Nancy Cullinane PT, MHS, WCS is today's guest blogger. Nancy has been practicing pelvic rehabilitation since 1994 and she is eager to share her knowledge with the medical community at large. Thank you, Nancy, for contributing this excellent article!

Clinically valid research on the efficacy and safety of therapeutic exercise and activities for individuals with osteoporosis or vertebral fractures is scarce, posing barriers for health care providers and patients seeking to utilize exercise as a means to improve function or reduce fracture risk^1,2. However, what evidence does exist strongly supports the use of exercise for the treatment of low Bone Mineral Density (BMD), thoracic kyphosis, and fall risk reduction, three themes that connect repeatedly in the body of literature addressing osteoporosis intervention.

Sinaki et al³ reported that osteoporotic women who participated in a prone back extensor strength exercise routine for 2 years experienced vertebral compression fracture at a 1% rate, while a control group experienced fracture rates of 4%. Back strength was significantly higher in the exercise group and at 10 years, the exercise group had lost 16% of their baseline strength, while the control group had lost 27%. In another study, Hongo correlated decreased back muscle strength with an increased thoracic kyphosis, which is associated with more fractures and less quality of life. Greater spine strength correlated to greater BMD⁴. Likewise, Mika reported that kyphosis deformity was more related to muscle weakness than to reduced BMD⁵. While strength is clearly a priority in choosing therapeutic exercise for this population, fall and fracture prevention is a critical component of treatment for them as well. Liu-Ambrose identified quadricep muscle weakness and balance deficit statistically more likely in an osteoporotic group versus non osteoporotics⁶. In a different study, Liu-Ambrose demonstrated exercise-induced reductions in fall risk that were maintained in older women following three different types of exercise over a six month timeframe. Fall risk was 43% lower in a resistance-exercise training group; 40% lower in a balance training exercise group, and 37% less in a general stretching exercise group⁷.

These studies allow us to unequivocally conclude that spinal extensor strengthening and therapeutic activities aimed at improving balance and decreasing fall risk are tantamount as therapeutic interventions for osteoporosis. But postural education/modification and weight bearing activities aimed at stimulating osteoblast production intended to improve BMD are a reasonable component of an osteoporosis treatment plan, despite the lack of concrete evidence for them. Nutrition and mineral supplementation with calcium and vitamin D have been shown to reduce morbidities, and hence we should incorporate this education into our treatment plans as well^{8, 9}. Studies on the efficacy of vibration platforms hold promise, but thus far, have not been substantiated as an evidence-based intervention to improve BMD.

Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures^1,2 is a multiple-part publication in the journal Osteoporosis International, based upon an international consensus process by expert researchers and clinicians in the osteoporosis field. These publications include exercise and physical activity recommendations for individuals with osteoporosis based upon a separation of patients into to three groups: osteoporosis based on BMD without fracture; osteoporosis with one vertebral fracture; and osteoporosis with multiple spine fractures, hyperkyphosis and pain. This group of experts emphasize the importance of teaching safe performance of ADLs with respect to bodymechanics as a priority to accompany strength, balance, fall & fracture prevention, nutrition and pharmacotherapy management. They promote establishment of an individualized program for each patient with adaptable variations of these concepts, with the most accommodation allotted for individuals with multiple vertebral compression fractures. An example of such an adaptation is altering prone back extensions such as those documented in the studies by Sinaki and Hongo, into supine shoulder presses, thus strengthening the back extensors in a less gravitationally demanding posture. Osteoporosis Canada has adapted the main concepts from these publications into a patient-friendly, instructional website with reproducible handouts at http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/

A firm conclusion from the Too Fit to Fracture project is that higher quality outcomes studies are desperately needed to assist all healthcare providers in managing osteoporosis more effectively and comprehensively, and to do so prior to the onset of debilitating fractures that tend to produce serious comorbidities.

1. Giangregorio et al. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International. 2014; 25(3): 821-835
2. Giangregorio et al. Too Fit to Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fracture. Osteoporosis International. 2015; 26(3):891-910
3. Sinaki et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002; 30: 836-841 4. Hongo et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis; a randomized controlled trial.Osteoporosis International. 2007; 10: 1389-1395
5. Mika et al. Differences in thoracic kyphosis and in back muscle strength in women with bone loss due to osteoporosis. Spine. 2005; 30(2): 241-246
6. Liu-Ambrose et al. Older women with osteoporosis have increased postural sway and weaker quadriceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontology, Series A Biolog Sci Med Sci. 2003; 58(9): M862-866
7. Liu-Ambrose et al. The beneficial effects of group-based exercise on fall risk profile and physical activity persist 1 year post intervention in older women with low bone mass: follow-up after withdrawal of exercise. J Am Geriat Soc. 2005; 53 (10): 1767-1773
8. Ensrud et al. Weight change and fractures in older women: study of osteoporotic fractures research group. Archives Int Med. 1997; 157 (8): 857-863
9. Kemmler et al. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results. Med and Sci in Sports Ex. 2002; 34 (12): 2115-2123

In manual therapy training, we do not learn just one position to mobilize a joint, so why should pelvic floor muscle training be limited by the standard training methods? There is almost always at least one patient in the clinic that fails to respond to the “normal” treatment and requires a twist on conventional therapy to get over a dysfunction. Thankfully, classes like “Integrative Techniques for Pelvic Floor and Core Function” provide clinicians with the extra tools that might help even just one patient with lingering symptoms.

In 2014, Tenfelde and Janusek considered yoga as a treatment for urge urinary incontinence in women, referring to it as a “biobehavioral approach.” The article reviews the benefits of yoga as it relates to improving the quality of life of women with urge urinary incontinence. Yoga may improve sympatho-vagal balance, which would lower inflammation and possibly psychological stress; therefore, the authors suggested yoga can reduce the severity and distress of urge UI symptoms and their effect on daily living. Since patho-physiologic inflammation within the bladder is commonly found, being able to minimize that inflammation through yoga techniques that activate the efferent vagus nerve (which releases acetylcholine) could help decrease urge UI symptoms. The breathing aspect of yoga can reduce UI symptoms as it modulates neuro-endocrine stress response symptoms, thus reducing activation of psychological and physiologic stress and inflammation associated with stress. The authors concluded the mind-body approach of yoga still requires systematic evaluation regarding its effect on pelvic floor dysfunction but offers a promising method for affecting inflammatory pathways.

Pang and Ali (2015) focused on complementary and alternative medicine (CAM) treatments for interstitial cystitis (IC) and bladder pain syndrome (BPS). Since conventional therapy has not been definitely determined for the IC/BPS population, CAM has been increasingly used as an optional treatment. Two of the treatments under the CAM umbrella include yoga (mind-body therapy) and Qigong (an energy therapy). Yoga can contribute to IC/BPS symptom relief via mechanisms that relax the pelvic floor muscle. Actual yoga poses of benefit include frog pose, fish pose, half-shoulder stand and alternate nostril breathing. According to a systematic review, Qigong and Tai Chi can improve function, immunity, stress, and quality of life. Qigong has been effective in managing chronic pain, although not specifically evidenced with IC/BPS groups. Qigong has also been shown to reduce stress and anxiety and activate the brain region that suppresses pain. The CAM gives a multimodal approach for treating IC/BPS, and this has been recommended by the International Consultation on Incontinence Research Society.

Evidence is emerging in every area of treatment these days, so it is only a matter of time before randomized controlled trials regarding alternative treatment methods for the pelvic floor begin to fill pages of our professional journals. Yoga, Qigong, Tai Chi, biologically based therapies, manipulative and body-based approaches, and whole medical systems all offer safe, effective treatment options for the IC/BPS and urinary incontinence patient populations. The more we use these extra treatment tools and document the results, the more likely we will see clinical trials proving their efficacy.

Tenfelde, S and Janusek, L. (2014). Yoga: A Biobehavioral Approach to Reduce Symptom Distress in Women with Urge Urinary Incontinence. THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE. 20 (10), 737–742. http://doi.org/10.1089/acm.2013.0308
Pang, R., & Ali, A. (2015). The Chinese approach to complementary and alternative medicine treatment for interstitial cystitis/bladder pain syndrome.Translational Andrology and Urology, 4(6), 653–661. http://doi.org/10.3978/j.issn.2223-4683.2015.08.10

Dr. Dischiavi is a Herman & Wallace faculty member who authored and teaches Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System, available this August in Boston, MA.

STEM is an acronym for science, technology, engineering, and math. These fields are deeply intertwined and taking this approach could potentially be a way to facilitate the physical therapist’s appreciation of human movement.

Science: I would bet most physical therapists would agree that science is the cornerstone of our profession. It is time to look across all the landscapes of science to better understand the physical principles that govern movement. Biotensegrity is a great example of how science from a field such as cellular biology can help possibly explain how we maintain an erect posture when the rigid bony structure of our skeleton is only connected from bone to bone by soft tissues [1]. The brain and central nervous system regulates muscle tone, and it is resting muscle tone that give our bodies the ability to be upright. Without resting muscle tone, we would crumple to the ground as a heap of bones within a bag of skin. Since the CNS can either up or down regulate muscle tone, this allows us to create the rigidity we need to accomplish higher level movements such as sport, and then return to a resting state after the movements are performed (see running skeleton picture below). This theory of organismic support was bred within the scientific field of cellular biology, and can potentially be applied effectively to the human organism. As physical therapists, I agree we need to be skeptical of new ideas, but we also need to embrace the idea that the physical sciences have applied to nature for centuries, and it is possible these various scientific fields can help us unlock new ideas and allow us to look at things through a different lens.

Technology: As not only a practicing physical therapist, but as a newly appointed assistant professor within a budding physical therapy program it is my duty to embrace evidence based practice. I believe without question, when evidence that is sound exists it should help direct patient care. It is also clear that our tests and measures that are currently being utilized to help develop new evidence are lacking, specifically with regard to human movement and sport performance.

Sports performance is such a complex system (more on this later) we can’t expect to study things such as injury prevention at slow speeds utilizing maneuvers that aren’t even seen in the sport itself. Recently, Bahr [2] suggested that screening for sports injuries is pretty much a futile effort as he titled his article “Why screening tests to predict injury do not work - and probably never will…: a critical review.” Eventually technology will need to be developed that can measure high speed movement across multiple planes and ranges of motion, and essentially capture the complex spiraling that occurs with human movement and the bodies effort to attenuate ground reaction forces. This concept can be illustrated in the current work of Tak and Langhout [3] who have developed a novel approach to measure hip ROM in soccer players. They have essentially performed a thorough needs analysis of the kicking motion and determined that the classical method of measuring hip ROM doesn’t take into account the body’s need to spiral itself to gain the energy in the system needed to kick a ball [Fig 1]. This global understanding of the dynamic integration of the kinetic chain (which is covered in my hip course!) is what has led them to design this new method to measure hip ROM. Now, we will need technological advancements to capture, record, and measure these types of positions across three planes and at high speeds to establish the data that will eventually lead to evidence that will translate into sport. This is a great example of how clinical innovation sometimes precedes actual evidence to support its use. As William Blake was quoted as saying “what is now proven was once only imagined.”

Engineering: Structural engineering should be included in every physical therapy education program. There are many basic structural engineering principles that directly apply to a physical therapists practice. For example, the principal of elastics is frequently discussed within structural engineering. Elastics describes to what extent deformation is proportional to the forces applied to a particular material. In physical therapy muscles are that particular material, muscles must have elasticity and extensibility, not flexibility! In elastics, a rubber band is often used as a simple example to explain this engineering concept.

A rubber band will elongate and develop potential energy until release and then unleash kinetic energy. Our human movement system relies heavily on the principle of elastics. The rectus femoris is a two-joint muscle across the hip. During gait and running the rectus femoris is elongated as the hip moves into extension, this elongation builds its potential energy until the foot comes off the ground to initiate the swing phase, and the kinetic energy released in the system allows momentum to carry the lower extremity forward.

I would add that possibly the twisting created by the contralateral counter trunk rotation and reciprocating arm and leg swing that accompanies the hip extension is what creates tension throughout the entire anterior chain, similar to why Tak and Langhout feel its important to take up all soft tissue slack three dimensionally to effectively measure hip ROM needed for a soccer kick. It is considering that the elasticity in the entire system (organism) is needed to create an efficient human movement, which is kicking a ball in this example. When the body utilizes passive lengthening of muscle chains, as in elastics, it allows the body to move more efficiently. This is described by Chu [4] who reports that in the pitching motion maximizing force development in the large muscles of the core and legs produces more than 51%- 55% of the kinetic energy that is transferred to the hand [Fig 2]. The thoracolumbar fascia is involved in the kinetic chain during throwing activities and connects the lower limbs through the gluteus maximus muscle to the upper limbs through the latissimus dorsi. This idea of a dynamic integration of the kinetic chain is the main concept of the exercise portion of my hip course!

Math: The dynamic systems theory is an area of mathematics that most physical therapists probably don’t consider during everyday treatment. Little do they know, every treatment decision we as therapists make for our patient/clients has some root found in the dynamic systems theory. In fact, it is a fitting description when this theory is applied to human movement. Human movement is an incredibly complex system comprised of many different systems all working at the same time. Paul Glazier recently offered a Grand Unified Theory (GUT) for sports performance [5] and he discusses in detail the various systems and dynamic elements involved in sports performance from musculoskeletal, to neural, to cognitive, environmental, hormonal, and emotional just to name a few. The systems at work during sport when combined are exponential and most likely infinite. This is why it is so difficult to try and capture all these dynamic systems in a laboratory setting with the current technology available. In my hip course offered through Herman & Wallace I offer a novel paradigm to help clinicians construct therapeutic exercise programs using the hip as a cornerstone to human movement. I try to compact these various systems into 8 overlapping elements related to sport performance. When each of these 8 components are “exploded” as you might see in an engineering schematic where an engine is exploded to see all the parts that make the engine or more simply explained using a cheeseburger as the example [Fig 3]. Sure its easy to spot the cheeseburger when its whole just like when you see an athlete on the field running it seems obvious. Once the cheeseburger is “exploded” you can now isolate each sub-element included in your cheeseburger. This cheeseburger example is an obvious over-simplification, but if we exploded the bun to see the underlying grain and the seeds and so on…you now start to get an idea of how deep and intertwined all these subsystems are. Interestingly, the engine and the cheeseburger have finite parts and fit together, the human system has different parts in different systems depending on the sport and who might be playing it, under ever-changing scenery, and so on. So you can now see how the 8 components I outline in my course can house many different aspects of these dynamic systems. Although, I think this is progress with regard to the current state of the evidence, specifically with regard to utilizing the hip during movement, there are other systems at work that clinicians simply cannot control, such as gender, hormonal, environmental, etc…The idea is to try to identify and then manipulate modifiable factors whenever possible. These concepts are more clearly described and implemented in my hip course! Please come and check it out, and let me know what you think!

I’m hoping the STEM approach can possibly make it into physical therapy curriculums to illustrate to future physical therapists that there are many different disciplines at work with regard to physical therapy, and taking a global view of these elements can certainly be worthwhile.

1. Ingber, D.E., N. Wang, and D. Stamenovic, Tensegrity, cellular biophysics, and the mechanics of living systems. Rep Prog Phys, 2014. 77(4): p. 046603.
2. Bahr, R., Why screening tests to predict injury do not work-and probably never will...: a critical review. Br J Sports Med, 2016.
3. Tak, I., et al., Hip Range of Motion Is Lower in Professional Soccer Players With Hip and Groin Symptoms or Previous Injuries, Independent of Cam Deformities. Am J Sports Med, 2016. 44(3): p. 682-8.
4. Chu, S.K., et al., The Kinetic Chain Revisited: New Concepts on Throwing Mechanics and Injury. PM R, 2016. 8(3 Suppl): p. S69-77.
5. Glazier, P.S., Towards a Grand Unified Theory of sports performance. Hum Mov Sci, 2015.

Figure 1

Figure 2

Figure 3

Figure 4

Today's blog is a contribution from Kristen Digwood, DPT, CLT, of the Elite Pelvic Rehab clinic in Wilkes-Barre, PA.

Urgency urinary incontinence (UUI), which is the involuntary loss of urine associated with urgency, is a common health problem in the female population. The effects of UUI result in limitations to daily activity and quality of life.

Current guidelines recommend conservative management as a first-line therapy in urinary incontinence, defined as "interventions that do not involve treatment with drugs or surgery targeted to the type of incontinence".

Electrical stimulation is commonly used as part of a treatment program for women with UUI. There are several methods and parameters that can be used to improve urge incontinence, however the magnitude of the alleged benefits and best parameters is not completely established. Studies have suggested that the use of electrical stimulation to inhibit an overactive bladder functions to modulate unwanted detrusor contractions by way of sensory afferent stimulation of S2 and S3. This causes parasympathetic inhibition.  In addition to this effect, contraction of the pelvic floor muscles results in inhibition and relaxation of the detrusor muscle which reduces urinary urgency.

Common methods of electrical stimulation include suprapubical, transvaginal, sacral and tibial nerves stimulation.

As with any medical treatment, practitioners seek the most effective methods and parameters to achieve the patient’s goals. A recent systematic review of electrical stimulation in the treatment of UUI included nine trials to treat UUI were included with total of 534 female patients. Most patients in the trials were close to 55 years of age. Five articles (total of nine) described a frequency of twice-weekly therapy and sessions of 20 minutes. Twelve weeks was the most common duration of therapy. All the studies applied an intensity of stimulation below 100 mA, with four of them (4/9) using 10 hz as the frequency. Intervaginal electrical stimulation showed the greatest subjective improvement and was the most effective.

The most frequent outcome measure was bladder diary, used in all papers; subjective satisfaction was used in 8; and quality-of-life questionnaires in 6, from a total of 9 papers.

The study noted that reports about electrical stimulation generally lack information on its cost-effectiveness. This is an important point, especially because in therapies with similar benefits cost may be one of the factors to indicate the most appropriate treatment. If we consider the relatively few adverse effects, low cost, and similar effectiveness when compared to medication, intravaginal electrical stimulation, according to available data, appears to be a good alternative treatment for UUI.

1. Thüroff JW, Abrams P, Andersson KE, Artibani W, Chapple CR, Drake MJ, et al.: EAU guidelines on urinary incontinence. Eur Urol. 2011; 59: 387-400.
2. Kralj B. The treatment of female urinary incontinence by functional electrical stimulation. In:Ostergard DR, Dent AD (eds). Urogenecology and Urodynamics. 3rd ed. Baltimore, MD: Williams and Wilkins; 1991.
3. Eriksen, BC. Electrical Stimulation. In: Benson JT editor. Female pelvic floor disorders: investigation and management. New York:Norton, 1992; 219-231.
4. Lucas Schreiner  , Thais Guimarães dos Santos  , Alessandra Borba Anton de Souza, et al. Int. braz j urol. vol.39 no.4 Rio de Janeiro July/Aug. 2013.

Vaginal wall thinning associated with menopausal changes can cause vaginal burning and pain, limitations in sexual function, and vaginal redness or even changes in discharge. Because these symptoms can mimic many other conditions such as pelvic floor muscle dysfunction or an infection, it is necessary for the pelvic rehabilitation therapist to be alert to identifying vaginal atrophy as an issue to rule out so that patients can access appropriate medical care when needed.

Atrophic vaginitis (AV) is a condition of the vaginal walls associated with tissue thinning, discomfort, and inflammation. The tissue changes often extend into the vulvar area as well. Atrophic vaginitis may also be called vaginal atrophy, vulvovaginal atrophy, urogenital atrophy, or genitourinary syndrome of menopause. Although we tend to associate menopause with women who are in their 40’s or 50’s, any woman who has stopped having her menstrual cycles or who has had a significant reduction in her cycles may be at risk for vaginal atrophy. Any woman who has had a hysterectomy may also be at risk of this thinning of the vaginal walls. Common symptoms of vaginal wall thinning include vaginal dryness, tissue irritation, redness, itching, and a “burning” pain. Interruption in sleep, limitations in activities of daily living, and changes in mood and temperament have also been reported.

One common pharmacological intervention for vaginal and vulvar atrophy is the topical application of hormone creams such as estrogen. A recent study examined the effects of low dose estrogen therapy on bacteria that populates the vaginal walls.^{Shen et al., 2016} This bacteria may be causal or correlated to vaginal health, and also appears related to estrogen levels. Sixty women diagnosed with atrophic vaginitis were treated with low dose estrogen therapy and followed for four weeks to assess the vaginal microbiotia via mid-vaginal swabs. Following are highlights from the linked study’s findings,

• Prior to treatment, in symptomatic postmenopausal women the Lactobacilli species were less abundant and made up 11.2% of the community, while in asymptomatic women, the communities were more than 50% lactobacilli
• Gardnerella was more abundant than Lactobacillus in women with atrophic vaginitis
• Overall diversity of bacterial communities between healthy women and those with atrophic vaginitis was not significantly different
• In response to treatment with estrogen, women with AV reported improved symptoms and decreased vaginal pH
• Serum estradiol improved on average from approximately 42 pmol/L to 168 pmol/L by week 2, with little change from week 2 to week 4
• Lactobacillus count was negatively correlated with symptoms (i.e., more Lactobacillis = less symptoms) and Gardnerella and Atopobium counts were positively correlated with symptoms
• There were variations noted in how each woman’s vaginal bacterial communities responded to the estrogen therapy in that some women had a dominance of other bacteria after 4 weeks even though their symptoms decreased

In conclusion, the authors stated that “…a Lactobacillus-dominated vaginal community may be considered as one of the signs of AV treatment success…” along with reduced symptoms and increased serum estradiol levels. Prior studies have recognized barriers to treatment that include lack of patient knowledge of vulvar and vaginal atrophy, failure to discuss associated symptoms with physicians, concerns about safety of treatments or poor symptom relief with prescribed interventions.^{Kingsburg et al., 2013} This leaves the pelvic rehabilitation provider in a excellent role of educating women in the signs and symptoms of atrophic vaginitis, observing the tissues for changes, and communicating with referring providers and prescribers if a concern is noted. Furthermore, failure to recognize the potential for vaginal atrophy and treating these tissues with manual therapy or exercise may injure or exacerbate the problem.

Interested in learning more? Keep an eye out for a Menopause Rehabilitation and Symptom Management course with Michelle Lyons!

Changes in the Vagina and Vulva. Retrieved June 27, 2016 from http://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-the-vagina-and-vulva
Kingsberg, S. A., Wysocki, S., Magnus, L., & Krychman, M. L. (2013). Vulvar and vaginal atrophy in postmenopausal women: findings from the REVIVE (REal Women's VIews of Treatment Options for Menopausal Vaginal ChangEs) survey. The journal of sexual medicine, 10(7), 1790-1799. 
Shen, J., Song, N., Williams, C. J., Brown, C. J., Yan, Z., Xu, C., & Forney, L. J. (2016). Effects of low dose estrogen therapy on the vaginal microbiomes of women with atrophic vaginitis. Scientific reports, 6.
Vaginal Atrophy. Retrieved June 27, 2016 from http://www.mayoclinic.org/diseases-conditions/vaginal-atrophy/home/ovc-20200167

Spending the past 5 years watching a lot of Disney Junior and reading Dr. Seuss, professional journal reading is generally reserved for the sanctuary of the bathroom. When patients ask if I’ve heard of certain new procedures or therapies, I try to sound intelligent and make a mental note to run a PubMed search on the topic when I get home. Making the effort to stay on top of research, however, makes you a more confident and competent clinician for the information-hungry patient and encourages physicians to respect you when it comes to discussing their patients.

A 2016 article in Translational Andrology and Urology, Lin et al., explored rehabilitation of men post radical prostatectomy on a deeper level, trying to prove that brain-derived neurotrophic factor (BDNF) promotes nerve regeneration. In many radical prostatectomies, even when the nerve-sparing approach is used, there is injury to the cavernous nerves, which course along the posterolateral portion of the prostate. Cavernous nerve injury can cause erectile dysfunction in 60.8-93% of males postoperatively. The authors discussed Schwann cells as being vital for maintaining integrity and function of peripheral nerves like the cavernous nerve. They hypothesized that BDNF, a member of the neurotrophin family that supports neuron survival and prevents neuronal death, activates the JAK/STAT (Janus kinase /signal transducer and activator of transcription) pathway in Schwann cells, thus facilitating axonal regeneration via secretion of cytokines (IL-6 and OSM-M). Through scientific experiment on a cellular level (please refer to the article for the specific details), the authors were able to confirm their hypothesis. Schwann cells do, in fact, produce cytokines that contribute to the regeneration of cavernous nerves.

From a different cellular perspective, Haahr et al., (2016) performed an open-label clinical trial involving intracavernous injection of “autologous adipose-derived regenerative cells” (ADRCs) in males experiencing erectile dysfunction (ED) after radical prostatectomy. Current treatments with PDE-5 inhibitors do not give satisfactory results, so the authors performed a human phase 1, single-arm trial to further the research behind the use of adipose-derived stem cells for ED. Some limitations included the study was un-blinded and had no control group. Seventeen males who had ED after radical prostatectomy 5-18 months prior to the study were followed for 6 months post intracavernosal transplantation. The primary outcome was safety/tolerance of stem cell treatment, and the secondary was improvement of ED. The single intracavernosal injection of freshly isolated autologous adipose-derived cells resulted in 8 of 17 men regaining erectile function for intercourse; however, the men who were not continent did not regain erectile function. The end results showed the procedure was safe and well-tolerated. There was a significant improvement in scores for the International Index of Erectile Function-5 (IIEF-5), suggesting this therapy may be a promising one for ED after radical prostatectomy.

In the clinic, we need to treat our patients to the best of our ability. Taking the Post-Prostatectomy Patient Rehabilitation course is vital if even just one patient enters your office seeking treatment. Keeping up on research (even that which seems too full of forgotten science) and learning new manual techniques and exercises can help us rise as clinicians prepared to optimize patients’ function.

Lin, G., Zhang, H., Sun, F., Lu, Z., Reed-Maldonado, A., Lee, Y.-C., … Lue, T. F. (2016). Brain-derived neurotrophic factor promotes nerve regeneration by activating the JAK/STAT pathway in Schwann cells. Translational Andrology and Urology, 5(2), 167–175. http://doi.org/10.21037/tau.2016.02.03
Haahr, M. K., Jensen, C. H., Toyserkani, N. M., Andersen, D. C., Damkier, P., Sørensen, J. A., … Sheikh, S. P. (2016). Safety and Potential Effect of a Single Intracavernous Injection of Autologous Adipose-Derived Regenerative Cells in Patients with Erectile Dysfunction Following Radical Prostatectomy: An Open-Label Phase I Clinical Trial. EBioMedicine, 5, 204–210. http://doi.org/10.1016/j.ebiom.2016.01.024

In case you’ve been under a rock (or maybe studying for the Pelvic Rehabilitation Provider Certification (PRPC) exam, the latest Netflix series starring Maria Bamford is out, and it is, as the kids say, amazeballs. We have Maria Bamford and team, and Lady Dynamite, to thank for getting the term vaginismus out in the public as the title of Season 1, Episode 8. The episode is named “A Vaginismus Miracle.” In this episode Maria is answering the question of when she last had sex. She answers that is was a year ago, which reminds her that the annual date of "Vaginismus" must be coming up. Maria further explains that she must have sex once per year because then everything is good "under the hood", and if she doesn't have sex once a year, her "vagina could close up." It's a nail biter of an episode as Maria's assistant has messed up the schedule, and Maria finds out that "Vaginismus" is that very night, and she must find a partner before midnight.

As a pelvic health provider, I knew that neither myself nor my colleagues would be able to sit back and worry about Maria suffering through another year with “Vaginismus” on her calendar, a looming deadline when we all know that with a little bit of rehabilitation, the issue could be much, much better, or maybe resolved altogether. The episode inspired me to write an open letter to Maria. Feel free to share and tag your friends who you think would love to watch a smart, funny show that puts real life issues including mental health in the spotlight.  

Dear Lady Dynamite,

I recently saw your Netflix show and I have to say that it is brilliant. I love how you weave humor, the messiness of life, and important topics into an unpredictable series of events. You are clearly one smart cookie, but I’m not convinced that your new agent, Karen Grisham, is such a great influence on you (or anyone for that matter). 

I wanted to reach out and let you know that, as a pelvic rehabilitation therapist and faculty member at the Herman & Wallace Pelvic Rehabilitation Institute, I really appreciate that you brought the term vaginismus into the big time. So many women suffer needlessly because there is so much that pelvic rehab can do for women like you! It does seem that you have figured out a system that works for you, but what if things hadn’t worked out with Scott that night? Hanging out in a bar hoping that you can find someone to hook up with is just so 80’s. Your condition of vaginismus, a tightening of the muscles around your Lady Dynamite parts, does often cause pain with sex, and that’s called dyspareunia. This is a condition that we pelvic rehab specialists treat every day with a heck of a lot of success. Your new boyfriend Scott (he is still your boyfriend after Thanksgiving and all, right?) could even help you overcome some tenderness and tightness by learning to help you release your vaginal muscle tension. Now if that doesn’t sound like great fodder for some stand-up I don’t know what does! 

It’s hard to know sometimes why vaginismus starts, maybe it was the years of freezing temperatures in Duluth that led to your  tight muscles, or sliding down Chester Bowl on the ice. Maybe it was spending too much time sitting in a wheelchair while medicated, or caused by medication itself (that happens too- even birth control pills can cause pelvic pain!) My point is, there’s no need to put so much pressure on yourself and have this horrible deadline of “vaginismus” hanging over your head when you can see a kind, smart health care provider about the issue. If you, dear Lady Dynamite, need a referral for a great pelvic rehab therapist in your neighborhood, let us know! We train hundreds of therapists every year, and can help you find the perfect fit (pun intended!) Ha! (We know you can handle a little “adult humor.”) Wishing you all the best, and thanks again for talking about your vagina! 

Yours in Pelvic Health,

Holly Tanner

P.S. Good luck with the Pussy Noodles representation! 

P.P.S Go ‘Toppers! 

P.P.P.S Can’t wait for Season 2!

P.P.P.P.S And if you see Mark McGrath around, say “hi” for me!

So, dear readers, if you would like to enjoy a smart and really funny show, check out Lady Dynamite. And if you want to learn more about vaginismus, Herman & Wallace offers several courses which would be up your alley. Consider joining faculty member Dee Hartmann, PT, DPT at Vulvodynia: Assessment and Treatment - Denver, CO this October 15-16.

Brady, P. & Hurwitz, M. (Creators). (2016). Lady Dynamite: Season 1, Episode 8. Retrieved from http://netflix.com

Yoga offers a compelling mind-body approach to maternal care that is forward thinking and aligns with the World Health Organization and Institute of Medicine’s recommendations for patient-centered care. But let’s take a look at WHY postpartum care MUST change in order to establish need for the entry of yoga into postpartum care.
 
Maternal Health Track Record
 
The United States and similarly developed countries have a very poor track record for postpartum care. The record is so poor that the problem in the US has been labeled a “human rights failure.”¹
 
On its own, the US has the worst track record for not only postpartum care, but for maternal and infant mortality and first-day infant death rate in the developed world (Save the Children 2013). Between 1999-2008, global mortality rates decreased by 34% while the US’s rates doubled for mothers.¹
 
Patient satisfaction also suffers under the current model of care, with many more mothers experiencing postpartum depression, a significant risk factor for both mother and baby during and after pregnancy.
 
The increase in mortality and poor outcomes can, in part, be attributed not to underuse, but overuse of medical intervention during pregnancy and birth. ^2,3,4  Countries that have “access to woman-centered care have fewer deaths and lower health care costs”; and, hospital system reviews in the US show that reducing medical interventions are both reducing cost and improving outcomes.^1,4,5
 
The notorious lack of accountability (reporting system) in maternal health care also plagues the US and suggests that maternal deaths are even higher than currently reported, leading to Coeytaux’s conclusion that the “United States is backsliding.”¹
 
Improving Postpartum Outcomes with Integrated Physical Therapy Care
 
In After the Baby’s Birth, maternal health advocate Robin Lim writes, 
"All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six-week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive, particularly to women suffering from painful physical and/or psychological disorders following childbirth."
 
Physical therapists can be instrumental change agents in improving current postpartum care, especially through the integration of contemplative sciences like yoga. Yoga can be the cornerstone of holistically-driven, person-centered care, especially in comorbid conditions such as pelvic pain and depression, where pharmacological side effects, stigma, can severely diminish adherence to biomedical interventions.⁶ Coeytaux, as well as other authors, clearly correlate the reduction of maternal mortality with improved postpartum care. The World Health Organization recommends that postpartum checkups should include screening for:

• Back pain
• Incontinence (stress)
• Hemorrhoids
• Constipation
• Fatigue
• Breast pain
• Perineal pain
• Depression
• Painful or difficult intercourse
• Headaches
• Bowel problems
• Dizziness or fainting

A physical therapist is a vital team member in not only screening for many of the
listed problems above, but in managing them. It is important to note that other countries, like France, deliver high quality postpartum rehab care plus in-home visits, all while spending far less than the US on maternal care.
 
The World Health Organization, however, clarifies the vital importance of postpartum care delivery by making a significant recommendation for a paradigm shift in biomedical care.⁷
 
Yoga as a “Best Care Practice” for Postpartum Care
 
The WHO recommends the use of a biopsychosocial model of care, which yoga is ideally suited to provide via its ancient, multi-faceted person-centered philosophy. Medical Therapeutic Yoga is a unique method of combining evidence-based rehabilitation with yoga to emerge with a new paradigm of practice. MTY:
 

• Addresses the mother as a person, not as a condition or diagnosis.
• Empowers mothers with self-care strategies for systems-based, not just musculoskeletal or neuromuscular, change.
• Addresses all domains of biopsychosocial impairment.
• Teaches interdisciplinary partnership-based theory, which is integral to creative collaborative discourse and innovation in postpartum care.
• Equips clinicians with business service, website development, practice paradigm, and social media campaign tools to fully develop the new clinical niche of Professional Yoga Therapy practice. 
• Promotes patient advocacy, health promotion, and public health education via mainstreaming yoga into rehabilitative and medical services.
• Provides the gender context for prescription that traditional yoga is lacking.
• Evolves yoga for use in prenatal and postpartum care.

 
Physical therapy screening and intervention in the postpartum is vital, but the addition of yoga can optimize postpartum care and has enormous potential to be a “Best Care Practice” for postpartum care in rehabilitation. 
 
As a mind-body intervention, yoga during pregnancy can increase birth weight, shorten labor, decrease pre-term birth, decrease instrument-assisted birth, reduce perceived pain, stress, anxiety sleep disturbances, and general pregnancy-related discomfort and quality of life physical domains.^8-9
 
In addition to the typical physical therapy intervention for postpartum physical therapy, the MTY paradigm provides:

• self-care strategies for psychoemotional health and social engagement, increasing self-efficacy, confidence, and self-worth,
• a concise container for clinical-decision through its algorithmic programming,
• psychoemotional and neuroendocrine intervention,
• nutritional counseling  and resource utilization,
• energetic adjunct therapies steeped in Ayurvedic science,
• executive functioning and cognitive support,
• epigenetic effect, and
• inter- and intrarelational development.

 
Postpartum integrated physical therapy care can provide more comprehensive care than rehab alone because of its multi-faceted biopsychosocial structure and systems-based model of care. Ginger’s course, Yoga as Medicine for Labor, Delivery, and Postpartum provides evidence-based methodology for prenatal and postpartum practice that streamlines clinical decision-making and intervention through introduction of a yogic model of assessment.
 
To learn more about Ginger’s course, visit Yoga as Medicine for Labor, Delivery, and Postpartum

Coeytauz et al., Maternal Mortality in the US: A Human Rights Failure. Contraception Editorial, March 2011. http://www.arhp.org/publications-and-resources/contraception-journal/march-2011
Kuklina E, Meikle S, Jamieson D, et al. Severe obstetric morbidity in the US, 1998–2005. Obstet Gynecol. 2009;113:293–299.
Tita ATN, Landon MB, Spong CY, et al. Timing of elective cesarean delivery at term and neonatal outcomes. NEJM. 2009;360:111–120.
Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:e1–105.e7.Abstract | Full Text | Full-Text PDF (100 KB)
Oshiro BT. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009;113:804–811.
Buttner, M. M., Brock, R. L., O'Hara, M. W., & Stuart, S. (2015). Efficacy of yoga for depressed postpartum women: A randomized controlled trial. Complementary Therapies in Clinical Practice, 21(2), 94-100. doi:10.1016/j.ctcp.2015.03.003 [doi]
WORLD HEALTH ORGANIZATION., 2002. Towards a common language for functioning, disability and health : ICF. Geneva: World Health Organisation.
Curtis, K., Weinrib, A., & Katz, J. (2012). Systematic review of yoga for pregnant women: Current status and future directions. Evidence-Based Complementary and Alternative Medicine : ECAM, 2012, 715942. doi:10.1155/2012/715942 [doi]
Sharma, M., & Branscum, P. (2015). Yoga interventions in pregnancy: A qualitative review. Journal of Alternative and Complementary Medicine (New York, N.Y.), 21(4), 208-216. doi:10.1089/acm.2014.0033 [doi]

Danielle is among the latest class of Certified Pelvic Rehabilitation Practitioners! Her experience treating patients and owning Core 3 Physical Therapy prepared her to pass the exam in flying colors. Read her bio here and check out our interview below. Congratulations, Danielle!

What/who inspired you to become involved in pelvic rehabilitation?
A patient was the first one to inspire me to improve my knowledge and treatment abilities in pelvic rehabilitation. I was working with a postpartum patient, while carrying my first child, and she felt that my guidance had been so helpful in her care that it made me interested learning more about the pelvic floor. Most of my fellow colleagues could discuss my orthopedic questions but I didn’t have any mentors that could offer advice in more advanced pelvic floor cases so I started attending the Herman and Wallace classes. They have been an invaluable at improving my ability to care for patients with pelvic pain which has even improved my treatment of orthopedic patients with low back pain and sacroiliac dysfunction.

What patient population do you find most rewarding in treating and why?
I enjoy working with chronic pelvic pain patients because it's rewarding to be able to bring relief to someone who has been living with pain, limited quality of life or even social anxiety and has not received any benefit with other treatment options. Being able to help this patient population understand the pelvic floor muscles and function as well as providing justification to why they are in pain and then help them progress through various treatment approaches makes my job rewarding.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
PT's are uniquely trained to provided internal pelvic floor muscle release. This is something that no other health care professional is licensed or has the schedule/time to perform. This technique can provide relief and feedback to your patients that is possible in no other way. If you do not want to address this region or feel comfortable providing this treatment, find a therapist local to you who has experience with pelvic floor and refer when appropriate. Additionally, we as physical therapists are often the first line of defense in recognizing and educating patients about the ability to address a wide variety of symptoms that they believe is "just a normal part of life". Asking the in-depth questions and providing a multimodal approach to their symptoms is not only a boon to the patient but to our profession.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
"Your most valuable tool is your finger." It is rare to treat an orthopedic patient without incorporating any hands on approach and the same holds true for the pelvic floor. With an internal exam you can make your most accurate assessment while providing valuable feedback to the patient.

What makes you the most proud to have earned PRPC?
I think it has helped me gain respect with my fellow health care professionals for my expertise in the area of pelvic floor treatment. It has broadened my knowledge base and provided me a strong guide for furthering my ability to treat patients with pelvic pain and dysfunction.

What is in store for you in the future?
I would like to become involved in research to further evidence based evaluation and treatment of pelvic conditions. I hope to facilitate the effectiveness and value in pelvic floor rehabilitation via physical therapy.

What role do you see pelvic health playing in general well-being?
It should become a staple for all pelvic floor surgeries just like a physical therapy is the staple post total knee surgery. Currently in my region I find it very underutilized despite the research behind our treatment. This is largely due to the general population not being aware of the treatment benefits physical therapy can play in pelvic dysfunction. European countries make it a standard of care in this area and I hope we progress to adopt a similar view of treatment.

More than a year ago, after working on updating the pelvic floor series courses PF1, 2A and 2B, the Institute turned our attention to the final course in our popular series, PF3. To determine what content our participants wanted to learn about in the last continuing education course of the series, we asked that exact question. From a large survey of therapists who had taken all or most of the courses in the pelvic core series, we collected detailed data from therapists about what was needed to round out their comprehensive training. The results of that survey guided hundreds (and hundreds!) of hours of work completed by a team of instructors. This month, in the beautiful city of Denver, the three instructors who created the Capstone course will share their wisdom, clinical experiences, as well as their thoughtfully-designed lectures and labs. You will have an opportunity to learn in depth about topics covered in the prior courses in the series. 

Such topics include lifespan issues and health issues common to different ages, conditions of polycystic ovarian syndrome, endometriosis, infertility, pelvic organ prolapse and surgeries, pelvic fascial anatomy, pharmacology and nutrition. Lab components are detailed and comprehensive for working with specific common implications from conditions in pelvic dysfunction or surgery. This course focuses on the female pelvis, including diving into the complexities of female pelvic health issues. The instructors have all worked in the field for many years, are experienced in working with complex patient presentations, and all excel at manual therapies. I asked each of them to briefly share thoughts about the Capstone course that they each dedicated the last year in developing; following you can read their thoughts.

Nari Clemons

"I'm excited for every therapist who will take this course, as it is made to help you approach your practice at a whole new level.  We are eager to help your hands work dynamically with more intelligence and how to tackle complex restrictions in the pelvis and abdomen that go far beyond releasing muscles.  Additionally, the practitioners will raise their capacity of recognizing and helping the patient manage complex conditions, such as endometriosis, PCOS, fibroids, and IBS." 

Allison Ariail

"One of the best things about the Capstone course is that it provides the participants tools to treat more complicated patients. Topics such as endocrinology, oncology, vulvar dermatology, and surgical procedures are addressed, which will complete the picture for some of those patients that are hard to treat due to the complexity of their case. This knowledge, along with more advanced manual treatment techniques, will add to the skill set of the participants to improve their treatment outcomes. I am excited for the participants to combine their current clinical skills along with some new knowledge and techniques to be able to treat the whole person when working with complex and challenging patients." 

Jennifer van de Vegte

"Designing and creating Capstone with Nari and Allison was an incredible experience. My own knowledge and clinical expertise grew profoundly while researching and writing this material. Capstone is designed to really take the experienced pelvic health therapist to the next level of understanding and treating more complex patients. I can't wait to see the impact this material has on participants and their patients."

There is still time to register for the few remaining seats in Denver this weekend!