Monday, November 14, 2016

Pelvic PT distance journal club - November 2016

Should women with incontinence and prolapse do abdominal curls? 

Hypermoblity and POP a systematic review and meta-analysis


 Next call is December 7, 2016

Should women with incontinence and prolapse do abdominal curls?

Simpson S, Deeble M, Thompson J, Andrews A, and Briffa K.  International Urogynecology Journal . 2016. Volume 14.  Page 53 - 60.

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

Veit-Rubin N, Cartwright R, Singh A, et al. International Urogynecology Journal. 2016; Volume 27. Pages 1469-1478.

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


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

Elizabeth Lewis, PT, OCS, WCS, 10/5/16

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).


 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.

Pelvic PT Distance Journal Club Oct 5, 2016

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

This month we discussed three articles about bowel dysfunction.   One on diet in IBS and two on hands on treatments in patient with IBS and constipation. 

 Meeting recording

 Next month's meeting is October 5th.

The Science, Evidence, and Practice of Dietary Interventions in Irritable Bowel Syndrome. Brian Lacey Clinical Gastroenterology and Hepatology 2015;13:1899-1906

Pelvic PT Distance Journal Club
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.

Journal Club September 7, 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).

Pelvic PT Distance Journal Club September 7, 2016
Jane Franczak

To investigate the effectiveness of Visceral Osteopathy for IBS

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

This month we review two articles on mediation and catasropizing in pelvic pain. 

August recording

Best Mediation apps of 2016

Understanding Pain in less than 5 minutes - great video for patients

The Role of Social Constraints and Catastrophizing in Pelvic and Urogenital Pain. Tomakowsky, et al. Int Urogynecol J. 2016 Jun 10.

Michelle Spicka, DPT
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).

Michelle Spicka, DPT
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

Outlines are on this blog

Next call is Aug 3 - pelvic pain

Vaginal Pessary in Women with Symptomatic Pelvic Organ Prolapse

Rachel Y. K. Cheung, Jacqueline H. S. Lee, L. L. Lee, Tony K. H. Chung, and Symphorosa S. C. Chan

Obstetrics & Gynecology Journal, Volume 128, Number 1, July 2016, pg. 73-80

Cora Huit July 18, 2016

 Clinical Question

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

Volloyhaug I, Morkved S., Salvesen KA. International Urogynecology Journal, Volume 27, Number 1, January 2016, Pages 39-47

 Cora Huit July 13, 2016


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

Pedriali FR, Gomes CS, Soares L, Urbano MR, Moreira EC, Averbeck MA, de Almeida SH.
Neurourol Urodyn. 2015 Mar 21. doi: 10.1002/nau.22761. [Epub ahead of print]
PMID: 25809925 [PubMed - as supplied by publisher]

Chmielewska D, Stania M, Sobota G, Kwaśna K, Błaszczak E, Taradaj J, Juras G.
Biomed Res Int. 2015;2015:905897. doi: 10.1155/2015/905897. Epub 2015 Feb 22.
PMID: 25793212 [PubMed - in process] Free PMC Article

Whitehead WE, Rao SS, Lowry A, Nagle D, Varma M, Bitar KN, Bharucha AE, Hamilton FA.
Am J Gastroenterol. 2015 Jan;110(1):138-46; quiz 147. doi: 10.1038/ajg.2014.303. Epub 2014 Oct 21.
PMID: 25331348 [PubMed - indexed for MEDLINE]

Bø K, Hilde G, Stær-Jensen J, Siafarikas F, Tennfjord MK, Engh ME.
Am J Obstet Gynecol. 2015 Jan;212(1):38.e1-7. doi: 10.1016/j.ajog.2014.06.049. Epub 2014 Jun 28.
PMID: 24983687 [PubMed - indexed for MEDLINE]

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.

New research in Pelvic PT

Crevenna R, Cenik F, Margreiter M, Marhold M, Sedghi Komanadj T, Keilani M.
Wien Med Wochenschr. 2016 Jun 24. [Epub ahead of print]
PMID: 27342596 [PubMed - as supplied by publisher]


Zhang AY, Fu AZ, Moore S, Zhu H, Strauss G, Kresevic D, Klein E, Ponsky L, Bodner DR.
J Cancer Surviv. 2016 Jun 24. [Epub ahead of print]
PMID: 27341843 [PubMed - as supplied by publisher]


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.
Int Urogynecol J. 2016 Jun 10. [Epub ahead of print]
PMID: 27287818 [PubMed - as supplied by publisher]


Starr JA, Drobnis EZ, Cornelius C.
Urol Nurs. 2016 Mar-Apr;36(2):88-91, 97.
PMID: 27281866 [PubMed - in process]


Iqbal F, Askari A, Adaba F, Choudhary A, Thomas G, Collins B, Tan E, Nicholls RJ, Vaizey CJ.
Clin Gastroenterol Hepatol. 2015 Oct;13(10):1785-92. doi: 10.1016/j.cgh.2015.05.037. Epub 2015 Jun 4.
PMID: 26051391 [PubMed - indexed for MEDLINE]


Sunday, June 12, 2016

June Pelvic PT Distance Journal club recording

Does PFM contraction affect urethral closure pressure? and overflow PFM exercises.

Next call July 13

Pelvic floor muscle training to improve urinary incontinence in young, nulliparous sport students: a pilot study

Da Roza t, de Araujo MP, Viana R, Viana S, Jorge RN, Bo K, Mascarenhas T: Int Urogynecol J, 2012; 23:1069-1073.
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

Zubieta M, Carr RL, Drake MJ, Bo K: Int Urogynecolo J, 2015.  DOI 10.1007/s00192-015-28856-9; Online ISSN 1433-3023.
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.

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

Slovak M, et al., Asian Journal of Urology (2015), 2, 92-101.
 Review provided by Cynthia Neville, PT, DPT, WCS for Pelvic Physiotherapy Journal Club May 4, 2016

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.


·         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?