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 birth2,3.  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 programs6-9 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 2nd 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 3rd 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 Urology4(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 medicine13(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 3rd 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:

Bio_pic 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 3rd 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.

 

Bladder Control: the topic that needs to be addressed more.

Most patients do not want to address this topic of incontinence, or loss of bladder control, unless it is directly asked. For many it is an embarrassing topic. Others believe it is something they just have to live with. That is far from true though. The sooner a patient seeks help for urinary incontinence the better. As physical therapists that spend quality time with patients, this is a topic we should address. It is often overlooked in primary care visits. Since we are musculoskeletal experts we should be providing optimal care and addressing musculoskeletal concerns. Incontinence can be due to muscle weakness that physical therapists, in particular pelvic floor or women’s health therapists can treat. It could also be due to bladder irritants. For a list of irritants go to: http://www.hopkinsmedicine.org/johns_hopkins_bayview/_docs/medical_services/gynecology_obstetrics/bladder_irritants.pdf

In 2009, a study was done looking at women from 25-80 years old in a managed care setting that had not been previously diagnosed with incontinence. The study conducted by Wallner et al found that out of the 875 women, 52% reported incontinence in the past year and 39% reported incontinence in the past week. This is alarmingly high considering incontinence has been linked to depression and nursing home admissions. This is an area that needs to be addressed more frequently in the health care field. So below are some ways to start.

Basic questions that all therapists should ask:

Do you experience any issues with bladder control? Making it to the bathroom on time or leaking when you cough? Or do you have to go frequently?

If yes, ask more:

How long has it been occurring?

Are you on any diuretics, HTN medications, depressants, or sleeping pills? (These can cause acute incontinence.)

How much do you drink per day?

How often do you need to go to the restroom during the day and at night?

Normal values therapists should know:

Average number of times you should urinate a day: 6-7 but it will vary depending on how much fluid you consume and if on diuretics. Anywhere from 4-10 times a day can be normal.

Average number of times one should have to urinate through the night: 0-1 time

Patients should consume eight 8 oz glasses of water per day or about 2 liters or ½ gallon.

If patients say they have to urinate frequently or cannot hold the urge, talk to them and see if they would be interested in seeing a PT that could address that issue!

What can be done to help with bladder control? Pelvic floor muscle re-education and training with biofeedback, pelvic floor strengthening, bladder diaries, avoiding bladder irritants, education on proper techniques to decrease intraabdominal pressure. Patients can look for physical therapists that have received additional training in this and have their Certification in Achievement of Pelvic Physical Therapy (CAPP). Click here to find a CAPP Certified Therapist: http://www.womenshealthapta.org/education/find-a-capp-certified-therapist/

 

Written by April Wenthe, SPT, a 3rd year at Maryville University in St. Louis, MO.

References:

Wallner LP, Porten S, Meenan RT, et al. Prevalence and severity of undiagnosed urinary incontinence in women. Am J Med. 2009: 122(11):1037-42. doi: 10.1016/j.amjmed.2009.05.016.

http://www.moveforwardpt.com/symptomsconditionsdetail.aspx?cid=a357f7d4-02f1-49cc-b03c-299c69d6dfc6