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Course Title: Men’s Health Issues: An Introduction from Front to Rear Presenters:
Daniel J. Kirages, DPT, OCS, FAAOMPT Jason J. Kutch, PhD
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Course Description: REGISTRATION urinary FEES With 6-12% of men suffering from chronic pelvic pain and 4-21% of men experiencing incontinence the role of physical therapy for men’s health issues has never been more important. Whether the symptoms are pelvic region pain in a younger group or bladder control problems in an older group, either way we as physical therapists play a large part in their recovery. Please join us so we can guide you through several clinical presentations of men’s health issues throughout the lifespan. You will see both low-tech and high-tech methods of investigation and intervention to assist with proper clinical decision making. This population needs you and this presentation will be a link towards adding them into your daily appointment schedule. Facility Name
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Note: Registration fee does not include special events or preconference course fees. Early Bird Registration
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DEADLINE 11/16/12
DEADLINE 12/21/12
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SPECIAL EVENTS (OPTIONAL)
Course Objectives: Participants will learn about:
PT-PAC’s 40th Anniversary Celebration at the House of Blues | Wednesday, January 23, 2013 | Fee: $40. Fee is nonrefundable. If a registrant cancels, this fee is not refunded.
Catch the Buzz Networking Coffee | Wednesday, January 23, 2013 | 6:30 am – 8:30 am | Tickets Sponsored by the Foundation for Physical Therapy and the Home Health Section
PRECONFERENCE COURSES AND FEES (OPTIONAL)
1. Common concepts of men’s health issues: a. Bladder and bowel dysfunctions including post-prostatectomy incontinence b. Pelvic region pain syndromes METHOD OF PAYMENT:
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Full payment must accompany your registration form. If paying by credit card, your signature below authorizes AP total payment and acknowledges there are no refunds after January 14, 2013 . APTA reserves the right to charge outstanding dues will be charged the nonmember registration fee.
2. Anatomical and physiological mechanisms that potentially contribute to male pelvic floor www.apta.org/CSM/Registration muscle dysfunctions. Make checks and POs payable to APTA PHONE: 877/585-6003 • ONLINE: Card Number
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3. Principles of examination, evaluation, and intervention of common male pelvic floor muscle dysfunctions using sEMG, 2D and 3D sonographic imaging, manual therapy, behavioral techniques, and therapeutic exercise. Signature
5. Existence of men’s health issues within a typical outpatient musculoskeletal setting and why we should embrace learning more about this population. 6. Ongoing research efforts to determine useful screening tools via sonographic imaging, sEMG and fMRI to enhance the effectiveness of physical therapy evaluation and intervention.
Topic #1 – Physical Therapy for Post-Prostatectomy Incontinence - (D. Kirages) Assist in answering some very common questions: • Why does incontinence occur? • What is the pelvic floor muscle? • What can be done to help me regain control? • How long will it take? Prostate Cancer (CaP) • Surgical Options • Robotic assisted • Open procedure Continence Recovery Timeline
Exp Date
Behavioral / Conservative Management • Scheduled voiding • prompting person to urinate at designated time • Usually every 2 hours • maintain dryness •
Fluid/Food Education • caffeine (coffee, tea, soda, chocolate) • citric acid (orange, grapefruit, lemon juice) • carbonated drinks (soda, ginger ale, tonic) • alcohol
Pelvic Floor Exercises • Retraining the Pelvic Floor Muscle • exercises • biofeedback • electrical stimulation Pelvic Floor Muscle Awareness Training • Verbal cues / responses • holding back gas expulsion • holding urine in during urge • stopping urine stream • “clearing the line” • penis wiggle • contraction during ejaculation •
Common errors • holding the breath • bearing down (Valsalva Maneuvor) • tightening abdominals • tightening buttocks
Effective conditioning requires proper: • isolated muscle group • sufficient load intensity • duration of exercise • training within specific activity • adherence to maintenance program (Johnson, 2001) Exercise Progression • Phases 1-2 – Supine (Week 1-5) • Phases 3-4 – Sitting (Week 6-12) • Phases 5 – Functional (Week 13-16)
Motor Plan Development • Anticipatory contraction • Repetition
Topic #2 – Physical Therapy for Voiding Dysfunction - (D. Kirages) Chief Complaints • Urinary difficulties • Fecal difficulties • Ejaculate difficulties • Incontinence Symptoms • Frequency / Urge • Nocturia • Hesitancy • Weak stream • Split stream • Not emptying • Straining • Post-void dribble • Fragmented stools • Thin stools • Fullness in rectum • Low ejaculate force Bladder Retraining • Gradually increase of voiding interval (2-4 hrs) • Delay of voiding • Urge Suppression • detrusor inhibition with PFM relaxation • parasympathetic quieting • cognitive distraction Lifestyle Modification • Improvements in posture • Increase LE exercise frequency • Stress reduction • Diaphragmatic breathing • Avoid aggravating factors
Topic #3 – Physical Therapy for Male Pelvic Pain - (D. Kirages) Typical referred medical diagnoses • chronic prostatitis • levator ani syndrome • coccygodynia • pudendal neuralgia
Descriptions of Pain • “It feels like a knot between my legs.” • “I feel like I am sitting on a golf ball.” • “The tip of my penis burns.” • “My testicles ache after ejaculation.” • “Burning feeling in my groin area.” Aggravating Factors • Prolonged sitting • Running • Lifting heavy items • Holding back urge to urinate • Ejaculation • Riding a cycle Easing Factors • Standing up • Sitting on toilet • Warm bath • Post - bowel movement • Post - urination What will a physical therapist do? • Perform an examination to look for body structure and function deficits in: o Mobility – contributions from lumbar spine, SIJ, hips o Flexibility – contributions from intra and extra-pelvic region musculature and tissues (PFM,adductors,abdominals,gluteals,etc) o Power/Endurance – pelvic floor muslce (muscle performance – awareness, concentric, eccentric loading) o Motor Coordination – proper synergy during voiding, evacuation strategy for BM, selective relaxation and activation when needed, with respiration How will a physical therapist intervene? A typical interventional skill set will include: Manual therapy • Joint mobilization (lumbar spine, sacro-iliac joint, hip, thoracic spine) • Soft tissue mobilization (stretching, trigger point release, skin rolling, etc.) Neuromuscular reeducation • Pelvic floor awareness training • Respiration training (relaxation, autonomic nervous system adjustment) • Biofeedback / down-training Therapeutic exercise • Stretching • General activity – walking program Patient education / counseling • Condition / behavioral modification / fear reduction / positive thinking / biologise
Topic #4 – Male chronic pelvic pain: the state of the science (J. Kutch - ampl.usc.edu) The diagnosis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is most commonly used in the research literature. Current critical research questions: • Chronicity of symptoms: problem in the pelvis, problem in the brain, or both? • Initiation of symptoms: how does a person transition from acute to chronic? • Most effective paradigms for inducing neuroplasticity and returning patient to health? Recent findings: • Heightened pelvic floor EMG predictive of CP/CPPS symptoms [1]. • Brain activity associated with CP/CPPS symptoms [2]. • Stress markers elevated in CP/CPPS patients [3]. • Uncontrolled trial: CP/CPPS patients reduce EMG with biofeedback [4]. Relevant neuromuscular research tools: • Intra-rectal electromyography (EMG). • Trans-perineal sonographic imaging (ultrasound). • Functional magnetic resonance imaging (fMRI). Research challenges and new approaches: • Is brain activity in CP/CPPS patients a marker of altered brain function or normal? • Randomized controlled trials of EMG biofeedback needed. • What are the optimal conditions for biofeedback: stress or no stress? Course objectives: • Understand current objective biomarkers of CP/CPPS. • Interpret brain imaging data in CP/CPPS and understand need for careful controls. • Conceptualize different models for CP/CPPS pathogenesis. References (DK): 1. Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005 Jul;174(1):155-60. 2. Parekh AR, Feng MI, Kirages D, Bremner H, Kaswick J, Aboseif S. The role of pelvic floor exercises on post-prostatectomy incontinence. J Urol. 2003 Jul;170(1):130-3. 3. Berger R.E.,. Ciol M.A,. Rothman I, and. Turner J.A. Pelvic tenderness is not limited to the prostate in chronic prostatitis/chronic pelvic pain syndrome (cpps) type iiia and iiib: comparison of men with and without cp/cpps. BMC Urology, 7(1):1–7, 2007. 4. Anderson RU, Wise D, Sawyer T, Chan CA. Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and paradoxical relaxation training. J Urol. 2006 Oct;176(4 Pt 1):1534-8; discussion 1538-9.
5. MacDonald R., Fink H.A., Huckabay C., Monga M., Wilt T.J. Pelvic Floor Muscle Training to Improve Urinary Incontinence After Radical Prostatectomy: A Systematic Review of Effectiveness. British Journal of Urology International (2007); 100:76–81 6. Weiss J. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency-frequency syndrome. The Journal of Urology 2001: 166:2226-2231 7. Campbell SE, Glazener CM, Hunter KF, Cody JD, Moore KN. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev. 2012 Jan 18;1:CD001843. Review. 8. Goode PS, Burgio KL, Johnson TM, Clay OJ, Roth DL, Markland AD, Burkhardt JH, Issa MM, Lloyd LK. Behavioral Therapy With or Without Biofeedback and Pelvic Floor Electrical Stimulation for Persistent Postprostatectomy Incontinence. JAMA. 2011;305(2):151-159. doi:10.1001/jama.2010.1972 References (JK): 1. Hetrick DC, Glazer H, Liu YW, Turner JA, Frest M, et al. (2006) Pelvic floor electromyography in men with chronic pelvic pain syndrome: A case-control study. Neurourol Urodyn 25: 46-49. 2. Farmer MA, Chanda ML, Parks EL, Baliki MN, Apkarian AV, et al. (2011) Brain functional and anatomical changes in chronic prostatitis/chronic pelvic pain syndrome. J Urol. 3. Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V (2008) Psychometric profiles and hpa axis function in men with chronic prostatitis/chronic pelvic pain syndrome (cp/cpps). J Urol 179: 956. 4. Cornel EB, van Haarst EP, Schaarsberg RWM, Geels J (2005) The effect of biofeedback physical therapy in men with chronic pelvic pain syndrome type iii. European urology 47: 607-611.
