Hypermoblity and POP a systematic review and meta-analysis
Monday, November 14, 2016
Pelvic PT distance journal club - November 2016
Should women with incontinence and prolapse do abdominal curls?
Laura Scheufele, PT, DPT, WCS
November 9, 2016
Aim: Determine the
magnitude of change in intra-abdominal pressure (IAP) during two functional
activities: 1) abdominal curl and 2) cough in patients with UI alone and UI and
POP.
Design: Exploratory
descriptive study.
Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis
Laura Scheufele, PT, DPT, WCS
November 9, 2016
Aim: Assess the
strength, consistency and potential for bias in pooled associations from prior
studies of the relationship between joint hypermobility (JHM) and pelvic organ
prolapse (POP).
Study Design: Systematic
review.
Materials and
Methods:
Inclusion Criteria: Case-control
and cross-sectional designs, with either population based samples and other
sampling methods. Ethical approval not required.
Thursday, October 6, 2016
Pelvic PT Distance Journal Club October 5, 2016
Discussion about ICS CPP terms and mucosal sensitivity versus
PFM pain in vulvodynia. Outlines on the
blog www.pelvicpt.blogspot.com
https://fccdl.in/c6VY5O2Mv
Next meeting November 9, 2016
Mucosal versus muscle pain sensitivity in provoked vestibulodynia Witzeman K, Nguyen R, Eanes A, Sawsan S, Zolnoun, D. Journal of Pain Research 2015:8 549-555
Pelvic PT distance journal
club
Aim: To
understand and compare the relative contribution of mucosal versus muscle pain
sensitivity with intercourse as reported from women with provoked vestibulodynia (PVD).
Background:
Estimated that 8.3%-16% of women experience
vulvovaginal discomfort in their lifetime and for many, it’s provoked
on contact, commonly referred to as provoked vestibulodynia (PVD).
Little is known about the
etiologies: PFM dysfunction and mucosal components, Or how abnormalities in muscle
form or function may impact pain during intercourse.
And, more information is
needed on the relationship of mucosal sensitivity to PFM
contracture/hypertonicity and potential pain and vice versa.
A Standard terminology in chronic pelvic pain syndromes: a report from the chronic pelvic pain working group of the international continence society. Doggweiler R, et al. Neurourol and Urodynam 2016 DOI 10.1002/nau.23072.
Beth
Shelly
The
following text in black is the exact text in the document. Red comments added for discussion. This is only a portion of the entire
document. The recording starts with a discussion of the taxonomy at the beginning
of the document and the question of what nociceptive, inflammatory and
neuropathic types of pain are only listed under visceral pain and not also
listed under somatic pain. The group
also discussed the confusion of the terms "centrally generated pain",
"hypersensitivity", and "central sensitization".
Friday, September 16, 2016
September Pelvic PT Distance Journal Club
The Science, Evidence, and Practice of Dietary Interventions in Irritable Bowel Syndrome. Brian Lacey Clinical Gastroenterology and Hepatology 2015;13:1899-1906
September 7, 2016
Jane O’Brien Franczak, PT, MSPT
Summary: This article is a review of
pathophysiologic mechanisms that may explain IBS food related symptoms (sx) and
evaluates clinical trials of specialized diets used to treat IBS sx.
Premise: Food can cause GI distress due to
stimulation of mechanoreceptors and chemoreceptors (ie capsaicin) or
alterations in GI transit, intestinal osmolarity and secretion. IBS patients
report more food related issues than healthy controls
What causes food
symptoms? :
Food Allergies
1. IgE mediated = Rapid onset, ie nuts, wheat,
shellfish, strawberries.
Sx of nausea, dysphagia, abdominal pain, vomiting,
diarrhea (urticaria)
2. Non IgE -mediated : cell mediated response (T
helper 2 cells), delayed onset, IgG antibodies are more prevalent with IBS pts.
Sx= GI only.
Food Intolerances
Non- immunologic events, (non-celiac gluten sensitivity,
presence of chemicals in foods, histamine, enzyme defects, short chain
carbohydrates.)
70% of IBS patients report symptoms representative of
food intolerances.
A Comprehensive physical therapy approach including visceral manipulation after failed biofeedback therapy for constipation. Archambault-Ezenwa, L. Tech Coloprotology, June 24, 2016.
Jane O’Brien Franczak, PT, MSPT
Case study of 41 year old female severe constipation, rectal
pain, levator ani spasm, 8 year hx. 2x/mo BM from daily use of laxative and
enemas/ 4-6 glasses H2O/day, 15g fiber/day. 75% time, strain for BM, hard stool, difficulty emptying 25% time, 15
min per attempt to evacuate, difficulty initiating urination 10% time, abdom
pain 3-5/10, rectal pain with defecation, 5-7/10, suprapubic pain with full
bladder and dysuria 3/10.
Bristol stool rating type 2,3,4. 5/7 sx for Rome III criteria for
chronic constipation.
Treatment of Refractory IBS with Visceral Osteopathy. Attali, Thu-Van. J of Digestive Diseases 14; 654-661 (2013).
Jane Franczak
Purpose
To investigate the effectiveness of Visceral Osteopathy for IBS
Definitions
IBS: Association between abdominal pain and or abdominal
distention and bowel dysfunction for recurrent periods. Rome III criterion
recurrent abdominal pain or distention lasting at least 3 days/month over 3
months with 2 or more of these: 1. Improves with defecation
2. Onset assoc. with change in stool frequency
3. Onset assoc with change in form of stool
32 Consecutive refractory IBS patients study: failed to
improve after variety of drug therapies or high health care usage despite
aggressive treatment and unhappy about care.
Osteopathy: manual treatment that relies on various mobilization
procedures aimed at relieving patient’s pain. Visceral mobilization was provided by an osteopath. Friday, August 12, 2016
August Pelvic PT Distance Journal Club
August recording
https://fccdl.in/2uqLYbvKh
Best Mediation apps of 2016
http://www.healthline.com/health/mental-health/top-meditation-iphone-android-apps#1
Understanding Pain in less than 5 minutes - great video
for patients
https://www.youtube.com/watch?v=C_3phB93rvIThe Role of Social Constraints and Catastrophizing in Pelvic and Urogenital Pain. Tomakowsky, et al. Int Urogynecol J. 2016 Jun 10.
August 3, 2016
Pelvic Physical Therapy Distance Journal Club
Description: This
study tested the hypothesis that social constraints (the perception that those
close to a patient can inhibit, discourage or dissuade a person from disclosing
one’s feelings or talking about one’s problems) would be associated with
distress, pain and problems with functioning, beyond the influence of the
widely recognized risk factor of pain catastrophizing.
Pain catastrophizing is the tendency to magnify pain, feel
helpless and ruminate on one’s pain and it has been established as a reliable
correlate of chronic pain in a variety of patient populations per previous
research. In women with IC and bladder
pain syndrome, pain catastrophizing has been linked to greater depression,
poorer general mental health, poorer quality of life and more severe pain.
No previous studies have examined how social constraints are
associated with pain and adjustment in patients with pelvic and urogenital
pain.
Mindfulness-based stress reduction as a novel treatment for interstitial cystitis/bladder pain syndrome: a randomized controlled trial. (Kanter et al. Int Urogynecol J. 2016 Apr 26).
August 3, 2016
Pelvic Physical Therapy Distance Journal Club
Description: Research
shows that up to 11% of women are affected by IC/BPS and the disorder may be
significantly underdiagnosed; up to 43% of patients with IC/BPS require
multimodal therapy. The underlying
pathophysiology of IC/BPS is poorly understood.
In IC/BPS, increased stress is positively correlated with increased pain
and up to 80% of IC/BPS patients noted in a previous survey that stress
reduction decreased their symptoms.
Mindfulness-based stress reduction (MBSR) is a complementary
alternative medicine-based therapist and is a standardized program including
components of meditations and yoga. MBSR
has been successfully employed to treatment chronic pain syndromes and has been
used in disorders such as multiple chemical sensitivity, chronic fatigue
syndrome, fibromyalgia, various pelvic floor disorders and IBS as well as
urinary urgency.
Monday, July 18, 2016
July 2016 Pelvic PT Distance Journal Club
Listen to experts in the field discuss two articles on POP
https://fccdl.in/9czfWB3Ck
Outlines are on this blog
Next call is Aug 3 - pelvic pain
https://fccdl.in/9czfWB3Ck
Outlines are on this blog
Next call is Aug 3 - pelvic pain
Vaginal Pessary in Women with Symptomatic Pelvic Organ Prolapse
Obstetrics
& Gynecology Journal, Volume 128, Number 1, July 2016, pg. 73-80
Cora
Huit July 18, 2016
Are
there improvements for women with symptomatic pelvic organ prolapse by using a
vaginal pessary?
Association Between Pelvic Floor Muscle Trauma and Pelvic Organ Prolapse 20 Years After Delivery
Clinical
Question
Since it is known that pelvic
floor trauma (PFMT) is associated with prolapse (POP) and symptoms of prolapse
(sPOP) and POP-Q>2 in patient populations, the aim was to establish
prevalence and possible associations between PFMT, sPOP, and POP > 2
in healthy women twenty years after their first delivery.
Saturday, July 2, 2016
More research
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1.
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Pedriali
FR, Gomes CS, Soares L, Urbano MR, Moreira EC, Averbeck MA, de Almeida SH.
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Neurourol Urodyn. 2015 Mar 21. doi:
10.1002/nau.22761. [Epub ahead of print]
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PMID:
25809925 [PubMed - as supplied by publisher]
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2.
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Chmielewska
D, Stania M, Sobota G, Kwaśna K, Błaszczak E, Taradaj J, Juras G.
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Biomed Res Int. 2015;2015:905897. doi: 10.1155/2015/905897. Epub 2015
Feb 22.
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PMID:
25793212 [PubMed - in process] Free PMC
Article
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4.
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Whitehead
WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA.
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Am J Gastroenterol. 2015 Jan;110(1):138-46;
quiz 147. doi: 10.1038/ajg.2014.303. Epub 2014 Oct 21.
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PMID:
25331348 [PubMed - indexed for MEDLINE]
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5.
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Bø
K, Hilde G, Stær-Jensen J, Siafarikas F, Tennfjord MK, Engh ME.
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Am J Obstet Gynecol. 2015 Jan;212(1):38.e1-7.
doi: 10.1016/j.ajog.2014.06.049. Epub 2014 Jun 28.
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PMID:
24983687 [PubMed - indexed for MEDLINE]
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Lecture: New ISM Perspectives for Treating Women with PGP, UI, POP, and DRA
By Diane Lee
It is well known that the abdominal wall and pelvic floor play key roles in function of the trunk and that pregnancy and delivery can have a significant, and long lasting, impact. Non-optimal strategies for the transference of loads through the trunk can create pain in a multitude of areas as well as affect the urinary continence mechanism and support of the pelvic organs. The Integrated Systems Model will be highlighted in part one of this lecture to demonstrate its use for determining when to treat the thorax, when to treat the pelvis and when to train the various muscles of the deep system (i.e. transversus abdominis and/or pelvic floor) for the restoration of form and function after pregnancy (how to Find the Primary Driver).
Widening of the linea alba and separation of the recti, known as diastasis rectus abominis (DRA), may prevent restoration of both the appearance and the function of the trunk and women with this condition often ask whether surgery will help them. Currently, there are no guidelines for clinicians to know which patients with DRA are appropriate for conservative treatment and which ones will also require surgery. Part two of this lecture will highlight Diane’s research that led to clinical tests that reveal who can be treated conservatively and who will require a surgical intervention.
https://learn.dianelee.ca/course/new-perspectives-from-the-integrated-systems-model-for-treating-women-with-pelvic-girdle-pain-urinary-incontinence-pelvic-organ-prolapse-and-diastasis-rectus-abdominis/?error=login
New research in Pelvic PT
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1.
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Crevenna
R, Cenik F, Margreiter M, Marhold M, Sedghi Komanadj T, Keilani M.
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Wien Med Wochenschr. 2016 Jun 24. [Epub ahead
of print]
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PMID:
27342596 [PubMed - as supplied by publisher]
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2.
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Zhang
AY, Fu AZ, Moore S, Zhu H, Strauss G, Kresevic D, Klein E, Ponsky L, Bodner
DR.
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J Cancer Surviv. 2016 Jun 24. [Epub ahead
of print]
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PMID:
27341843 [PubMed - as supplied by publisher]
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3.
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Sung
VW, Borello-France D, Dunivan G, Gantz M, Lukacz ES, Moalli P, Newman DK,
Richter HE, Ridgeway B, Smith AL, Weidner AC, Meikle S; Pelvic Floor
Disorders Network.
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Int Urogynecol J. 2016 Jun 10. [Epub ahead
of print]
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PMID:
27287818 [PubMed - as supplied by publisher]
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4.
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Starr
JA, Drobnis EZ, Cornelius C.
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Urol Nurs. 2016 Mar-Apr;36(2):88-91, 97.
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PMID:
27281866 [PubMed - in process]
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5.
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Iqbal
F, Askari A, Adaba F, Choudhary A, Thomas G, Collins B, Tan E, Nicholls RJ,
Vaizey CJ.
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Clin Gastroenterol Hepatol. 2015 Oct;13(10):1785-92.
doi: 10.1016/j.cgh.2015.05.037. Epub 2015 Jun 4.
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PMID:
26051391 [PubMed - indexed for MEDLINE]
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Sunday, June 12, 2016
June Pelvic PT Distance Journal club recording
Does PFM contraction affect urethral closure pressure?
and overflow PFM exercises.
https://fccdl.in/B74jk6eVW
Next call July 13
Pelvic floor muscle training to improve urinary incontinence in young, nulliparous sport students: a pilot study
Ann Dunbar PT, DPT, MS, WCS
June 8, 2016
Introduction: Urinary
incontinence (UI) is thought of as a problem with aging however, studies
demonstrate young, physically fit nulliparous women also experience UI. Factors
that contribute to incontinence in this population of women are not well
understood. Studies suggest weak connective tissue, high-intensity and
high-impact activities, heavy training, and possible pelvic floor muscle (PFM)
fatigue. Though RCTs demonstrate benefit of pelvic floor muscle training (PFMT)
for SUI, none assess the intervention for nulliparous sports women.
Influence of voluntary pelvic floor muscle contraction and pelvic floor muscle training on urethral closure pressures: a systematic literature review
Ann Dunbar PT, DPT, MS, WCS
June 8. 2016
Introduction: Though pelvic floor m training (PFMT) is
effective for treatment of stress urinary incontinence (SUI) (Level I
evidence), how this works is not clear. Several theories are presented including
(1) PFM morphology is altered; (2) PFMT prevents bladder and urethral descent
with activities increasing intra-abdominal pressure; (3) PFMT increases
strength of a voluntary pre-PFM contraction and appears to reduce downward
movement of bladder neck with cough (ie the Knack) ; PFMT facilitates unconscious,
automatic firing of PFM, increasing maximal urethral closure pressure (MUCP)
during increases in intra-abdominal pressure.
Friday, May 13, 2016
May 2016 Pelvic PT Distance Journal Club Recording
Listen to a discussion about electrical stimulation for OAB and PFM dysfunction in the out patient population.
https://fccdl.in/eSGfDrLv2
Outlines for the two articles are found on this blog. The electrical stimulation article is now being discussed on this blog.
Next call is June 8th
https://fccdl.in/eSGfDrLv2
Outlines for the two articles are found on this blog. The electrical stimulation article is now being discussed on this blog.
Next call is June 8th
Non-invasive transcutaneous electrical stimulation in the treatment of overactive bladder
Discussion of this article is open. Please post comments below.
Reason
for choosing article: I strongly believe in NMES/TENS for pelvic floor rehab.
I use NMES on 80% of patients with PF dysfunctions,
especially bladder control problems. I have had truly miraculous results with
NMES on some patients (case report presented at CSM 2007). I met the author at
ICS and was so excited that he was putting this info out to support clinical
decision making.
·
Electrical stimulation (ES) has been used over several
decades in the treatment of various lower urinary tract dysfunctions.
·
The S2-S4 nerve roots provide the principle motor supply to
the bladder. Specifically the S3 root mainly innervates the detrusor muscle and
is the main target of sacral neuromodulation.
·
Neuromodulation
may be defined as affecting a nerve with stimulation or medication in order to
directly impact the other nerves regulated by that nerve(?)
·
Posterior tibial nerve (PTN) is a mixed nerve containing
L5-S3 fibers, originating again from the same spinal segments as the
parasympathetic innervations to the bladder (S2-S4) is a well established sit
for stimulation to the bladder
o
A commercial device (Urgent-PC, Uroplasty, Inc.,
Minnetonka, USA) uses PTNS over 12 sessions of the percutaneous posterior
tibial nerve stimulation (PTNS), at weekly intervals. RCT showed significant
improvement in overall OAB symptoms (60/110) compare to sham (23/110). It was
shown that PTNS responders can continue to benefit from the therapy over 12
months.
Methods:
·
This review considers only non-invasive ES techniques,
defined as “a procedure which does not involve introduction of an instrument
into the body”; no needles, no intra-vaginal nor intra-anal electrodes; transcutaneous
electrical nerve stimulation (TENS) was defined as a technique where the
electrical stimuli are passed through the intact skin
·
Authors searched the electronic database PubMed
from inception until December 2013. Search terms used were “urge incontinence”,
“urgency”, “overactive bladder”, “urinary incontinence” or “detrusor
instability” in combination with “electrical stimulation”, “TENS”,
“transcutaneous electrical nerve stimulation”, “nerve stimulation”, “surface neuromodulation”,
“non-invasive stimulation”, “trial” or “study”. In addition, we followed
citations from the primary references to relevant articles which the database could
not locate.
·
Exclusion criteria were: studies which were not
in English; studies of fecal incontinence treatment; those involving children,
those studying animal models; those involving percutaneous electrical
stimulation, anal stimulation, vaginal/penile stimulation or implanted devices
or those not primarily focused on storage symptoms. A flow diagram of the
selection process is shown in Fig. 1.
·
The primary search identified 410 articles. Using the defined
exclusion criteria authors reviewed in detail 16 articles; populations were widely
heterogeneous
Sacral
stimulation Electrode placement:
·
Peri-anal S2-S3 dermatomes 3 studies showed improvement =
reduction in detrusor over activity, parameters varied: 12 h/day, 6 h/day,
·
Over sacral foramina , 2x/day x 15 min
Tibial Posterior Tibial Nerve
Stimulation
·
Initially
developed using the SANS (Stoller afferent nerve stimulator) 34 gauge needle
electrode in SP6 acupuncture point and surface elect rode placed behind medial
malellelus
·
Non-implanted
electrodes are placed the above medial
malleolus and at medial aspect of calcaneus
·
Studies show
promising results, 1 shows good acceptance of use of device at home
Suprapubic- study to reduce pain in PBS also showed
decr urinary frequency, efficacy for use in OAB is unproven
Are the acute effects of
stimulation of clinical significance?
·
Researchers
have tried to answer this by assessing the immediate effects of ES during a
urodynamic study
·
A study on
SCI patients receiving ES to thigh showed Increased maximum cystometry capacity
MCC and decreased maximum detrusor pressure MDP, improved continence
·
A study on
ES over S3 dermatome did not clearly demonstrated effects on MCC, but improved
decrease in MDP
·
Studies in
neurologic patients 50% improvement in MCC, other studies no sig difference
Which stimulation parameters?
·
The location of electrodes and
range of stimulus parameters are likely to be critical factors in all forms of
stimulation.
·
Relevant stimulus parameters
include pulse width; pulse repetition frequency; burst length (if applicable)
and stimulus intensity (preferably quoted as current as voltage stimulation
coupled with uncertain electrode-tissue interface impedance leads to
uncertainty as to delivered stimulus strength). The technical description of
the stimuli used in some studies does not give all these details.
·
Stimulus intensity in question-
below motor threshold? Above perception threshold? To anal wink?
·
Sham ES is difficult to produce 2
to sensation
·
One method : Habituation as sham-
tell the pt that they are getting used to stim then turn intensity to 0
·
One study did not tell
participants that them may receive sham stim- ethical?
Conclusion: The current consensus is that
the most promising site of stimulation is the S3 area of the spinal cord over
the sacral region or over the posterior tibial nerve, but it is not clear which
approach to stimulus delivery is the most effective. Little is known about the
underlying mechanisms of action and which exact structures need to be
stimulated.
Questions for discussion:
·
How often do you use TENS/NMES?
·
What parameters?
·
Do you issue units for home use?
·
What are barriers to using TENS?
·
What are best results?
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