Sunday, December 21, 2014

Pelvic - floor muscle rehabilitation in erectile dysfunction and premature ejaculation. Lavoisier P, et al. PTJ (2014)94:1731-1743.

This French research group has set out to objectively measure the increased pressure generated by the ischiocavernosus (IC) muscle during erection. Several papers have proposed that PFM exercises can improve erectile dysfunction (ED) through the following mechanism - stronger PFM, specifically the IC muscle, provides pressure at the base of the penis so that blood is maintained in the penis and erection is maintained.  This paper has a much more scientific explanation.  Study was observational - no control group or variations in treatment groups.  Patients were seen weekly (up to 20 sessions) and received
·         Penile injection of prostaglandin E1 to induce erection
·         Electrical stimulation to the dorsal penis 80 Hz, 30 minutes
·         Isolated, voluntary IC muscle exercises - they are not specific as to how they are sure it is an isolated contraction or the instructions given to achieve an isolated contraction. Results state there were a median of 318 to 312 "pressure peaks per session".  Not sure if this means they did over three hundred IC contractions?

Results show increase in pressure as a result of training over 80% with a conclusion that "pelvic floor muscle rehabilitation was found to be beneficial in erectile dysfunction". 

 Hoping for a little stimulating Holiday discussion:

Firstly I think it is wrong to make this conclusion when penile injections where also given.  Do we know if weekly penile injections will improve penile pressures?

 Secondly, how do you isolate the IC muscle and how many PTs are recommending over 300 contractions in their training programs?

 Also wonder if anyone is doing electrical stimulation on the penis for ED?

 Please post comments. 

Friday, December 19, 2014

Free IUGA Journal Articles

Free access to the IUGA Journal top 5 downloaded articles of 2014
Now through December 31st, read the top 5 downloaded articles of 2014 for free.
 scroll down to "Popular content within this publication", then click the title of the article you wish to read.

Tuesday, December 16, 2014

December Pelvic PT Distance Journal Club recording link

Next call January 7, 2015
Happy Holiday

Myofascial Trigger Points of the Pelvic Floor: Associations with Urological Pain Syndromes and Treatment Strategies Including Injection therapy

Moldwin and Fariello
Curr Urol Rep (2013) 14:409-417

Journal Club 12/10/14 Jane OBrien Franczak, PT, MSPT

MTrP: Knots in taut muscle bands that produce pain, local or referred. Twitch response when palpated; active or Latent,

Trigger points of the pelvic floor are almost always accompanied by high tone  pelvic floor muscular dysfunction (HTPDF)

Pain with MTrP attributed to high local concentrations of inflammatory mediators, neuropeptides and neurotransmitters.

Stimulation of local nocioceptors elicits pain- local and referred.

Shah study: n=12, 3 groups- no pain, no TrP (normal)
                                                no pain, TrP present (latent)
                                                pain, TrP present (active)

Effect of Abdominal and Pelvic floor Activation on Urine Flow in Women

Sapsford and Hodges
Jane O. Franczak

to see the effect of muscle contraction of abdominals on urine flow versus the effect of PFM contraction


Urine stop test (stopping the flow of urine midstream) used to test the ability to activate PFM and indication of strength

Argument: Don’t use it for training due to the possibility of retention of urine(post void residual) and interfere with normal reflexative action of micturition or bladder’s ability to fully empty.

Abdominal drawing in ( activation of TrA) in association with increased mid urethral pressure. (Due to co-activation of PFM)

Wednesday, December 10, 2014

Managing Female Stress Urinary Incontinence

American Medical Systems (AMS) is proud to be a sponsor of a new public television episode about SUI titled Managing Female Stress Urinary Incontinence. It will air on the National Public Television Network (PBS) as part of the popular Healthy Body, Healthy Mind series.
  • This 30-minute program is sure to make a connection with your patients who may be concerned about SUI.
  • Three women with SUI share inspiring personal stories of symptoms, struggles and successful treatment.
You and your patients can also view the episode online at
Contact your local AMS representative for more information about this program.
We are committed to women’s pelvic health and value your partnership in bringing forward a topic that many of those affected feel too embarrassed to discuss.

Tuesday, November 11, 2014

Pelvic PT Distance Journal Club November Recording

 Next call Dec 10, 2014
Happy Thanksgiving

Cortical Activation Associated with Muscle Synergies of the Human Male Pelvic Floor.

Asavasopon S, Rana M, Kirages DJ, Yani MS, Fisher BE, Hwang DH, Lohman EB, Berk LS, Kutch JJ.  The Journal of Neuroscience, 10-8-14. 34(41):13811–13818

Trisha Jenkyns PT, DPT, WCS
11-5-2014   Pelvic PT Distance Journal Club


The purpose of this study was to look the connection between the brain and the pelvic floor & pelvic floor synergies.

·         The authors hypothesized that, if the motor cortex is associated with pelvic muscle synergies, there would be a medial wall region in the brain that was active during voluntary pelvic floor activation and voluntary activation of synergists, and that moreover, stimulation of this region would generate pelvic floor activation.

·         Overview: First, EMG was first used to define PFM synergies.  Second, fMRI was used to define the part of the brain that is associated with the synergies.  Third, transcranial stimulation was then done to confirm that the fMRI-identified medial wall region is ‘likely’ to generate pelvic floor muscle activation

Intra-abdominal Pressure with pelvic Floor Dysfunction: Do Postoperative Restrictions Make Sense?

Yamasato KS, Oyama IA, Kaneshiro B. The Journal of Reproductive Medicine 2014 Jul-Aug;59 (7-8):409-13

Trisha Jenkyns PT, DPT, WCS
11-5-2014  Pelvic PT Distance Journal Club

OBJECTIVE: To quantify and compare intraabdominal pressures (IAPs) in women with pelvic floor dysfunction… during standard activities.


Prospective, descriptive study done at the University of Hawaii between 2007-2008.  Women were sequentially recruited when presenting for urodynamic testing with dysfunctions of POP and /or UI 

Sunday, October 12, 2014

Pelvic PT Distance Journal Club October 2014

Outlines are posted on this blog


Next journal club meeting November 5, 2014

Check out this meeting review

Examination of the Significant Placebo Effect in the Treatment of Interstitial Cystitis/Bladder Pain Syndrome. Bosch P. UROLOGY 84:321-326, 2014.

Michelle Spicka, DPT
October 8th
Pelvic Physical Therapy Distance Journal Club

Objective: To examine the significant “placebo effect” in a randomized, double-blind, placebo-controlled interstitial cystitis (IC)/bladder pain syndrome (BPS) trial.  Randomized clinical trials are the reference standard for therapeutic impact assessment however, proving efficacy of treatments for IC/BPS with rigorous placebo-controlled trials is difficult due to a significant effect of the placebo intervention.
In past studies, a significant effect has been repeatedly observed in patients who only received placebo interventions in IC/BPS trials and the placebo global response assessment overall response ranged from 12% to 20%.
Another study by this same author in 2014 showed 50% of the placebo patients had an over 50% overall improvement in the global response assessment. 
The significant improvement with only advice and support is higher than many commonly used medications for the treatment of IC/BPS.

Nonsurgical Management of Urinary Incontinence in Women: A Clinical Practice Guideline from the American College of Physicians. Qaseem A, Dallad P, Forciea MA, Starkey M, et al. Ann Intern Med. 2014;161:429-440

Michelle Spicka, DPT
October 8th, 2014  
Pelvic Physical Therapy Distance Journal Club

Description: This guideline from the American College of Physicians (ACP) presents the available evidence on the nonsurgical (pharmacologic and nonpharmacologic) treatment of UI in women in the primary care setting.   

Nonpharmacologic Treatments for UI
1)      PFMT
a.       Instruction on the voluntary contraction of pelvic floor muscles

2)      PFMT with biofeedback using vaginal EMG
a.       PFMT with vaginal probe

3)      Bladder training
a.       Behavioral therapy that includes extending the time between voiding

4)      Continence service        
a.       Treatment program involving nurses and clinicians trained in identifying, diagnosing and appropriately treatment patients with UI

Friday, October 3, 2014

AUA IC Guideline Update Sept 2014

Thanks to the IC Association for providing the updated summary of the AUA IC guidelines.
PT is still prominently encouraged. Good marketing tool.

Check out for more resources for professionals and patients.

Friday, September 26, 2014

IUGA / AUGS Annual Meeting

Highlights of the IUGA / AUGS Annual Meeting webinar is a review of some of the best research from the meeting in Washington DC July 2014. John DeLancey gives a great state of the art on imaging.  It's free, take a look and LIKE to IUGA page for more updates and free stuff.

Monday, September 15, 2014

Do stages of menopause affect the outcomes of pelvic floor muscle training?

Tosum OC, Mutle EK, Tosun G, Ergenoglu AM, Yeniel AO, Malkoc M, Askar N, Itil IM.  Menopause.  2014; 22(2): 1-10. DOI: 10.1097/gme.0000000000000278.

Ann Dunbar PT, DPT, MS, WCS
September 10, 2014

Introduction: UI is a common complaint. Numerous hormonal changes occur during the menopause transition.  A relationship exists between hormone levels and the urinary system.  A relationship also exists between hormonal changes and muscle mass including decreases in the ratio of connective tissues to muscle fibrils in the urethral stricture and pelvic floor.  Pelvic floor exercise is recommended as the first line of treatment for stress urinary incontinence (SUI).  Little research exists on the impact of menopausal changes on PFMT.

Primary Aim:  (1) Determine impact of pelvic floor muscle training (PFMT) on increases in PFM strength during different stages of menopause.

Subjects: 122 women with stress and mixed urinary incontinence; separated into 3 groups according to stage of menopause

Study Design:  Prospective controlled clinical trial

Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicenter randomized controlled trial

Hagen S, Stark D, Glazener C, Dickson S, Barry S, Elders A, Frawley H, Galea MP, Logan J, Mc Donald A, McPherson G, Moore KH, Norrie J, Walker A, Wilson D. Lancet. 2014; 383:796-806.

Ann Dunbar PT, DPT, MS, WCS
September 10, 2014


  • Pelvic organ prolapse (P)to some degree is found on examination in 40% of women over 50
  • Women with prolapse may present with bladder, vaginal, bowel, abdominal, back and sexual sx affecting daily living and QOL
  • Conservative intervention offered for women who are not candidates for surgery or who have P low in severity; Interventions could include physical, mechanical, and lifestyle interventions as well as care offered by women’s health PTs
  • Physiotherapists (PTs) provide pelvic floor muscle training (PFMT) aimed at improving strength, endurance, and coordination of PFMs
  • Additional research needed to determine medium and long term effectiveness of PFMT as well as cost-effectiveness   
Primary Aim:  To assess whether (1)   One-on-one PFMT would reduce sx of P as well as the need for further treatment.  (2)  One-to-one PFMT would be cost effective compared with patient education handout on P lifestyle advice.
Study Design:  RCT

Friday, August 22, 2014

Your Pace Yoga: Optimizing Bladder Control by Dustienne Miller

This is Dustienne's second video and it is as wonderful as the first (your pace yoga for pelvic pain).  This 1 hour and 20 minute DVD provides instruction in pelvic awareness and PFM contraction is many different position.    Visualization and breath are incorporated into many yoga positions enhancing the correct muscle action.  Relaxation of the PFM is also stressed making this applicable to patients who are toward the end of treatment of overactive PFM who need to restore strength and stability of the area without reactivating muscle spasm.  This can be used as a home exercise to enhance individualized treatment.  Thanks Dustienne for another helpful DVD.

Sunday, August 17, 2014

Aug Pelvic PT journal club recording link

Please let me know if you cannot open this link
Outlines for this call are posted on this blog.

next call Sept 10th

Consensus statement AIGO/SICCR diagnosis and treatment of chronic constipation and obstructed defecation (Part II: Treatment)

Bove A, Bellini M, Battaglia E, et al. World J Gastroenterol. 2012 September 28;18(36):4994-5013. Focusing on biofeedback treatment/”Rehabilitative Treatment”

AIGO: Italian Association of Hospital Gastroenterologists
SICCR: Italian Society of Colo-Rectal Surgery

Laura Scheufele PT, DPT, WCS
August 5, 2014

Background from Consensus statement AIGO/SICCR: Diagnosis and treatment of chronic constipation and obstructed defecation (part I: Diagnosis)

The Joint Committee AIGO/SICCR is made up of members of these two scientific societies, elected on the basis of their experience in treating functional and organic problems of the colon and rectum.

Biofeedback for treatment of chronic idiopathic constipation in adults.

Woodward S, Norton C, Chiarelli P. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD008486. DOI: 10.1002/14651858.CD008486.pub2.
Laura Scheufele, PT, DPT, WCS
August 6, 2014

Purpose: Examine the effectiveness and side effects of biofeedback (BF) therapy used for the treatment of chronic constipation in adults who are unable to relax the muscles ,which control bowel movements.

Aim: Answer the question “Does biofeedback decrease physical or psychological morbidity and symptom distress and improve QoL in patients with a diagnosis of chronic constipation (functional constipation.)

Sunday, July 13, 2014

July 9th Pelvic PT Distance Journal Club recording

Next call August 6, 2014

Hip dysfunction-related urinary incontinence: a prospective analysis of 189 female patients undergoing total hip arthroplasty. Tamaki T, Oinuma K, Shiratsuchi H, et al. International J Urol. 2014; DOI: 10.1111/iju.2014.

MJ Strauhal, PT, DPT, BCB-PMD
July 9, 2014 Pelvic PT Distance Journal Club

Purpose of the study:  to evaluate the symptoms of urinary incontinence (UI) before and after total hip arthroplasty (THA)
·         Study was done at the Funabashi Orthopedic Hospital, Japan

·         Osteoarthritis (OA) of the hip is an important cause of pain and disability
·         In Japan, prevalence of secondary OA from congenital dislocation or acetabular dysplasia is high among elderly women
·         THA is one of the most frequent surgeries carried out to improve QOL related to OA
·         In daily practice, patients report improvement in UI post THA

Is urinary incontinence the hidden secret complications after total hip arthroplasty? Baba T, Homma Y, Takazawa N, et al. Eur J Orthop Surg Traumatol. 2014; DOI 10.1007/s00590-014-1413-4.

MJ Strauhal, PT, DPT, BCB-PMD
July 9, 2014 Pelvic PT Distance Journal Club

Purpose of the study:  to investigate whether the posterior approach (PA) total hip arthroplasty (THA) differs from the anterior approach (AA) THA in influence on urinary incontinence (UI)
·         Study was done at the Department of Orthopedic Surgery, Juntendo University School of Medicine, Tokyo, Japan

·         PA description
o   Patient position is lateral recumbent
o   Surgical method thought to be safer, provides wider visual field
o   Differences in muscle strength and walking ability compared to the AP were limited to the early post-op period; muscle strength at 6-12 months do not differ between PA and AP
o   Gluteus maximus is divided, short external rotators (ER) including the obturator internus are detached
o   T-shaped incision in the articular capsule, femoral head resected, prosthetic implanted
o   Short ER are sutured to their original position as much as possible

Monday, June 16, 2014

Comparison of Abdominal Muscle Thickness with Vaginal Pressure Changes in Healthy Women. Kim BI, Hwang-Bo G, Kim H. J Phys Ther Sci 26:427-430, 2014.

Michelle Spicka, DPT
June 4th Pelvic Physical Therapy Distance Journal Club
Objective: The purpose of this study was to compare the effect of childbirth delivery method on vaginal pressure and abdominal thickness during Valsalva maneuver.

Methods: Subjects were 30 female adults in their 20s and 30s.  Subjects were divided into nulliparous, vaginal delivery and Cesarean delivery groups with 10 subjects in each group.
A digital perineometer was used to measure the vaginal contraction pressure during Valsalva.  Ultrasound was used to measure the thickness of the abdominal muscles.
Valsalva maneuver was defined as the maximum straining effort with forced expiration against a closed glottis. 

Comparison of Abdominal Muscle Thickness with Vaginal Pressure Changes in Healthy Women. Kim BI, Hwang-Bo G, Kim H. J Phys Ther Sci 26:427-430, 2014.

Michelle Spicka, DPT
June 4th Pelvic Physical Therapy Distance Journal Club

Objective: The purpose of this study was to verify the efficacy of a pelvic floor muscle exercise program by comparing subjects’ muscle thickness with changes in vaginal pressure.  It is known that abdominal muscle activity occurs in conjunction with pelvic floor muscle exercises but studies have rarely been conducted to measure abdominal muscle thickness in response to vaginal pressure generated by pelvic floor muscles.

In this study, normal adult females were divided into different age groups and changes in abdominal muscle thickness in repose to changing vaginal pressure were comparatively analyzed. 

Effect of Variations in Forced Expiration Effort on Pelvic Floor Activation in Asymptomatic Women. Kitani LJ, Apte GG, Dedrick GS, Sizer PS, Brismee JM. J Womens Health Phys Ther 2014. Vol38;Num1.

Michelle Spicka, DPT
June 4th  Pelvic Physical Therapy Distance Journal Club

Objective: The purpose of this study was to investigate the effect of variations in forced expiration effort on the automatic activation of pelvic floor muscles.  The investigators were interested in gaining normative data for PF squeeze pressure and displacement in response to a standardized variation in forced expiration effort so an asymptomatic population was utilized.  It is known that forced expiration facilitates PF activation but it is unknown how the PF automatically responds to gradations of forced expirations.  Despite the importance of appropriate PF activity before and during times of forced expiration, few authors have discussed respiration concepts and methods in a clinic PF rehab program.

Friday, June 13, 2014

ICS World Continence Week

World Continence Week will take place this year from 23rd to 29th June. The Continence Promotion Committee is pleased to announce that the focus this year will be Bladder Diary Day!
The aim of Bladder Diary Day is to collate thousands of Bladder Diaries from people all over the world. The ICS Standardisation Steering Committee plans to use this information to define “normal bladder function”. Watch our introduction video at  where anyone can download a Bladder Diary, once completed they can be uploaded to the website or emailed to
The ICS office has created Bladder Diary Day promotional materials that can be found in the World Continence Week promotion pack. We have also added a Contact Form for World Continence Week event organisers to complete to assist the ICS office in promoting the events on our website and social media.
The Continence Promotion Committee will select one event to be the paragon World Continence Week event to highlight in ICS Newsletters as inspiration to all our members worldwide!
Thank you in advance for your cooperation to help improve the awareness about incontinence through the World Continence Week 2014.
Lots of success,

Tamara Dickinson           
CPC Chair
Nicole Huige 
CPC World Continence
Week Subcommittee Chair
Marcus Drake
SSC Chair

Wednesday, June 11, 2014

Odds and ends - check it out

AUA 2014 - Urologic Pelvic Pain Meets Late Night TV

Review by ICA web site  - "Drs. Jeannette M. Potts, Rhonda Kotarinos, and Christopher K. Payne presented this entertaining course in which they gave many useful recommendations for treating urologic pelvic pain. Their findings show that wholly two-thirds of IC patients have pelvic floor dysfunction that can be treated with physical therapy. They also found that the ability of the pelvic floor to lengthen is critical to pelvic health and therefore Kegal exercises may not be appropriate for someone with urgency and frequency. Dr. Payne encouraged healthcare providers to be positive and if they can’t offer a patient hope, to refer them to someone who can. Additionally, and perhaps most importantly, the presenters told the attendees that the best continuing medical education can be obtained by listening to their patients."

ICA book and media reference list -  is backed with information for professionals and patients  including a new video from Amy Stein

New Guidelines for evaluation

Committee Opinion No. 603: Evaluation of Uncomplicated Stress Urinary Incontinence in Women Before Surgical Treatment

Friday, May 16, 2014

May Pelvic PT Distance Journal Club

May journal club outlines are available on the blog

Recordings can be accessed with this link

Next call will be June 4th.

Impact of levator trauma on pelvic floor muscle function

Rojas RG, Wong V, Shek KL, Dietz HP. Int Urogynecol J 2014;25:375-380.

Beth Shelly PT, DPT, WCS, BCB PMD
May 7, 2014 Pelvic PT Distance Journal Club

Method - 433 primips, Blinded measurements before and after delivery
·         Questionnaires
·         MMT by Oxford scale
·         4D translabial US (specifics on page 377)

Macrotrauma = levator avulsion
·         15% of parous women
·         Defined as puborectalis insertion of all three central segments of US were abnormal.

Microtrauma = overdistention of levator hiatus
·         21%  of vaginal deliveries
·         Defined as increase of over 20% in hiatus during valsalva comparing pre to post delivery
·         May be related to
o   Over stretching of connective tissue
o   Overstretching of PFM
o   Changes in resting tone, baseline cortical activation
o   Changes in neuromuscular pathways

Managing chronic pelvic pain following reconstructive pelvic surgery with transvaginal mesh.

Gyang AN, Feranec JB, Patel RC, Lamvu GM. Int Urogynecol J 2014;25:313-318

Beth Shelly PT, DPT, WCS, BCB PMD
May 7, 2014 Distance Journal Club

Method - expert opinion paper on management of post mesh pain

Post op mesh pain = 0% to 30%
Causes - PFM spasm, pudendal neuralgia, infection

PFM spasm
·         14% to 22% prevalence
·         Symptoms - dyspareunia, LBP, bowel sx (constipation, diarrhea, excessive flatus, painful defecation), urinary sx (frequency, urgency, nocturia)
·         Signs - PFM pain greater than 3/10, increased PFM tone

Saturday, April 19, 2014

Does It Work in the Long Term?—A Systematic Review on Pelvic Floor Muscle Training for Female Stress Urinary Incontinence

BØ K and Hilde G: Neurol and Urodynam 32:215-223 (2013)

Ann Dunbar PT, DPT, MS, WCS
April 9, 2014

Primary Aim:  To present long-term results of pelvic floor muscle training (PFMT) with or without biofeedback on stress urinary incontinence (SUI) and mixed urinary incontinence (MUI) with predominant SUI symptoms (including both RCTs and pre- and post-evaluation studies)

Study Design:  Systematic Review


  • Inclusion criteria: Pre-and post-test design, non-RCT and RCT’s using PFMT with or without biofeedback to treat SUI and SUI predominant MUI
  • Authors completed a computerized search on PubMed
    1. Pelvic floor AND (training OR exercise OR physical  activity)AND (urinary incontinence  OR stress urinary incontinence) AND (follow-up OR long-term)
    2. Limits: humans, female, clinical trial, English, only adult subjects

Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor

Talasz H, Kremser C, Kofler M, Kalchschmid E, Lechleitner M, Rudisch A:  Eur J Obstet Gynec and Repord Biology 164(2012) 227-233

Ann Dunbar PT, DPT, MS, WCS
April 9, 2014

Introduction: History of Valsalva Maneuver (VM): 

  • Named after physician (Antonio Maria Valsalva 1666-1723) whose main interest was in studying the ear. He described use of forceful inflation of air from the oro-nasopharyngeal cavity into Eustachian tubes and then into middle ear with closed mouth and nostrils. Over time, VM became widely used  in medicine including otorhinology, internal medicine (see article for details), and OB/GYN (to assess urinary incontinence, pelvic organ prolapse, to aid diagnosis of intrinsic sphincter deficiency in urodynamic testing, to demonstrate maximum impact of IAP on pelvic organ descent.
  • More recently, an article published in 2006, reported on current understanding of VM which demonstrated variance from its original definition thus presenting confusion between 2 different maneuvers.

Friday, March 21, 2014

Systematic review reports the best web sites for Bladder Pain Syndrome

A good resource for patient

Tirlapur SA, Leiu C, Khan KS.  Int Urogynecol 2013;24:1257-1262.

Friday, March 7, 2014

Recognition of central sensitization in patients with musculoskeletal pain: application of pain neurophysiology in manual therapy practice.

Nijs J, Van Houdenhove B, Oostendrop RAB. Manual Therapy 2010 15:135-141.
Pelvic PT distance journal club 3/5/14
Beth Shelly PT, DPT, WCS, BCB PMD

Mechanism based clinical guidelines using medical diagnosis and history, clinical examination

·         Primary hyperalgesia - acute pain - several days - sensitization of the nociceptors to protect from further damage - local phenomenon
·         Secondary hyperalgesia - chronic pain -  increased responsiveness of dorsal horn neurons in the spinal segments of the primary nociceptors - central sensitization

Central sensitization (CS) - defined by Meyer 1995 - "an augmentation of responsiveness of central neurons to input from unimodal and polymodal receptors."
·         Altered sensory processing in the brain
·         Impaired descending inhibition of pain
·         Overactive ascending pain facilitatory pathways
·         Temporal summation of secondary pain = wind up
·         Long term enhancement of synapses in some areas of the brain
·         Net result
o   Augmented nociceptive signal
o   Increase responsiveness to a variety of peripheral stimuli
o   Decrease tolerance of senses