National Student Conclave Recap

Five SSIG directors were able to attend NSC this year, making it a memorable and productive experience for the students of the Section on Women’s Health. Student directors ran the exhibit hall booth, met current and prospective students, and hosted a meet-and-greet to further develop the women’s health community. The student directors collaborated on a blog post and shared their unique experiences during NSC.

Aly Beck, Communications Director, wrote, “This was my second year attending NSC, and my favorite part is getting to connect with different students from all over the country. I think it’s a particularly awesome experience for students who are curious about Women’s Health. NSC is a great place to learn more about whether it’s something you might be interested in from other students, and to share you passion with other students if you’ve found it. Between informal networking opportunities, conversations at the SoWH booth in the exhibit hall, and our super fun brewery meet-and- greet, I had such a great time talking with different students, sharing experiences with Women’s Health, and hearing about their ideas for how we could improve student involvement in the section. Definitely be on the lookout for info regarding our SSIG Meet-and-Greet and CSM if you’re interested in learning more about women’s health and pelvic PT, or you’d like to get more involved with the section!

I also loved the focus of the educational sessions at NSC this year. Hearing from different clinicians about the alternative career paths and non-traditional roles they’ve taken, some just a few years out of school, was motivating and inspiring. Women’s health is definitely a setting that lends itself to thinking outside the box in clinical practice and beyond, and the enthusiasm that many of the speakers brought to their sessions was contagious.”

Ariana Jones, Director of Programming, states, “We were able to put on an amazing meet and greet. I was able to talk with students who were first years and didnt even know if they have gender health in their DPT program to those who are getting excited about their pelvic health clinics. I was able to tell students about the benefits of being in the SoWH SSIG like networking, applying for scholarships and taking Pelvic courses. This NSC experience very different than last years for me because I was running for Director of Membership for the Student Assembly. It was an exhausting but amazing weekend that I wish all first year students could experience a NSC!”

Claire Hamnett, Assistant Director of Programming, wrote, “My experience at NSC, like my experience at CSM, was completely invaluable to me. I took two finals early in order to spend my Thursday – Saturday, the weekend before having four more finals Monday- Wednesday, on the opposite coast in a different time zone, just to be at NSC. I love helping with the booth at NSC because I am afforded the opportunity to share with other students my passion for Women’s Health physical therapy, and help them to become more involved in the section through exploring their interests. The opportunity to meet, collaborate, and brainstorm with other members of the SSIG BOD made us stronger as a group and will improve the quality of our work as a whole. At NSC, the conference is designed for students, and therefore having our strong student leadership board present at the conference to personally connect with other students fostered an environment of growth, respect, and excitement where lifelong connections were created. Through strengthening my relationship with the other board members, as well as creating meaningful connections with other interested students, I left NSC with a renewed sense of passion for the field, and belonging to the section. I hope to continue to attend APTA conferences in order to build upon these experiences and connections and work towards becoming the best physical therapist I possibly can be.”

Ebony Carothers, Assistant Director of Communications, wrote, “Working the booth at NSC 2017 was a great experience. I enjoyed meeting and talking to other students who were interested in pursuing careers in Women’s Health. One of the best parts about representing the SSIG at our booth was being able to offer advice and resources to students who were interested in getting involved in Women’s Health but didn’t know where to start. Another highlight of working at the booth was hearing about other student’s paths and experiences with Women’s Health and taking away tip and ideas from them. I strongly believe that our representation at the conference proved very valuable not only to the students present at the conference by providing exposure and resources but equally to the booth volunteers.”

The SSIG is grateful for the continued support from the Section on Women’s Health as well as the enthusiasm from women’s health students across the country!

Healthy Mothers, Happy Babies: a Student-Run, Pro Bono Women’s Health Program

Health Mothers, Happy Babies is a pro bono initiative designed by two recent graduates from the University of Montana Physical Therapy program: Abby Mytty, DPT and Leigh Bailey, DPT. The program focuses on providing pro bono women’s health physical therapy care to 9 pre- and post-partum women ages 16-24 residing in a group home in Missoula, Montana. The program design is 2-pronged, and comprises of educational classes and physical therapy consults.

Mytty and Bailey developed a women’s health course made up of 5 classes of different topics: introduction to pregnancy, pelvic floor, biomechanics for pregnancy, exercise indications, and pain free playtime that encourages child development. The twice-monthly classes typically had 2-4 participants, and were heavily discussion based. Mytty and Bailey brought in pelvic floor models, and handouts summarizing the general concepts of each class. They wrote the class scripts, provided education, and facilitated discussion.

The second prong of the program, physical therapy consults, allowed for the women to receive individualized physical therapy care. Consults were 30 minutes in length, and consisted of an evaluation, a treatment, and education. Common complaints were low back pain, incontinence, and general pelvic floor weakness. The consults allowed for 2 physical therapy student volunteers and 1 licensed clinician to collaborate and provide care. Consults also provided an opportunity for women to ask further questions about their health or topics from the course.

Mytty and Bailey were tasked with developing this project when a professor offered up a connection to the group home, and encouraged the students to create a way to serve the women. A passion for pro bono care and interest in women’s health are what drove the project to fruition. Mytty expressed: “The main purpose of the project was to provide any PT service that would be beneficial to the women.” It also provided an opportunity for PT students to work with a population they would not commonly work with while in school. In addition, the program introduced many of the women to physical therapy, and advocated for their health by demonstrating the effectiveness of physical therapy care.

A vital part of developing this program was the strong relationship between University of Montana and the group home. Mytty and Bailey spent time on their first visit getting to know the women and gauging their interests and needs in regards to women’s health, physical therapy, and education. Lot’s of education centered around the pelvic floor and incontinence, topics within the scope of practice for physical therapists, but lesser known to the public. An important factor in the success of the program was the dedication and hard work of Mytty and Bailey for disseminating crucial information for the women in a way that met their needs, fit their wants, and got the educational messages across.

Mytty and Bailey both recently graduated from University of Montana, and have handed the Healthy Mothers, Happy Babies program down to the next class of students. Future directions for the program include setting up regular women’s health appointments with the University pro bono clinic, incorporating an exercise class, and providing pediatric interventions. One of the challenges of the program was consistency of attendance from participants, a challenge shared by many pro bono clinics all over the country.

Mytty and Bailey reflected on their biggest personal takeaways from the project, both of them emphasized that all their hard work was completely worth it:

Mytty: “It was crazy seeing how many women do have musculoskeletal issues related to pregnancy. It gets brushed aside because they don’t get information about it, and don’t realize it’s something that can get treated easily with physical therapy.”

Bailey: “It was surprising how little information these women had gotten in past medical visits about incontinence or diastasis recti, something treatable. The group environment was cool, having the women open up and enjoy the process.”

The student special interest group for the APTA section on Women’s Health would like to formally congratulate Abby Mytty and Leigh Bailey for their commitment to providing pro bono women’s health care to a population in need of their services. These two recent graduates are an example of how students can combine a passion for women’s health and volunteering. For more information about the program, or for ideas to initiate a similar project, contact Abby Mytty (abigail.mytty@umontana.edu) and Leigh Bailey (leigh.bailey@umontana.edu).

Written by: Maggie Delaney, DPT. Maggie is the Director of Membership for the APTA Women’s Health Section Student Special Interest Group. She is a recent graduate of the Northern Arizona University Physical Therapy program.

 

Contact

Email: md472@nau.edu

Twitter: @maggierdelaney

An Intro to Vaginismus

Vaginismus is a prevalent type of female psychosexual dysfunction. It is a diagnosis referring to uncomfortable or painful penetration of the vaginal entrance by any object despite the desire to do so. This can happen during many different scenarios, such as sexual intercourse, masturbation, gynecological examinations, or tampon insertion and can result in a variety of symptoms including discomfort, burning, pain, spasming, or closure of the vaginal opening. It is also accompanied by psychological symptoms such as fear, along with anxiety with and avoidance of intercourse.

Vaginismus is distinguished from vulvodynia (chronic vulvar pain without an identifiable cause) and vestibulodynia (severe pain and discomfort in the vestibule area of the vulva) by some of the symptoms mentioned above which all involve the introitus, or entrance, of the vagina: inability to use or remove a tampon, severe pain or inability to achieve penetration during intercourse, and the lack of tolerance to complete a gynecological examination. In clinical settings, the rate of vaginismus is about 5-17%. The success of treatment for vaginismus compared to vulvodynia and vestibulodynia is high.

The manifestation of vaginismus can range from mild to severe. It can affect anybody. However, not everybody with vaginismus is affected in the same way. It is referred to as primary when it affects a woman who has never experienced non-painful intercourse, and secondary when it affects a woman who has previously experienced non-painful sexual intercourse.

Sexual experience is not necessarily a factor in the manifestation of vaginismus. It can be caused by psychological and/or physical factors such as childbirth, infections, STIs, hysterectomies, surgeries, cancer, menopause, sexual trauma, abuse or strict religious or sexual upbringing, and fear and anxiety issues. Many women do not know why they have developed vaginismus and experience intense shame that can affect their relationships, marriages, work and mental health. What is known is that it is involuntary.

There are a plethora of treatments for vaginismus: pelvic floor physical therapy, dilation training, exercises, biofeedback, counseling, behavior therapy, psychotherapy, Botox, and many others. Generally, the best outcomes for treatment are multimodal and include both psychological and physical treatments.

For more information on the topic of vaginismus, please visit http://www.vaginismus.com

References

1. Palick PT, Geletta S. Vaginismus treatment: Clinical trials follow up 241 patients. The Journal of Sexual Medicine. 2017; 5:e114-e123.
2. Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ. 2009; 338 :b2284
3. Macey K, Gregory A, Nunns D, das Nair R. Women’s experiences of using vaginal trainers (dilators) to treat vaginal penetration difficulties diagnosed as vaginismus: a qualitative interview study. BMC Women’s Health. 2015; 15:49

Written by Ebony Carothers, a 1st year DPT student at the University of Oklahoma Health Sciences Center and Assistant Director of Communications for the Section on Women’s Health Student Special Interest Group.

So, you want to be a Women’s Health therapist. Now what?: A Student Perspective from Pelvic Floor Level 1

Hi! My name is Aly, and I’m a second year DPT student at Texas Woman’s University in Houston, TX. Last month, I took my first pelvic floor and Women’s Health continuing education course. I had a lot of questions throughout the whole process, so I thought I would share my personal experience in hopes of persuading another student like me to take the leap.

Before starting my DPT program in 2015, I knew little of Women’s Health or pelvic PT, save a few mentions of Kegels. My introduction to Women’s Health came from Dr. Kimberlee Sullivan of Sullivan Physical Therapy in Austin, TX, who gave a guest lecture to my class in our first semester. I was intrigued and curious, and appalled at the lack of knowledge and care offered to women and men with pelvic pain, but still wasn’t totally convinced. Did I really want to be all up in someone’s business all day?

After a second lecture in my second year by Dr. Uchenna Ossai, I knew it was something I wanted to pursue. I talked to my Director of Clinical Education and set up my internship with a Women’s Health therapist, who strongly recommended I take a Pelvic Floor 1 course before my rotation. This was not something I had considered doing (“I’m broke; why am I taking continuing education before I’ve finished my first education? When do I find time for this??”), but after she mentioned it, I realized I wouldn’t be able to get the most out of my internship without it. Internal pelvic floor exams put our patients in extremely vulnerable positions, and learning and practicing a proper exam before treating patients would be ideal.

This is where all my questions began. I looked for classes to take through the Section on Women’s Health (SOWH) and Herman and Wallace Pelvic Rehabilitation Institute (H&W). Both offer a Pelvic Floor series of courses, but may cover different topics in different courses. Both Pelvic Floor Level 1 courses include external and internal vaginal pelvic floor exams, and each participant is expected to participate as both a therapist and patient within the labs. The SOWH course covers the topic of urinary incontinence with deeper anatomical and physiological explanations, while the H&W course more briefly covers urinary incontinence and other urogynecologic pain syndromes. A friend who has taken both courses enjoyed H&W for the repetition of important and basic knowledge in an easy to understand way, and enjoyed SOWH for all of the evidence based research you are provided with throughout the course. Please note that I am not endorsing one course over the other, as both would be excellent choices to get your feet wet.

Some other considerations when choosing a course are location, timing, and price. When looking at the cost of the course, you also have to consider if you’ll be paying for a flight, a hotel, and food for the weekend. Before deciding which course to take, I would recommend checking if either course is being offered in your city, in a city within driving distance, or in a city where you would have a place to stay, as this would significantly reduce the burden of cost.

Next, I would look at the timing of the courses being offered. If you’re starting a rotation, do you need to take a course before you begin? Can you take it during your rotation? Do you have a Friday off from school or rotation that corresponds with a date that the course is being offered? It’s also important to realize that these courses typically fill up 2-3 months prior to the date, so being organized in advance is a must. You can put your name on a waitlist if the course is full, but there is no guarantee a spot will open up.

Finally, you’ve already considered price with the location of the course, but as a student you’re also eligible for discounts. H&W offers a 10% student discount, and SOWH offers a student discount as well as a member and multiple course discount.

Another thing you may want to consider in the long run is the certifications you are able to get obtained based on the courses you take. If you take the series of Pelvic Floor courses through the SOWH, you are eligible to apply for the Certificate of Achievement in Pelvic Physical Therapy (CAPP-Pelvic). The Pelvic Rehabilitation Practitioner Certification (PRPC)  is another certification offered through H&W. You don’t have to take any specific courses for this, however the H&W courses and resources are helpful for preparing. Finally the WCS is the board specialization exam you sit for after completion of a residency program or 2000 hours of patient contact hours in Women’s Health.

I chose to take the H&W course because there was one being offered in the city I live in at a convenient time for me, and also because I was still in my second year when I took the course. The SOWH policy for continuing education courses is that only students in the last half of their third year are able to attend. However, I know they are re-evaluating this policy, so stay tuned.

I was so excited after actually registering for my course, even though it was 2 months away. I couldn’t wait to learn all the pelvic floor things I hadn’t learned in school. Having that 3 day spread in all caps in my planner was something I looked forward to every time I flipped to March.

Then, before I knew it, it was the Thursday night before the course and it hit me. I was super nervous. Beyond the worries of taking my first continuing education course (“What if I’m the only student?” “What if I don’t understand anything they’re talking about?” “What should I wear?” “How long will it take to get there?”), there was the obvious “I’m going to see another person’s vulva tomorrow.”

And then the, “Someone else is going to see my vulva tomorrow.”

And then, “Why am I doing this again?”

Luckily, I have a new grad friend working in Women’s Health who was able to give me some advice and talk me down from my panicked state. But, I still went to bed and woke up pretty darn nervous.

I arrived to the course early on Friday morning, because nothing makes me more anxious than running late. And trust me, late anxiety and vagina anxiety combined would have been way too much for me to handle. I saw a friendly face while registering and had a friend to sit next to which definitely helped soothe the introvert in me.

There were about 50 people taking the course, 2 instructors, and 4 teaching assistants. I was one of three students, and there was a wide range of experience amongst the practitioners in the room, from those learning about the pelvic floor for the first time to those who were expanding their knowledge for their current practice. Physical therapists, physical therapy assistants, and occupational therapists were all represented. The course began with introductions, goal setting, and an overview for the course. It would be 3 days long, with lectures and labs on different topics occurring each day.

In addition to being extremely qualified and knowledgeable, the instructors were warm and welcoming which helped me to realize that I was in the right place despite what the knots in my stomach were telling me. By the time the second lecture was over midway through the morning, I almost felt completely at ease with the same excitement I had first had when registering for the course.

And then it was time. The first lab was upon us. The instructors did a great job of addressing the elephant in the room and letting everyone know it was okay to be nervous and to participate to your comfort level.

Many of the students (including me) prolonged our break time by waiting in the long bathroom line, grabbing an extra drink of water, and awkwardly meandering around looking for a partner. We introduced ourselves, and then both confessed to how nervous we were. After realizing that a lot of the participants felt the same way I did, I felt better. After the first lab was finished, it felt like a weight had been lifted. It wasn’t nearly as difficult or uncomfortable as I had made it out to be in my head. Examining and evaluating a pelvic floor could be much like any other part of the body. As the weekend continued, it only got easier.

I learned so much at my first Pelvic Floor 1 course and am glad I decided to take it as a student to reaffirm my interest and prepare me for my internship in Women’s Health.

Here are some other questions you might have about taking a PF1 course and may be too embarrassed to ask:

• Male therapists are welcome at both courses. For the SOWH courses, male participants are required to bring a lab model with them for the lab portion of the course. In the H&W course I took, the male participants were not required to bring a model, and were allowed to participate to the comfort level of the female participants. Female participants who were comfortable being a “patient” for a male participant were asked to invite male participants to be a partner, or males were able to observe in groups of 3 with willing female participants.
• You are able to participate in the lab portion of the course as a patient if you are menstruating. In my course, this was up to you and your comfort level, but there is no contraindication to internal vaginal exams while on your period.
• If you are pregnant, you need to bring a medical model or a letter from your physician that clears you to participate in labs.

I’ll leave you with two of my favorite things I learned at the course. The first one came from Dr. Jessica Reale, one of the instructors, who eloquently stated that after delving into Women’s Health and pelvic PT, it’s important not to “get sucked into the blackhole of the vagina” and never come out. While we’re learning how to treat the pelvic floor internally and externally, it’s important to take a step back and make sure we’re holistically treating the whole patient, regardless of what approach we take.

Secondly, Dr. Holly Tanner, the other course instructor, spoke with us about how much body language, words, and the way we say them matter to our patients. One of my favorite quotes from the weekend was “Stand in front of the mirror and watch what your face does when you say vagina.” We need to feel comfortable speaking with our patients about topics that they may feel uncomfortable about to put them at ease, whether we are Women’s Health therapists or not.

While I don’t claim to be an expert, I hope this helped answer some questions you may have had about taking a PF1 course as a student. Please feel free to reach out to me if you have any additional questions and I’ll do my best to answer them! I hope this inspired you to take the next step in your journey into pelvic PT!

Contact

Email: abeck1@twu.edu

Twitter: @AlyBeckPT

Postpartum Depression and Exercise as a Treatment

To many of us from afar, it may seem that the postpartum period is one of pure, inexplicable joy brought by something so precious and exquisite as new life.

To many new mothers, however, it may become frustrating and unclear why the postnatal period can be filled with almost just the opposite: “baby blues” or, more intense than that, postpartum depression.

The term “baby blues” refers to an emotional state of tearfulness, unhappiness, worry, self-doubt and fatigue.  Typically, these emotions emerge within a week after delivery and diminish within a week or two.  Postpartum depression (PPD) is usually characterized by more intense and unsubsiding feelings of emptiness, hopelessness, rage, loneliness, worry, sadness, failure, and despair; anxiety is commonly interwoven among these features of PPD¹.

Women with PPD are not alone!  Research has demonstrated that PPD affects about 10-15% of women in the year after giving birth^2,3.  Certain risk factors place a woman at an increased risk for developing PPD including¹:

• History of depression, anxiety, or psychiatric illness
• Family member who has been diagnosed with depression
• Stressful life event during pregnancy or shortly after delivery such as the death of a loved one
• Medical complications during delivery
• Mixed feelings about the pregnancy
• Lack of emotional social support
• Drug or alcohol abuse problems

PPD can be attributed to a multitude of factors.  Estrogen and progesterone drop quickly following childbirth which triggers chemical changes in the brain¹.  Furthermore, sleep deprivation is a common theme among new mothers that can exacerbate the symptoms of PPD.

Extensive literature highlights the efficacy of physical exercise as an intervention for depression, specifically because of its positive effect on sleep, physical well-being, and stress.  Research focusing on the effect of exercise specifically on postpartum depression is more limited.  The existing literature has found pram-walking⁴, yoga⁵, and individualized aerobic exercise programs^6-9 to be effective in lessening depressive symptoms.

As women’s health physical therapists, we may be bias ourselves to be more cognizant of our patients’ physical symptoms.  I challenge us to widen our view so that we see the whole presentation: mind, body, and spirit.  These new mothers are overwhelmed.  Their energy tanks are on empty; all their fuel is burned simply by getting through…rather, surviving the day.

I propose an increased emphasis on exercise prescription for this population.  Many mothers will whip out their laundry lists of excuses (mighty valid, may I say):

• “I have no time”
• “I have no energy”
• “I have no one to watch the baby”
• “I’m too tired”

I propose we purposefully listen, empathize, and validate these concerns and engage in conversation about the potential benefits about incorporating physical activity into their daily routine.  I propose we work together to develop a feasible plan and I propose that we, as physical therapists, support this plan by researching and providing resources to our patients about community resources available to this population (pram-walking groups, etc.).

We can do more for our postpartum patients to improve their quality of life than helping to strengthen the pelvic floor and abdominals.  We can be a teammate to these ladies in their pursuit of a more physically active, happier, and bliss-filled life.

Resources:

1. National institute of mental health. “Postpartum depression facts.” Available at:https://www.nimh.nih.gov/health/publications/postpartum-depression-facts/index.shtms
2. Dennis CL, Chung-Lee L. Postpartum depression help-seeking barriers and maternal treatment preferences: a qualitative systematic review. 2006;33(4):323-331.
3. Stocky A, Lynch J. Acute psychiatric disturbance in pregnancy and the puerperium. Baillieres Best Pract Res Clin Obstet Gynaecol. 2000;14(1):73-87.
4. Armstrong K, Edwards H. The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women. Int J Nurs Pract. 2004;10(4):177-194.
5. Buttner MM, Brock RL, O’Hara MW, Stuart S. Efficacy of yoga for depressed postpartum women: A randomized controlled trial. Complement Ther Clin Pract. 2015;21(2):94-100.
6. Daley AJ, Blamey RV, Jolly K, et al. A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial. Psychol Med. 2015;45(11):2413-2425.
7. Dritsa M, Da Costa D, Dupuis G, Lowensteyn I, Khalifé S. Effects of a home-based exercise intervention on fatigue in postpartum depressed women: Results of a randomized controlled trial. Annals of Behavioral Medicine. 2008;35(2):179-187.
8. Dritsa M, Dupuis G, Lowensteyn I, Da Costa D. Effects of home-based exercise on fatigue in postpartum depressed women: who is more likely to benefit and why? J Psychosom Res. 2009;67(2):159-163.
9. Heh SS, Huang LH, Ho SM, Fu YY, Wang LL. Effectiveness of an exercise support program in reducing the severity of postnatal depression in Taiwanese women. 2008;35(1):60-65.

Written by Valerie Adams.  Valerie is a 2^nd year PT student at Duke University and serves as the Assistant Director of Research for the Section on Women’s Health Student Special Interest Group.

Endometriosis and Pain Relief with TENS

Endometriosis is an estrogen-dependent inflammatory disease that occurs when tissue similar to the lining of the uterus, the endometrium, is found outside of the uterus (1).  It most commonly affects women during their child-bearing years, and often causes pain in the hypogastric and perineal regions, as well as the lower back (2). This pain can also include chronic pelvic pain, deep dyspareunia (painful sexual intercourse), dysmenorrhea (painful menstruation), dyschezia (difficult or painful defecation), and dysuria (painful urination). One research article even reported that a substantial number of women with endometriosis in their study had pain so bad “that it prevented them from going to work or they had to lay down frequently” (3).  The pain caused by endometriosis can be severe, debilitating and complex, and there is no correlation between the severity of endometriosis and the experienced pain symptoms (2).

Common treatment options for endometriosis can consist of pain relievers, hormone therapy, or surgery.  High-intensity exercise has also been suggested as a possible mechanism for pain relief as it not only increases endorphins, but it also decreases the amount of estrogen that the body produces. What about other treatments that can provide pain relief?

Mira et al. (2015) in a randomized control trial studied transcutaneous electrical nerve stimulation (TENS) as a potential complementary pain treatment for women with deep endometriosis (4).  In this study, the electrodes were placed at the S3-S4 region.  One group received acupuncture-like TENS (Frequency: 8 Hz, Pulse duration: ~250 µs, 30 minutes 1 x a week) while the other group received self-applied TENS (85 Hz, Pulse duration: ~75 µs, 20 minutes 2 x a day).  Their results showed that all the women who received TENS, regardless of which type, had significant pain relief specifically with their symptoms of dyspareunia and dyschezia. In addition, ratings of quality of life for both groups also improved.  In this study, TENS did not improve pain relief related to dysmenorrhea or dysuria. 

Although the study had a small sample size of 22 women and no control group, one take away from this data is that for some women, TENS may be an effective, complimentary pain-relieving treatment to add to the care plan.  Additional benefits of TENS units are that they are small, portable, non-invasive, low-cost and they can be used at home, overall making them relatively convenient and easy to use.

For more resources on endometriosis, check out endometriosis.org or The Endometriosis Association. 

 References:

1. Troyer, M. R. (2007). Differential Diagnosis of Endometriosis in a Young Adult Woman With Nonspecific Low Back Pain. Physical Therapy, 87(6),801-810. Accessed August 17, 2016. http://dx.doi.org/10.2522/ptj.20060141.
2. Morotti, Vincent, & Becker. (2016). Mechanisms of pain in endometriosis. European Journal of Obstetrics and Gynecology, European Journal of Obstetrics and Gynecology.
3. De Graaff, D’Hooghe, Dunselman, Dirksen, Hummelshoj, Simoens, . . . Wullschleger. (2013). The significant effect of endometriosis on physical, mental and social wellbeing: Results from an international cross-sectional survey. Human Reproduction, 28(10), 2677-2685
4. Mira, T. A., Giraldo, P. C., Yela, D. A., & Benetti-Pinto, C. L. (2015). Effectiveness of complementary pain treatment for women with deep endometriosis through Transcutaneous Electrical Nerve Stimulation (TENS): randomized controlled trial. European Journal of Obstetrics & Gynecology and Reproductive Biology, 194, 1-6.

Written by Kayley Mikolajczyk, a 3^rd year PT student at the University of Minnesota and Assistant Director of Research for the Section on Women’s Health Student Special Interest Group.

Vulvodynia – What’s New in Research?

Vulvodynia is a diagnosis of exclusion and is often described as discomfort in the vulvar region at the opening of the vagina that can consist of burning, stinging or itching pain.  The prevalence of vulvodynia has been reported to be 7-8% in the general population (1).  Some clinicians and researchers, however, believe this prevalence vastly underestimates the reality.  Not much is known about the pathophysiology and etiology of vulvodynia and why some people get it while others do not.

Last month we talked about interstitial cystitis, and vulvodynia is similar in that patients with this condition also oftentimes have pain and trigger points in the muscles of the pelvic floor; PT for both conditions often involves internal and external myofascial release and soft tissue mobilization (2). What the research does show us is that vulvodynia is multifactorial and it requires a multidisciplinary approach when it comes to treatment.

A recent study by Goldfinger et al. (2016) compared cognitive behavioral therapy, which involved items such as diaphragmatic breathing and desensitization exercises, to physical therapy for the treatment of vestibulodynia, a common form of vulvodynia (3).  Their findings were that both types of treatment decreased pain and improved both perceived control over pain and pain catastrophizing.

A few research studies on vulvodynia treatment are in progress as well – one is a large randomized control trial (RCT) comparing physical therapy treatment including education, manual techniques and intravaginal biofeedback to a nightly 5% lidocaine ointment application (4), and another proposed RCT is examining the efficacy of non-invasive transcranial direct-current stimulation to treat women with vestibulodynia in attempt to target the central mechanism of pain sensitization (5). All in all, what we do know is that there is a lot that we still do not know, and there are exciting times ahead as we look to see where the research will take us.

If you would like to read some inspirational stories on how physical therapy was able to help individuals suffering with pelvic pain, then check out this recent article from MoveForwardPT here and this case study on vulvodynia here.

For additional information and resources, check out the National Vulvodynia Association at http://www.nva.org/

References

1. B.L. Harlow, C.G. Kunitz, R.H. Nguyen, S.A. Rydell, R.M. Turner, R.F. MacLehose, (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: populationbased estimates from 2 geographic regions, Am. J. Obstet. Gynecol. 210 (1).
2. Fariello, J. Y., & Moldwin, R. M. (2015). Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management. Translational Andrology and Urology, 4(6), 643–652. http://doi.org/10.3978/j.issn.2223-4683.2015.10.09
3. Goldfinger, C., Pukall, C. F., Thibault-Gagnon, S., McLean, L., & Chamberlain, S. (2016). Effectiveness of cognitive-behavioral therapy and physical therapy for provoked vestibulodynia: A randomized pilot study. The journal of sexual medicine, 13(1), 88-94.
4. Morin, Dumoulin, Bergeron, Mayrand, Khalifé, Waddell, & Dubois. (2016). Randomized clinical trial of multimodal physiotherapy treatment compared to overnight lidocaine ointment in women with provoked vestibulodynia: Design and methods. Contemporary Clinical Trials,46, 52-59.
5. Morin, Annie, Léonard, Guillaume, Gougeon, Véronique, Waddell, Guy, Bureau, Yves-André, Girard, Isabelle, & Morin, Mélanie. (2016). Efficacy of transcranial direct-current stimulation (tDCS) in women with provoked vestibulodynia: Study protocol for a randomized controlled trial. Trials,17, Trials, 2016, Vol.17.

Written by Kayley Mikolajczyk, a 3^rd year PT student at the University of Minnesota and Assistant Director of Research for the Section on Women’s Health Student Special Interest Group.

Advocating for Patients Who Are Transgender

As a student physical therapist, I witnessed some incredible examples of competent and compassionate care. The only experience that did not live up to this standard was with a patient who was transgender. I observed this patient being treated exclusively with passive modalities, likely because the treating therapist was uncomfortable dealing with her (thankfully, my instructor advocated for this patient and took over her care). This experience stuck out in my mind for years to come. The APTA Code of Ethics¹ implores us to treat all patients with dignity and respect, as well as to recognize our own personal biases. Why was it so hard for this otherwise compassionate therapist to do so with this one particular patient?

The July issue of PT in Motion featured an article entitled “Managing Patients Who are Transgender”. If you have not read it, I highly suggest that you read it here. This article² provides information for creating a welcoming space for our patients in the LGBTQ community and addressing sensitive issues that may come up during the course of treatment. According to the article, our own Section on Women’s Health is compiling resources for practitioners regarding issues of gender and sexual orientation. This is extremely important, as these topics are barely covered in PT education, if at all. The article states that 70% of patients who are transgender report some form of discrimination within the healthcare system, and 28% report postponing medical care for fear of mistreatment. As Women’s Health physical therapists, we have a unique opportunity to end this cycle and to serve as advocates for all of our patients.

Curious about the experiences of patients who are transgender, I decided to ask a dear friend of mine to share his thoughts on dealing with the healthcare system. Aryn was born physically female, and announced his transition to the male gender several years ago. He states that he hasn’t experienced any outright abuse when dealing with healthcare professionals, but has had several instances where he felt neither heard nor respected. He has a primary care physician who has years of experience with the LGBTQ community. When dealing with other providers who do not have this level of expertise, however, he describes the experience as “hell.” In particular, he states that providers have seemed fixated on questions that feel irrelevant to his medical complaints, such as whether or not he has had gender reassignment surgery and why or why not (of course, there are times when this information may be important for the practitioner, but he feels that it has been overemphasized). He also describes medical professionals looking at him like he is “a freak or crazy, and I am neither of those things.”   As healthcare professionals, we need to consider what this would be like as a patient—to seek treatment for one ailment only to find your physician more (perhaps solely) interested in an unrelated aspect of your life. Would you feel like you were receiving the best possible care?

I asked Aryn if he had any advice for a new healthcare practitioner when working with patients who are transgender. He answered, “You are the doctor. It should not be my responsibility to educate you about the special needs of the transgender community. Educate yourself, and then educate your peers.” This resonated with me, as I realized that the Section on Women’s Health is one of the only voices in the PT community trying to do just that. We have a wonderful opportunity to be leaders in this area- we can educate ourselves and share resources with our peers, and we can commit ourselves to providing the highest quality, most culturally sensitive care to every single patient we see.

1. Swisher LL, Hiller P, others. The revised APTA Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant: theory, purpose, process, and significance. Phys Ther. 2010;90(5):803-824.
2. Hayhurst C. Managing Patients Who Are Transgender. http://www.apta.org/PTinMotion/2016/7/Feature/Transgender/. Accessed July 26, 2016.

About the Author:

 Lisa Cheek, PT, DPT, is a 2016 graduate of Regis University.  She currently serves as the Assistant Director of Membership for the SOWH SSIG.  She is passionate about educating healthcare practitioners and the community about pelvic health PT.  She is currently employed at N2 Physical Therapy in Denver, CO, a specialty pelvic health and oncology clinic.

 

Evaluation of Percutaneous Tibial Nerve Stimulation for the Treatment of Refractory Painful Bladder Syndrome

By Yewande Apatira

Painful bladder syndrome/interstitial cystitis (PBS/IC) is a condition that has garnered much interest over the years. Several treatment strategies for the management of PBS/IC have been researched into, including percutaneous tibial nerve stimulation (PTNS). Percutaneous tibial nerve stimulation (PTNS) is a minimally invasive treatment during which a needle electrode is inserted about one and a half to two inches proximal to the medial malleolus, and slightly less than an inch behind the tibia. Flexion of the great toe or fanning of the remaining toes confirms correct placement of the electrode. The intensity selected is the highest level tolerated by the patient, and sessions are performed for 30 minutes, one time a week for 10 to 12 weeks.

Several theories have been proposed for the positive effects of PTNS on PBS/IC and overactive bladder (OAB) syndrome. The tibial nerve, a branch of the sciatic nerve has fibers from nerve roots L4 to S3 and courses down the posterior lower leg, passing behind the medial malleolus en route the sole of the foot. The parasympathetic control of the bladder arises from sacral roots S2 to S4, and therefore, one theory is that stimulation of the tibial nerve leads to stimulation of S2 and S3 which in turn suppresses detrusor overactivity. Another theory discovered through animal studies is that PTNS decreased mast cell counts in the bladder of the female rats post-stimulation.

In a recent study by Ragab et al. 20 women aged between 31 and 53 years, with an average duration of PBS/IC symptoms of about five years and with poor response to other forms of treatments, were treated with PTNS for 30 minutes, one time a week for 12 weeks. At initial evaluation the majority of the patients (85%) complained of suprapubic pain, all patients reported frequency of micturition and nocturia, and glomerulations were seen in 95 percent of subjects. The outcome measures included the visual analog scale (VAS) for pain, O’Leary-Sant interstitial cystitis symptom index (ICSI), O’ Leary- Sant interstitial problem index (ICPI) and global response score (GRA). Measures were repeated after 6 and 12 weeks of treatment. Compared to baseline, no significant changes in all the outcome measures were recorded. However, the pain completely disappeared in one patient after 12 weeks.

The authors addressed only one aspect of PBS/IC, however PBS/IC has several drivers, including pelvic floor dysfunction and these drivers vary from person to person.  Therefore, reliance on only one form of treatment may not yield lasting or significant results for all patients. Furthermore, due to the chronicity of the PBS/IC among the subjects, chronic pain education and strategies may have been beneficial.

References

• Gaziev G, Topazio L, Iacovelli V, et al. Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC Urol. 2013;13:61.
• Preyer O, Umek W, Laml T, et al. Percutaneous tibial nerve stimulation versus tolterodine for overactive bladder in women: a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. Vol 191. Ireland: 2015 Elsevier Ireland Ltd; 2015:51-56.
• Ragab MM, Tawfik AM, Abo El-enen M, et al. Evaluation of Percutaneous Tibial Nerve Stimulation for Treatment of Refractory Painful Bladder Syndrome. Vol 86. United States: 2015 Elsevier Inc; 2015:707-711.

Non-hip, Non-vertebral Fracture Sites: Don’t Forget About Me!

Why do hip and vertebral fractures get all the glory when it comes to fracture prevention related to osteoporosis in the current literature?  One study by Holloway et al. published in Osteoporosis International set out to change that trend.  The goal of the study was to introduce identified risk factors for non-hip non-vertebral fracture (NHNVF) sites, which commonly include the ribs, pelvis, humerus, forearm, wrist, upper and lower leg, and compare those risk factors to those for hip and vertebral fractures.  The authors suggest this is an important topic to look into because it has been found that NHNVF sites are actually responsible for a greater proportion of fractures when compared to hip or vertebral fractures.

Let’s get into how the data was collected before we dive into the results.  Control data was obtained from the Geelong Osteoporosis Study, which is a population based study that comes from southeastern Australia. Potential participants with fractures were obtained from the Geelong Osteoporosis Study Fracture Grid, and those who were 60 years of age and older and who sustained a fracture were then invited to participate in the study.  Final participants included 734 men and 1427 women.

How were those who had fractures different than controls in this study? The study found that women with NHNVF’s were heavier, while those with hip fractures were more likely to be older, have higher reports of past smoking, alcohol consumption and walking aid use, and reported lower mobility levels.  Women who had vertebral fractures had higher rates of dairy consumption.

Participants who had NHNVF’s were then compared to those who had hip fractures. Women who experienced a NHNVF had higher age-adjusted bone mineral density (BMD) levels at the femoral neck and spine, were heavier, had higher mobility rates, and reported more alcohol consumption.  In contrast, women who experienced hip fractures were on average older, had higher rates of past smoking and low dairy consumption, and reported using a walking aid more.   When women who experienced NHNVF’s were compared to those who had vertebral fractures, they found that those with NHNVF’s had higher age-adjusted BMD at the femoral neck, spine, ultradistal forearm, as well as total body.  Those with NHNVF’s were also heavier, younger, and reported more falls.

So what do these findings mean to us as physical therapists and physical therapy students?  This study has identified that the risk factors for different fracture sites are variable, and fracture prevention strategies should take this into consideration when developing prevention programs and identifying those individuals most at risk.

If you are interested in seeing how different clinical risk fractures (such as previous spontaneous fracture, parental hip fracture, history of smoking or alcohol use, RA, glucocorticoids, secondary osteoporosis, and BMD) can effect an individual’s risk for the development of fractures, check out the World Health Organization fracture risk assessment tool at http://www.shef.ac.uk/FRAX/.

Written by Kayley Mikolajczyk, a 3^rd year PT student at the University of Minnesota and Assistant Director of Research for the Section on Women’s Health Student Special Interest Group.

References:

Holloway, Henry, Brennan-Olsen, Bucki-Smith, Nicholson, Korn, Sanders, Pasco, and Kotowicz. “Non-hip and Non-vertebral Fractures: The Neglected Fracture Sites.” Osteoporosis International 27.3 (2016): 905-13. Web.