Manual Therapy Forum

 

Continuing our coverage of the APTA Combined Sections Meeting for 2018, we bring you highlights from the programming provided largely by the Women’s Health Section.  We also bring you the first guest post, written by Rachael Thomason PT, DPT.  Rachael has been working in the pelvic health arena of physical therapy for several years now and accompanied me to New Orleans.  Here, she provides a synopsis of a few key presentations that were meaningful to her:

 

 

CSM is always fun.  Lots of young minds, new research and ideas, and a great exhibit (with lots of freebies).  The last time I went, I was a student myself and that was 11 years ago.  I am not sure why I have not gone more.  Well, I can come up with a number of excuses such as time off from work, cost, kids, life, and more important things to do.  But I am glad I got to attend this year in New Orleans.  When I attended CSM Boston in 2007, I thought I would be interested in sports physical therapy because I viewed myself as an athlete, and I wanted to treat athletes.  I went to several seminars that centered around sports, but it was hard to apply what I learned since I was a student in my first year and would not be doing my first clinical rotation for at least 4 months.  Even then, my first rotation was in the acute setting.  Needless to say, I did not see a lot of athletes there. 

Now it is 10 years later, and my goals and interest in therapy have definitely changed, mostly because my life has changed.  When I was a student in under grad and grad school, I viewed myself as a runner and soon-to-be physical therapist.  Now I am a mom, a wife, a physical therapist, and a “sort-of” runner.  I still love treating other runners and young athletes; they are a fun population to work with.  But my focused has changed to women’s health/pelvic floor therapy.  After experiencing changes and issues with my own body with child bearing, I wanted to be able to fix them or at least improve them.  I have spent the last 5 years or so learning more about the pelvis and how to fix/treat problems that arise there.  So I find myself attending the few seminars each day that are offered by the Women’s Health Section at CSM 2018.

The Women’s Health Section is not new.  It was founded in 1977, but had slow growth initially.  Interest has grown exponentially over the past 20 years.  That was evident at CSM this year.  I was amazed that each seminar (over 200 people in the room) was at least half full of students.  Students who were open-minded to treating this delicate and sensitive area of the body.  And not just females were present, but plenty of males.  This shows great promise for this area of treatment as well as the growth of our profession as physical therapists.  Someday, we as PT’s might be the front line of health care.  As our profession grows and expands into new areas and new treatments, we need to be knowledgable of the body as a whole. 

I attended 6 educational seminars in total with each one being 2 hours.  Some were a review of recent literature and some discussed case studies, while others offered practical evaluation and treatment skills as well as protocols to follow.  Below, I have summarized of few of the seminars I attended with a “Take home message” for each.  I enjoyed learning at each of these seminars and I hope you see the value in them too. 

 

 

A Novel Approach to Vaginal Trainer Therapy: It’s not just about sticking it in.

Darla Cathcart, PhD(cand), DPT, WCS, CLT; Amber Anderson, DPT, WCS, CLT; Mandi Murtaugh, DPT, WCS

Vaginal Trainers, or otherwise known as dilators, are used primarily for treatment of Vaginismus, Dyspareunia, and Provoked Vestibulodynia.  There primary purpose is to decrease pain with insertion into the vagina whether clinical (annual exam), menstral (tampon use), or sexual.  There is little research to support the benefits of using vaginal trainers and even less on how to use them.  The presenters of this seminar gave their way of instructing, guiding, and progressing a patient with vaginal trainers. 

• The patient purchases their own vaginal trainer set and brings them in.  The first session with the trainer is done in the office.  PT reviews anatomy and uses the trainer on a model to show the patient what to do.  Have the patient then try on themselves.  Provide gloves, lubricant, towel, and a mirror.  The best position is having the patient semi reclined.
• • Start with the smallest size, have patient insert trainer, and stop at first discomfort.  Have patient breath in, exhale, and squeeze (kegel- which should be already taught).  Repeat 3-5 times. 
  • Start to add pressure posterior, right, or left.  Repeat the breathing exercise above for each direction.  Also can insert trainer further.
  • Continue with these steps until trainer is fully inserted with no discomfort, then do sweeps and in/out movements
  • Guide pt with breathing and keep open communication.  Watch patient closely for non-verbal “stop cues”
  • Session should last about 20-30 min, followed by cryotherapy

• Home program: Use vaginal trainer every other day between therapy visits.  Position in semi reclined, bath tub, or seated on toilet.  Session should last about 10 mins using the technique shown above.  Follow with 10 min cryotherapy.
• When patient comes into the office, work on manual therapy, biofeedback, relaxation techniques, and education.  Progression of vaginal trainer size can be done as well.
• Differential Diagnosis and things to be aware of

• • Red Flags- refer out: abnormal bleeding, foul smelling vaginal discharge, pain that does not appear to be musculoskeletal, night pain that does not ease with position changes, fever, or urine with foul odor.
  • Yellow Flags- education and proceed slowly: reporting pain as unbearable, catastrophizing, fear of sex, ill informed beliefs about pain, expecting a passive fix.
  • Precautions: Infection, pregnancy, and emotional reaction or fear.
  • When to stop PT and refer patient out: no progress despite compliance, bleeding after treatment, psycho-emotional factors that are barriers to progress, or patient does not want to participate.

• • Progressing to Sex

• • Communicate prior and know when to stop
  • Start sexual activity with trainer or finger
  • Use deep breathing and contract/relax methods stated above with penile insertion.
  • Follow with cryotherapy

 

Take home: Dilators or vaginal trainers have been around for a long time and they are a gold standard for treating vaginismus and dyspareunia.  However, in the past, we instructed patients to just “stick it in” and wait.  Maybe even try to do something distracting.  The presenters of this seminar have a different approach; an active approach.  Doing contract/relax can help decrease pain and actually improve a muscles ability to stretch.  Passive stretching can increase pain and guarding.  An active approach to vaginal trainer use involves the patient in their own care which can also increase compliance and self efficacy.  These guidelines will help PTs start and progress patients on the path to pain free lifestyle and intimacy.

 

 

Management of Pelvic floor dysfunction in Female runners

Kari Brown-Budde PT, DPT; Angela Dukaric-Page PT; Phil Page PhD, PT, ATC; Teresa L. Schuemann PT, DPT, ATC

Female runners may go through many body changes during their running life including puberty, pregnancy, and menopause, as well as changes in weight and muscle mass.  They also might have a history with the female athlete triad.  These changes take a toll on the pelvic floor and most female runners never seek treatment for issues related to this area.  The pelvic floor is part of the core and without good function, a runner cannot achieve good stability.  When evaluating and treating a female runner, a PT should ask questions and give a questionnaire that pertain to the pelvic floor.  Here are some question a PT should be asking:

• Do you leak with coughing, laughing, jumping, running, or playing a sport?
• Do you frequently use the restroom?
• Do you have to rush to get to the bathroom?
• Do you find it difficult to fully empty bowel or bladder?
• Have you ever accidentally lost control of bowel or bladder?
• Do you suffer pelvic pain before, during, or after intimacy?
• Do you have a feeling of heaviness or bulging from your vagina?

 

If your patient answers yes to any of these questions, a full pelvic floor muscle exam should be performed or the pt should be referred out to a physical therapist who specializes in pelvic floor therapy.  There are many times that dysfunction of the pelvic floor can lead to gait abnormalities, overuse injuries, stability problems, and self confidence issues.

 

Treatment of these patients needs to be holistic and multi-dimensional. 

• A thorough history including pelvic floor history, previous injuries, previous running status, psychological status, and goals
• A running gait analysis needs to be performed to assess for deviations and imbalance
• Pelvic floor issues need to be addressed with bladder retraining, diet education, strengthening, relaxation techniques, and manual therapy as needed
• Motor control, muscle strength, and joints of the mid back, low back, pelvis, hips, knees, and ankles needs to also be screened.

 

Returning to running should be a slow progression with definite goals for the patient to aim for.  Having defined goals from special tests also give a patient an idea of where they stand and what needs to be done to return to running safely.  One of the presenters, Kari Budde, PT, DPT, SCS, talked about a Running Readiness Scale that will be published shortly.  This scale uses 5 functional tests at 1 min each with 30 second rest in between.  A patient must pass all 5 with pain to be able to return to running.  Here are the 5 functional test:

• hopping off toes with knees apart x1 minute
• plank with good form and no diastasis x1 min
• step Ups onto 8 inch step at 160 BPM x1 min
• single leg squat x30 seconds on each leg at 80 BPM maintaining balance and good form
• wall sit with quads parallel to the ground, trunk upright, and equal weight bearing x1 min

 

Deficiencies in single leg squat, plank, or wall sit is possibly due to weakness or decreased coordination in the core and hip muscles while deficiencies in hopping, step ups, and wall sit would indicate more weakness in the legs.  While progressing a patient back into running, periodic gait analysis is beneficial to do to see deviations and asymmetries.  In general, women runners tend to have more knee flexion in mid stance, increased hip adduction with increased speed, and weight acceptance during stride that is anterior to the body.  When doing gait analysis, these things should be looked at and addressed as well as each area of the body using markers and angles when possible.

• Trunk- sidebending, rotation, forward/backward lean, hyperextension
• Pelvis- hip extension, hip adduction, rotation, depression/elevation
• Knees- knee adduction/abduction, internal/external rotation, and increased knee flexion
• Feet- ankle PF/DF, push off, overstriding, over heel strike.

 

Take Home: When treating a female runner, her pelvic history must be taken into consideration and treated before progressing her back to running.  The pelvic floor is an essential part of our core and feed forward system.  This is especially important when returning to running after child birth.  Progression back to running needs to be multi-factorial, and a patient may need to see a couple different therapist to have the best results.  Also, a patient needs to be given functional goals to aim for to have a safe return to running.  I will admit that I did not follow any type of protocol to return to running after having babies.  I just went out and ran.  It was not pretty.  I felt slow, heavy, uncoordinated, and “off”.  It took months to feel like I had my regular stride back, and even then it was not at the pace I had been doing previously.  Doing the running readiness screen that was presented here may have given me an idea of how much my body had changed and how much endurance/strength/balance/etc I had lost.  My youngest child is almost 3 (and I have run 2 marathons since having him), and I still have difficulty doing some of these functional tests.  This has definitely given me some things to work on personally as well as a great way to progress my patients in the clinic.

 

 

Staying Present: Yoga and Meditation for the Pelvic Health Therapist

Susan Giglio, PT, RYT; Laurie VanCott, MSPT

What is Meditation? Methods of turning attention inwards in order to achieve consciousness.

• many types
• all types involve self observation of mental activity and attention focus training.
• goal is to attain calm and clarity of mind

 

Types of Meditation

• Mindfulness: try to achieve a stable and non reactive awareness. Self regulation of attention

• focus internally: witness to thoughts, emotions, and sensations without judgement
• focus externally: enables a person to pause between stimulus and response

• Mindful Based Stress Reduction (MBSR): eight week educational program

• used for treatment of depression, chronic pain, eating disorders, addictions, child birth, and parenting
• allows sensations to occur without coercion

• Yoga: “to yoke” mind, body, and spirit; linked between meditation and movement.

• many schools and styles
• can increase presence in daily activities and relationships
• can increase joy and confidence in self

 

Physiology of stress in the body

Acute stress: sympathetic nervous system               parasympathetic nervous system

• Adrenalin is the main neurotransmitter          –    secretes acetylcholine
• body gets ready for flight or fight                   –    healing, repair, immunity
• shunts blood away from gut                          –    vagus nerve is the brake for SNS           

                   

Chronic stress

• cortisol is dumped into the system which results in decreased gray matter, decreased immunity, and decreased memory
• the body/brain becomes less sensitive to cortisol.

• Polyvagal Theory:  two distinct branches of the vagal nerve

• sub diaphragmatic/unmyelinated- freeze response (primitive)
• supra diaphragmatic/myelinated- social communication and self soothing behaviors (newer branch)
• stress disrupts the ANS and the primitive branch overrides the newer branch
• you can engage the newer branch by concentrated breathing, smiling, talking, eye contact or lifting gaze.  These can help manage stress.

 

Yoga as Therapy

• compliance with HEP is low due to time constraints, understanding, and importance/purpose
• we need to find exercises that are meaningful to the patient and create positive behaviors and results
• Yoga can be calming and connecting while creating space as well as strengthen, stretch, and improve balance
• Full body movement with focus of breathing, connecting the mind and body, not just exercises and repetition
• Foundation of yoga is breath work which can calm vagal tone and increase our awareness of other body sensations. It also reorients us to the “here and now” to decrease stress.

 

Mechanics of breathing

• Three part breath- diaphragm moves down, ribs move lateral, and upper chest expansion
• Transverse abdominus and pelvic floor move opposite the diaphragm

 

Types of resisted breathing

• Ujjaya- ocean breath or fog the mirror

• constricts vocal cords with inhale and exhale
• Engages transverse abdominus and pelvic floor
• improves concentration, focus, and postural support
• aim for equal inhalation and exhalation

• Brahmiri- “humming bee breath”

• creates vibrational energy
• calming, relaxing, warming
• stops the chatter of a busy mind

• Sitali Pranayama- breaths done with tongue curled

• increased surface area of tongue, thought to be cooling

• Nodi Shodhama- alternate nostril breathing

• breath in through one nostril, hold, breath out through other nostril
• increased alertness and cools the body

 

Asana Yoga Poses

• designed to restore health and vitality
• Must consider base of support, spinal alignment, stacking joints, position of pelvis and scapula, and maintenance of breath.
• Specific poses for pelvic health patients

• Incontinence- Reciprocal movement of pelvic floor with breathing: easy seat, down dog/puppy pose, cat cow. Standing poses tadasana, triangle, warrior 1, pyramid, squats
• Prolapse- Inversions including downward down, puppy pose, bridge with variations, waterfall with variations, wide leg forward fold.  Quadruped poses include cat/cow and bird dog. Seated twists with PFM pre contraction
• Pelvic Pain- happy baby with one or both legs, butterfly in supine or seated, cat/cow and childs pose, squats, pigeon pose

 

Find a good meditation for patients

• Apps: headspace, calm, 10% happier
• YouTube: “all it takes is 10 mindful minutes” and “the science behind mindfulness meditation”
• TED talks: David Vago and Daniel Siegel
• Websites: Greater Good Science Center, Stanford Mindfulness Well MD, Center for Healthy Minds

 

Take Home: Yoga and meditation can help our bodies heal from injuries by improving our awareness of body sensations, decreasing stress, giving pause between stressor and reaction, and improving posture, strength, balance, and coordination.  It is a great way to build a HEP because it gives the patient purpose in the exercises they are doing and only takes a few minutes a day.  The pelvic floor can be incorporated into the exercises on the exhale and can be directed to specific diagnoses.  Doing yoga and meditation can also stimulate the vagal nerve and PNS which in turn decreases the stress response.  I personally have found yoga to be a great way to cross train my own body.  It has helped me prevent injuries with running, be more productive in my day, and be able to handle stress without over reaction.