§ Dysmenorrhea is a long word to describe pain during menstruation. These pains can range from slight irritability to intestinal upset, severe abdominal cramping, and even fainting. There are two types of dysmenorrhea:

· Primary dysmenorrhea – This term is used to describe normal period pain experienced by many women around the time of their period. Although still painful, there is no underlying medical problem, and it most commonly affects teenagers and young women.

· Secondary dysmenorrhea – This term is used to describe pain around the time of the period that is caused by an underlying medical problem. This is less common and tends to affect women later in their reproductive lives.

Ø What causes painful periods?

§ The cause of painful periods is as of yet uncertain. Below are listed some of the more prominent ideas as to what might cause painful periods:

· Once an egg has been released from one of the ovaries, natural chemicals produced by the body called prostaglandins are made in the lining of the uterus. Some prostaglandins are made in the walls of the uterus to contract. Some women produce higher levels of prostaglandins, which may cause increased contractions of the uterus. These cramps may be more painful because there is reduced blood (and therefore oxygen) supply to the muscle wall of the uterus during those contractions.

· Pain during a period can be worsened because of a vicious cycle: the menstrual cramping cause’s pain in the lower abdomen causing your muscles to tighten which causes you more pain which then makes you tense, causing your muscles to tighten even more.

Ø How can a physical therapist treat pain experienced during a period?

§ There are many different ways to treat a painful period and physical therapy is just one of them. Over-the-counter medications work well for some women, but others cannot take these remedies because of stomach upset. There are also prescription medications that can help but often times these can cause unpleasant side affects.

§ Once your gynecologist has determined there is no abnormal cause of pain, a physical therapist at Her Health Physical therapy can help you deal effectively with the pain brought on by menstruation. First the therapist would perform a thorough evaluation of the patient, including a postural evaluation to rule out musculoskeletal dysfunction. Then they would design an individualized program of care. Treatment options can include but are not limited to the following:

· Manual Techniques: Gentle myo-facial release, massage, joint mobilization and trigger-point release can be used to relax tight tissue, balance muscles and mobilize joints.

· Modalities: At Her Health these are used rarely however occasionally cold packs, moist heat, electrical stimulation and ultrasound, if desired by the patient, can be used effectively to treat pain during periods. Women with severe cramping reported success with TENS (transcutaneous electrical nerve stimulation). Physical therapists are experienced in the use of TENS for a variety of conditions that require pain management. The TENS unit is a small machine that delivers electrical stimulation to the pain site through electrodes placed around the areas of discomfort. This stimulation blocks nerve impulses to help control pain.

· Education: There is a wealth of information about pain during periods and women’s health in general that is available at Her Health Physical Therapy. The physical therapists at Her Health will provide extensive education on, amongst other things, pain control techniques and deep breathing We will do our very best to give you all the information that we can as well as resources where you can learn more. Education is the most important part of your treatment.

· Exercise: When appropriate, stretching and strengthening exercises, designed specifically for a woman experiencing pain during her period, are prescribed to decrease your pain. These exercises will focus on: a) stretching the anterior abdominal wall, loosening those tight muscles, b) Pumping blood into the abdominal wall muscles and therefore increasing the oxygen supply.

v Constipation

Ø Constipation is defined as the inability to evacuate the bowel on a normal schedule without excessive straining.

Ø Your Physician’s evaluation can help determine the primary cause of constipation. In some cases the problem is associated with tight or uncoordinated pelvic floor muscles.

Ø Physical therapy treatments can include:

§ Biofeedback to train the muscles to relax appropriately and work more efficiently.

§ Manual therapy to evaluate and treat tight muscles allowing improved relaxation to improve bowel evacuation.

§ Careful therapeutic exercises that emphasize relaxation of the pelvic floor musculature to allow improved motility.

§ Education: There is a wealth of information about constipation and women’s health in general that is available at Her Health Physical Therapy. We will do our very best to give you all the information that we can as well as resources where you can learn more. Education is the most important part of your treatment. For example diet can make a tremendous difference in assisting with constipation and so by simply learning what foods and drinks can assist with improved bowel regularity you can decrease your constipation.

v Osteoporosis

Ø What is Osteoporosis?

§ Osteoporosis is defined as a progressive bone disease in which the amount of bone tissue is decreased and the structural integrity of trabecular bone (bone tissue found at the center of long bones which also comprises a majority of the hip and vertebrae) is impaired, becoming more brittle. Cortical bone (the dense outer layer of bone) becomes more porous and thinner. Bone that is both thinner and brittle is more prone to fracture.

§ Although the entire skeleton may be involved in postmenopausal osteoporosis, bone loss is usually greatest in the spine, hips and ribs.

§ There are two different types of Osteoporosis:

· Primary Osteoporosis is where bone loss occurs but does not result from an identifiable pathological process. There are two types:

¨ Type 1 primary osteoporosis is where bone loss is due to estrogen decline associated with menopause.

¨ Type 2 primary osteoporosis is where bone loss is due to aging.

· Primary Osteoporosis predictors of low bone mass include:

§ Female gender

§ Increased age

§ Estrogen deficiency

§ White in race

§ Low weight and body mass index

§ Family history of osteoporosis

§ smoking

Ø Can occur in both genders

Ø Can occur at any age

Ø Often follows menopause in women and occurs later in life for men

· Secondary Osteoporosis is where bone loss is associated with an identifiable medical condition or disease, treatment with certain drugs or immobility. Several examples are listed below:

¨ Drug related:

Ø Alcoholism

Ø Chronic heparin administration

Ø Corticosteroids

¨ Endocrine diseases:

Ø Cushing’s Syndrome

Ø Diabetes Mellitus

Ø Hyperparathyroidism

¨ Nutritional disorders

Ø Vitamin C deficiency

Ø Calcium or vitamin D deficiency

Ø High Protein diet

¨ Genetic Disorders:

Ø Osteogenesis imperfecta

Ø Marfan’s Syndrome

Ø Osteoporosis is a complex condition involving lifestyle, nutritional and environmental factors. Studies have concluded that prevention is the most important step and that women of all ages should be encouraged to take 1000 to 1500mg of supplemental calcium daily, participate in regular weight-bearing exercise, avoid medications known to compromise bone integrity, institute hormone replacement therapy at menopause unless contraindicated and avoid tobacco as well as excessive alcohol intake.

Ø When does Osteoporosis begin?

§ Normally there is a decrease in bone mass after the age of 35-40.

§ 16% of white women aged 20-29 have osteopenia (where bone density is somewhat lower) and less than 1% have osteoporosis.

§ 38% of women aged 65 have osteopenia and 20% have osteoporosis.

§ By age 80 only 15% of women still have normal bone density.

§ If exercise and good nutrition have been and are presently a part of your lifestyle, you may have lost only a little bone mass. If you are sedentary and regularly ingest foods that interfere with calcium absorption (such as coffee, soda pop, alcohol, white flour products, processed meats, nutritional yeast and bran) you may have lost a lot.

§ The risk of a fracture will double with every decade past the age of 50 no matter what the current bone density.

Ø How can Physical Therapy help with treatment and prevention of Osteoporosis?

§ Treatment of patients already diagnosed with osteoporosis is a very delicate process. There are several different approaches but any approach is focused on prevention of falls and promoting an increase in bone mass:

· First a physical therapist will assess balance, strength, gait and posture. If there is a significant strength loss, poor balance and slow gait, these things increase the risk of falls. Strength training of the lower extremities, shoulders, neck and back improves strength and balance which help prevent falls that lead to fractures.

· Preventable falls are the biggest cause of broken bones. A physical therapist will also educate you on how to best reduce your risk for falls.

· A physical therapist will also educate you on safe rest, work and exercise positions that will minimize the risk of fracture occurring during activities of daily living.

· Evidence has shown that exercise late in life even with a diagnosis of osteoarthritis and even beyond 90 years of age can increase muscle mass and strength two-fold or more in frail individuals. There just needs to be a special amount of care taken in the design of each individualized exercise program as each and every exercise needs to be safe for the client with osteoporosis. These exercise programs are best designed by a physical therapist that is familiar with osteoporosis and its various risks.

§ For prevention of osteoporosis there is strong evidence that physical activity early in life contributes to higher peak bone mass. Some research indicates that resistance and high impact exercises are likely the most beneficial.

§ Exercise during the later years in the presence of adequate calcium and vitamin D intake does have an effect on slowing the decline in bone density. With this in mind, a carefully designed exercise program will be an important part of the total effort to slow and or prevent bone loss leading to osteoporosis.

v Post-Obstetric and Gynecological Surgical Procedures

Ø First a Physical Therapist will obtain a thorough history and then will examine: 1) Sensory function, 2) Musculoskeletal function, 3) Perineal function (assessment of the pelvic floor) and 4) Pain intensity and its source.

Ø How can a physical therapist treat pain and dysfunction after an obstetric or gynecological surgical procedure?

§ Treatment can include the following:

· First and foremost a patient will receive education about caring for themselves after the procedure. This will include:

¨ Instruction in positioning, abdominal massage, correct coughing and sneezing techniques and exercises to promote optimal bowel and bladder function.

¨ How to avoid the Valsalva maneuver and other abdominal/pelvic stress through relaxation, modified methods of mobility and activities of daily living.

¨ Care of perineal or abdominal incision, including methods of muscular support.

¨ Scar massage

¨ Body mechanics and postural awareness.

· The patient will also receive education on the anatomy and function of the affected musculature and common problems associated with postoperative recovery.

· Therapeutic Exercise:

¨ Each patient will receive an individually designed program using exercises to strengthen weak musculature, including the weakened abdomen and pelvic floor.

¨ Patients will be given exercises to facilitate sluggish postoperative bowel and bladder functioning.

· Home Program:

¨ Instruction in self-management

¨ Individualized exercise program that can be performed at home

¨ Training in bowel and bladder control

· Other treatments:

¨ Local application of moist heat, ice and massage

¨ Modalities such as electrical stimulation, ultrasound and interferential current.

¨ Fitting and instruction in the use of orthoses and other supports

v Urinary Incontinence

Ø What Is Urinary Incontinence?

§ Urinary Incontinence (UI) presents in many ways but ultimately it is an uncontrolled loss of urine. UI affects 15-25 million Americans, including at one time or another, one-third of all women. One-third of those women will have a long-term problem with UI. UI costs the United States 27.9 billion dollars per year.

Ø What are some of the more common types of Urinary Incontinence?

§ Urge Incontinence – Urine loss occurs with a sudden and strong desire to urinate with only a few minutes or even seconds warning. Typically urine is leaked on the way to the toilet while rushing to get there.

§ Stress Incontinence – The involuntary loss of urine during physical exertion including: coughing, laughing, sneezing, lifting heavy object, exercise or any other activities that put pressure on the bladder.

§ Mixed Stress and Urge Incontinence – This is a combination of the two diagnosis listed above. Because of this there is typically an increase in how frequently you go to the bathroom.

§ Overflow Incontinence – When urine leaks and dribbles from a bladder that is full or even overfilled. There is typically pain and pressure in the lower abdomen around the bladder, a reduced urine stream and difficulty initiating the urine stream.

§ Functional Incontinence – When there is normal urine control but there is difficulty reaching the toilet prior to leaking urine. This is because of difficulty walking or getting out of a chair or the bed.

§ Overactive Bladder – May include an increase in frequency, a strong and sudden desire to urinate that cannot be controlled with leakage when the urge sensation cannot be suppressed. Leakage typically occurs while on the way to the bathroom or during a change of position.

Ø What Causes Urinary Incontinence?

§ The causes of UI are broad and numerous. Below are summarized some of the more common causes of UI:

· The muscles of the pelvic floor that support the bladder in its proper position and control the flow of urine, loose their strength and coordination which causes UI. This can also cause a prolapse of the pelvic organs (the bladder, rectum, and uterus) which indirectly can cause UI. Weakness of the pelvic floor muscles is often associated with: pregnancy, childbirth, obesity, lack of exercise/general deconditioning, estrogen deficiency, chronic respiratory conditions and prior surgeries and nerve damage affecting the pelvic floor.

· Overactive detrusor function or in other words the muscles in the wall of the bladder contract and empty the bladder without your control.

· An underactive detrusor or in other words the muscles in the wall of the bladder do not contract fully when they should (i.e. when the bladder is full).

· Constipation.

· Urinary Tract Infections or abnormalities and/or Bladder infections.

· Various medications can cause UI.

· Neuromuscular disorders

· Post-surgical causes.

· Vaginal or urinary tract infection.

· Hormonal alteration, particularly a decrease in estrogen.

· Prolapse of the bladder, uterus or rectum.

· Lifestyle causes such as stress, diet, cigarette smoking and caffeine intake.

Ø How can we treat Urinary Incontinence?

§ There are many aspects to effective treatment of UI and physical therapy is just one of them. Other treatments may include but are not limited to medications, surgery, pessary placement, and catheterization.

§ You should always consult with a physician first to rule out whether or not an infection or other medical condition is causing your loss of bladder control.

§ At Her Health Physical therapy we can help resolve UI by first evaluating your particular case and designing an individualized program of care. Treatment options can include but are not limited to the following:

· Pelvic Floor Biofeedback: This is a type of treatment that gives you visual feedback on the strength of your pelvic floor muscles. Learning how to properly contract and relax your muscles, along with learning the correct technique for performing pelvic floor exercises is vital to your recovery.

· Manual Techniques: Gentle myo-facial release, massage, joint mobilization and trigger-point release can be used to relax tight tissue, balance muscles and mobilize joints.

· Modalities: At Her Health these are used rarely however when indicated we will use electrical stimulation to reeducate the pelvic floor muscles.

· Education: There is a wealth of information about UI and women’s health in general that is available at Her Health Physical Therapy. We will do our very best to give you all the information that we can as well as resources where you can learn more. Education is the most important part of your treatment.

· Exercise: Often times you will be given a home exercise program to treat the pelvic floor muscles as well as any other musculature that is unbalanced and perhaps a contributing factor to your urinary incontinence.

· Behavior Modification: use of pelvic floor contractions for urge control, diet changes, and instruction in functional activities to improve the use of pelvic floor muscles during activities of daily living.

v Fecal Incontinence

Ø Fecal Incontinence is defined as the inability to control gas or bowel movements. Incontinence occurs either when you feel the urge to have a bowel movement and are unable to hold it until you can get to a toilet or when stool leaks from the rectum unexpectedly.

Ø More than 5.5 million Americans have fecal incontinence. It affects people of all ages--children as well as adults.

Ø How can we treat Urinary Incontinence?

§ There are many aspects to effective treatment of Fecal Incontinence and physical therapy is just one of them. Other treatments may include but are not limited to medications or surgery.

§ You should always consult with a physician first to rule out whether or not an infection or other medical condition is causing your loss of fecal control.

§ At Her Health Physical therapy we can help resolve fecal incontinence by first evaluating your particular case and designing an individualized program of care. Treatment options can include but are not limited to the following:

· Manual Techniques: Gentle myo-facial release, massage, joint mobilization and trigger-point release can be used to relax tight tissue, balance muscles and mobilize joints.

· Modalities: At Her Health these are used rarely however when indicated we will use electrical stimulation to reeducate the pelvic floor muscles.

· Education: There is a wealth of information about fecal incontinence and women’s health in general that is available at Her Health Physical Therapy. We will do our very best to give you all the information that we can as well as resources where you can learn more. Education is the most important part of your treatment.

v Oncology

Ø Lymphedema

§ Please see the section on Lymphedema Management for more details.

Ø Post mastectomy Rehabilitation

§ What is the most common reason for performing a mastectomy?

· The most common reason to perform a mastectomy is a diagnosis of breast cancer. Breast cancer is usually discovered when a lump, a change in the appearance of the breast (such as dimpling or puckering), or a suspicious mammogram is investigated.

§ What are the different types of breast cancer surgery?

· There are two main types of breast cancer surgery:

¨ The first is known as breast conservation, where only the tumor and a rim of surrounding tissue are removed. Breast conservation surgery, also known as lumpectomy or partial mastectomy, is usually followed by radiation therapy to the breast.

¨ The other type of surgery is a mastectomy, or removal of the entire breast. There are four types of mastectomy:

Ø Subcutaneous mastectomy: removes the entire breast but leaves the nipple in place

Ø Total (or Simple) mastectomy: removal of the whole breast, but not the lymph nodes under the arm

Ø Modified Radical mastectomy: removal of the whole breast as well as most of the lymph nodes under the arm

Ø Radical mastectomy: involves removal of the chest wall muscles in addition to the breast and axillary lymph nodes.

· Another far more rare type of mastectomy is the Preventative (or Prophylactic) mastectomy: this is where a mastectomy is performed without any presence of breast cancer. Women who might consider this typically have a strong family history of breast cancer or a genetic mutation that predisposes the woman to breast cancer. It is important to note that this type of mastectomy greatly reduces but does not eliminate the risk of breast cancer.

§ What are the risks involved in a mastectomy?

· Mastectomy is a very safe surgery and most patients recover well with no complications. As with any surgery however there are risks. Possible complications are:

¨ Bleeding externally and sometimes bleeding into the space where the breast used to be, but this is rare

¨ Infection

¨ Injury to nearby tissues

¨ Possible reactions to medications used in the general anesthesia

¨ A compromised blood supply to the skin of the chest wall, which may cause some loss of skin, rarely requiring a skin graft

· Some postoperative pain and soreness is expected but can be effectively treated with pain medications. There will also be a scar on the chest wall however scarring occurs with all surgery and is unavoidable.

· There are specific risks involved when lymph nodes (from under the arm pit) are removed along with the breast tissue:

¨ There is a risk of nerve damage with numbness and weakness after the surgery as there are a lot of important nerves in the arm pit.

¨ Since the lymph nodes normally drain excess fluid from the arm, the removal of those lymph nodes can result in postoperative swelling of the arm on the same side that the breast was removed. This swelling is called lymphedema and can be a persistent problem.

¨ Many patients experience shoulder stiffness after the removal of the lymph nodes in the armpit.

§ What can a physical therapist do to treat the pain, discomfort, swelling and stiffness after mastectomy?

· Women who go through a moderate or radical mastectomy are often worried about their body image and are afraid to move their arms because of the tightness they feel in their chest and shoulders. A physical therapist will help you become accustomed to your new shape.

· At Her Health Physical therapy we can help resolve the many symptoms often experienced after mastectomy. First we will perform a complete evaluation of your particular problem and then we will design an individualized program of care. Treatment options can include but are not limited to the following:

¨ Manual Techniques: Gentle myo-facial release, massage, joint mobilization and trigger-point release can be used to relax tight tissue, balance muscles and mobilize joints. An important manual technique will be scar tissue massage. The patient will be taught how to do this to help prevent adhesion.

¨ Modalities: At Her Health these are used rarely however occasionally cold packs, moist heat (at appropriate temperatures) and other modalities, if desired by the pregnant patient, can be used effectively to treat pain during pregnancy.

¨ Education: There is a wealth of information about breast cancer, partial mastectomies and mastectomies and women’s health in general that is available at Her Health Physical Therapy. The physical therapists at Her Health will provide extensive education on, amongst other things, prosthetics, pros and cons of reconstructive surgery, posture and body mechanics. We will do our very best to give you all the information that we can as well as resources where you can learn more. Education is the most important part of your treatment.

¨ Exercise: When appropriate, stretching and strengthening exercises, designed specifically for post-mastectomy patients, are prescribed to help the patient regain full range of motion and strength in the shoulder and the upper body.

¨ Lymphedema treatment: Please see the Lymphedema section of this website.

v Pelvic Pain/dysfunction

Ø What Is Pelvic Pain?

§ Pelvic pain presents in many forms. For some women, intercourse is terribly painful or not even possible and a visit to the OB-GYN is a terribly painful ordeal. Often times even inserting a tampon is a painful struggle. For other women it presents as pain around the vaginal opening with pressure of any kind making sitting, walking, wearing jeans or even underwear terribly irritating. Pelvic pain can also be felt in the abdomen, the low back and the hips and sometimes can present as pain during menstruation.

Ø What Causes Pelvic Pain?

§ The exact cause of most types of pelvic pain is unknown, due mainly to the lack of research on the majority of these disorders. Most researchers and medical practitioners speculate that pelvic pain may be caused by one or more of the following:

· An injury to, or irritation of, the nerves that supply sensation to the area around the vagina.

· An abnormal response of different cells around the vagina to infection or trauma.

· Genetic factors associated with susceptibility to chronic vaginal inflammation.

· Spasms of the muscles that support the pelvis.

· A localized hypersensitivity to yeast in the vagina.

· Postural mal-alignments and musculoskeletal imbalances causing instability of the pelvis.

· Adhesions from prior surgery or other adhesions of the uterine wall.

· Childbirth complications like, amongst other things, episiotomy or tears during childbirth or birthing trauma with forceps or vacuum extraction.

· Vaginal or urinary tract infection.

· Hormonal alteration, particularly a decrease in estrogen.

· Prolapse of the bladder, uterus or rectum.

· Physical, sexual or verbal abuse.

· Psychological elements such as: a) fear of ones sexuality, body or intimacy, b) a religious taboo learned from childhood, c) guilt, d) stress

Ø How can we treat your pelvic pain?

§ There are many aspects to effective treatment of pelvic pain and physical therapy is just one of them. The other treatments for pelvic pain include topical creams, anti-inflammatory medications, diet modification, pain medications, and in extreme cases, surgery.

§ You should always consult with a physician first to rule out an infection or other medical diagnosis.

§ At Her Health Physical therapy we can help resolve pelvic pain by first evaluating your particular problem and designing an individualized program of care. Treatment options can include but are not limited to the following:

· Manual Techniques: Gentle myo-facial release, massage, gentle scar tissue mobilization, joint mobilization, Strain Counter Strain and trigger-point release can be used to relax tight tissue, balance muscles and mobilize joints.