#PTonICE Daily Show

Dr. Christina Prevett discusses rethinking post-operative guidelines for enhanced recovery and challenging traditional restrictive guidelines. She emphasizes advocacy and collaboration in elderly care, highlighting the importance of smooth handoffs and advocating with evidence and respect to improve care outcomes.

Dr. Cody Gingerich, a physical therapist specializing in extremity management, discusses the hidden details of tendinopathy. He emphasizes the complexities of treating tendinopathies, addressing weaknesses, movement patterns, managing stress, compression, and the impact of speed on tendon aggravation.

Dr. April Dominick // #ICEPelvic // www.ptonice.com  In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick shares how YOU can make a huge impact on the quality of life of a client with an upcoming prostatectomy simply through education on pelvic floor muscle retraining, lifestyle changes and physical activity AND learn the ESSENTIAL clinical pearls to include in a pre-operative physical therapy session when working with this population. Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our live pregnancy and postpartum physical therapy courses or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. Are you looking for more information on how to keep lifting weights while pregnant? Check out the ICE Pelvic bi-weekly newsletter! EPISODE TRANSCRIPTION APRIL DOMINICK This is Dr. April Dominick. I am on faculty with the ICE Pelvic Division. Today we are chatting about prehab for a prostatectomy surgery. Why is prehab important and what should be included in your PT session with that pre prostatectomy client? This topic, it is so near and dear to my heart. it's because these humans just don't have the treatment or education that they deserve prior to going into these surgeries and afterwards when they come out. And if I can convince you why it is so important to be able to connect with these humans and to even just educate them on, hey, there is Help for you. There's pelvic floor muscle training that can be done education about behaviors whether that is you actually doing the PT session or you referring them to someone else it can have incredible outcomes for them post-op just because they are aware of pelvic floor physical therapy for their surgery the prostatectomy so Let's dive into what a prostatectomy surgery actually is. It is something to treat prostate cancer, and that's going to be by removing part or the full gland of the prostate. They're also going to remove surrounding tissues and seminal vesicles. The gold standard for surgery is a radical prostatectomy where they remove the entire prostate gland. I didn't have a walnut, so here's what we're working with. This fig represents the prostate. So let's run through some real estate of where everything is situated in someone with a prostate in terms of the pelvic floor and the organs. So we have our bladder here and then we have the bladder neck with the urethra that goes through our prostate. and this is going to be representative of the urethra itself. So the urethra goes from the bladder neck through this fig or the prostate and then down into the penis and that is how everything is set up. With a prostatectomy, after the prostate is removed, that extra support around the urethra is now lost, and the remaining bit of that urethra now needs to be reconnected back to the bladder. This reconnection, we can think about it like a bridge, or a fancy term is the anastomosis, and that anastomosis needs time to heal. So a Foley catheter is placed in for about five to ten days. That means that the bladder is or the urine is emptying passively. The bladder is not doing its job. It's off on vacation. And then once the catheter is removed, the bladder acts like it forgot how to start or how to store urine. It doesn't know what to do with it. And so we have a lot of urinary leakage. So among other things, this is why urinary incontinence or urinary leakage is a major side effect with these prostatectomy surgeries. post-op, the external urethral sphincter is relied on for maintaining continence. So good news for us, the pelvic floor muscles help to close that sphincter and keep pee in until it's appropriate to release it. And that's why pelvic floor muscle training with physical therapy can be so important pre-op and post-op, at least from the bladder side of things. So who does the prostatectomy surgery affect? Well, obviously those diagnosed with prostate cancer. It is the second leading cause of death from cancer in males. It's going to affect our individuals who are older than 50 years old and who are African-American. So if you think about who you are treating currently, if you're treating individuals who have prostates who are older than 50, one in eight of them are probably gonna have some run-in with prostate cancer, whether that's treated with a surgery or not. That's where you come in. You could have such a profound effect with these individuals just by educating them that pelvic floor muscle training exists And whether you're again, whether you're doing the treatment or you're referring out to someone else, you can have such an incredible impact on their post-op outcomes potentially. So, We talked about with a post-prostatectomy, we talked about that surgery can result in urinary incontinence or leakage. It can also affect sexual function. There can be reduced physical function. Think about it. If you're leaking all the time, is that really going to convince or motivate you to go work out? For some, no. And then it'll also affect the overall health-related quality of life. Take 65 year old Phil. You've got a Phil in your clinic. You're already treating him for low back pain, um, with his hikes and his weightlifting, say. And he went in for his annual physical, and then he walked out with a date for a surgery for radical prostatectomy. Besides being in shock that he now has this potentially life threatening diagnosis, Phil comes in and is like, this happened. He's like, am I, am I ever going to be able to hike with my hiking group and not be the person that smells like pee? Am I going to be able to be cool with being in the changing room in the, in the locker room after my weightlifting session, like removing this soggy pair of underwear, or am I going to be able to enjoy sexy times with his partner? Well, since you're here and you intently are listening to this podcast, You, your first line of question is, hey, Phil, did they recommend any sort of physical therapy for you? Um, whether it's pre-op or post-op. And of course, Phil's like, no. So you teach him that pelvic floor muscle training can be so effective and helpful, um, and play a huge role in those side effects that he's worried about. Y'all, what if we could have an incredibly bigger impact, building the foundation, setting the stage for what to expect post-surgery, just with PT sessions? Clinically, I've been treating this population, hopefully you can hear my passion behind it, for about seven years. I've interacted with so many fills that come in, if they even get to me, right? and they are just slapped with that surgery date, and the side effects are kind of breezed through during their appointment, it seems like. And their concerns aren't really heard, their well-being and their questions, they're just kind of like not given a lot of attention. I didn't always do pre-op sessions, but once I started, hoo-wee, I was just blown away by how different the clinical outcomes were in terms of improving, whether that was decreasing the volume of urinary leakage for some or having them return back to their ADLs exercise a little bit sooner. The biggest thing, which was so powerful for me, is these people came in extremely uncertain, having no idea even why, if their doctor did send them to PT, why they were there. And they were just uncertain about these really scary side effects, about how maybe for the first time they were going to experience some sort of losing control of their bodies, from peeing unexpectedly to changes in their erections. And they walked out of that first session feeling a little more confident, a little more certain. And that is the power, I believe, of these pre-op sessions. And then from a research side of things, what's shaking out in the few RCTs that we have for these pre-op sessions and their effects on prostatectomy, some may be helpful in improving quality of life. they may affect a shorter hospital stay. They may reduce post-op urinary leakage in the short term. So some studies find around month one, three, or six, that the individual is leaking less, meaning they're drier faster. Now, when you compare someone who had some pre-op PT to someone who did not around 12 months, they are about the same with their rate. But I would argue that I bet folks are going to be a lot more satisfied if they did that prehab and they are drier sooner, right? So let's go into what a prostatectomy PT session entails before that surgery. We've got these sessions already in place. for folks who are going in for surgery for their ACL repair, for their hip replacement. But just like we're fighting with our pregnant and postpartum population, we are somehow having to fight for someone to have a pre-obsession for something like a prostatectomy, and that impacts so many daily functions. Let's outline what is involved in that pre-op PT session. Again, you can educate someone on what to expect if you're referring them to someone to do this. So we'll go over subjective, objective, and the treatment. From an assessment side of things, from that subjective piece, what you can be talking to your patient about is what are their current bladder and sexual habits? How many voids do they have during the day? How many times do they go pee? Do they have an urge? Do they have urinary leakage or hesitancy? And there are some outcome measures that go over these things. The International Prostate Symptom Score goes over those things. Plus they ask about nocturia or nighttime urination. And then the NIH Chronic Prostatitis Symptom Index is another outcome measure. And I love it because it asks about the impact of these symptoms. How is it affecting your quality of life? Then you want to also ask about their sexual function. How would they rate their erection strength or their satisfaction with their sexual life? From an outcome measure standpoint, you can give them the International Index of Erectile Function. This is something that asks them to rate qualities of their erection from the past four weeks. Then you want to also get a good idea of their current physical activity regimen. What a wonderful time to, if they're already a little physically inactive, hey, let's like plug in for, here's why it would be really great if you could up that physical activity. Not just for that immediate post-op surgical outcome, but also, hey, we can lower all cause mortality. And then from an objective side of things, so we went over the subjective, objectively speaking, we want to get a pelvic assessment. Whether that is over the clothes, external, near that midline, or it is a visual or tactile palpation, or an internal rectal assessment, if that's what you're trained in. So we're looking for, what's their awareness? Do they even know that they have this group of muscles that they can control? called the pelvic floor. We want to be looking at their coordination, timing of the pelvic floor, and then also getting an idea of what is their breathing and bracing strategies for things that increase interabdominal pressure, like fitness activities or functional lifting of the groceries, coughing, running, weightlifting. Typically, this population tends to be a breath holder. So we're gonna spend some time, there's just so much that we can do to help them in this area, to help them have improvements in their methods with that. And then we also wanna be doing some sort of general orthoscreen because what if their hips are cranky? Obviously that's gonna affect pelvic floor, low back, and all those surgical outcomes. From a treatment side of things, so we went over subjective, objective, highlights from the treatment side of things. where we'll talk about education, what to expect post-op, and some homework for them to work on. Education. I cannot stress this enough. The education piece here is vital for affecting their outcomes and well-being. Let's educate them on the pelvic floor. Here's what it is. Here's the anatomy and physiology. Here's how it affects your penis. whether that's for sexual health or for the urethra for urination. Here is what happens during the surgery. Get to know the surgeons in your area and which methods they use. What are their outcomes, right? And then you want to be explaining the risk factors for these side effects like urinary leakage and sexual function. dysfunction. Non-modifiable factors. If you're older, it's not going to help you as much. And if you already have some reductions in urinary function, like you're already leaking, that is not going to help you on the backside. Modifiable factors, tons. So things like smoking, poor nutrition, That is gonna delay healing post-op. Can we identify some current bladder irritants and reduce those immediately post-op? What about poor mental health? Things like low self-efficacy or if they're experiencing anxiety or depression, helping them ID these things and finding them some psychosocial support to have upcoming for the surgery and post-op, so key. and then reduced physical activity. Hard health is heart health. What do I mean by that? Erections, ejaculation, is related to vascular health. Hard health is heart health. So what affects our vascular system? Aerobic and resistance training exercise. If we can have them and talk to them about how it's important and how increasing that physical activity is going to improve their physiologic resilience to the surgery itself and any complications that come up, that is gonna be having such a huge impact on their quality of life. Regarding physical activity, in a 2014 RCT by Mina et al, they found that men who were meeting physical activity guidelines prior to surgery had greater health-related quality of life at six and 26 weeks post-op compared to men who were not meeting those physical activity guidelines. So, from a post-op perspective, we want to tell them what to expect. Urinary incontinence and sexual dysfunction. From the urinary incontinence side of things, they will have a Foley catheter in for five to 10 days. Remember, the bladder doesn't work during this time. Once that catheter is removed, we gotta retrain that neural pathway to help control the bladder so that they know, oh, my bladder is filling, or this is how I'm gonna stop that leakage from coming out, and how to fully empty the bladder. Another huge tip, have them bring a hygiene product, whether that's a pad or a diaper or something, with them to the hospital so that when they are discharged, they have something to help protect them on their way home or on their way to the store to grab their meds. And then urinary incontinence could be present from a couple of months to a year post-op. We see a significant improvement in that three to six month range, but it could be affected by things like, hey, it gets worse at the end of the day because the pelvic floor muscles are tired, or with transitional movements like sitting to stand. So working on these movements with them is gonna be super helpful pre-op. And then maybe talking to them about how, if you're not going to see them for 10 days or so post-op, we may be using the pad weight or the number of pads in a 24-hour period as a marker for our progress. So just having that in the back of their mind. When it comes to what to expect from a sexual function standpoint post-op, it can take up to two years to recover to baseline function from an erection standpoint. We want to set these expectations from an ejaculation standpoint. Dry ejaculate is going to happen now because those seminal vesicles were removed, and that's what helps produce that ejaculate. There may be some changes in their orgasm sensation. Erections, it could be dependent on surgery outcomes. How much nerve sparing was there in that procedure? They have the potential to get better with this, especially with pelvic floor muscle training or things like pumps. And then loss of penile length. This is something that we want to let them know can happen so they don't get a little surprise. Homework wise, we want to address any of those pelvic floor deficits we found from that objective piece, especially that breathing and bracing strategy. We can do that with biofeedback, whether that's with a mirror, with a palpation from the therapist or from them, and just to really improve their awareness and coordination there. And then giving them cues that connect them to the pelvic floor. Evidence supports, hey, pelvic floor contractions with the following cues, like shortening the penis, though I've been told nobody wants to have that. So something like nuts to guts or stopping the flow of urine is great for that. One side of the range of motion, the contraction side of the range of motion of the pelvic floor, and then something for the relaxation side, like let the testicles or base of penis hang loose. I did an Instagram post recently, so you can check that out on the ICE or Revitalize Pelvic Physio page. And then we wanna be, for homework, modifying their poor lifestyle habits. Can we reduce those bladder irritants, process sugar? Can we increase your physical activity and mental health? And then finally, we want to be scheduling their followup visits on the calendar. So whether that's for pre-op, a couple more sessions, or as early as 10 days, once that catheter is removed, they can pop back in to your office. SUMMARY So, I hope you found that information helpful. We reviewed how prevalent prostate cancer is, especially for those who are 50 plus. We know that radical prostatectomy is the gold standard for treatment. Two major things that are affected post-op are urinary incontinence and erectile dysfunction. Pre-op PT sessions are fairly new, but we have some evidence that says, hey, those who partake in pre-op sessions are drier sooner than their counterparts. And then from a PT session standpoint, thinking about asking what their current bladder and sexual function is, asking them about physical activity, mental health, objectively getting a measurement of the pelvic area, and helping them connect with that area a little bit more. Treatment-wise, we want to really harp on that education. about what the pelvic floor is, how it can help with their function, and also what to expect, possible side effects, modifiable risk factors, and then giving them homework to work on those deficits, and then finally scheduling that additional follow-up before surgery and then getting their post-op session on the calendar. My next podcast, I'm going to go into detail on what a post-op session post prostatectomy looks like. So tune in for that. And then if you want to learn more about pelvic floor examination, join us live. We have our next two courses. One is July 20th, 21st in Cincinnati, Ohio. And then July 27th and 28th, we are gonna be in Laramie, Wyoming. If you're wanting more of a virtual option, we have our two different courses that are eight weeks, L1 and L2. And in L2, we go over the male pelvic health conditions as well. Thank y'all so much for tuning in from my prostate slash walnut. Happy Monday, and I'll see you next time. OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

Dr. Jason Lunden, Fitness Athlete division leader, talks about the significance of uphill and downhill running for endurance athletes. He explores biomechanical differences, injury prevention, and strategies for safely incorporating vertical aspects into training programs.

Alan Fredendall, #LeadershipThursday expert from www.ptonice.com, discusses the American mindset of saving everyone and the challenges for physical therapists. He explores imposter syndrome and the importance of focusing efforts on motivated patients while being a supportive resource for others.

Dr. Jeff Musgrave, from Modern Management of the Older Adult, discusses tips for teaching fall landings for elderly individuals. He emphasizes the importance of falls preparedness, strategies like the tuck and roll method, and building confidence in frail older adults. Additionally, he mentions upcoming live courses and the MMOA Summit in Denver.

Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com  In today's episode of the PT on ICE Daily Show, Dry Needling Division faculty member Ellison Melrose discusses the benefits of utilizing dry needling as a treatment for sexual dysfunction in women. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ELLISON MELROSEGood morning PT on ICE Daily Show I am coming to you live from Durango, Colorado this morning in my truck so excuse the background, but we are here to talk about First of all, my name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am coming to you today to talk about dry needling in the pelvic health space, particularly for sexual dysfunction in females or in women. And I wanted to highlight two common diagnoses we have, which is vulvodynia and vaginismus. So let's dive right into that. First, I want to highlight in 2018, there was a joint report done by both the International Urogynecology Association and International Continence Society that overviewed sexual function and dysfunction. They did a deep dive into things like the proper screening, what proper history or physical subjective objective exam would look like. And then they had a huge section on the prevalence of pelvic floor dysfunction in folks that had sexual dysfunction as well. So that's what I wanted to highlight today. We, in the pelvic floor practice or pelvic floor space, we see it often where pelvic floor dysfunction and sexual dysfunction is highly linked and correlated. what I, what this report, um, highlighted is that there's actually 37 different diagnoses of sexual dysfunction that can be attributed to some form of pelvic floor dysfunction. And that's a lot, right? So, um, there granted, I mean, if you look at all of the, the nitty gritty diagnoses, um, we may be thinking maybe we're over medicalizing this, patient population a little bit with specific diagnoses, but it highlights the fact that there's so many people out there that have pelvic floor dysfunction that is contributing to a form of sexual dysfunction. 45% of women that have urinary incontinence will complain of sexual dysfunction at some point in their life. Of that 45%, 34% of that is hyposexual desire disorder. Um, and 44% of those are a brand of sexual pain disorder, which is either dyspareunia or a non-coital, so a genital pain that's not associated with intimacy. And that's what I wanted to highlight. Two most common diagnosis that we see in the clinic that can be challenging for us as pelvic floor PTs often are both vulvodynia and vaginismus. And we'll kind of get into potentially why these can be challenging diagnoses for us. DRY NEEDLING FOR VULVODYNIA Um, but for vulvodynia, the clinical definition of this is anyone that has had pain in or around the vulva region for at least three months without a clear ideology of symptoms. So they don't have, They've had negative cultures, so they don't have either fungal or bacterial infection going on here. And so there's this idiopathic pain presentation in the vulva region. And then vaginismus is a recurrent or a persistent muscle spasm of the pelvic floor, which inhibits any form or enables penetration and there's different forms of vaginismus and different diagnosis underneath that umbrella of vaginismus. And we can kind of dive into that when we talk about vaginismus specifically. I wanted to highlight these two diagnoses particularly because without a proper diagnosis, oftentimes the internal assessment can either be very challenging or it can be very non-therapeutic and actually traumatizing to some of these folks. So if we don't have a particular subjective exam that allows us to understand what is going on with our patients, the whole pelvic floor assessment may be not therapeutic. So for both of these diagnoses, everything starts in the subjective exam. Let's start with vulvodynia. So vulvodynia, oftentimes folks may have symptoms similar to that of a yeast infection or a UTI that then kind of snowballs from there. They may have actually had recurrent yeast infections or UTIs in the past and are familiar with those symptoms, but, and so they do their normal treatment with that, which a lot of times is either over-the-counter medication or they might phone up their OBGYN and say, well, let's get some of these either antifungals or antibiotics on board ahead of time while we wait for the culture. Well, culture comes back negative and the symptoms are still persisting. Sometimes they may get taken away with some of the medication a little bit, but the symptoms overall typically will persist past that. Um, and for folks that have this at this point, it is no longer a, um, you know, bacterial or yeast causing these symptoms. There is a brand of neuropathic pain going So a lot of times they have either had this for quite a long time, at least three months, they've seen other providers that have either provided a medical treatment or something that has been ineffective. And so symptoms have continued. When we think about neuropathic pain and the chronicity and the persistent pain or the chronic pain side of things here, this actually heightened symptoms typically. Um, other subjective things that you might see in these folks is that they may have, um, some sensitivity to, uh, like touch in, in the vulva region, right? So wearing specific type of clothing may be uncomfortable where they may have other brands of, uh, nerve related symptoms like itching or burning. Um, which oftentimes are two symptoms that we think about for either a yeast infection or ATI. And so that's why they get mismanaged in their medical treatment. So it all starts in the subjective exam. And while an internal assessment in these folks isn't out of the question, it can definitely be helpful. It doesn't always, it's not the most efficient way to go about treating this pain presentation. when we think about neuropathic pain, we need to think about, okay, why is this nerve so irritated? And a lot of times in vulvodynia, they see that there is either a irritation of the nerve. Sometimes there can even be, you know, some, some changes in the myelin sheath of these nerves. So there's actual nerve damage associated with it. Depending on maybe what the original cause of the, nerve irritation was. And so when we dive into, we've highlighted their subjective complaints, we know what's going on here, where do we go from there, the internal assessment may be valuable in order to see is this maybe a hypertonicity issue. So if we have tight pelvic floor musculature, can we teach them to relax their pelvic floor and allow for improved blood flow to the pudendal nerve that could be contributing to some of these symptoms. So there is a lot, there is value in that. And I believe that there is, um, oftentimes in the pelvic health space, we are so used to, um, you know, trying to treat, the patient's symptoms ourselves, whereas we can teach our patients to help themselves with learning how to relax their pelvic floor. So there is a benefit in the vulvodynia patient population to utilize the internal assessment. But when we think about efficiency, so how can we treat a neuropathic pain presentation the most efficiently in our in our clinical setting? I am in the dry needling space, and so we use dry needling a ton outside of the pelvic floor world for treating various different brands of pain, one of which is neuropathic pain. So dry needling can be a super efficient tool to improve, to talk to the nervous system and do a nervous system reset to the nerve in question, which oftentimes is the lupudendal nerve. So dry needling is a very efficient tool in order to improve those neuropathic symptoms. With that being said, everything we do physically, manually, we need to highlight that this is a persistent pain diagnosis at this point. And so we need to be utilizing our pain neuroscience education. um, educating these folks about, um, what, what happens to our nervous system when we have had pain for a long period of time. Um, and, and that pain doesn't necessarily equal damage at this point or else everything that we do with our, our manual skills or dry needling, uh, will only get us so far. Right. So, um, vulvodynia again a lot of times these patients come in to us with chronic symptoms so they've been going at this for a very long time they've had typically a medical mismanagement where they've been having some medications on board that weren't helping their symptoms they have a lot of sensitized nervous system and so we want to make sure that we are using the most clinically efficient tool to treat these symptoms. Oftentimes as well, you might actually get some reproduction of symptoms with dry needling when we're approximating the pudendal nerve or getting close to that pudendal nerve, which can be helpful in almost diagnosing, right? So using our tools to help with localizing their symptoms. So that is how we would use dry needling in a case for vulvodynia and in a patient population where we would still likely be able to utilize the internal assessment. DRY NEEDLING FOR VAGINISMUS Now let's pivot to vaginismus. Let's talk a little bit more about different diagnoses under the umbrella of vaginismus and then how we would and why we would use dry needling in this patient population. So, Vaginismus, there's two different diagnoses and underneath that we have two other subdivisions. So we have both primary and secondary vaginismus. So again, a reminder vaginismus is either a persistent muscle spasm of the pelvic floor. It's either persistent or it's associated with something and we'll get into that. Primary means that this has been forever. So this has always been an issue. Um, sometimes there may be a congenital malformation of the genital track on board with this patient population as well. Um, and if that is the case, even things like typically their first, um, like, uh, association with any form of penetration, uh, is oftentimes a, when they get their menstrual cycle. So, um, having a tampon and they're unable to actually insert a tampon into their vagina. Um, from there, then they, they often with this congenital, um, malformation or having it be a primary diagnosis is they, they often are treated fairly medicalized in that state and, and they may require some form of surgical procedure to, widen the vaginal canal. So that's primary vaginismus. Secondary vaginismus is acquired. So it wasn't always an issue, but it could be acquired from a form of trauma. So either an emotional or a physical trauma that then caused muscles in the pelvic floor to spasm. And this can be either global. So what I mean by global is that it's every time anything is enters the vaginal canal, there is a muscle spasm associated with that or it's situational, meaning that things like inserting a tampon may be possible, but physical intimacy with, um, or sexual intimacy is not possible. So there's no, uh, penetration available during, uh, sexual intimacy. Um, so those are the different kind of clinical or, diagnosis we find under the umbrella of vaginismus. Oftentimes in pelvic floor PT, we will see, um, a lot more probably of the secondary vaginismus in that they've, you know, they've never had, they hadn't always had issues, but then something caused or something triggered an issue, which causes the pelvic floor muscles to, um, to spasm, right? And that could be a traumatic birth of vaginal delivery. It could be a sexual trauma. So a, um, yeah, a sexual assault or something of the sort. It could be a, uh, traumatic pelvic exam by their OBGYN, uh, which we've, I see a ton in the clinic and, um, so it could be, a natural physical trauma with that. And then it could also be heightened with a, um, an emotional trauma as well. So a lot of times, I mean, this is a very intimate part of our body. And so there's a lot of times a very, uh, pertinent, uh, or very prevalent emotional, well, um, 70%, I would say probably about 70% of your initial evaluation evaluation, is going to be a subjective exam. Understanding the why behind these patient symptoms is crucial to dictate the course of your treatment or even the course of your assessment in that initial evaluation, right? Like, are we going to be doing an internal assessment on these folks? And a lot of times, probably, probably not, right? So what does day one look like or our initial evaluation look like with folks that have vaginismus? and how and what does our course of treatment look like for them. So typically education goes a long way with folks that have had either a physical or an emotional trauma that has caused muscle spasms here, right? So teaching folks about the anatomy of the pelvic floor musculature uh, why they feel like there's a brick wall when they try to insert a tampon. Right. Um, how, uh, what a Kegel is. Right. So anytime people have any association with the pelvic floor, they are often just think, Oh, I should be doing Kegels. Right. Um, and teaching them what, what a Kegel or what a pelvic floor muscular muscle contraction is and educating like the benefits of relaxing the pelvic floor. And this is just all done through education. So no even physical touch or assessment has been done at this point, but just educating folks around the anatomy of the pelvic floor. Anatomy and physiology of the pelvic floor can go a long way here. We also want to educate about vaginismus itself. So vaginismus is another brand of chronic pain, right? So these folks have typically had pain for an extended period of time, Um, there's not a diagnostic criteria for, for duration of symptoms like there is for vulvodynia. Um, but there is a pain cycle on board here, right? So it all starts in the brain. So it, it either the, the brain perceives an emotional trauma due to either a physical trauma or, or purely emotional that registers discomfort or, or fear associated with, uh, penetration either from a previous, uh, you know, exam with a speculum from a previous sexual encounter, um, from a trauma traumatic birth, right? So the brain remembers those things, which is then going to be causing, it causes muscle guarding. So public for guards, the tight muscles in the public for cause the penetration to be painful. or impossible at sometimes. And then this difficulty in pain reinforces that alarm, the amygdala alarm that's going on up in the brain, right? That reinforces that this is a threat, right? The nervous system then remembers this pain, and so every time our brain is their, their brain is thinking about, you know, either having to go to the OBGYN or having a sexual encounter, anything like that. Um, it is going to remember that and we are going to get the same physical symptoms as the, the tight muscles, um, which is often going to lead to, you know, decrease blood flow to the nervous system, which is going to cause potentially, you know, perceived as pain by these folks. And so they're going to avoid those, uh, you know, avoid whatever is causing this pain cycle, right? And those folks, which ultimately, especially if this is a sexual nature is going to, um, reduce the desire to either have sexual intimacy with their partner or, um, and it's, it's going to reduce that, that overall desire, which is then going to, again, any thought of that intimacy is going to be threatening. So discussing that, that pain cycle with these patients can be very therapeutic and, and helpful in that this isn't their fault, you know? So the nervous system, I like to say it's smart, but dumb, right? It remembers things and not always for the right reasons. And so education about anatomy, physiology, about the vaginismus pain cycle, can take up a majority of your initial assessment with these folks. I also like to do, again, a guided pelvic floor relaxation series with my folks, even if we're not doing an internal assessment. So on day one, these folks, we may not be getting into an internal assessment. We may never get into an internal assessment, but we do want to teach them how to um, feel their pelvic floor muscles and, and learn how to relax them. And so sometimes, um, I will educate them on how to do some self biofeedback either with tactile cueing, um, just medial to their ischial tuberosities sitting on, um, you know, a yoga ball or something like that, where we have some, uh, tactile cueing to the, um, perineal region or the pelvic floor area. Um, and, and teaching them about, again, the anatomy and that when, We're breathing. We're trying to make some of these muscles move. Increasing movement in these tissues is going to increase blood flow to the tissues, which is going to reduce irritation to the nervous system. So teaching them how to relax their pelvic floor without even doing any physical touch yourself can also be helpful. This is a patient population where after we kind of break down and help them understand the why, I like to highlight other tools we have in our toolbox as physical therapists, right? A lot of times when these folks, um, come to pelvic floor PT, they, they've done their research. So they know often that pelvic floor PT equals an internal assessment, which they've had done by their OBGYN and it's maybe been traumatic in the past or Um, they know any form of penetration is, is traumatic. And so, um, right out the gate, I'll say, you know what, that is a tool we have in our toolbox. The internal assessment's a tool. It is gold standard for assessing how the pelvic floor muscles function, but is not everything that we do here at pelvic floor PT. And I introduced dry needling. And I know that seems like for folks that have, don't have vaginismus or don't have trauma associated with penetration, they're like, Isn't dry needling more of a threat than an internal assessment? And for folks that have vaginismus, oftentimes it's not, right? So dry needling the pelvic floor muscles can be an amazing tool as we don't necessarily need to do an internal assessment. on these folks, we know there's likely not going to be anything therapeutic initially with that initial internal assessment. So if we can utilize dry needling in the earlier stages of our pelvic floor PT with these folks, it can be an amazing tool to talk to the nervous system, you know, put a break in that pain cycle associated with the muscle spasms or the tight pelvic floor musculature. It's a beautiful kind of what I like to say control or delete to the nervous system and so it can really help with Retraining that cycle of you know, these muscles Have more control other than just muscle spasm, right? and so if we can take some of the the heightened neuropath or the heightened symptoms down with a tool like dry needling, it may allow us to either ourselves or them do a form of stretching or manual therapy where they can improve the tissue's mobility as well, right? SUMMARY So I could probably talk about this stuff all day. I've already been on here for almost 25 minutes, so I'm going to stop it here, but I want to kind of summarize everything we talked about today. Um, I, we kind of went into a recent report done in 2018 that dove into some pelvic floor dysfunction in, um, sexual function and sexual dysfunction. And we dove into two specific diagnoses today. We looked at vulvodynia and vaginismus clinically and how we can utilize things like dry needling for either treatment or even, um, diving into a little bit of some diagnostic, uh, with, utilize with dry needling as well. Um, and so, uh, while we're, you know, dry needling, the pelvic floor is a fairly unique, um, skill. Uh, there's a lot we can do with dry needling outside of the pelvic floor as well for these folks. And so, um, for those that are in this space, I highly recommend taking our lower body dry needling course if you haven't already, We go into needling for the lumbar spine, the glutes, muscles that surround the sciatic nerve. And so again, taking those principles and utilizing them in the pelvic floor space can be really helpful as well. So we have some courses upcoming this fall. We have, let me pull it up right here. We have a lower body course, I believe in Scottsdale, Arizona, in the beginning of September. We, for those that have taken lower body or upper body, we have two advanced courses coming to you this August. So we have our, our juggling summit up in Seattle and the second weekend in August. And then we have one down in Longmont, Colorado at the second to last weekend in August, um, right before Labor Day. Uh, we have a ton of lower body courses coming to you this fall. So hop onto ptlnice.com and check out what courses we have, um, coming to you. Um, if you guys don't see something in your area, feel free to reach out to us and, um, we can look at getting something booked near you as well. Well, hopefully you guys have a great rest of your Tuesday and enjoy the holiday this week. Bye. OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.

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