This November, Herman & Wallace is thrilled to be offering a brand-new course instructed by Carolyn McManus, PT, MS, MA, called Mindfulness-Based Biopsychosocial Approach to Chronic Pain. This course will be offered November 15-16, 2014 in Seattle, WA. We sat down with Carolyn to learn more about her course.

What inspired you to create this course?

I want to improve the lives of people with chronic pain and help my colleagues be successful in providing care to this often challenging patient population. With my academic training in both PT and psychology, my longstanding mindfulness meditation practice and over 25 years specializing in the care of people with chronic pain, I have a wealth of information and a wide range of practical skills to share with my colleagues.

Among my co-workers at Swedish Medical Center, I learned that those who liked working with patients with persistent pain felt they had something to offer that would help. Those who did not like this patient population felt there was nothing they could do to make a difference in the lives of these patients. I want physical therapists to have the skills and confidence to make a difference and improve the lives of people with chronic pain. I want others to know the same feeling of reward I feel when I have made that difference.

I have had colleagues comment to me that although they understand the basic principles of chronic pain, they do not feel confident to explain pain to patients or talk about the role of stress, cognitions and emotions in amplifying pain. I want to give my colleagues the language to do just that. I do not mean stepping beyond our comfort zone or scope of practice, but rather to offer patients a basic framework for the mind body relationship, based in neuroscience, that can change a patient’s attitude and belief system about pain.

I also want to introduce my colleagues to mindfulness. Mindfulness is the ability to rest the mind in the present moment with an open, friendly, curious attitude. This skillful way to pay attention has made an enormous difference in my personal and professional life and in my patient’s lives. Although it takes years of training to teach mindfulness meditation, any healthcare provider can draw on the basic principles of mindfulness to support a patient’s well being and healing.

What resources and research were used when writing this course?

I track the pain literature closely and am especially interested in how the brain changes with chronic pain and the role of stress, emotions and cognitive variables in contributing to chronic pain conditions. PTs are highly skilled to address the nociceptive component of a patient’s pain complaints. As our understanding of chronic pain has broadened to include principles of central sensitization, structural and functional brain changes and the cognitive modulation of nociceptive input, we need to have the training and skills to address these multiple and complex components that give rise to chronic pain conditions. I draw from literature in physical therapy, pain, psychology and mindfulness meditation.

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

If you ever feel overwhelmed, frustrated or challenged by patients with persistent pain conditions, this is the course for you. You will learn the about the exciting new science of pain, the amazing ways stress and cognitive modulation impacts the pain system, and how to apply mindfulness to help manage your own stress during your workday. In addition, you will be able to explain pain, the role of stress in amplifying pain, the mind-body connection and mindfulness to your patients to help empower them to maximize what they can do for themselves to promote healing and well being.

Want to learn more from Carolyn? Join us in November in Seattle!

This blog was written by Carolyn McManus, PT, MS, MA, who will be presenting at the APTA's Virtual NEXT conference in North Carolina. Carolyn is instructing a new course with Mindfulness-Based Biopsychosocial Approach to Chronic Pain. This course will be offered November 15-16, 2014 in Seattle, WA.

Last fall, I was honored to receive an invitation from the APTA’s National Conference team to contribute to this year’s Virtual NEXT programming. Virtual NEXT offers live and on-demand streaming of annual conference's signature lectures and select educational sessions, worth up to 1.6 CEUs. New this year, you can purchase presentations individually. For the price of one registration, you and your colleagues can get together and be part of a worldwide Virtual NEXT viewing party!

The title of my presentation, to be delivered on Thursday, June 12th, is “The Pain Puzzle: Empowering Your Patients to Put the Pieces Together.” I will highlight basic chronic pain neurophysiology, and briefly discuss the brain in chronic pain, stress-induced hyperalgesia and the cognitive modulation of pain. I will describe how this current evidence affects our clinical practice and suggest evidence-based treatment strategies. These will include therapeutic pain neurophysiology education and mindful awareness training. I will close with a case study that demonstrates how our treatment choices must be based on an understanding of underlying pain generating mechanisms in order to achieve success with this complex patient population.

If you cannot join me in Charlotte, North Carolina for APTA’s NEXT conference, I hope you can make an online date! For more information, go to the APTA’s NEXT Conference website:

Want to learn more from Carolyn? Join us in November in Seattle!

This post was written by H&W instructor Lila Abbate PT, DPT, MS, OCS. Lila will be instructing the course that she wrote on "Coccyx Pain" in New Hampshire in September.

“Sit up tall, stand up straight” were comments we heard from our teachers and our caregivers. Do you find that you are saying that now to your patients? Postural correction can go beyond just preventing neck and low back pain. For a women’s health therapist, improved posture may help our patients prevent uterine prolapse or reduce coccyx pain.

Lind, Lucente and Kohn published a study back in 1996 titled Thoracic Kyphosis and the Prevalence of Advanced Uterine Prolapse. They determined that, in patients with uterine prolapse, the degree of thoracic kyphosis was about 13 degrees higher than in the 48 matched controls.¹ Hodges, in the chapter titled “Chronic Low Back and Coccygeal Pain” in Clinical Reasoning for Manual Therapists, presents a case of a 39 year old woman with poor posture who has reproducible coccygeal pain, despite a coccygectomy, with palpation of her L4 segment. This poor posture perpetuates nerve and muscle dysfunction along with decreased and inappropriate muscle firing patterns that have created this long-term condition.

Whether our patients present with pelvic organ prolapse, chronic low back or coccygeal pain, it is important to step back and look at their overall posture. Decreasing thoracic kyphosis, or improving thoracic mobility, can help change an entire system. If you are looking for a course that takes you back to the basics and then enhances it with a twist of advanced techniques think about taking the Institute’s 2-day Coccydynia course.

References:

1. Lind LR, Lucente V, Kohn N. Thoracic Kyphosis and the Prevenlence of Advanced Uterine Prolapse. Obstet Gynecol. 1996 Apr; 84 (4): 605-609.

2. Hodges P. Clinical Reasoning for Manual Therapists, Chapter 7, Chronic Low Back and Coccygeal Pain. Elsevier.2004; 103-122.

In a recently published study, an anti-inflammatory diet (AID) for inflammatory bowel disease (IBD) was offered to 40 patients as an adjunctive regimen. Retrospective medical chart review was utilized to assess dietary adherence and outcomes. Of the 40 patients who were offered the program, 13 patients did not attempt the diet. Of the remaining 27 patients who did attempt the AID, 24 of them had a good or very good response, 3 of them had a "mixed" response. After following the diet, all patients were able to discontinue 1 or more IBD medications, and all patients reported decreased symptoms such as improved bowel frequency. Interestingly, of the 3 patients who had an ambivalent or negative response to the AID, 2 of them were diagnosed with C-difficile, a very challenging condition to resolve.

Inflammatory bowel disease can include the diagnoses of Chrohn's disease and ulcerative colitis, and each are characterized by periods of relapse. Patients are often reliant upon medications such as corticosteroids or immunomodulators during flare-ups, and surgical interventions including colectomy. As medical theories have evolved, the authors of this study point out that the gut microbiome is believed to play an importnant role in IBD, and therefore treatments directed at improving intestinal microbiome have increased.

The IBD anti-inflammatory diet (AID) includes lean meats, poultry, fish, omega-3 eggs, particular carbohydrates, specified fruits and vegetables, flours from nuts and legumes, a few limited cheeses, cultured yogurt, kefir, miso and other foods rich in certain probiotics, and honey. Bananas, oats, blended chicory root, and flax meal are also included. Additional suggestions are given based on the acuity of patient symptoms such as pureeing food or avoiding food with seeds. The diet is detailed into "phases" that progress from Phase I+ to Phase IV, to be followed when the patient is in remission and without dietary restrictions.

As this study is a case series, the authors are hesitant to extrapolate findings beyond stating that "some of our patients with inflammatory bowel disease can benefit.." from an anti-inflammatory diet, with respect to decreased symptoms and a resultant decrease in medication usage. In the study, patients were primarily seen by a nutritionist. As the mechanism for the improvement noted with an AID is still theorized but not known, the article describes different proposed mechanisms for improved symptoms, such as changes in the gut flora, or gut mucosal healing due to decreased irritants.

As pelvic rehabilitation providers, we have a responsibility, not to counsel our patients in detailed nutritional regiments aimed at curing disease, but in educating our patients about the potential benefits of nutritional counseling and attention to diet. Many patients are not offered nutritional counseling, or need support in order to initiate or maintain dietary changes. We can play an important role in guiding our patients to help and in supporting them in their efforts to make lasting changes. If you find that you are working with more patients who have bowel dysfunction, and wish to increase your knowledge beyond the PF2A course, you still have time to register for the Bowel Pathology and Function course, taking place in June in Minneapolis, which addresses many factors specific to bowel health and pelvic rehabilitation approaches.

Prostate removal via open, laparoscopic or robotic surgical techniques has been a treatment of choice for patients with prostate cancer. Historically, patients have been keen to inquire about "nerve-sparing" procedures for prostatectomy with a goal of reducing erectile dysfunction or urinary incontinence, two common unwanted side effects of prostate surgery. Research published in Prostate International journal proposes that exquisite knowledge of fascial anatomy is a key to minimizing negative impact from surgery caused by damage to the prostatic neurovascular bundles. The authors in this paper point out that anatomical controversy exists in the literature and that the anatomy is still being investigated, increasing the surgical challenge for those physicians who aim to identify the structures.

The pelvic organs are covered by pelvic, also called endopelvic, fascia, that is commonly divided into two layers: that which covers the viscera (wrapping around each organ structure and the parietal component which covers the medial levator ani, obturator internus, and piriformis. Access to the prostate gland is gained by an anterolateral incision through the endopelvic fascia at the fusion of the visceral and parietal fascia, according to the article. Layers of prostatic fascia and the endopelvic fascia attach laterally at the tendinous arch of the pelvic fascia, and these structures attach to the puboprostatic ligaments. The puboprostatic ligaments anchor the prostate to the pubic bone, creating an important aspect of continence through fascial tension and support.

While nerve-sparing techniques have focused on preserving pelvic plexus autonomic nerve fibers, the authors argue that there is not a definite anatomy of the periprostatic nerve fibers, possibly contributing to the variability in surgical outcomes reporting for nerve-sparing procedures. Various approaches have been detailed in the literature, and are described in this article, with emphasis on dissection plane and intra- and interfascial techniques utilized.

This is a full access article with images and details beyond what most pelvic rehabilitation providers need. What is of great interest across professions is the recognized need for acute anatomical knowledge with application of skilled techniques with such anatomy in mind. The authors conclude that "…the relation of the periprostatic fascial layers on the anterior, lateral, and posterior sides of the prostate should be of great interest. A better understanding of the relation between nerve fibers and pelvic fascial layers is crucial…" Most of us were never introduced to detailed pelvic anatomy, male or female, in school. To learn more about male pelvic anatomy, you can attend either the pelvic floor series course that introduces male pelvic health, called PF2A, offered in October in St. Louis- this is the only PF2A with open seats this year. You can also attend the Male Course, offered again this year in October in Tampa.

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Michele Syska, PT, PRPC

Describe Your Clinic:

Orthopedic manual based.  I love figuring out how mechanical issues may be affecting the current presentation.   I would also characterize my practice as open.  I’m up for trying new ideas either from course work, other therapists or patients.  I enjoy learning from the experience of others and have an open mind to many techniques.

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

I spoke with the therapist who had started the program at my clinic.  She helped to bring knowledge and understanding to the world of pelvic floor dysfunction.  She helped me gain motivation to attend my first course.  Upon attending Herman and Wallace level 1, I can truly say that it was Holly and Kathe’s unique and passionate teaching that solidified my decision.

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

Male chronic pelvic pain.  For the most part, women are used to the medical profession “messing” with them.  After having several paps and babies, most women don’t arrive with the embarrassment and anxiety that more often is associated with male pelvic pain.  It’s rewarding to be able to bring comfort and relief to these patients through education and understanding.  The progression from start to finish is typically more dramatic in the way they improve their overall comfort in talking about the dysfunction and the re-integration into their work and social lives.

What Role do you See Pelvic Rehab Playing in Overall Patient Health?

One’s ability to be continent, have normal sexual function and go through their day without pain, play a large role in general well-being.  Looking for a restroom at every turn does not make for a very pleasant day.  An unhealthy pelvic floor can be extremely debilitating.  It can get in the way of basic daily activities and significantly affect ones social and work life.

Learn more about Michelle Syska, PT, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also read more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

This post was written by H&W instructor, Ginger Garner, PT, MPT, ATC, PYT, who teaches the Yoga as Medicine for Pregnancy and Labor & Delivery and Postpartum courses, and is teaching her brand new course, Extra-Articular Pelvic and Hip Labrum Injury, in June in Akron, OH.

Research into the surgical and nonsurgical management of acetebaular labral tears is young, but growing fast. Physical therapy is considered an integral part of nonoperative management of acetabular labral tears, with a trial of therapy also serving as the newest standard in preoperative and postoperative care. Conservative care becomes even more important in young dancers.

A critical concern in all individuals is hip joint preservation and prevention of premature joint degeneration and development of osteoarthritis. Especially in young females, who start with a higher risk of labral tears, sports like figure skating, dancing, and gymnastics further increase risk and prevalence of tears.

There are several reasons young women can experience a labral tear, but in general the etiology will fall under five possible categories: 1) congenital, 2) traumatic, 3) degenerative (far less likely with a young population), 4) capsular laxity, and/or 5) idiopathic causes such as femoral acetabular impingement. There are many more causes that fall under each category, but early intervention is repeatedly found in the literature to be perhaps the most important variable in long-term hip joint preservation and outcomes. Duke University physical therapist and orthopaedic surgeon, Michael Reiman and Chad Mather, respectively, authored a 2014 article with colleagues from Ohio that outlines the five major etiological categories, discussing the increasing prevalence of labral tears in high-risk populations and underscoring the need for early intervention. Citing diagnosis of labral tears as “continuously challenging”, the article emphasizes that a battery of tests and screening, rather than a single diagnostic viewpoint, are requisite in identifying an acetabular labral tear.

For young dancers, early intervention is of utmost importance. A case study currently in press (April 2014) reports success with a 12-year-old skeletally immature figure skater with a diagnosis made within the first month of the onset of pain and impairment. A six-week trial of physical therapy began immediately on consensus of three pediatric orthopaedic surgeons specializing in arthroscopic management of the acetabular hip labrum. At the 4-week follow-up, progress in PT was being objectively made with pain levels diminishing and functional performance improving (with no return to skating yet). After a continuation of therapy for an additional 6 weeks, the figure skater was able to return to skating and perform single jumps and double Lutz at 75% of her normal jump height without pain. At that time, PT was decreased to 1x/day weekly while continuing her normal home therapy program. After another month of therapy, she returned to her full training schedule. At the four-month visit she had returned to full competition with full spins and jumps (double axels) without pain. The one-year follow-up found the young patient pain-free and competing at local and national competitions.

The importance of physical therapy cannot be underestimated in young athletes, especially females, due to their inherently increased risk of labral injury. Further, multiple studies cite the importance of a multi-disciplinary, integrated approach in managing the hip labrum.

My Hip Labrum Injury course will focus on this biopsychosocial and integrated approach, including both conventional and integrative techniques in order to obtain the best outcomes for patients.

You can read some of my previous posts on evaluating risk and prevalence of hip labral injury:

• Lady Gaga’s Hip Labral Tear: Are you at Risk?

• The Postpartum Hip and Labral Tear Risk

• The Importance of Early Intervention in Labral Tears

• Implicating the Iliopsoas in Acetabular Labral Tears: Focus on Anatomy

Want to learn more from Ginger? Join us in June!

This post was written by H&W instructor Lila Abbate PT, DPT, MS, OCS. Lila will be instructing Pelvic Floor Level 3 with Institute founder Holly Herman in San Diego at the end of this month! Sign up for the few remaining seats left in this popular course!

When treating your patient who has undergone a pelvic reconstruction in the not-so-distant past, does the mesh controversy come to your mind?Is the effect of the mesh causing your patient this dysfunction and is she complaining of urinary urgency, urinary frequency, or pelvic pain? Understanding pelvic muscle dysfunction, as pelvic rehabilitation providers do, can put us in a good position to help our patients, as well as to help our physicians with this oftentimes litigious issue.

Urogynecologists, gynecologists, urologists, or any surgeon who deals in the business of female sexual medicine and pelvic reconstruction seems to have been put in a position to defend their stance on the use of mesh when working with patients who present with any degree of pelvic organ prolapse (POP), be it complicated or simple.The decision to utilize mesh is now made with greater emphasis on education for the patient who is undergoing the procedure.

The Food and Drug Adminstration (FDA) has released a proposal on April 29, 2014 in order to address the potential reclassification of surgical mesh for transvaginal POP from a class II (moderate risk) to a class III (high risk) device and would “require manufacturers to submit a premarket approval (PMA) application for the agency to evaluate safety and effectiveness.” ¹ A similar proposal was put in place with breast implants in 1992 in order to create more awareness of safety concerns with the use of breast implants. ²

While older mesh kits (demonstrated to be more likely to cause complications) have been pulled from the market, any mesh surgery can create complications. As the body heals, scar tissue forms and contracts which is part of the normal healing process, and for some patients, this process can wreak havoc as the tissues and the mesh shrink. Muscles are bypassed, pressed upon, and ligaments are used as supportive measures for the mesh arms, and this can set up the pelvic floor muscles for edema, weakness, or even muscle over-activity. We know that different patients heal in different ways; just as a patient who has had a total hip replacement experiences muscle swelling, soreness, weakness, and scarring, a mesh surgery will necessarily create temporary dysfunction. However, physical therapists are skilled and well-versed in palpating and treating muscle dysfunction, scar tissue and adhesions, and we can educate our patients on the symptoms of mesh complication that may in fact be a muscle problem. Not every patient who has had mesh placement is suffering from mesh erosion, and physical therapists can help patients improve or resolve their symptoms over time through treatment.

Pelvic Floor Level 3 is an advanced course offered by the Institute that covers surgical procedures, pharmacology including hormone replacement, and other medical interventions that address pelvic muscle over-activity, tissue dysfunction, and surgical complications. Lab activities include manual techniques to downtrain (decrease muscle over-activity) such as Strain-Counterstrain of the pelvic floor muscles.

1.http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm395192.htm. Accessed on May 5, 2014.

2. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/ImplantsandProsthetics/BreastImplants/ucm064461.htm. Accessed on May 5, 2014.

During a pelvic muscle assessment, patients who have pelvic pain or other dysfunction that includes pelvic floor muscle tenderness will often ask the pelvic rehabilitation practitioner the following question: "Doesn't everyone have tenderness if you push on the muscles like that?" The answer should be "no," and we have research to support this claim. While it may seem incredibly simple to a pelvic rehabilitation provider that a "healthy muscle does not hurt" and that in order to optimize muscle function, the length-tension curve should be optimized, this knowledge is not universally understood by most patients. Tenderness, especially if severe or if the intensity of the discomfort inhibits a healthy muscle contraction, can be eased so that a patient can learn to appropriately contract and relax the pelvic floor muscles.

While logical to rehabilitation providers, the concept that healthy muscles are typically devoid of significant tenderness must be well-established if we wish patients, providers, and payor sources to join in our belief that diminishing such tenderness can be a marker of progress. (Of course we keep in mind that function trumps tenderness, especially when a person has no functional limitations despite presenting with muscle tension or tenderness.) Researchers have aided our profession in establishing that significant muscle tenderness is not present in young, healthy, asymptomatic patients.

In research published last year, Kavvadias and colleagues assessed pelvic floor muscle tenderness in 17 asymptomatic, nulliparous female volunteers (mean age 21.5 years with results indicating low overall pain scores. The authors also aimed to examine inter-rater and test-retest reliability of specific muscle tenderness testing using a visual analog scale (VAS) and a muscle examination method recommended by the International Continence Society (ICS) over 2 testing sessions. This study used a cut-off score of 3 or less on the 0-10 VAS to determine clinically non-significant pain. Inter-rater and test-retest reliability was reported as good to excellent for palpation to the posterior levator ani, obturator internus, piriformis muscle, and for pelvic muscle contraction, yet found to be poor to fair for pelvic floor muscle tone and anterior levator ani palpation. Resulting scores on the VAS were less than 3 for all muscles tested, leading the investigators to conclude that in nulliparous women aged 18-30 who have no lower urinary tract (LUT) symptoms or history of back or pelvic pain, tenderness "…should be considered an uncommon finding."

While this research is in moderate contrast to some research cited in the report, the authors point out that the exclusion criteria and the ages of the women were more narrow in their studied population. Other authors such as Montenegro et al. (2010) have also reported a low prevalence of pelvic muscle tenderness in healthy volunteers (4.2%) whereas Tu et al. reported a high prevalence of tenderness (75%) in women who present with chronic pelvic pain. For male patients, Hetrick et al. concluded that patients with chronic pelvic pain syndrome, or CPPS, have more pain and tension in pelvic and abdominal muscles than men without pain.

The value of research that establishes markers of health in tissues relating to function cannot be underestimated within the realm of pelvic rehabilitation. If we propose or document that reducing tender points, tension and muscle dysfunction is valuable for our patients, research that creates a baseline of non tenderness in patient populations is needed. The research from Kavvadias and colleagues assists our cause, as we can put this information together with other valuable modes of intervention to address pelvic muscle dysfunction within a holistic model of care. If you are interested in discussing further research about pelvic muscle tension, tenderness, and muscle releases, check out faculty member Ramona Horton's Myofascial Release for Pelvic Dysfunction, taking place next in Dayton, Ohio, this June.

How the concepts of stigma and taboos affect bowel function is the focus of a recent article by Chelvanayagam, a lecturer in mental health in England. The author establishes that previously taboo subjects are becoming less hidden in the media, such as sexual function or urinary incontinence, but that in the UK, bowel function is still considered taboo. When people are not given language and social permission to discuss health concerns, conditions go underreported or unrecognized and under treated.

The author points out that patients with bowel dysfunction such as irritable bowel disease, fecal incontinence, and stomas feel stigmatized and are hesitant to discuss concerns with heath care providers or loved ones. The social implications of bowel disorders can lead to socially isolating behaviors including difficulty going out to eat, participating in physical activities, or taking sick leave from work.

Because pelvic rehabilitation providers discuss intimate issues including bowel function with patients, communication skills are very important in order to allow the patient to feel comfortable about the topic. Both verbal and non-verbal techniques will be observed and responded to by the patient. Various stigma-reducing strategies are described in the article. At the interpersonal level, cognitive-behavioral and empowerment strategies are recommended, and at the community level, education and advocacy are listed. Each of these strategies are ones that the pelvic rehabilitation provider is capable of providing.

If you have been wanting to learn more about bowel dysfunction and pelvic rehabilitation, the Institute added to our offeringsa bowel course that is next offered in June in Minneapolis, and November in Los Angeles area.