Herman & Wallace Pelvic Rehabilitation Institute would like to express thanks to the following therapists who participated in the development of our new certification, the Pelvic Rehabilitation Provider Certification, or PRPC. There were many stages of development in the rigorous process required to create a certification. Expertise was needed to provide input about examination content, format, and scope. Item writers were needed to create the 450 items needed for our test bank. Teams of reviewers volunteered time to revise items prior to the first exam offering, and raters spent many hours in team web conferences following the exam so that a cut score could be created.

Each of the following therapists contributed in some way to this process, and we are grateful for their time and expertise. (If I have forgotten to list anyone, let me know- we want to give credit where credit is due!) The PRPC is the only certification available that recognizes pelvic rehabilitation providers treating men and women across the lifespan. Congratulations to the first group of PRPC!

Dustienne Miller

Allison Ariail

Peter Philip

Karen Vande Vegte

Elizabeth Hampton

Lila Abbate

Holly Tanner

Nari Clemons

Heather Rader

Deanna Dreier

Joyce Steele

Michelle Lyons

Susannah Haarmann

Christine Cabelka

Brandi Kirk

Sagira Vora

Teri Elliott-Burke

Holly Herman

Pamela Downey

Genne DeHenau-McDonald

Tina Tyndall

Rachel Kilgore

Tina Allen

Kristina VanNiel

Megan Kranenburg

Rachel Brandt

In our blog, we have highlighted the importance of recognizing and screening for postpartum depression. What relationships exist between a person's posture and depression in the postpartum period? Prior research reporting on four studies of posture (Riskind & Gotay, 1982) noted that subjects placed in a slumped physical posture appeared to develop helplessness more easily than those placed in an upright posture. These authors also stated that physical posture was a valuable clue for an observer who attempted to identify states of depression. Results of the fourth study include that "…subjects who were placed in a hunched, threatened physical posture verbally reported self-perceptions of greater stress than subjects who were placed in a relaxed position."

A recent study addressed depression, back pain and postural alignment in eighty women between 2 and 30 weeks postpartum. Depressive symptoms were measured with the Edinburgh Postnatal Depression Scale (EPDS). Pain scales included a visual analog scale (VAS) and the Nordic Musculoskeletal Questionnaire (NMQ while posture was assessed with visual observation. Findings of the study include that VAS pain scores were elevated in the women who were depressed. Back pain intensity and postpartum depression were also strongly associated. The authors suggest that back pain may be a risk factor for postpartum depression as well as a comorbidity. The article further states that physical therapists "…should be prepared to identify depressive symptoms as a comorbidity associated with posture changes and recurrent symptoms, signs of remission and recurrence that generate difficulties for treatment progression."

Can we look at this issue as a chicken and egg discussion, as in, is poor posture causativeto depression, or vice versa? And,if smiling has been determined to have the ability to improve happiness, can improved posture positively affect symptoms of depression? We know that postural dysfunction and pain can be a vicious cycle in our patients. Is screening for depression an equally important aspect of postural correction? Could postural taping, support, or re-training positively affect postpartum depression, and if so, should we be assessing and re-assessing our patients for depression as a means to document therapy benefits? The fun thing about reading research results is that the studies often lead to more questions, further hypotheses, and curiosity in relationship to how we interact with our patients. Can patients understand the relationship between postural correction and emotional health? Sounds like an opportunity for more research, and for dialoging with our patients!

If you are interested in learning more about postpartum health, click here for more information about the second course in our Peripartum series, Care of the Postpartum Patient. The next opportunities to take this class are June in Houston, and Chicago in September!

A qualitative study based in patient interview aimed to identify the reasons that survivors of gynecologic cancer do not seek help for pelvic floor dysfunction (PFD). Interviews of 15 patients by a medical provider asked both open-ended questions and provided a list of reasons why a patient may not seek care for PFD. (These reasons were compiled by the researchers based on clinical experience and on literature reviews.) Reasons for not seeking care for PFD were separated into four categories: that the pelvic floor symptoms in comparison to cancer diagnosis seemed bearable, the specialists did not make any recommendations about the PFD, the patient did not want to go to the doctor or hospital, and the patient or provider was unaware of treatment options. Of the women included in this study, cancer diagnoses included cancer of the cervix, endometrium, and vulva, and types of pelvic floor dysfunction included urinary and/or fecal incontinence, overactive bladder, constipation, painful bladder, or obstructed voiding.

One of the primary reasons women did not seek care for PFD was lack of knowledge about potential treatments. Another frequent statement from the 15 women interviewed is that the pelvic floor symptoms, when compared to dealing with cancer, were "bearable." The authors in this research suggest that the medical community needs to consistently give attention to PFD following cancer treatment. In addition to screening for PFD, the medical community should provide "…timely referral to pelvic floor specialists."

In regards to the first category of reasons for not seeking referral, women made statements such as feeling "lucky" to only have PFD rather than the cancer, or that the PFD symptoms were not as severe as other symptoms related to cancer diagnosis and treatment. Other women reported that they had symptoms prior to cancer treatment and were "used to them." Reasons women reported for not wanting to visit the doctor or hospital included fear that the symptoms meant that the cancer had returned or that the symptoms were too embarrassing. When discussing the lack of awareness about treatment for PFD, some women assumed that the physician would have referred for treatment if therapy was warranted or needed, and others did not not know where to go for help. Some women even reported that the oncologist stated that there was no treatment available to help with symptoms of PFD.

This information begs a reaction from pelvic floor therapists everywhere. How can we best interface with both these patients and the physicians? How can we infiltrate the journals, community lectures, national conferences, and also educate our peers about available options? While women who have suffered from cancer and pelvic floor dysfunction are not unique in the lack of awareness about treatment for PFD, common treatments for cancer can create increased tissue dysfunction, fatigue, and comorbid issues such as lymph dysfunction which complicate recovery. If you would like to work more with patients who have dealt with cancer diagnoses, but have a lot of questions about how to appropriately direct treatment, the Institute has new coursework developed by Michelle Lyons, who brings her expertise to this patient population. The next opportunity to take Oncology and the Pelvic Floor A: Female Reproductive and Gynecologic Cancers is this June in Orlando.

While the literature is clear that childbirth is a risk factor for pelvic floor dysfunction, how does a first childbirth affect the pelvic floor muscles? Does a vaginal delivery, instrumented delivery, or cesarean delivery affect the muscles differently? These questions were addressed in a prospective, repeated measures study involving 36 women. Outcomes included pelvic muscle function via vaginal squeeze pressure and questionnaires, prior to and following childbirth. The women were first evaluated between 20-26 weeks gestation and again between 6-12 weeks postpartum. All participants were primiparas, meaning that they had not given birth previously, and were found to have a significant decrease in strength and endurance after their first childbirth.

Pelvic floor muscle strength and endurance testing included maximum voluntary contraction (3 repetitions for up to 5 seconds) , sustained contraction, and repeated contractions at least 15 times. Ability to correctly contract the pelvic muscles was assessed via vaginal digital testing (with one examining finger) and perineal observation. A Myomed device was utilized with a vaginal sensor to more accurately measure strength. At the time of postpartum measurement, 33 of the 36 women were breastfeeding, the instrumented deliveries were completed with vacuum extraction, and all episiotomies were performed as right mediolateral procedures. Although the women in the study were asked if they completed pelvic muscle exercises- they were not instructed in any specific exercises.

Prior to childbirth, there were no significant differences in pelvic muscle strength and endurance between the three delivery groups. Following vaginal delivery (assisted or unassisted) pelvic muscle strength was significantly reduced, but endurance was not significantly influenced by delivery mode. While in this study, patients who had a cesarean procedure had decreased pelvic muscle dysfunction, the authors also point out that cesarean "…performed for obstructed labor or after the onset of labor has been reported to be ineffective in protecting the pelvic floor."

This study aimed to document the effect of a first childbirth on pelvic muscle strength. The authors acknowledge that controlled studies with larger sample sizes are needed to make further claims about pelvic muscle health postpartum. Ideally, even though pelvic muscle strength is reduced, we can utilize this information to establish connections about labor and delivery, and more importantly, how to minimize the impact or maximize the healing of pelvic muscles following childbirth. To further discuss postpartum issues, join us for Care of the Postpartum Patient in Houston (June) or Chicago (September)!

This post was written by H&W instructor Brandi Kirk, PT, BCB-PMD. Brandi teaches Pelvic Floor Level One and Pelvic Floor Level 2A. You can catch Brandi teaching PF2A in Maywood, IL later this month!

Recently, I was lucky enough to attend a 3-day frozen cadaver (no formaldehyde) dissection course that sparked an inquiry in my ever-inquisitive mind. While we were working on our cadaver, the coroner who was working on the other side of the complex invited us over. She wanted to show us what Crohn’s disease looks like. She had small intestines on the table and they were dissected in order to show the inside lining. The terminal ileum, where the Crohn’s disease was located, had patches of red inflamed tissue in it. The coroner proceeded to say that there was a significant amount of adhesions along the cecum, around the ileocecal valve and into the terminal ileum stemming from a prior appendectomy. Of course my mind cannot just let this information go by without some analysis…. could the appendectomy have contributed to the development of Crohn’s disease?

Travel along this thought process with me for a moment. The field of science has, to date, not found the actual cause of Crohn’s disease. With the new information I gained at my dissection course, I began to formulate a theory. My theory? Maybe the adhesions and scar tissue created by the appendectomy began to cause issues in the terminal ileum, ileocecal valve and cecum. One issue could be a decreased flow in undigested or digested food particles/chyme that causes stagnation in the terminal ileum, and over time irritation and then an inflammation of the inner mucosa. The second issue could be that the adhesions could additionally cause a decrease in circulation and lymphatic flow in the area, which also could cause an inflammatory condition.

Evidently, I’m not the only one with an inquisitive mind in the medical community! When I got home from the course, I did a search on “appendectomy and Crohn’s disease.” There is actually research that has already been completed on the topic. Some of my findings were: Appendix surgery cause Crohn’s disease? This article discusses the January 2003 issue of Journal Gastroenterology where it was found that people who had their appendix removed were 47% more likely to develop Crohn’s disease than those who did not have surgery. Badgut.org: “ IBD and Appendectomy” This article discusses the appendix having an influence over the immune system and thus appendicitis increasing the risks of Crohn’s disease. IBD and Your Appendix: This article discusses two studies on this topic. The first one showed an increase risk of Crohn’s disease within the first 20 years after an appendectomy and that women were at a higher risk than men. Unfortunately, the article did not share why the women were at higher risk than men. The second study showed a hypothesis that the original attack of appendicitis may actually be the first flare of Crohn’s disease. Potentially the patient always had Crohn’s, which went undiagnosed until the disease progressed enough. It was stated that more research is definitely needed on this correlation.

So what does this mean for practicing therapists, who are treating patients who are suffering from Crohn’s disease? If the patient has had an appendectomy, we should start there. Use all of your manual therapy skills such as visceral manipulation, myofascial release, scar massage and connective tissue manipulation in that area. In my clinical experience, which is correlated to research findings, the pelvic musculature in patients with Crohn’s disease tends to be hypertonic. These muscles need to be treated, but only after you address all of the abdominal restrictions. Through my dissection course, I was able to expand my vision about how connected the human body is. I’m afraid that as “pelvic therapists,” we tend to get tunnel-vision and we tend to blame those poor little pelvic muscles that are usually just doing their job. Yes, in the patient with Crohn’s disease they will be hypertonic, but why? They are just trying to guard and protect! They will still have to be released, but maybe not as the first step in your treatment plan. Once you release some of the fascial restrictions and improve the movement of the intestines and improve the circulation and lymphatic flow, then the pelvic muscles will not have a reason to become hypertonic again after you release them.

So let’s try to keep in mind the correlation between appendectomies and Crohn’s disease and treat those fascial restrictions first before you treat the compensatory pelvic muscles.

While hysterectomy is the second most common surgery performed on women; hysterectomy rates in the US have been declining as awareness improves about minimally invasive alternatives. According to the National Women's Health Network (NWHN hysterectomy may be associated with increased risk of heart attack, surgical complications, urinary dysfunction, fistula, UTI's, sexual dysfunction, depression, and hormonal deficiencies. The NWHN describes medical necessity for hysterectomy as occurring in cases of invasive cancer, unmanageable infection or bleeding, and uterine rupture or other serious peripartum complications.

What can a woman do as an alternative to surgery? For fibroids, medication, laser ablation, cryosurgery, and myomectomy may be options available to a woman. For precancerous cells or non-cancerous growths, a LEEP procedure or cryosurgery can be performed, or a partial rather than a complete hysterectomy can be completed. Endometrial ablation or dilation and curettage (D&C) can be used to remove the lining of abnormal tissue. Endometroisis may be managed with laparoscopy, pain medication, and hormone therapy, and symptoms of a uterine prolapse may be aided by a pessary, suspension surgery, or by pelvic rehabilitation. (Hysterectomy, 2005)

In an article by Solnik and Munro (2014) indications and alternatives to hysterectomy are discussed. The authors emphasize that the physician must make every effort to determine the true etiology of the patient's pain, and they caution that women who have chronic pelvic pain "…should be counseled against hysterectomy…" In the clinical practice of the pelvic rehabilitation provider, there is value in being aware of the alternatives to the extent that we can present the current options available to a patient. Directing women to discuss alternatives to hysterectomy with their medical providers may be helpful, and directing women to websites such as the National Women's Health Network or womenshealth.gov can allow the patient to explore options for herself.

If you are interested in learning more about advanced concepts in pelvic rehabilitation such as clinical reasoning regarding patients who are candidates for hysterectomy or conservative care for symptom management, the PF3 Course in the pelvic floor series is an excellent class. Click here to find out when you can sign up for this popular course!

References

Hysterectomy. (2014). Retrieved April 16, 2014 fromhttps://nwhn.org/hysterectomy.

SOLNIK, M. J., & MUNRO, M. G. (2014). Indications and Alternatives to Hysterectomy.Clinical obstetrics and gynecology,57(1 14-42.

This post was written by H&W faculty instructor Peter Philip, PT, ScD, COMT. Peter instructs the Differential Diagnostics of Chronic Pelvic Pain and the Sacroilliac Joint Evaluation and Treatment courses.

Have you ever palpated “marbles” - rolling masses along the SIJ that just don’t seem to go-away? Let’s take into consideration that you are a competent clinician, and that your patient is compliant with all of your requests. Clinical testing is negative for lumbar involvement, and both provocation and movement tests alike indicate involvement of the SIJ. Despite countless treatments directed at core training, and pelvic stabilization, the “marbles” persist.

Clinically speaking, often what is seen is that the innominate structures attain a more neutral alignment, where the sacrum maintains its hyper-nutated position. As a synovial joint, the SIJ is prone to swelling and subsequent scarring when placed under mechanical stress - hence the “marbles”. With great sincerity, the patient and clinicians alike focus on core strengthening, which often produces the correction of the innominate, but for reasons “unknown” to many clinicians and patients alike, the relative angle of the sacrum remains unchanged. Why would this be, how could this occur?

As a clinician, have you ever considered evaluating, and subsequently treating the anterior SIJ ligament? Running obliquely across from the sacrum to the innominate, the anterior SIJ ligaments have been found to be an underlying cause of chronic lower back pain, and sacroiliitis. As ligaments will do under mechanical stress, the anterior SIJ ligaments will stretch and scar, forming fibrous unions that limit their flexibility and hinder your manual techniques to improve SIJ osteokinematic motion. Akin to other ligaments of the body, once the origin of the mechanical insult has been addressed, the ligament can be directly treated via cross fiber massage, and to the surprise of many clinicians and patients alike heal in an expedient fashion; regardless of symptom duration. To best serve their patients, it would behoove the clinicians to take into consideration the concepts of central sensitization and knowledge that the anterior portion of the SIJ is innervated by segments L4 to S3! These and other strategies are discussed and implemented in both the Differential Diagnostics of Pelvic Pain, and The Evaluation and Treatment of the Sacroiliac Joint & Pelvic Ring courses.

Want more from Peter? You can catch him teaching his course on the SI Joint in Baltimore in July and the Differential Diagnostics course in New Canaan, CT in October.

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.

In my previous two posts, I have discussed The Postpartum Hip and Labral Tear Risk and The Importance of Early Intervention in Labral Tears. Today I want to highlight the importance of the iliopsoas and its potential contribution to intraarticular injury sequelae at the hip joint.

A recent collaborative paper including Harvard University’s Department of Orthopaedic Surgery, New York’s Hospital for Special Surgery and the Midwest Bone and Joint Institute in Illinois took on the task of a 3-D cross-sectional analysis of the iliopsoas in order to explain its relationship to the acetabular labrum. The findings are important not only for athletes, the targeted population who most frequently experiences labral tears, but also for the postpartum population I discussed in a previous blog post, The Postpartum Hip. This study represented the first attempt of 3-D analysis of the iliopsoas musculotendinous unit, and here is what the study found from dissection of 8 joints:

• The iliopsoas is found anterior to, and at the level of, the anterosuperior capsulolabral complex at the 2-3 o’clock position, or slightly lateral.

• The iliopsoas is comprised of about 44.5% tendon and 55.5% muscle belly at the exact level of the anterior labrum.

• An inflexible, not just a snapping, iliopsoas could possibly increase labral tear risk and prevalence in athletes.

• A labral tear associated with FAI (femoroacetabular impingement) is typically found at the 11:30-1 o’clock position, as opposed to an iliopsoas-induced tear, which is found at the 2-3 o’clock position.

• The researchers were led to study the iliopsoas’ contribution because the 2-3 o’clock position labral tear was being found with similar frequency as the typically expected 11:30-1 o’clock position during hip arthroscopy.

The acetabular labrum is responsible for not only maintaining joint congruity but also for pressurization. This means that In the absence of an intact labrum, contact forces are greatly increased in the hip joint, leading to premature aging of the hip and early osteoarthritis. In addition, repeat hip arthroscopy can be reduced and hip labral injury prevented or even mediated by addressing the iliopsoas length/tension relationship conservatively. The option also exists to release the tendon surgically at the level of the labrum (rather than the trochanter), and for athletes, early intervention using a team approach could mean the difference between hip joint preservation or hip joint degeneration.

Ginger's new Hip Labrum Injury course emphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. Her courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. Ginger will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip.

The first round of certification candidates have completed their testing, and we will soon announce the test takers who will be awarded with the letters "PRPC" for Pelvic Rehabilitation Practitioner Certification. Just over 70 candidates sat for the exam during our inaugural 2014 testing window, and are now eagerly awaiting their results (we thank them for their patience!)

Each step of this vigorous (and often tedious) process has been guided by Kryterion, a company who specializes in certification development. We want to give you an update about where we are in the process as many are interested in finding out how they performed on the test.

The "cut score" for passing the exam and earning the certification can only be determined after all the examinees have completed the exam, so we could not begin our work until the testing window closed on March 1st. Then, a group of 11-14 SME's (Subject Matter Experts) are gathered together on phone and web conferences to review each item. A SME is a person who meets the criteria to take the PRPC exam but cannot be someone who took the exam this year. Many of the SME's are therapists who have been involved in the process from the beginning, others have joined the group specifically for this last step, the review process.

Prior to the phone and web conferences, the each SME completes a training in rating the difficulty of items. She then independently rates every single item based on this thought: "what percentage of minimally acceptable candidates would get this item correct?" The criteria for a minimally acceptable candidate was determined in the exam development process and constitutes what a therapist should know or be able to do at a minimum to earn the credential. During our review phone calls the SMEs are all presented with the given ratings for each item, discuss the ratings as needed, and then an average rating for each item is created. At this time, we have completed over 4 hours of conferences together and have approximately 3-4 hours more to complete. As the SMEs live across the United States (and across several time zones), work full time jobs, attend school, and are raising families, this process is quite a challenge to coordinate and a sacrifice on the part of the SME.

Despite the hard work and sacrifices, the subject matter experts are committed to finalizing the cut score process within the next couple weeks. Once this is completed the cut score is determined based on the review and rating process, and we will be able to present therapists whose exam scores meet or exceed the cut score with their new designation. Participants who meet the criteria and earn a score at or above the cut score will be notified by email of their status. If you are currently awaiting notification of PRPC status, please be patient; we are very close to having the information that we need to finalize this rigorous process. We will also announce on our Facebook page and in a newsletter once we have completed the rating process, so stay in touch with us and watch your email.

If you are considering applying for the PRPC exam, all the information that you need to know can be found here. The next opportunity to sit for the exam happens in November of 2014. Thank you to everyone who has been a part of the process, from the administrative to the clinical to the test taking side! The PRPC exam is the only certification currently available that recognizes expertise in pelvic rehabilitation, a distinction that will serve to set a therapist apart and acknowledge all of the hard work that he/she has completed.

This post was written by H&W faculty member Teri Elliott-Burke, PT, MHS, BCB-PMD. Teri will be teaching Pelvic Floor Level 2A in Maywood, IL next month.

A new product has hit the stores – Butterfly Body Liners. These pads are specifically designed to deal with fecal incontinence (aka ABL – Accidental Bowel Leakage). The good news is that advertisements for these pads bring fecal incontinence out in the open. The ads promote discussion of this topic and offer one solution for this condition. A patient first brought this product to my attention. So I thought it would be a good idea for all of you to know about them as well (as I have discussed the concept of the pad with other patients they have liked the idea). However, I would also like to voice two concerns: One is that the pads seem pricey ($.30 each) especially for patients who have to change them often or are on a fixed income. My second reaction is that for some people these small pads don’t have enough capacity to deal with the problem.

I am grateful for the development of pads for this condition, however I find myself frustrated with this advertisement, as well as advertisements for urinary incontinence pads. I find myself wanting to strangle celebrities touting the use of pads (notice so far none of them are willing to own up to fecal incontinence). The pads, which are a necessity for some, offer only a passive solution. The fact that this condition can be accurately diagnosed and treated is never mentioned. Of course, mentioning an active solution doesn’t sell the products. Therefore, we need to be the voices out there letting people know there is an active solution to this issue. This includes marketing to physicians to let them know of the treatment we can provide.

Another “product” related to fecal incontinence is the newly developed Fecal Incontinence and Constipation Questionnaire. (Check out the February 2004 Physical Therapy Journal (PTJ) article that addressed the formation of this questionnaire). This is an exciting development in the area of outcomes questionnaires to address the specific patient population of fecal incontinence and constipation. Although there are other questionnaires available this one was developed specifically for patients seeking put patient rehabilitation services for pelvic-floor dysfunction. This questionnaire has two subscales Fecal Incontinence (FI) and Fecal Constipation (FC). Analysis showed sound psychometric properties of this scale, although further fecal constipation items were recommended to increase content coverage. Reminder: For those of you how are APTA members the PTJ has a app.

If you are treating patients with urinary incontinence, but are not adequately addressing fecal incontinence or constipation you are missing out on giving relief to many people. Make your way to PF2A where issues of constipation and fecal incontinence are addressed.