 45-70 where the intervention groups included exercises that improved aerobic capacity or improved aerobic capacity and muscle strength and had a comparison group completing “usual activity: or placebo intervention. The duration of exercise lasted from 6 months to 2 years in the various studies. The results of the review demonstrated decreased bone loss (of the spine or hips) in groups who performed any type of exercise compared to the control groups. The review also performed additional sub group analysis to take into account the various types of exercise programs in the studies and found favorable effect for all types of exercises completed (dynamic, low force, high force, weight bearing, or non-weight bearing) all had favorable effect on bone density. The take home message from this systematic review is that exercise programs combining various forms of exercises lasting 6 months to 2 years resulted in reduced risk for fracture, and a slightly beneficial effect on bone mineral density of the spine, trochanter, and neck of the femur in postmenopausal women with osteoporosis.

At the end of this article¹ the authors give a case of an active, postmenopausal female patient with history of osteopenia without a fracture seeking PT for an unrelated complaint. The authors took the findings from this review and showed the relevance of the findings, applying it to the patient and the outcome of care for this patient when giving her an exercise program. We can implement findings from this review simply to the common question posed by our patients… “what exercises should I be doing to help with my osteoporosis?”

Exercises for a patient with osteoporosis should be forms of exercises that may improve bone density by loading bones (weight bearing exercise) and by increasing muscle mass (strengthening resistive exercise) to produce mechanical load and stress to the bone. Also as we age we tend to experience changes with not just a reduction of bone mineral density, but also a reduction of muscle mass. Additionally complicating the natural progression of aging are balance and gait changes leading to impaired physical performance. We should be giving our patients a comprehensive exercise program including safe weight bearing exercises and a strengthening program. Common examples of weight bearing exercises include regular walking, jogging, jumping, dancing, and racquet sports. Common examples of strengthening activities would include use of resistive exercises for upper and lower body with bands, free weights or resistive equipment. All of these classifications of exercise were considered as beneficial in the review.

To learn more about helping postmenopausal patients, consider joining Michelle Lyons, PT, MISCP for "Menopause Rehabilitation and Symptom Management". This course will be taking place March 19, 2016 - March 20, 2016 in Atlanta, GA. Another great resource to consider is "Geriatric Pelvic Floor Rehab: Modifying Treatments for Seniors and Older Patients" with Heather S. Rader, PT, DPT, BCB-PMD, taking place January 16-17, 2016 in Tampa, FL.

¹ Palombaro, K. M., Black, J. D., Buchbinder, R., & Jette, D. U. (2013). Effectiveness of exercise for managing osteoporosis in women postmenopause. Physical Therapy, 93(8), 1021-1025.
² Howe, T. E., Shea, B., Dawson, L. J., Downie, F., Murray, A., Ross, C., ... & Creed, G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women (Review).

Can patients benefit from a non-face-to-face treatment program for stress urinary incontinence? A recent study addressing this question was published in the British Journal of Urology International. This randomized, controlled trial utilized online recruitment of 250 community-dwelling women ages 18-70 years. Criteria was stress urinary incontinence (SUI) at least 1x/week, diagnosis based on self-assessment questionnaires, 2 days of bladder diaries, as well as a telephone interview with a urotherapist. The Outcomes tools included the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF), the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), the Patient Global Impression of Improvement, health-specific quality of life (EQ-VAS), use if incontinence aids, and satisfaction with treatment.

The participants were randomized into 2 pelvic floor muscle training groups: an “internet-based” group (n=124) and a group who were sent information in the mail (n=126). The internet-based program contained information about pelvic muscle contractions (8 escalating levels of training), behavioral training related to lifestyle changes. The internet group received email support from the urotherapist, and the postal group did not. Pelvic floor muscle training was instructed at at least 8 contractions 3 times/day. After the 3 month training period, the internet-based treatment group was advised to continue pelvic floor muscle training 2-3 times/week, whereas the mail training group were not given any advice about continued training frequency. Follow-up data was collected at 4 months post-intervention, at 1 year and 2 years. At 2 years follow-up, 38% of the participants were lost from the study.

Within both groups, the authors report that the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) showed “highly significant improvements” after 1 and 2 years compared to baseline data. Much of the improvement occurred within the first 4 months of the study “…and then persisted throughout the follow-up period.” When comparing the internet group to the mail-only group, the perception of improvement following treatment was higher. Approximately 2/3 of the women in both groups reported satisfaction with the treatment even at the 2 year follow-up. The authors conclude that the internet or mail-based exercise programs may “…have the potential to increase access to care and the quality of care given to women with SUI [stress urinary incontinence] in a sustainable way.” Additionally, not all patients will improve significantly unless they have one-on-one intervention, leaving plenty of patients who do need our direct care.

If you would like to learn more about exercise prescription for urinary incontinence, consider attending one of Herman & Wallace's many continuing education courses.

After pushing a double stroller for a 3 mile run to the park yesterday, I had a flare up of hip pain that made me doubt my ability to get my kids back home. While they were playing, a hanging ladder caught my eye and sent my manual therapy wheels spinning. I carefully slipped my leg over one of the rungs, angled my body just right, and leaned away to distract my hip. I noticed a toddler staring at me, so I politely told her, “I’m just mobilizing my hip joint, sweetie, but you can go ahead and climb now!” My relief was almost immediate, and I realized my patients need to know how to help themselves, too! We all know how to prescribe home exercises for patients regarding stretching and strengthening, but once a therapist is competent performing joint mobilizations, the need for this arthokinematic movement is often found to be essential prior to the osteokinematic movement of stretching. The hip joint in particular is affected by pathologies of the lumbar spine, the sacroiliac joint, and the pelvic floor. When the hip joint is not moving around the proper physiological axis, then the knee can be negatively impacted as well as the areas just mentioned.

Therapists need to discern whether a patient is appropriate for self-hip mobilization instruction, as a “motor moron” probably would not be a good candidate to whom you would explain how to perform mobilizations at home. When you realize a patient “gets it,” then you can suggest the techniques to that patient. Reiman and Matheson (2013) presented a paper regarding suggestions for self-mobilization of the hip joint. They demonstrate an inferior-posterior hip glide with a towel, weight, and a step with or without muscle reeducation in hip flexion; an inferior and lateral glide with hip flexion movement; a hip posterior glide with or without movement; a hip lateral glide with or without muscle reeducation; a hip anterior glide with or without muscle reeducation; and, a long axis distraction mobilization. The authors conclude the efficacy of their protocol and techniques are not completely backed up by evidence yet and recommend they be implemented as an adjunct to evidence based practice, not a primary treatment approach.

Regarding the efficacy of hip mobilization in the clinic by a skilled clinician, a study by Makofsky et al, (2007) discusses the effect of inferior hip joint mobilization on hip abductor force. This study leaves little doubt that mobilizing the hip can facilitate contraction of the gluteus medius. A 17.35% increase in hip abduction torque was noted immediately after the inferior Grade IV hip mobilization; whereas, the control group without mobilization experienced a 3.68% decrease in hip abduction torque. We generally see patients much less often than our services are needed, so being able to teach patients how to mobilize on their own to supplement our work could be extremely effective in the long run.

I have the extreme fortune of being married to a manual therapist, so I do not always have to find crafty ways to mobilize my own joints, but my recent experience was encouraging to know it is more than possible to help myself. My hip pain had caused some patellofemoral symptoms because my gluteal muscles were inhibited. Performing a self-distraction close to my hip joint helped kick in the muscles required for greater stability of my knee. I cruised home with the kids without a hitch. We should all be ready to educate our patients to take potentially embarrassing measures to help themselves as well.

Reiman, M. P., & Matheson, J. W. (2013). RESTRICTED HIP MOBILITY: CLINICAL SUGGESTIONS FOR SELF‐MOBILIZATION AND MUSCLE RE‐EDUCATION. International Journal of Sports Physical Therapy, 8(5), 729–740.

Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., … Sileo, R. (2007). Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abductor Torque: A Pilot Study. The Journal of Manual & Manipulative Therapy, 15(2), 103–110.

Inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease (CD), according to Lan et al., are characterized by chronic inflammation in intestinal mucosa. There is little information available based on human studies that links nutritional support with inflammatory bowel disease. The authors of this article analyzed the available information about supplements that appear beneficial in healing the gut mucosa. 

The intestinal epithelium acts as a selective barrier, and inflammatory bowel disease can disrupt this important barrier, affecting absorption, mucus production, and enteroendocrine secretion. Intestinal wound healing, according to the linked article, is “dependent on the precise balance of several processes including migration, proliferation, differentiation, and apoptosis of the epithelial cells.” Although there are few human clinical studies (more are animal and cell model studies) there is evidence that both macronutrient and micronutrient deficiencies may exist in patients who have inflammatory bowel disease. Patients may have malnutrition of proteins, of minerals and vitamins. Following are some points from the article:

• Arginine, glutamine, and glutamate are noted as amino acids that contribute to mucosal healing in animal studies, as well as threonine, methionine, proline, serine, and cysteine. 
• Short-chain fatty acids, which are the result of metabolized dietary fiber (grains, legumes, fruits and vegetables), and resistant starch (beans, potatoes, brown rice) are a major source of energy for epithelial cells in the colon
• Vitamin A deficiency is common in patients with newly diagnosed IBD
• Vitamin D may decrease intestinal fibrosis, and reduce risk of Crohn’s relapse
• Vitamin C and Zinc may both help heal epithelial wounds in the colon
• During the remission phase, some foods may be poorly tolerated, such as dairy
• During an active flare of IBD, a patient may require enteral nutrition 

The authors conclude that the exact mechanisms by which the various dietary compounds contribute to bowel healing is still unknown. Furthermore, the ability to make clear dietary recommendations is limited by the lack of clinical studies. At a minimum, this information can alert the pelvic rehab provider to discuss the potential benefits of nutrition on bowel health with patients. Many of us are quite comfortable giving advice about drinking appropriate amounts and types of fluid, or eating more whole and less processed foods. We can take our nutritional education a step further by encouraging a patient to discuss healing supplements with a provider and/or nutritionist to best support the healing bowel. If you are interested in learning more about nutrition and pelvic health, you might love our newer course Nutrition Perspectives for the Pelvic Rehab Therapist Kansas City in March of next year with instructor Megan Pribyl.

Lan, A., Blachier, F., Benamouzig, R., Beaumont, M., Barrat, C., Coelho, D., & Tomé, D. (2015). "Mucosal healing in inflammatory bowel diseases: is there a place for nutritional supplementation?" Inflammatory bowel diseases, 21(1), 198-207.

Postpartum perineal injuries can cause pain and dysfunction for a short or an extended period of time. Pelvic rehab providers are in a position to educate women about the immediate and long-term management of perineal pain. A 2015 study by Manfre et al. assessed the response of cortisone cream application to the perineum in the immediate postpartum period. The study was a randomized controlled trial involving 27 subjects with each subject serving as her own control. Three different treatments were given over a 12 hour period: corticosteroid, placebo, and no treatment. (The hydrocortisone cream was at 1% in an alcohol-based cream, the placebo was a non-medicated acetyl alcohol-based cream.) The cream was applied by an investigator who placed the cream on a Witch Hazel pad. The participants and the researchers were blinded to the type of cream applied, and the applications were randomized and took place within the first 12.5 hours after birth. Perineal pain levels were assessed immediately before cream application, and at 30 and 60 minutes after application. Using a visual analog scale (VAS), the symptom of pain was assessed and compared to baseline. In the study, the authors report that in the immediate postpartum period, women in their institution were often prescribed medication ranging from ibuprofen to hydrocodone. Topical medications, ice packs, heat packs are also mentioned as available treatments. Other pain medications or cold packs were available during the study; no other topical creams were utilized.

Results indicated that the participants responded positively to both creams with significantly more pain reduction than the no treatment group. The authors propose that both creams provided a soothing effect by providing moisture to the tissues, creating a protective barrier, and preventing friction and irritation. Because the placebo emollient cream was not significantly more expensive than the hydrocortisone cream, the article suggests using hydrocortisone on the postpartum perineum due to the medication’s potential beneficial anti-inflammatory effects. Also of note was that ice packs were used by less than half of the women in the study, and when ice was used, it was only during the first four hours after birth. One reason for the low frequency use of ice was thought to be the difficulty in maintaining ice application on the perineum.^{Manfre 2015}

Because the pelvic rehab provider is in an optimal role as educator for pain reduction strategies, this study provides some interesting information to share with other birth providers and with patients. Learn more about postpartum patient care at Care of the Postpartum Patient, available in Seattle this March.

Manfre, M., Adams, D., Callahan, G., Gould, P., Lang, S., McCubbins, H., ... & Chulay, M. (2015). Hydrocortisone Cream to Reduce Perineal Pain after Vaginal Birth: A Randomized Controlled Trial. MCN: The American Journal of Maternal/Child Nursing, 40(5), 306-312.

Diastasis of the Rectus Abdominis Muscle (DRAM) is the separation of the two rectus abdominis muscles along the linea alba and is very common during and after pregnancy as the rectus abdominis and linea alba stretches and thins. Patients with DRAM are often sent to seek non-surgical management for DRAM from a physical therapist (PT). Typically these patients are either at the end of their pregnancy or adjusting to round the clock care of an infant. They can be sleep deprived, and have a full schedule of doctor’s appointments, having difficulty finding childcare, making attending PT somewhat challenging. Furthermore, they may have difficulty finding the time for a home exercise program (HEP). As PT’s we often struggle with making sure to give the patient exercises that will accomplish the goal of improving DRAM, however, making sure the HEP is not so extensive or time consuming that it becomes unmanageable. Is something as easy as abdominal bracing with exercise effective for reducing DRAM in post-partum women? A recent study published in 2015 in the International Journal of Physiotherapy and Research explores just this topic^(Acharry).

Why is Diastasis of the Rectus Abdominis Muscle (DRAM) important?

Women with DRAM tend to have a higher degree of abdominal and pelvic region pain^(Parker). Also women with DRAM may be more likely to have support related pelvic floor problem such stress urinary incontinence, fecal incontinence, or pelvic organ prolapse. The linea alba and rectus abdominis play an integral role in maintaining the anterior support of the trunk, these structures work together with pelvic girdle, posterior trunk muscles, and hips in maintaining stability when we shift weight (or transfer load) such as with standing, squatting, walking, carrying, and lifting. Therefore postural stability may be impaired with these daily tasks. Lastly, the abdominal muscles and fascia protect and support our organs so women with DRAM may have compromised support and protection of visceral structures.

Is DRAM common?

Pregnancy is the most common cause of DRAM and studies widely range from 50-100% of women experiencing DRAM at end stage pregnancy. Natural reduction and greatest recovery of DRAM usually occurs between day 1 and week 8 after delivery. Various ways exist to diagnose DRAM. The gold standard for diagnosis is computed tomography but is sometimes considered impractical due to expense. Clinically a separation of 2.0-2.7cm or “two finger widths” of horizontal separation at the umbilicus or 4.5cm above or below while performing a hooklying (supine with knees bent) abdominal curl up is considered pathological separation.

What can be done for DRAM?

Current guidelines for conservative treatment of DRAM are sparse with little established recommendations. The earlier referenced recent cross sectional study^(Acharry) explores efficacy of abdominal bracing as a treatment for reduction of DRAM in post-partum females. The study included 30 females that were one month post-partum or more who had vaginal delivery with or without episiotomy. The average distance of the diastasis was measured before and after treatment using the finger width technique. The treatment included teaching the subject four abdominal exercises, and the subjects were encouraged to complete abdominal bracing while carrying out daily activities. The four exercises included 1) static abdominal bracing exercise, lying supine with arms crossed over the diastasis for support and then pulling abdominals inwards with an isometric contraction of abdominal muscles. 2) Head lift with bracing, in hooklying with arms crossed over diastasis, exhale, lift head and use hands (or a towel/sheet) to approximate diastasis towards midline. 3) Head lift and pelvic tilt with bracing, is the same as previous exercise only adding a posterior pelvic tilt. 4) Pelvic clock exercise with bracing, visualize a clock on the lower abdominals and complete gentle movements from 12-6 o’clock, 3-9 o’clock, 12-3-6-9-12 o’clock, in a clockwise fashion and then reverse the pattern in a counter clockwise pattern. All exercises were performed twice daily, with a repetition of 5-6 days per week, for 2 weeks duration. After completing the program for two weeks the distance of the diastasis was re-measured and the average DRAM distance decreased from 3.5 to 2.5 finger widths which was considered significant. The results of this study show abdominal exercise with bracing is effective for reducing DRAM in early post partal females.

As PT’s who treat DRAM we should encourage our patients to use abdominal exercises with bracing as well as encourage our patients to use abdominal bracing with their daily tasks such as standing, lifting, weight shifting, and carrying. A home exercise program such as the one in this study proved to be effective for reducing DRAM and included only four exercises making this a manageable home exercise program for our post-partum patients.

Herman & Wallace offers a full series of peripartum courses called the "Pregnancy Series". To learn more about diastasis of the rectus abdominis muscle, join Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI at Care of the Postpartum Patient in Seattle, WA this March 12-13, 2016!

Acharry, N., & Kutty, R. K. (2015). ABDOMINAL EXERCISE WITH BRACING, A THERAPEUTIC EFFICACY IN REDUCING DIASTASIS-RECTI AMONG POSTPARTAL FEMALES. Int J Physiother Res, 3(2), 999-05.

Parker, M. A., Millar, L. A., & Dugan, S. A. (2009). Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy, 33(2), 15-22.

Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups; 20 women completed the study. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.

The following factors made up the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, and a 4 month history of stable symptoms. All of the participants were sexually active and were found to be able to contract pelvic floor muscles correctly. Group 1 patients were treated with “sham” electrical stimulation using surface electrodes placed over the sacrum at a pulse width of 50 ms and a frequency of 2 Hz. Patients in Group 2 used an internal (vaginal) electrode at 200 ms at 10 Hz. Group 3 were given transcutaneous tibial nerve stimulation at 200 ms and 10 Hz. All groups followed these treatments with pelvic floor muscle exercises using a vaginal sensor and biofeedback.

The authors concluded that pelvic floor muscle training alone or in combination with intravaginal neuromuscular electrostimulation or transcutaneous tibial nerve stimulation is effective in treating sexual dysfunction in women who have MS. Improvements were noted in these groups in sexual arousal, vaginal lubrication, satisfaction, and in the Female Sexual Function Index. While the numbers in the respective intervention groups is not large enough to determine the best option for patients who have multiple sclerosis, the research reminds us that neurostimulation in conjunction with pelvic muscle training may be very valuable.

As pelvic rehab practitioners, it is common for our patients to ask us dietary questions pertaining to their unique pelvic floor symptoms. We often counsel on fluid consumption, bladder irritants, and fiber intake. At times, we even give our patients a bladder or bowel diary to better monitor nutritional status and habits. However, how often do we ask about vitamin D status? It is common knowledge that vitamin D deficiency contributes to osteoporosis, fractures, and muscle pain and weakness, but what is the role of vitamin D in overall health of the female pelvic floor. Is vitamin D supplementation something we as health care providers need to at least discuss? An article published in the International Urogynecology Journal ^{(Parker-Autry)} explores this topic. This interesting paper reviews current knowledge regarding vitamin D nutritional status, the importance of vitamin D in muscle function, and how vitamin D deficiency may play a role in the function of the female pelvic floor.

How may vitamin D play a role in the function of the pelvic floor?

Vitamin D affects skeletal muscle strength and function, and insufficiency is associated with notable muscle weakness. Vitamin D has been shown to increase skeletal muscle efficiency at adequate levels. The levator ani muscles and coccygeus pelvic floor muscles are skeletal muscle that are crucial supporting structures to the pelvic floor. Pelvic floor musculature weakness can contribute to pelvic floor disorders such as urinary or fecal incontinence and pelvic organ prolapse. Pelvic floor muscle training for strengthening, endurance, and coordination, are first line treatment for both stress and urge urinary incontinence, fecal incontinence, pelvic organ prolapse, and overactive bladder syndrome. The pelvic floor muscles are thought to be affected by vitamin D nutrition status. Additionally, as women age, they are more prone to vitamin D deficiency and pelvic floor disorders.

This article reviews several studies, including small case and observational, that show an association between insufficient vitamin D and pelvic floor disorder symptoms and severity of symptoms. The recommendation from this review is that more studies of high quality evidence are needed to fully understand and demonstrate this relationship between vitamin D deficiency and pelvic floor disorders. However, the authors feel that vitamin D supplementation may be a helpful adjunct to treatment by helping to optimize our physiological response to pelvic floor muscle training and improving the overall quality of life for women suffering from pelvic floor disorders.

How much vitamin D?

The Institute of Medicine has only made recommendations for dietary allowance for vitamin D and calcium for bone health. There is no consensus for adequate vitamin D levels for a condition specific goal (other than bone health), and the levels of vitamin D varied throughout the reviewed studies. It has been shown that very high levels of vitamin D are tolerated well, so supplementation of vitamin D seems to be very safe in low and very high doses.

Food for thought?

As pelvic rehabilitation providers, it is our job to assess the whole person, however, we are not dieticians. As physical therapists we are musculoskeletal specialists and vitamin D affects muscle function. What our patients put in their bodies (wholesome nutritious food vs nutrient lacking artificial food) affects the quality of the cells they produce and tissues that are made, which can influence their healing. When reviewing health history, maybe consider discussing vitamin D status and possible supplementation with the patient, or with the patients’ primary care provider or naturopathic doctor. This team approach may provide more comprehensive health care, hopefully yielding more successful outcomes.

Parker-Autry, C. Y., Burgio, K. L., & Richter, H. E. (2012). Vitamin D status: a review with implications for the pelvic floor. International urogynecology journal, 23(11), 1517-1526.

With age, many of our patients may be at higher risk of developing dementia. Dementia has a wide range of causes and symptoms, and is most often associated with Alzheimer’s disease. Memory loss, difficulty in communicating, in organizing complex tasks and in coordinating motor functions can add to the challenge of participating in rehabilitation. In pelvic rehabilitation, we are already faced with the importance task of effectively communicating about sensitive topics, obtaining clear consent, and instructing in exercise that may be difficult for the patient to “see” or appreciate in the same way as with a biceps curl or leg raise. How can we set ourselves and our patients up for success when working with a patient who has dementia or other cognitive issues?

An article with a focus on communication with older people who have dementia ^{de Vries, 2013} summarizes practical information that can positively affect our skills in communication with patients who have cognitive dysfunction. From the impact of hearing loss on orientation and sense of vulnerability, to the types of listening skills recognized as means to improve communication, the article integrates a wide range of valuable information.

Some of the suggestions for enhancing interactions with patients who have dementia come from the work of Wilson et al., 2012, and include the following:

• slow the rate of your speech
• use verbatim repetition
• ask questions that can be answered with a “yes” or “no”
• decrease the complexity of your sentences
• ask one question at a time give instructions for one idea or concept at a time
• avoid use of pronouns when able (can be confusing, refer instead to the person)

Other research-based advice given in the article includes eliminating distraction, such as turning off a radio or television, and avoid interrupting the person who has dementia. Sitting face to face is recommended, as is using non-verbal communication such as facial expressions and gestures. Also very interesting is the idea that using a more controlling tone of voice can lead to increased resistance to care. A terrific strategy that is recommended in the article is this “Ask a colleague to observe your practice…and make notes on how you communicate…” Although being critiqued may feel intimidating, learning how others perceive our use of the above skills can help to optimize communication with patients who have dementia.

Providing optimal communication strategies during rehabilitation is just one of the topics that is discussed in the Institute’s new Geriatric Pelvic Floor Rehab continuing education course. The first opportunity to take this new course is Tampa, Florida this January. The course is taught by Heather Rader who immerses herself in the care of people in the geriatric age range. Her expertise not only in pelvic rehab, but also in adaptations for the geriatric population, billing practices, and marketing will be shared.

De Vries, K. (2013). Communicating with older people with dementia. Nursing older people, (25), 30-7.

Wilson, R., Rochon, E., Mihailidis, A., & Leonard, C. (2012). Examining success of communication strategies used by formal caregivers assisting individuals with Alzheimer’s disease during an activity of daily living. Journal of Speech, Language, and Hearing Research, 55(2), 328-341.