By Melinda Fontaine

The physical and occupational therapistss at PHRC work as a team to help each other figure out the most efficient ways to help our patients. One way we share information is through weekly case studies, where one of our physical and occupational therapistss describes a patient’s case, why they chose to evaluate the structures they did, how the results of the evaluation lead to an assessment and treatment plan, and how the therapists carried out the treatment plan to help the patient reach their goals. This week’s blog features a case study by Melinda Fontaine, a PHRC physical and occupational therapists in our Berkeley location.

 

Here is what Melinda has to say:

 

ABOUT ROBERT

Robert, a healthy 34 year old man, started having pain in his tailbone, especially with sitting, driving, having sex, having bowel movements, and exercising. The only things he could think that might have contributed to his pain were heavy squats and abdominal workouts. He later started to have scrotal pain as well.  Robert went to a doctor who did a pudendal nerve block.  After the nerve block, he developed a rectal abscess at the site of the injection, which is an uncommon response to the procedure.  This abscess then turned into a fistula, which is an abnormal tunnel between the anal canal and the skin. Fistulas are problematic because they can lead to serious infections.  Because of this risk Robert underwent a fistulotomy, a surgical procedure to open a fistula and help it heal. This helped the fistula but his pain persisted.  Robert started seeing a physical and occupational therapists, but had to stop because the drive was too long and he had tailbone pain with sitting.

 

ROBERT’S PHYSICAL THERAPY FINDINGS

Four years after the start of his pain, and with no relief, Robert decided to seek out pelvic floor physical and occupational therapy. He found PHRC on the web and came in for an evaluation. Since the pain started with heavy abdominal workouts, I examined the abdomen for a cause and found tight rectus abdominus muscles with trigger points. The rectus abdominus commonly refers pain to the genitals, so I confirmed that he should not be doing abdominal exercise until his rectus abdominus issues had been addressed. I looked at the muscles near the tailbone for sources of the tailbone pain and found left coccygeus trigger points externally that reproduced his tailbone pain. Also, Robert had fascial restrictions around his ischial tuberosities, or ‘sitz bones’.  Because of his scrotal pain and urinary hesitancy, I also examined the muscles of the pelvic floor located near the urethra and found high tone in ischiocavernosus and bulbospongiosus. Because of their connections near the urethra, the ischiocavernosus muscles can lead to urinary hesitancy by not releasing fully and immediately. I also looked for any signs of the abscess and fistula and could not find any adherent scar tissue.

 

POTENTIAL CAUSES

I explained how repeated heavy squatting created coccygeus trigger points and fascial restrictions at the ischial tuberosities.  This pulled on Robert’s tailbone creating pain. His pelvic floor started to become tight in response to the tailbone pain and new length-tension relationship in the posterior pelvic floor muscles because of the abdominal workouts. Robert reported that manual therapy had helped previously, which is often the case when there is a muscular issue.  For Robert’s particular case, we don’t know if the pudendal nerve block helped because it immediately turned into an abscess.  I concluded the scrotal pain and urinary hesitancy are results of the tight anterior pelvic floor muscles around the urethra and the rectus abdominis trigger points.

 

TREATMENT PLAN

The initial plan was to perform manual trigger point release to the rectus abdominus and coccygeus muscles, connective tissue manipulation around the ischial tuberosities, and myofascial release to the ischiocavernosus and bulbospongiosus muscles internally and externally for 8-12 weeks. Robert’s home program consisted of pelvic floor drops/releases and self myofascial release using a tennis ball around the coccygeus and pelvic girdle muscles. He was already doing a stretching routine of pigeon, butterfly, and cat/cow stretches, which he reported felt good, so he continued with these stretches.

 

Robert’s goals for physical and occupational therapy were:

• Tolerate sitting 1 hour at a time repeatedly for a full day of work
• Tolerate sitting 2.5 hours for car ride, which he does often with family
• Return to weight lifting without pain
• No pain with sex
• No pain with bowel movements

 

PROGRESS

At the third visit, Robert reported feeling “a lot better”.  When the trigger points in his rectus abdominis were reduced, we started core strengthening.  His transversus abdominis was weak, and I wanted it to work harder especially during his weightlifting, so that his pelvic floor did not have to work as hard, which can result in injury and likely the coccygeus, pain-causing trigger point. I waited until the point when the trigger points were relieved because I was concerned that he would activate his rectus abdominus during transversus abdominus exercises. People with pain/trigger points often have faulty motor recruitment patterns which can lead to further pain/dysfunction. When left uncorrected, the faulty motor patterns can result in normal movements causing abnormal stress on structures and subsequent impairments and pain. Once corrected, people can resume exercise without trouble.  Next, we added light weight lifting exercises for the upper body in a seated position to ease the demand on the pelvic floor. At visit 4, he was sitting for 4 hours at work with standing breaks and the coccygeus trigger points were gone. Robert reported no pain with bowel movements and less pain after sex. He gradually increased the intensity of his workouts. On the 5th visit, he was sitting for a full work day with standing breaks. On the 9th visit, he increased exercises too much and felt a pull in his abdominal muscles. I treated the attachment of rectus abdominis at the pubic symphysis which reproduced his pain, and his pelvic floor muscles were more hypertonic that day as well in response to this incident. This eliminated his symptoms.  After the 10th visit, he took a 5 hour flight.  He had a little discomfort on the way there because he sat for almost the whole 5 hours.  Otherwise, he reported no pain on the trip or after he returned! Robert and I were both pleased that his goals have been met.  His progression followed what I expected given his initial assessment. We planned to have Robert increase his workout intensity and follow up with me in 3-4 weeks.

 

Now, several months later, Robert’s goals have been met and he has been discharged from physical and occupational therapy.  

 

Take Away Messages from the PHRC team

 

Melinda did a great job identifying that Robert’s exercise routine may have specific implications to his abdominal wall and pelvic floor muscles. This suspicion guided her evaluation; she identified that palpation of these structures reproduced the pain Robert was experiencing. Malinda’s treatment plan was effective because she began with manual therapy to treat his impairments and supplemented the therapy with a home program. Then, she helped him identify faulty movement problems and weak muscles. She was able to help him correct these deficiencies and help return to exercise in a manner that was therapeutic versus provocative. The timing on how and when to introduce activities is important when restoring function and transitioning back into the very activities that initially caused problems. With proper rehabilitation it is possible!

 

Hormones drive me crazy. As a woman, my biological clock seems to be more like an overactive alarm clock lately. For example, on a certain day I may see a baby and feel an intense urge to procreate. It is as if my uterus wants nothing more than for me to have 18 babies right now and then star in my own reality show on TLC. If we fast forward a week, I may see the same baby and be grateful for birth control.  Although each month I experience some sort of unending hormonal rollercoaster, my patient’s ride may come with more than just cravings for chocolate and binging on episodes of The Bachelor. In fact, these hormonal fluctuations may greatly contribute to their pain levels and even their ability to function.

 

In my professional life, I find helping my patients navigate the world of hormones to be frustrating. Why? Because hormone levels are constantly changing: daily, weekly and monthly. So if a patient wants to be tested for a potential hormone dysfunction, it is difficult to ensure that any lab work done will show the full hormonal picture for that particular person. It is not impossible mind you, but still difficult. Also, there isn’t just one hormone for one body part or one hormone that controls one bodily function (It makes sense since there isn’t even one brand of toothpaste nowadays, so why would the human body be any simpler but I digress). With this in mind, it is my goal to uncomplicate the topic of hormones. To make it even easier, (and to keep this post from becoming a dissertation) I will only discuss on the “main” hormones of the female reproductive system. Some of these hormones are also present in men, but again to keep things simple I will only talk about these hormones and how they impact women.

 

Let’s start with the three that get the most notoriety: Estrogen, Progesterone and Testosterone.

Wait a minute, I thought only men have testosterone!? That is false. The ovaries, along with the adrenal glands, produce a small amount of testosterone. This hormone is involved in bone and muscle mass formation. Testosterone may be linked to a woman’s sex drive, but like with most things libido can be impacted by many other factors, like some Marvin Gaye and pictures of Ryan Reynolds, but that is just a personal preference. Speaking of sex, testosterone helps keep the glands in the vulva functioning like a well oiled-machine. These glands contribute to increased lubrication during sexual arousal, which can make sexual activity more fun. Now during the menstrual cycle, testosterone peaks right around ovulation, which may be the body trying to promote the chance of intercourse and therefore pregnancy. To understand why this would happen, it is important to understand the process the body goes through to prepare for a potential pregnancy, which brings us to our next hormone: estrogen.

 

There are actually three types of estrogen: Estradiol, Estrone and Estriol. Estradiol is the most common form in nonpregnant women and is produced by the ovaries. Estriol is most abundant in pregnant women as it is produced in large amounts by the placenta, and estrone is produced in lower amounts from the ovaries, liver and fat tissue. Again, to keep things simple for the remainder of this post I will refer to all the forms as estrogen.

 

Estrogen is the hormone responsible for that fun time known as puberty. It is the sex hormone that causes breast development, hair growth and for menstruation to begin (Woohoo!).  During the reproductive years (teens to forties) estrogen levels fluctuate during the month. During menstruation, one’s estrogen levels are pretty low, and your body has some cool Jedi skills that sense this and cause a release of two other key hormones Follicle-Stimulating Hormone (FSH) and Luteinizing Hormone (LH). FSH and LH go tell the ovary that it’s time to get another egg ready to be released. The ovary begins to produce more estrogen, which is telling your uterus to get ready for the upcoming houseguest and helps “ripen” the egg into maturity. A woman’s estrogen levels continue to rise until mid-cycle, which causes a spike in LH which is what tells the egg, in Price is Right style to “Come on down!” Estrogen levels begin to increase again (along with progesterone, which I’ll talk more about later) to help keep the uterus nice and habitable in the event the egg is fertilized. If the egg is not fertilized, then estrogen levels drop and the body sheds the uterine lining and the whole process starts again.

 

Now what if the egg is fertilized? In pregnant women estrogen levels continue to rise, until the end of the first trimester and then they level out. However, during delivery estrogen levels sky-rocket and then plummet. A woman’s estrogen levels will continue to be low during the postpartum period, especially if a woman is breastfeeding, as the hormone that allows for lactation is antagonistic to estrogen production. This decrease is estrogen may be one of the causes of Postpartum Depression (PPD) as estrogen can impact mood and behavior.

 

Now as women age, estrogen levels continue to change. Estrogen levels continue to decline which is what results in something called Menopause. Many people associate this with the end of their periods and therefore a cause for celebration, but a decline is estrogen comes with negative side effects.

 

First, Estrogen is also involved in bone health, which is why osteoporosis is a concern during menopause. Estrogen helps prevent bone resorption, or breakdown, so as your estrogen levels drop, which they do during menopause, your bones are no longer as protected and susceptible to bone loss. Second, the vulva and the vagina are big fans of estrogen, because this hormone keeps the tissue thick, elastic and moist. So less estrogen can mean thinner, drier and impaired vaginal tissue. A decrease in estrogen can cause an increase in the vaginal pH which puts postmenopausal women at an increased risk for UTIs.

 

Now let’s move on to another important hormone: Progesterone. Progesterone is also produced by the ovaries, as well as the placenta and the adrenal glands. As your estrogen levels decrease mid-cycle, your progesterone levels begin to increase to help prepare the uterine lining in the event pregnancy occurs. Again, if the egg is not fertilized progesterone levels drop and menstruation begins. But during pregnancy, the placenta continues to produce progesterone to maintain the uterine lining. Progesterone, along with estrogen, help maintain pregnancy by preventing ovulation. Similar to estrogen, progesterone levels rise and then plateau. This hormone relaxes smooth muscle in the body, including the uterus, as well as blood vessels in the body. This can lead to low blood pressure or dizziness during pregnancy. It also stimulates milk gland production during pregnancy. During delivery, progesterone levels also increase and then drop dramatically. This drop in progesterone allows for an increase in prolactin which stimulates breast-milk secretion. A decline in progesterone may also play a role in PPD, as progesterone plays an important role in brain health. Similarly, a disruption in progesterone can be the cause of PMS. Since most of these hormones impact one another, any mishap in the many feedback loops can lead to a hormonal imbalance.

 

But wait, if our bodies are amazing self-regulating machines, how can our hormones get all out of whack?

First, there is our good pal genetics. Some researchers suspect that some individuals carry genes that lead to hormone imbalance which can then cause certain diseases, such as endometriosis and polycystic ovarian disease (PCOS). The jury is still out on that one, but some women may just be wired to over or underproduce certain hormones.

 

Luckily, there are some more concrete factors that can impact hormone levels. For example, diet can affect your hormone levels, some key dietary culprits that can mess with your hormone levels include: sugar, dairy, meat and soy products. (I will discuss this topic more in a later post, so stay tuned).

 

Stress is another factor that can bully our poor hormones. To break it down, stress leads to increased production of a stress hormone: cortisol. Cortisol is very helpful when produced in appropriate quantities, but if a person is continually stressed and the body overproduces cortisol it can begin to mess with the balance of other hormones, including the sex hormones discussed above. Making sure you take time to relax during your busy workday is important to allow for hormonal harmony to exist. For those of you hip with the times, there are some great apps these days for mindful meditation such as: Headspace, Insight Timer and Breath. Making sure you get enough sleep is also important in keeping your hormone levels in check.

 

Finally, there are medications that can impact hormone levels, primarily oral contraceptive pills (OCPs). A few years ago, we discussed the impact of OCPS and vulvodynia.To summarize, OCPs produce a protein that inhibits androgen-hormones ie testosterone. This can lead to problems with lubrication during arousal and sexual activity and therefore lead to pain. OCPs can also mess with your bodies natural hormone production of progesterone and estrogen, which as we know play a role not only in mood and brain health but vaginal and vulvar integrity. A decrease in these sex hormones can lead to the same structural changes as described in postmenopausal women. This is not to say that taking the birth control pill is going to cause you to go into early menopause or develop pain with intercourse, but it is something to consider if you are noticing symptoms and are unsure of the cause.

 

Now that was a lot of information. Again, I couldn’t cover everything and plan to return with more information regarding hormones and all the fun things they do. But hopefully this cleared a few things up or taught you something new! Or maybe it raised more questions? Please let me know your thoughts!

Regards,

Rachel Gelman, DPT

 

At PHRC we treat a wide variety of patient populations. One population that we’re beginning to see more often is patients undergoing treatment for anal cancer.

Recent research has shown that the incidence of anal cancer, which is linked to the human papillomavirus (HPV), is on the rise, especially among men and women under the age of 45.

Although we’re seeing more of these patients, they remain highly underserved when it comes to physical and occupational therapy. That’s because many physicians and patients simply are not aware of the help that physical and occupational therapistss, specifically pelvic floor physical and occupational therapistss, can offer.

Thus, I’ve decided to write this blog, which gives a complete overview of how pelvic floor PT can help anal cancer patients.

Anal cancer is a malignancy that starts in the anus, the opening at the end of the rectum. The American Cancer Society estimates that 7,210 cases will be diagnosed in 2014. The good news is that when detected early, anal cancer is usually curable. This page on the website of the Anal Cancer Foundation is one of the best sources of information on the disease.

Anal cancer is typically treated with combined chemoradiation therapy, and even in early diagnoses, treatment can often have serious and difficult side effects.

Patients who receive local radiation to their pelvis and anus, for example, may suffer from long-term fatigue, gastrointestinal, and sexual health dysfunction. In addition, in women, treatment may result in vaginal stenosis, which is the narrowing of the vagina due to scar tissue formation, and anal stenosis, often rendering sexual activity extremely painful. For men, it cause erectile dysfunction and anal stenosis.

Fortunately, pelvic floor PT can help with these side effects, as well as with the following:

• hip pain and/or pelvic pain, patients will often say that they feel as though they’ve lost range of motion in their hip/pelvis;
• surgical pain if there is a surgery;
• fatigue, which can be a short-term or long-term effect;
• lymphedema, which is localized fluid retention due to a compromised lymphatic system;
• general musculoskeletal impairments, such as overall weakness, neuropathy or just general deconditioning;
• pelvic floor dysfunction, which includes, in addition to the above-mentioned issues, gas and fecal incontinence, urinary symptoms, such as hesitancy or a weak urine stream;
• and scar tissue due to radiation burns.

PT can Help

I believe there is a big role that physical and occupational therapy can play in the management of the above-mentioned side effects. While there is not much research literature to support this, we’ve seen very good clinical evidence that indicates pelvic PT is worth the time and resources for patients.

So exactly how can PT help?

For one thing, many patients experience musculoskeletal pain as a result of treatment, typically in the pelvic area. Even areas of the pelvis that haven’t been radiated can be affected due to radiation of nearby tissue. To be sure, the pelvic floor can act as a veritable house of cards, where one problematic area can cause issues to adjacent areas. Thus, manual therapy techniques such as myofascial trigger point release, connective tissue manipulation, scar mobilization, and joint mobilization can treat the affected tissues.

For pelvic floor dysfunction caused by stenosis of the anus and/or vagina, manual therapy can help to maintain the openness of the organ. Patients with stenosis also need to be placed on a dilator program that ensures progress continues outside of treatment. A PT can help patients learn how to use dilators, and monitor their progress.

Another pelvic floor-related issue that can occur as a result of cancer treatment, is gas and/or fecal incontinence. This is because radiation therapy can damage the integrity of pelvic floor tissues, which can in turn cause a laxity in the muscles that results in uncontrollable gas, or a loss of bowels. There may also be a situation where tissue such as the external sphincter, must be removed.

For its part, pelvic floor rehab can help to strengthen any affected muscles by using techniques such as biofeedback, patient education, and/or neuromuscular electrical stimulation. That said, although gas and fecal incontinence are dysfunctions that pelvic physical and occupational therapy can help to decrease, I should make it clear that we can’t always completely cure these issues.

When it comes to overall function, patients often feel that their body has significantly changed as a result of having endured incessant pain or fatigue. Many patients that I have treated feel as though they’ve lost mobility, strength, or their muscles have been deconditioned as a result of lack of use. As PTs, we can help to recondition patients by working to correct their posture, sitting position, gait and walking, and by treating any lower back or hip impairments with manual therapy, neuromuscular reeducation, and patient-specific exercises.

Fatigue is a big issue for patients going through cancer treatment. And there is evidence to support that PT is a great tool that can help combat chronic fatigue. A therapist can help patients pace out their daily activities, and whenever possible, help them to resume physical activity. When it comes to a body in motion, we want to place patients on a program that combines aerobic, strengthening, stretching, and balance activities.

A final point that I’d like to mention pertains to lymphedema caused by cancer treatment. If for instance, lymphedema occurs in the groin area, pelvic floor rehab can manually drain the lymphatic system, and decrease symptoms like pain and swelling.

For any patient who is considering pelvic floor rehab, please be aware that it’s a good idea to receive clearance by your physician in order to start therapy. Additionally, like all other forms of therapy, it’s important to give PT a fair chance to make a difference. Meaning, this type of therapy requires at least a three to twelve month patient commitment. However, patients may not be required to come on a weekly basis.

If you have any questions about pelvic floor rehabilitation in the case of anal cancer treatment, please do not hesitate to leave them in the comment section below.