Psychological distress and cognitive impact are common sequelae of a cancer diagnosis, even once a patient is considered disease-free. Fear of cancer recurrence or progression is a significant issue for many patients, and can have severe impacts on a patient's well-being and function. Research published in August of last year describes predictors of this fear of recurrence, or FOR, in almost 1300 patients who completed a range of validated measures. The study reports that patients within a lower social class, this with skin cancer, colon or blood cancer, palliative treatment intention, pain, an increased number of physical symptoms, depression, and decreased social support were at higher risk of having fear of cancer.

Fear and psychological distress could potentially impact a patient's life in many ways, and also may have an effect on a patient's ability to maximally participate in recommended rehabilitation. If a patient is experiencing anxiety and/or depression, getting out of the house, making it to appointments on time, and participating in health programs may be very difficult. Cognitive impact from treatment or from psychological stress can also make remembering a home program or other instruction from you very challenging. What are things we can do to support a patient who has been impacted by a diagnosis of prior cancer? We can ask some simple questions…

What if we, as rehabilitation experts, acknowledged this research and simply asked the patient if fear of cancer recurrence or progression was creating any struggles for him or her? We already inquire about pain and physical symptoms, so can we link a reduction in physical symptoms to reduced psychological distress? Reducing pain and improving function is a logical way for us to have a positive impact. We can also screen a patient for the FOR risk factors mentioned in the literature, and ask if the patient has noticed some changes in the way information is processed or retained since having treatment for cancer. Knowledge that the patient experiences quick mental fatigue is valuable when designing home programs or when teaching important concepts; a therapist could use brief, repeated instruction rather than one long explanation. If a patient describes significant distress, discussing referral options is another way in which rehabilitation providers can serve our patients.

A Cochrane summary that was updated last in 2012 confirmed that a regular physical examination and annual mammogram are as effective as "more intense methods" of exam in detecting a cancer recurrence. If fear of recurrence prevents a patient from wanting to schedule a medical follow-up, we can encourage a patient to make any recommended medical appointments so that changes in health status are caught as early as possible. For further discussions in caring for patients who have experienced cancer, the Pelvic Rehab Institute offers Rehabilitation for the Breast Oncology Patient as well as Oncology and the Pelvic Floor, Parts A and B. The breast oncology course is taking place next month in San Diego, and the pelvic floor oncology (female) course is scheduled for June in Orlando!

This blog post was written by faculty member Bridgid Ellingson, DPT, MPT, OCS, BCB-PMD. Bridgid is a private practice owner in the Chicago area and she is an instructor for the Institute's pelvic floor course series Level 2B course.

For years I resisted taking a physical therapy student into my clinic for their final rotation. The traditional physical therapy curriculum does not adequately prepare a student for the experience and I do not believe that physical therapy for the pelvic floor is entry level work. However, I recently had a particularly motivated student convince me to give it a try and I’d like to share my experience to help prepare other clinicians interested in taking students.

I first reached out to physical therapists in the community for advice- there were very few in the private clinic setting who had taken students. I was advised to interview the student to make sure she was a good fit. I was also advised to set realistic expectations with the student and the advisor- I could not guarantee how much hands-on experience she would get in my clinic. In the end, we agreed to a split clinical with the student in my clinic two days per week for ten weeks. This student had displayed entry level skills in previous clinicals and her advisor was not concerned that she would not be working independently or even with just supervision.

The next step was to prepare her for the clinical. The ideal scenario would have been to have her attend Pelvic Floor Function, Dysfunction and Treatment (Level 1) prior to the clinical, but the logistics did not work out for her. Instead she took two online continuing education courses: Functional Applications in Pelvic Rehabilitation Part A and B. She studied anatomy extensively and utilized many other internet resources. In my clinic, I prepared my clients by telling them that a special PT student with a strong interest in learning about pelvic floor rehabilitation would be working with me for the next ten weeks but that their care would not change and they always would have a choice as to whether to allow the student to observe or participate in treatment.

In the end, I feel that the clinical went quite well for me, the student, and my clients. The student was well prepared, respectful, professional, and had a good rapport with my clients. She was able to participate in history taking, health screening, orthopedic assessment, treatment planning, and documentation. Her ability to analyze data and formulate hypotheses and prognoses progressed well over the ten weeks. While she did not perform a pelvic floor examination on a client, she did bring in a “model” and I talked her through a complete pelvic floor examination. She did learn a variety of external treatment techniques and was exposed to the use of visceral manipulation, craniosacral therapy, trigger point dry needling, biofeedback, and rehabilitative ultrasound imaging specific to the pelvic floor. I believe that the after she gains hands-on experience by taking the Herman Wallace Pelvic Floor Series courses, she will be adequately prepared to start her career as a physical therapist specializing in pelvic floor disorders.

As rehabilitation providers move towards primary care for musculoskeletal dysfunction, the privileges bring responsibilities. Regardless of our level of training and degree attainment, screening for underlying medical conditions is at the forefront of our work at all times. During the postpartum period, it is understandable that a new mother may report fatigue, aches and pains, as she tends first to the needs of her newborn. Many pelvic rehabilitation providers love working with new mothers because we have such a powerful opportunity to serve, support, educate, and nurture our patients.

One important health risk to keep in mind in the postpartum period is blood clots, or thrombosis. Changes in a woman's physiology during the peripartum period alter her risk factors for experiencing blood clots, a topic that is discussed in our pregnancy and postpartum courses. A deep vein thrombosis, or DVT, often occurs in the calf area, but the upper extremity can also develop clots. While local injury can result from a DVT, a major risk of a DVT is the progression to a pulmonary embolism, when a blood clot travels through the blood stream to the lungs- this is a life threatening condition. An article in the New England Journal of Medicine reports that the most significant risk period is within the 6 weeks postpartum. Let's get to the heart of this issue: how do we screen for a DVT or pulmonary embolism?

According to the Mayo clinic, in about 50% of cases of DVT, symptoms are not noticeable. When they are, they include:

Symptoms

• Swelling in the affected limb
• Pain in the leg, like a charley horse
• Warmth over affected area
• Changes in skin color (blue, pale, or red)

Warning signs of a pulmonary embolism:

• Sudden shortness of breath
• Chest discomfort that increases with deep inspiration
• Faintness, lightheadedness, dizziness
• Rapid heart rate
• Sweating
• Coughing up blood
• Anxiety or nervousness

If a patient is screened for the above, and you suspect a DVT, what should you do? If the first thought that comes to mind is the clinical test known as "Homans's Sign," unfortunately, that is not a current response. The best thing to do is to contact an appropriate provider (perhaps the referring provider, primary care provider, emergency room provider, etc) and report on the findings of Wells criteria. Providers can base further diagnostic testing upon this clinical prediction rule for DVT screening. To read an article about application of Wells criteria in the clinical setting, click here. If you google "Wells criteria" you will also find many reliable sites that calculate the test for you.

If you are already working with women in peripartum periods, please join us in our Peripartum Course Series! The next opportunity to take Care of the Pregnant Patient is April in Illinois and Care of the Postpartum Patient happens at the end of this month in California!

xPop Quiz

1. Can a pelvic rehabilitation provider help a male patient who has erectile dysfunction (ED)?
2. Is there research to support a claim that rehab helps with ED?
3. Are there any medical conditions a pelvic rehab provider should suspect when a patient complains of ED?
4. Are there any screening tests a pelvic rehab provider can complete to rule out medical causes of ED?
5. Are there any pelvic rehabilitation courses that discuss ED in men?

If you answered "yes" to all of the above questions, well done. A pelvic rehabilitation provider can indeed help a patient who presents with complaints of erectile dysfunction, and the highest level of evidence (randomized, controlled clinical trial) has been completed to support this claim. Medically, a patient with ED may be suffering from heart disease, diabetes, metabolic syndrome, or even multiple sclerosis and should be screened by a medical provider prior to working with a pelvic rehabilitation provider. Skilled listening, and screening tests such as blood pressure, balance, and medication screening can be utilized in the clinic to alert the therapist to a medical issue.

As many of our readers are members of the APTA Section on Women's Health, you may have seen a recent email inviting interest in a men's health subgroup. Hooray! As we know intimately, both men and women are underserved in the world of pelvic rehab. In our training programs, it was rare to learn about the specific pelvic floor muscles, let alone the male versus female sexual health dysfunctions. If you are interested in learning more about the clinical reasoning process, the anatomy, and the research behind erectile dysfunction, join Holly Tanner and Stacey Futterman in California at the end of the month in Torrance!

Male Pelvic Floor Function, Dysfunction, & Treatment not only covers male sexual health, but covers in depth the topics of urinary incontinence and male chronic pelvic pain. As many therapists are already working with patients following prostate cancer surgery, these topics are very applicable in current practice. The course is only a couple weeks away, and it's in sunny California near the ocean. The men in your care will thank you!

This blog was written by H&W faculty member Jenni Gabelsberg DPT, MSc, MTC, WCS, BCB-PMD. You can catch Jenni teaching Care of the Postpartum Patient later this month in Oakland, CA.

Physical Therapists specializing in Women’s Health are in a unique position to help guide and inspire women during their perinatal years, affecting both the health of the woman, as well as the long-term health of any unborn children.

In a recent study published in The Journal of Perinatal and Neonatal Nursing, early onset childhood obesity was determined to be one of the leading pediatric health concerns in the US. Women in their peripartum years need to be educated on what the risk factors for childhood obesity are, and how their personal health decisions can affect their children even before they are conceived. These risk factors are stated as being: maternal obesity at time of conception; excessive weight gain during pregnancy; smoking before, during, and/or after pregnancy; and bottle-feeding the infant after birth.

If a child is born of an obese mother, it has been shown that by four years of age, 24% of children were already obese (and only 9% of children born to mothers of normal weight during first trimester of pregnancy). If a mother gained more than the recommended amount of weight during her pregnancy, it has been shown that there is a 6 times increased risk of that child being overweight or obese by preschool. According to the WHO, an obese mom who gains more than the WHO recommended 11-20 pounds during pregnancy has a 48% increased risk of having an overweight or obese child by age 7. Children who are exposed to smoke in utero were both higher risk of being obese in childhood, and also being of shorter stature. And finally, infants who were fed by bottle were shown to have three times greater risk of rapid weight gain compared to those breast-fed in the first three years of life.

These risk factors not only affect the infant’s birth weight, but can also influence their weight as toddlers and preschool ages. According to the WHO, “Childhood obesity is one of the most serious public health challenges of the 21st century. “ The prevalence of childhood obesity globally is increasing at a rapid rate and has serious implications into adulthood. If children begin life as overweight or obese, they are much more likely to remain obese into adulthood, and also more likely to develop lifelong chronic conditions such as diabetes and heart disease.

More information about childhood and adult obesity can be obtained by watching the HBO series “Weight of the Nation”, which has interviews of many researchers who are focusing their studies on the secondary complications of obesity and how we can fight them. As physical therapists treat women during their childbearing years, it is critical that we use that time to educate women on the long term impact of their health choices and inspire them to make positive changes that will impact both their health and their children’s health for the long term.

A recent article titled "Pain, Catastrophizing, and Depression in Chronic Prostatitis/Chronic Pelvic Pain Syndrome" describes the variations in patient symptom report and perception of the condition. The article describes the evidence-based links between chronic pelvic pain and anxiety, depression, and stress, and highlights the important role that coping mechanisms have in reported pain and quality of life levels. One of the ways in which a provider can assist in patient perception of health or lack thereof is to provide current information about the condition, instruct the patient in pathways for healing, and provide specific care that aims to alleviate concurrent neuromusculoskeletal dysfunction.

Most pelvic rehabilitation providers will have graduated from training without being informed about chronic pelvic pain syndromes. And as most pelvic rehabilitation providers receive their pelvic health knowledge from continuing education courses, unless a therapist has attended coursework specifically about male patients, the awareness of male pelvic dysfunctions remains low. If you are interested in learning about male pelvic health issues, the Institute introduces participants to male pelvic health in the Level 2A series course. The practitioner who would like more information about male patients can attend the Male Pelvic Floor Function, Dysfunction, and Treatment course that is offered in Torrance, CA at the end of this month.

The authors in this study point out that chronic pelvic pain is not a disease, but rather is a symptom complex. Despite the persistent attempts to identify a specific pathogen as the cause of prostatitis-like pain, this article states that "…no postulated molecular mechanism explains the symptoms…" As with any other chronic pain condition, research in pain sciences tells us that behavioral tendencies such as catastrophizing is not associated with improved health. The authors utilized a psychotherapy model in developing a cognitive-behavioral symptom management approach and found significant reductions in CPP symptoms. The relevance of this information for our patient population includes having the ability to screen our patients for depression, to recognize tendencies to catastrophize, and to implement useful strategies for our patient.

What does your facility currently use as a depression screening tool? Having this information at hand when communicating with a referring provider is very helpful. Explaining the biology of the vicious cycle of emotional stress and pain responses can help a patient understand why following up on a referral to a psychologist or counselor may be helpful towards his health. Identifying catastrophizing as the patient who is hypervigilent about symptoms, ruminates about his condition, expresses an attitude of helplessness, or magnifies the threat of the perceived pain can aid in identification of the patient who needs more than a few stretches, a TENS unit, or manual therapy.

A new course offered this year by the Institute will provide excellent foundational background information as well as practical patient care techniques about emotional and psychological principles that influence chronic pain. This course, Integrating Meditation and Neuropsych Principles to Maximize Physical Therapy Interventions, is instructed by Nari Clemons, a physical therapist who excels in pelvic rehabilitation, and Shawn Sidhu, a psychiatrist with a special interest in mind body medicine. The course is offered only one time this year, in September in Illinois, so sign up early!

This blog was written by H&W instructor, Tracy Spitznagle,PT, DPT, MHS, who instructs the Movement Systems Approach course with Herman & Wallace. You can catch Tracy in the next offering of her course, April 12-13 in Houston, TX.

Should pelvic health practitioners be concerned about movement? Based on personal conversations this month, I would argue an emphatic “yes!”

The first part of 2014 has been exciting for me for understanding movement impairment education. Recently, I attended the Washington University Program in Physical Therapy MSI retreat, where discussion focused on movement and the hip. It was an amazingly cool dialog! The retreat was hosted by Dr. Shirley Sahrmann and guest speaker Dr. Donald Neumann. After the retreat, the University had a visiting lectureship and I had the pleasure of having a breakfast meeting with guest speaker Dr Chris Powers. It has been a movement system educational smorgasbord.

Consider this: the physiological system for which physical therapists are responsible is the movement system. Pain in the pelvic region is commonly associated with myofascial pain, but why did the neural muscular system develop the problem pain to touch? I believe the therapist needs to consider how the neuro-muscular components of the lumbopelvic region could be foremost in the cause of the pain.

At this retreat, I had great reaffirmation of my ideas related to movement. According to Chris Powers, “Increased hip adduction with medial rotation is the most common movement impairment during cutting, jumping and running in women with ACL injuries, there is a huge body of research to support this.”

However, the female athlete is not the only one who moves improperly and develops pain and tissue injuries. Women of all ages are more likely to adduct and medially rotate their hip, simply the habit of leg crossing when sitting re-enforces this issue. This movement impairment can be partially explained by the shape of the female pelvis and the architecture of the muscles. Believe it or not, my favorite muscle, (Don Neumann’s, too) the obturator Internus, is implicated in the movement impairment of the female with an ACL injury as well as the female with pain with intercourse.

Don Neumann PT PhD agrees; according to Dr Neumann, “it is logical to consider that the obturator Internus is more susceptible to strain due to the 130 degree turn it takes out of the pelvis.”

Thus, I believe it is logical to test for hip lateral rotation weakness as well as excessive movement in to adduction and medical rotation as a common movement habit of women, and especially women with pain located deep in the pelvis over the region of the obturator internus.

Motion analysis based on the methods developed by Chris Powers requires a lot of expensive equipment to analyze movement and only those who can run, jump and cut benefit from his information. On the other hand, movement testing of simple tasks that you already know how to do (i.e. bending, standing on one leg, and reaching up overhead) are inexpensive tools to evaluate movement. The hardest part is learning what to look for. Once you recognize kinesiological-based movement impairments you can provide corrective activities at a very low overhead!

The Movement course I teach for Herman and Wallace provides the opportunity to learn a basic movement exam that can be used for women of all ages. The course provides an overview of the anatomy of the hip, spine and SIJ and how impairment movement of these regions relate to common pelvic pain conditions you may be treating. This course provides a means for you to specifically educate your patient on how to move with less pain!

Want more from Tracy? Check her out in Houston in April!

Does wearing a pelvic belt affect the activation of the gluteus maximus and gluteus medius muscles in healthy males? Recent research asked this question, and the results, although difficult to extrapolate to other patient populations, are interesting. Surface electromyography (sEMG) amplitude was measured in 20 male patients during 6 exercises, and the amplitude during the exercise was compared to a maximum voluntary contraction. The findings demonstrated that muscle activation increased in the gluteus maximus when a pelvic belt was worn. Activation in the gluteus medius was unchanged for all exercise except during the clam exercise when the gluteus medius was noted to be more active.

Mean age in the study was 23 years, and all participants reported a lack of disease or injury. All were able to complete the exercises without pain. The 6 exercises that were instructed by an experienced physical therapist included hip clam, side lying hip abduction, single limb squat, single limb deadlift, frontal planar lunge, and frontal planar hop. Each exercise was performed 3 times, the order of exercise was randomized, and the dominant limb was used.

The authors bring up interesting points and hypotheses in relation to the sEMG findings. In a patient who presents with lumbar pain and delayed gluteus maximus activation, can a pelvic belt be utilized to improve muscle activation and therefore pelvic stability? Is adding a belt such as the COMPRESSOR belt used in this study valuable for allowing a patient to optimally complete dynamic activities, or does the belt inhibit gluteus medius activity by providing support that the muscles are supposed to provide? Most research invites us to consider the clinical implications of an intervention or a strategy, and the rehabilitation provider must assess the value of the strategy for that particular patient.

For practitioners who are interested in fine-tuning skills in lumbopelvic and hip assessment, Tracy Spitznagle, instructor in the Physical Therapy program at Washington University, will teach the Movement System Approach to Musculoskeletal Pelvic Pain: Lumbar, Hip, and SI Joint in April in Houston, TX. In this 2-day continuing education course, participants will learn to recognize movement impairment syndromes, perform movement tests, and develop a corrective exercise program based on a specific movement examination.

Postpartum mothers are often juggling intense schedules: infant feeding, mealtimes for other family members, work both in and outside of the home, and there is scarce time for self-care. Throw in the typical postpartum fatigue, potential for postpartum depression, adjustment to parenting or adding another child to a family, risk for weight retention, and the ability of a new mom to resume or begin exercises can be beyond daunting. An additional complication arises when a woman has been on bed rest, as she has lost muscle mass and cardiorespiratory function and endurance. How can we best set up a new mother for success?

Research published in the journal Clinical Sciences reports that regardless of exercise intensity, women receiving postpartum intervention experience health benefits. If a woman is unable to reduce the weight gain that occurs in pregnancy, by 6 months postpartum she will have increased risk factors for developing chronic disease, according to the authors. In the study, 20 women were instructed in nutrition advice and low intensity (30% heart rate reserve (HRR)) and another 20 women women were instructed in nutrition advice and moderate intensity(70% HRR) exercise. A group of controls (n = 20) was included and matched for BMI, age and parity.

The exercise program included supervised walking for 45 minutes, 3-4 times per week for 16 weeks. In order to achieve the target heart rate, some women walked with or without a stroller, or with a double stroller with added weight. The participants attended a supervised exercise session at least one time per week, and the first session was limited to 25 minutes, including a 5 minute warm-up and 5 minute cool down. Sessions were increased by 5 minutes per week up to a 45 minute limit. Pedometers were administered, home exercise logs were used to record distance when not in the clinic. and food intake diaries were completed. Each woman met with a nutritionist to be given a program that met her caloric needs and allowed for weight loss as appropriate. Women were screened for chronic disease at 7-8 weeks postpartum and again at 23-25 weeks postpartum.

Regardless of exercise intensity, both intervention groups lost body mass, had decreases in plasma low-density lipoprotein, and had reduced glucose and adiponectin concentrations, all positive changes for reducing chronic disease risk. As hypothesized, the control group did not experience the same positive changes. Here's the bad news: hanging on to increased BMI and low activity levels in the postpartum period can lead to lack of health. The good news: low-intensity walking programs and nutrition advice can improve risk factors for chronic disease. Many women may think they have to exercise at moderate intensity, 5-7 days per week, and while there may be additional fitness benefits from increased exercise intensity, our first goal for patients can be overall health versus fitness.

How do we get new moms into exercise? Make it reasonable, fun, social! Hold postpartum fitness classes at your clinic or at a local center. Teach the women who are in your care about wellness principles, or offer a community lecture. If you want to learn more about postpartum fitness classes, the topic is discussed in the Care of the Postpartum Patient and in Postpartum Special Topics. The next Postpartum class happens in early April, so check out the website for details!

In 2011, H&W was thrilled to add a new course to our list of offerings. Pediatric Incontinence and Pelvic Floor Dysfunction was a much-needed addition to our pelvic floor courses. Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served, which can cause undo stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Dawn Sandalcidi, the author of this course, and Robin Lund, her co-instructor, sat down with Pelvic Rehab Report to talk more about this course and their work with children.

PRR: Dawn, you developed this course many years ago. What initially inspired you to write this course?

When I set out to create this course, there were no courses offered in pediatrics for pelvic health. There was also nobody doing any pediatric courses when I began this quest.

PRR: How has this course evolved over the years?

My first class had only eight people that attended. I was shocked to see that half of the class were pediatric physical therapists looking to help their patients. At that point in time I realized I needed to rewrite the class to accommodate those learning the pelvic floor information for the first time

PRR: Robin, you will be joining Dawn as a co-instructor of this course in 2014. What pearls of wisdom have you picked up in your clinical practice that you'd like to pass onto course participants?

The only population I work with is pediatrics, usually up to 18 years of age, but sometimes up to mid 20's. Children coming to me for treatment of pelvic floor dysfunction are usually between the ages of 5 and 14 years old, but sometimes I treat children slightly younger or older than this. I am specialized in the treatment of torticollis also, so I work with babies a lot. What i've learned is:

1.) Most incontinence symptoms I see are caused or worsened by constipation and most of the time parents don't know their children are constipated because they are "going" every day. If you don't hit constipation management hard in your treatment plan, you will rarely be 100% successful.

2.) Another thing I have learned is that pediatricians and pediatric gastroenterologists often just treat the symptoms and are not always aggressive enough in their management of constipation. I educate my parents on constipation and its effect on bladder and bowel dysfunction and he;p them become good advocates for their child so they can get more action from their doctor.

3.) Work extra hard to earn your pediatric patient's trust and friendship. You will soon become their favorite person and they will want to please you and will work harder on their home program.

PRR: What can you tell us about this course that isn't covered in the description and objectives?

Dawn: It will change your life and the lives of your patients. Pediatrics is a career changing specialty that you will fall in love with!

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

Dawn: Most of us see patients who are adults who also have children with bowel and bladder issues. The pediatric patient suffers most. Not only is a problem for the child but it's also a problem for his/her entire family. We know, based on the literature, that children suffer significantly with psychological disorders related to bowel and bladder issues. The change you see in the child and the family when their discharge from therapy is remarkable!

If you'd like to learn more from Dawn and Robin, we will be offering the Pediatric course twice in 2014. The first offering will be in Nashua, NH in April. The second event will take place in Greenvile, SC in August.