When you think of the physical shape of Downward Facing Dog, what comes to mind? Do you think of a long upside-down V with the heels touching the ground and knees straight? That might be the way the shape looks on some people, but for many folks, downward dog can take many different forms - all of which are still accomplishing the same energetic purpose of this inversion posture.

Using the language customizing instead of modifying might help some patients realize they are not “doing less” by not being able to comfortably attain the physical shape of what they think they should be able to do. In fact, it is an opportunity to be rewarded for listening to one’s inner wisdom about how the body wants to move in that particular moment. We are not robots, and our bodies’ energy and pliability can change greatly during the day and from week to week, especially for people experiencing hormonally influenced persistent pain.

From a clinical perspective, customization emphasizes patient empowerment. For example, patients with pelvic pain often present with increased muscle guarding in the pelvic floor, hips, or abdominals. Asking them to force their heels to the floor or straighten their knees in Downward Facing Dog can increase tension and exacerbate symptoms. Instead, inviting them to bend their knees, widen their stance, or elevate their hands on blocks or a chair creates a version of the pose that is supportive and therapeutic. This allows patients to access the benefits of the posture - inversion, elongation, breath awareness—without reinforcing pain patterns.

This shift in perspective also serves the nervous system. Persistent pelvic pain frequently involves central sensitization and heightened protective responses. When patients hear that creating the shape of a posture that serves them is not only allowed but encouraged, the perceived threat decreases, and there may be less fear-avoidance. Clinicians can use language such as, “Notice how your body feels with the knees bent,” or “Try widening your stance and see there is less neural tension.” These cues guide patients toward building interoceptive awareness, giving them tools for self-regulation that extend beyond the clinic.

Customization also highlights the principle that yoga is not one-size-fits-all. Each patient comes with a unique history - postpartum recovery, endometriosis, hip impingement, abdominal surgery, hypermobility, etc. The physical shape of a posture that is accessible for one person may be provocative for another. By offering variations and inviting exploration, clinicians can encourage self-efficacy and reduce fear-avoidance behaviors. This builds confidence in movement and often translates into improved participation in daily activities outside of therapy.

For rehab professionals, integrating yoga in this way reinforces biopsychosocial care. By blending mindful movement with therapeutic exercise, you can help patients reframe movement as safe, adaptable, and nourishing. Consider weaving in reflective questions during sessions: “How do you know this version feels better for you?” or “What would make this position feel even more supported?” These simple prompts deepen the patient’s awareness and reinforce the therapeutic alliance.

Ultimately, customizing yoga postures is not about diluting the practice but about making it clinically relevant. When patients learn that the value of a pose lies not in how closely it matches a picture in a yoga text but in how it supports their body and nervous system in that moment, the practice becomes inclusive and sustainable. For people with pelvic pain, this can be a turning point: shifting from frustration with limitations to curiosity, agency, and resilience in movement.

Clinician Takeaways: Customizing Yoga for Pelvic Pain

• Use empowering language: Swap out “modification” for “customization” to reduce stigma and emphasize patient agency.
• Prioritize nervous system safety: Encourage patients to notice what feels supportive rather than pushing into shapes that increase tension or pain.
• Offer accessible variations: For Downward Dog, consider bent knees, wide stance, hands on blocks, or using a wall/chair.
• Cue interoception: Ask reflective questions like, “What do you notice in your body?” or “Can you breathe with more ease here?”
• Honor individuality: Recognize that each patient’s pelvic health journey is unique; customize postures according to surgical history, musculoskeletal patterns, and pain triggers.
• Blend yoga with rehab principles: Use posture customization to reinforce body awareness, reduce fear-avoidance, and build resilience in movement.

Want to deepen your understanding of how yoga can support patients with pelvic pain? Join Yoga for Pelvic Pain with Dustienne Miller, PT, MS, WCS, CYT on September 13–14, 2025. This remote course offers practical, evidence-informed strategies to integrate yoga into pelvic health care. Register here.

AUTHOR BIO
Dustienne Miller MSPT, WCS, CYT

Dustienne Miller MSPT, WCS, CYT (she/her) is the creator of the two-day course, Yoga for Pelvic Pain, and an instructor for Pelvic Function Level 1. Born out of an interest in creating yoga home programs for her patients, she developed a pelvic health yoga video series called Your Pace Yoga in 2012. She is a contributing author in two books about the integration of pelvic health and yoga, Yoga Mama: The Practitioner’s Guide to Prenatal Yoga (Shambhala Publications, 2016) and Healing in Urology (World Scientific). Prior conference and workshop engagements include APTA's CSM, International Pelvic Pain Society, Woman on Fire, Wound Ostomy and Continence Society, and the American Academy of Physical Medicine and Rehabilitation Annual Assembly.

Her clinical practice, Flourish Physical Therapy, is located in Boston's Back Bay. She is a board-certified women's health clinical specialist recognized by the American Board of Physical Therapy Specialties. Dustienne weaves yoga, mindfulness, and breathwork into her clinical practice, having received her yoga teacher certification through the Kripalu Center for Yoga and Health in 2005.

Dustienne's love of movement carried over into her physical therapy and yoga practice, stemming from her previous career as a professional dancer. She danced professionally in New York City for several years, most notably with the national tour of Fosse. She bridged her dance and physical therapy backgrounds, working for Physioarts, who contracted her to work backstage at various Broadway shows and for Radio City Christmas Spectacular. She is currently an assistant professor of jazz dance at Boston Conservatory at Berklee.

Dustienne passionately believes in the integration of physical therapy and yoga within a holistic model of care. Her course aims to provide therapists and patients with an additional resource centered on supporting the nervous system and enhancing patient self-efficacy.

What if a seemingly harmless prescription were quietly undermining the very therapy intended to restore a patient's function and quality of life? Could the side effect of one medication be the missing puzzle piece in an unresolved case of pelvic pain? Might an overlooked drug interaction complicate recovery or hinder treatment progress, despite the best efforts of the therapist?

Understanding medications and their complexities is not just helpful, but essential in rehab.

What Role Do Medications Play in Pelvic Health Rehab?
Medications are everywhere in modern healthcare. But are rehab providers fully aware of how the drugs their patients take may influence treatment outcomes? For patients with pelvic floor dysfunction, benign prostatic hypertrophy (BPH), breast cancer, and those navigating the unpredictable terrain of menopause, pharmaceuticals can serve as both an ally and an adversary.

Pelvic floor dysfunction, for instance, is rarely the result of a single cause. Pain, incontinence, urgency, and sexual dysfunction are symptoms that overlap with other conditions—often managed with medications that can influence outcomes. For example, anticholinergic drugs prescribed for an overactive bladder may reduce urgency but can also cause constipation, dry mouth, and cognitive changes. Are we asking the right questions or thoroughly reviewing the medication list to fully understand the clinical presentation?

In the case of breast cancer, medication regimens are typically complex. Patients might be prescribed chemotherapy, hormone blockers, steroids, bisphosphonates, antiemetics, and more. These drugs come with a host of possible side effects including joint pain, neuropathy, lymphedema, muscle weakness, or even cardiovascular complications. How might these adverse effects alter a patient’s ability to engage in, or respond to, rehab interventions?

Similarly, menopausal symptoms—whether naturally occurring or induced by cancer therapies—are often treated with hormone replacement therapy, antidepressants, and non-hormonal agents. Each can carry risks and benefits that impact the tissues, joints, and sense of well-being.

Understanding Medication Side Effects
Medication side effects can present as a new or worsening symptom. If someone receiving treatment for breast cancer develops sudden muscle or joint pain, is it from increased activity, chemotherapy-induced arthralgia, or perhaps an aromatase inhibitor?

Consider a patient with endometriosis who is prescribed a gonadotropin-releasing hormone (GnRH) agonist to manage their symptoms. While these medications can effectively reduce pelvic pain, they can cause symptoms commonly seen in menopause. The side effects of these drugs may not only affect the patient’s comfort and daily activities but can also create new challenges in rehab, such as increased risk of bone injury or exacerbation of emotional distress. Recognizing and managing these medication effects is crucial for optimizing both patient safety and treatment success.

Drug Interactions and Rehab Challenges
The average patient with pelvic health dysfunction takes several medications, sometimes prescribed by different specialists. How are these drugs interacting, or are some combinations quietly sabotaging progress? A comprehensive understanding of medication interactions and pharmacological principles is essential for delivering appropriate patient care and facilitating effective communication with other healthcare professionals.

Pharmacologic Knowledge Empowers Rehab Providers
A deeper pharmacologic awareness enables therapists to better treat, educate, and advocate for their patients. Understanding the nuances of medication management allows therapists to adapt rehabilitation goals and strategies to the patient’s current medication profile. This knowledge also enables them to help patients recognize symptoms that require urgent attention and reduce frustration and confusion when symptoms do not resolve as expected.

Therapists with a strong knowledge of medications can communicate well with doctors and pharmacists, helping ensure safer, more effective treatment outcomes.

Real-World Challenges
Clinicians often encounter challenges in pharmacology because of the large number of drugs, ongoing introductions of new medications, and the diversity of patient responses. Many rehab providers receive limited pharmacology training, focusing more on anatomy, physiology, and therapeutic techniques. As patients present increasingly complex medical histories, it is essential for rehab providers to maintain comprehensive knowledge and understanding.

It is also common for patients to underreport, forget, or misunderstand their medication regimens. Rehab providers must ask probing questions: "Have you started any new medications recently?" "Have you noticed changes in your symptoms since beginning this treatment?" "Are you taking any over-the-counter drugs, supplements, or herbal products?"

Rehab providers can help ensure patient safety by carefully reviewing medication and supplement lists. By identifying interactions and side effects, and collaborating closely with physicians and pharmacists, therapists contribute to safer, more effective, and patient-centric care.

Join Kristina Koch, PT, DPT, MS, CLT, PCES on September 13, 2025, for the two-day, virtual course offering of Pharmacologic Considerations for the Pelvic Health Provider. Day 1 includes self-paced, pre-recorded lectures, while Day 2 is a live, interactive Zoom session for Q&A, clinical implications, and case-based scenarios.

Your patients are more than their symptoms. And the answers aren’t always in the pelvic floor—they may be hiding in the medication list!

AUTHOR BIO:
Kristina Koch, PT, DPT, CLT, PCES

Kristina Koch, PT, DPT, CLT, PCES (she/her) received her Master of Science in Physical Therapy in 1996 from Springfield College in Massachusetts. In 2001, while living in the Los Angeles area, Kristina started specializing in the treatment of pelvic floor dysfunction, including bowel/bladder issues and pelvic pain, and in 2021, she went on to earn her doctorate of physical therapy from The College of St. Scholastica. During her time in Los Angeles, she was fortunate to work with and be mentored by fellow Herman & Wallace faculty member, Jenni Gabelsburg, DPT, WCS, MSc, MTC. Kristina is a Board Certified Specialist in Women's Health Physical Therapist (2013-2023) by the American Board of Physical Therapy Specialties. She then received her lymphatic therapist certification (CLT) in 2015.

Kristina has successfully helped establish women’s health and pelvic floor physical therapy programs in San Diego, CA and Colorado Springs, CO where she currently works in private practice. Kristina treats men, women, children, trans, and gender non-binary individuals in her practice. In addition, Kristina serves as a guest lecturer for graduate physical therapy students at Regis University in Denver, CO, and provides educational lectures to medical providers and local community groups. Outside of work, Kristina enjoys spending time with her husband and two children, skiing, running, and hiking.

Pelvic organ prolapse (POP) and stress urinary incontinence (SUI) are common conditions affecting people with a vagina across the lifespan, often leading to significant impairments in quality of life. Conservative management is increasingly prioritized, particularly among those who are not surgical candidates, wish to delay surgery, or are managing symptoms during pregnancy or postpartum recovery. Pessaries, intravaginal devices used to support the pelvic organs or compress the urethra, represent a cornerstone of conservative pelvic health management. Their safe, relatively non-invasive nature and growing evidence base make them essential tools in a clinician’s pelvic health toolkit. Pessaries are considered relatively safe for many patient populations and are well tolerated when a proper fit is achieved (Rogers 2017). Well fit pessaries are expected to allow people with POP to participate in a full range of physical activities and exercise comfortably (O’Dell 2012).

This essay explores the current evidence on pessary use, including types, indications, contraindications, patient selection, fitting considerations, and integration with pelvic therapy. Emphasis is placed on empowering pelvic health providers to incorporate pessaries confidently and collaboratively in clinical practice.

Clinical Indications
Pessaries can be used for a range of pelvic health conditions, including:

• Pelvic organ prolapse (POP), this includes management of symptomatic cystocele, rectocele, uterine prolapse, or vault prolapse.
• Stress urinary incontinence (SUI): Especially in cases where the patient is participating in pelvic therapy and making gains in pelvic floor function but continues to have symptoms during lifting or during high-impact activities.
• Pregnancy-related prolapse or urinary symptoms: Providing support during gestation. This is prescribed by a birth provider including an MD, NP, or CNM.
• Postpartum recovery: For temporary support during tissue remodeling.

Types of Pessaries and Their Functions
Pessaries are broadly categorized into supportive and space-filling devices. The selection of type depends on the specific condition being treated, the degree of prolapse, and the patient’s anatomy and functional goals.

1. Support Pessaries

These include the ring pessary (with or without support) and are generally used for mild to moderate prolapse or stress urinary incontinence. Ring with support is frequently used in patients with a widened introitus some apical loss of support (either the cervix or the cuff in the event of hysterectomy). Ring without support can be a good choice for patients with mild to moderate cystocele and/or rectocele with generally good pelvic floor muscle tone.

2. Space-Filling Pessaries

Designed for more advanced prolapse or when support pessaries fail, these include Gellhorn, Donut, and Cube pessaries. The Gellhorn is often used in cases of more severe prolapse (stage III or IV prolapse). For stress urinary incontinence, the incontinence dish or ring with knob can elevate the urethra and reduce leakage under load of the knob.

Contraindications and Cautions
Although pessaries are safe, contraindications and red flags must be observed. They include:

• Active vaginal infections (e.g., candidiasis or bacterial vaginosis) should be treated prior to fitting.
• Severe vaginal atrophy may increase the risk of erosion and should be managed with topical estrogen before long-term use.
• Noncompliance with prior use and cleaning, or cognitive impairment may limit self-care ability unless caregivers are trained.
• Allergy to pessary material (e.g., latex, silicone), though rare, must be considered.

Fitting Process: A Collaborative and Individualized Approach
Proper fitting is essential for comfort, function, and adherence. The process typically includes a pelvic exam to assess prolapse stage, vaginal length, introital laxity, and tissue integrity. Additionally, trial and error during fitting with a range of pessary sizes and types is common. The right pessary should sit comfortably behind the pubic symphysis and under the cervix or vaginal vault without protruding or causing discomfort.

Functional testing during the fitting process is helpful to ensure comfort and optimal use for the patient. To do this, ask the patient to stand, bear down, cough, and walk around the office to ensure stability and effectiveness.

Patient education: On insertion, removal, cleaning, and signs of complications.
Follow-up after a pessary is fit is usually done after 1–2 weeks, then at 3-month intervals depending on patient autonomy and tissue health. Patients should also be instructed in managing complications and problem solving. Most pessary complications are minor and manageable, including:

• Increased vaginal discharge
• Odor or irritation
• Light bleeding or spotting, especially in estrogen-deficient tissues
• Expulsion or shifting of the pessary
• Urinary retention (rare, more common with space-filling devices)

Management strategies:

• Encourage regular removal and cleaning (daily to weekly for self-managing patients; every 1–3 months for clinician-managed).
• Use vaginal estrogen for tissue health in postmenopausal patients.
• Resize or switch device types if discomfort or expulsion occurs.
• Refer for evaluation to a physician or nurse practitioner if persistent bleeding, pain, or infection is noted.

Patient Empowerment and Adherence
Patient-centered education improves long-term success with a pessary. Education that pessaries are not permanent and can be removed at any time often alleviates anxiety that they may be feeling. Additionally, pessaries do not stretch or weaken the vagina; in fact, they often support pelvic rehabilitation efforts in conjunction with pelvic health therapy. Additionally, self-care is safe and achievable with practice and symptom relief can be immediate, as the patient works on restoring mobility, confidence, and function. Offering video tutorials, printed guides, and in-person instruction increases adherence and reduces fear or confusion.

Conclusion
Pessaries are a powerful, evidence-based tool for managing pelvic organ prolapse and stress urinary incontinence. When thoughtfully integrated into a multidisciplinary pelvic health plan, they provide a non-invasive, low-risk option that empowers patients while supporting tissue healing and function. Pelvic health providers play a crucial role in identifying appropriate candidates, facilitating fittings, and supporting ongoing care, especially when combined with targeted physical therapy. Understanding the nuances of pessary selection, education, and monitoring will continue to elevate care standards and improve outcomes in this essential area of women’s health.

References:

1. O’Dell K, Atnip S. (2012). Pessary Care: Follow Up and Management of Complications. Urologic Nursing.32 (3), 126-145. 
2. Rogers, R. G., & Fashokun, T. B. (2017). Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. Waltham, MA: Wolters Kluwer.

 

AUTHOR BIO
Dr. Amanda Olson

Dr. Amanda Olson is a pelvic health physical therapist, entrepreneur, author, and global educator with a passion for empowering men and women and advancing conversations around pelvic health. She has dedicated her career to breaking stigmas around pelvic health, supporting patients with conditions including cancer, incontinence, pelvic pain, cancer, pelvic organ prolapse, endometriosis, and MRKH, and developing innovative solutions to improve quality of life.

Dr. Olson is the president of Intimate Rose, a successful pelvic health device company that includes tools for managing pelvic pain, holds multiple patents, and has authored six peer-reviewed journal articles as well as the book Restoring the Pelvic Floor for Women. She is also the recipient of the Elizabeth Nobel Award, the highest honor bestowed in the field of pelvic health. She has collaborated with clinics worldwide, transforming lives through her tools, teaching, and consulting. As an advocate for patients with sensitive issues, and medical innovation, Dr. Olson is committed to bridging the gap in pelvic and women’s healthcare and bringing education to underserved patient populations.

People with idiopathic Parkinson disease (PD) commonly experience lower urinary tract symptoms (LUTS), referred to as neurogenic bladder, with a prevalence reported between 27-80% (Cheng, B., et al., 2023). The neuroanatomical degeneration in the dopaminergic system is one of the main precipitating factors for LUTS and other autonomic dysfunction. The most common LUTS reported are urgency/frequency (detrusor hyperreflexia) and nocturia. As the disease progresses or in cases when the individual has atypical Parkinsonism, urinary incontinence and urinary retention (detrusor hyporeflexia, detrusor sphincter dyssynergia, bladder outlet obstruction/benign prostatic hypertrophy) become more prevalent. Taken together, these storage and voiding symptoms increase the risk of developing a urinary tract infection (UTI). Additionally, PD is considered an age-related disease, occurring most often in people over 60. Generally, the risks for UTIs increase with age, in particular, affecting aging women more due to age-related changes in the lower urinary tract after menopause.

UTIs are a leading cause of hospitalization, morbidity, and mortality in people with PD. These individuals happen to be twice as likely to be admitted to the hospital for a UTI in comparison to age-matched controls, 48% to 23% respectively (Su, C., M., et al., 2018). Additionally, UTIs seem to occur in equal proportions between older men and women with PD. This gives implication to the theory that there may be something about PD itself that overrides the typical age-related female UTI risk. Additionally, the literature reports a dramatic elevated risk in UTIs for people with PD undergoing orthopedic surgeries, with 1/3 developing a UTI after knee arthroplasty. We can also examine the inverse relationship of the person with PD experiencing UTI, inducing motor and cognitive dysfunction, especially with systemic infection causing a “UTI-induced neurotoxicity,” leading to falls and orthopedic injury with surgical repair (Hogg, E., et al., 2022). UTIs happen to be the single most frequent underlying cause for PD motor symptoms exacerbation, accounting for 25% of exacerbations (Zheng, K.S., et al., 2012). UTI-related sepsis is of very large concern as people with PD are twice as likely to experience a hospital stay longer than 3 months, and it is a leading cause of morbidity in PD.

Several other compounding factors can also increase the risk of UTI in people with PD. First, it is reported that greater than 80% of people with PD experience gastrointestinal symptoms, referred to as neurogenic bowel, with the most common being constipation. Constipation in PD is complex and is often due to both slow motility and dyssynergic defecation, leading to the risk of microorganisms entering the urinary tract. Second, is the use of anticholinergic bladder medication, especially since PD motor symptoms medications cause anticholinergic side effects, which will then be compounded and potentially increase constipation and potential urinary retention. Third, immobility and frailty affect getting to the bathroom regularly and safely, increasing the risk of urinary incontinence and pad use. There may be challenges with self-hygiene and an increased chance of long-term care facility admission, where there is an increased risk of being exposed to antibiotic-resistant bacteria. Fourth, is cognitive impairment, which ranges from mild cognitive impairment (MCI) to dementia and is 2.5-6 times more likely to develop in the person with Parkinson disease (Aarsland, D., et al., 2021). This may lead to difficulty expressing toileting needs, difficulty expressing symptoms of UTI, leading to over or under treatment, and potentially catheterization, further increasing the risk. Fifth, it may be related to the urinary tract microbiome in individuals with neurogenic bladder. A shift from a healthy microbiome to overgrowth of pathogenic species is theorized to worsen with antibiotic overuse and catheterization. There is, however, a research gap in this area, especially with PD subjects.

Multiple modifiable and non-modifiable risk factors have been identified, resulting in the person with PD being more susceptible to UTI. As pelvic health therapists, we have the opportunity for prevention education and recommendations, from lifestyle modifications to formal holistic assessment, treatment, and specialist referral. Join me for my course, Parkinson disease and Pelvic Rehabilitation, as we explore how to optimize your treatment plan for modifiable risk factors of UTI.

Resources:

1. Aarsland, D., Batzu, L., Halliday, G. M., Geurtsen, G. J., Ballard, C., Ray Chaudhuri, K., & Weintraub, D. (2021). Parkinson disease-associated cognitive impairment. Nature reviews Disease primers, 7(1), 47.
2. Cheng, B., Huang, S., Huang, Q., Zhou, Z., & Bao, Y. (2023). The efficacy and safety of medication for treating overactive bladder in patients with Parkinson's disease: a meta-analysis and systematic review of randomized double-blind placebo-controlled trials. International Urogynecology Journal, 34(9), 2207-2216.
3. Gerlach, O. H., Winogrodzka, A., & Weber, W. E. (2011). Clinical problems in the hospitalized Parkinson's disease patient: systematic review. Movement Disorders, 26(2), 197-208.
4. Hogg, E., Frank, S., Oft, J., Benway, B., Rashid, M. H., & Lahiri, S. (2022). Urinary tract infection in Parkinson’s disease. Journal of Parkinson’s Disease, 12(3), 743-757.
5. Su, C. M., Kung, C. T., Chen, F. C., Cheng, H. H., Hsiao, S. Y., Lai, Y. R., ... & Lu, C. H. (2018). Manifestations and Outcomes of Patients with Parkinson’s Disease and Serious Infection in the Emergency Department. BioMed Research International. 2018; 2018: 6014896.
6. Zheng, K. S., Dorfman, B. J., Christos, P. J., Khadem, N. R., Henchcliffe, C., Piboolnurak, P., & Nirenberg, M. J. (2012). Clinical characteristics of exacerbations in Parkinson disease. The neurologist, 18(3), 120-124.

 

AUTHOR BIO:
Erica Vitek, MOT, OTR, BCB-PMD, PRPC

Erica Vitek, MOT, OTR, BCB-PMD, PRPC (she/her) graduated with her master’s degree in Occupational Therapy from Concordia University Wisconsin in 2002 and works for Aurora Health Care at Aurora Sinai Medical Center in downtown Milwaukee, Wisconsin. Erica specializes in female, male, and pediatric evaluation and treatment of the pelvic floor and related bladder, bowel, and sexual health issues. She is board-certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD) and is a Certified Pelvic Rehabilitation Practitioner (PRPC) through Herman and Wallace Pelvic Rehabilitation Institute.

Erica has attended extensive post-graduate rehabilitation education in the area of Parkinson disease and exercise. She is certified in LSVT (Lee Silverman) BIG and is a trained PWR! (Parkinson’s Wellness Recovery) provider, both focusing on intensive, amplitude, and neuroplasticity-based exercise programs for people with Parkinson disease. Erica is an LSVT Global faculty member. She instructs both the LSVT BIG training and certification course throughout the nation and online webinars. Erica partners with the Wisconsin Parkinson Association (WPA) as a support group, event presenter, and author in their publication, The Network. Erica has taken a special interest in the unique pelvic floor, bladder, bowel, and sexual health issues experienced by individuals diagnosed with Parkinson disease.

In preparation for this blog, I searched Burnout in the Facebook group Global Health Physio. Here are some snippets. See if you can relate?

The struggle is real and relatable.

Then this comment held me in contemplation...

“Within our profession as physical therapists there is a PERVASIVE culture of giving away too much of ourselves and our time. Corporations have long taken advantage of our giving/helping nature by overloading our schedules and demanding impossible productivity standards such that we end up not feeling good about the care we provide, and we do documentation on our personal time. “

In last session’s Boundaries Meditation and Self Care class we were all relating to the fact that we tend to care TOO much, spend too much time with patients and paperwork piled up leaving us stressed and depleted in both time and energy.

This led to Nari (Clemons, my bestie and brains behind this class we developed and co-teach) vibrantly encouraging us all to “channel our inner Selfish B****” to the result of a Zoom full of laughter!

Nari went on to explain that our ability to accurately judge ourselves for healthy boundaries with patients was skewed or even broken. Holding a HEALTHY boundary with our time or energy was to US going to FEEL LIKE we were being totally selfish! And so why not just allow that bass a** chick to have a much-needed voice!

So, what does being a (tongue-in-cheek) “Selfish B” look like in clinical practice??

Developing a model of clinical practice that values YOU the clinician and your health and well-being as MUCH (or MORE) than that of our patients.

Some behaviors to strive for:

• Finish sessions 5 mins early or spend the last 5 minutes documenting your intervention.
• Hold that “one last thing” you want to do with that patient and put it in the plan for the next visit.
• Actually, take your WHOLE lunch time to refresh yourself, finish paperwork, eat, move, rest, breathe or connect with coworkers.
• Be proactive in setting up a shared model of care with your patients on an initial visit.
• Say things like:
  • Our time is up, and my next patient is here, I look forward to (answering your questions, furthering your program, seeing you, etc) in our next appointment.
  • I don’t take phone calls, but you may email me concerns and we can talk about them at your next visit.

Let’s be honest about a few things. We serve a population of patients that can be emotionally taxing, medically challenging, and complex on all levels. AND while we learn excellent clinical skills, no one teaches us energetic, emotional, and behavioral skills to manage this level of patient care and interaction.

Until NOW.

If you’ve been struggling with burnout, exhaustion, time management, energy depletion or your own Selfish B is struggling to find her voice, come join us on a journey of healing and equipping.

We promise you won’t regret the investment in YOU and your future.

---

Boundaries, Self-Care, and Meditation (scheduled for September 27-28) is a course built from the combined experience of me and my bestie, Nari Clemons, as we navigated the complex task of Burnout recovery. 

This course is for anyone who finds themselves over-giving, spending too much time on paperwork, not having energy for their life outside of work, knowing something is not working, but not knowing how to change.

We explore how to set boundaries with time, energy, and patient care. We reframe the narrative of what it means to be a therapist, a giver, an empath. This course is one part equipping through shared information, and one part deep reflective soul search tied up in story, values, intentions, and accountability.

 

AUTHOR BIO
Jenna Ross, PT, BCB-PMD, PRPC

Jennafer Ross PT, BCB-PMD, PRPC, (she/her) After graduating from Ithaca College, Jenna began her career as a physical therapist at Spectrum Health in Grand Rapids, MI. Since 2002, she has focused her professional attention on treating women, men, and children with pelvic health disorders. She is energized through education and enjoys her position as adjunct faculty at Grand Valley University, speaking at community events, organizing a regional pelvic floor mentorship and study group, and didn’t necessarily enjoy but survived part-time home-schooling her two daughters. She has been faculty for Herman & Wallace Pelvic Rehabilitation Institute since 2009 and loves to inspire other rehab professionals treating pelvic floor dysfunction. She is the author of the chapter, “Manual Therapy for the Pelvic Floor,” which was published in the book, “Healing in Urology.” Jenna was a contributing writer for the Pelvic Floor Capstone curriculum and also co-authored the continuing education course, “Boundaries, Self-Care and Meditation” with Nari Clemons. She is certified in pelvic floor rehabilitation and biofeedback for pelvic floor disorders. Outside of teaching and treating patients, Jenna loves to spend time with family and friends, run, cook, travel, do yoga, and snuggle with her doggo.

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When discussing the use of ultrasound imaging in my clinical practice, I am often asked, “What type of patient is your favorite to use ultrasound with?” This is a hard question for me to answer because ultrasound is so beneficial for several types of patients.

Ultrasound is used in a wide range of clinical scenarios, including sacroiliac joint (SIJ) and lumbar spine pain, guiding core strengthening for oncology or post-surgical patients, supporting recovery after prostatectomy, and assessing pediatric and adolescent pelvic floor function. I often highlight that ultrasound imaging is particularly valuable when internal pelvic assessments are not possible, for example, in the immediate postpartum period when pelvic rest is prescribed. In such cases, transabdominal ultrasound can help confirm whether patients are correctly engaging their pelvic floor muscles following a vaginal delivery.

A recent study in the Journal of Women’s & Pelvic Health Physical Therapy explored the use of ultrasound imaging in the early postpartum period. The study included 75 women between 0 and 5 days after vaginal delivery. Each participant took part in a single in-person session where ultrasound was used both as an assessment tool for the clinician and as biofeedback for the patient.

The study concluded that with only one session, using ultrasound as biofeedback improved contractions for participants. Vertical bladder excursion during a pelvic floor contraction was improved, especially in those patients who initially presented with paradoxical excursions, and those who suffered perineal trauma during delivery. Participants were satisfied with the experience of using ultrasound imaging and receiving early postpartum PFM rehabilitation.

This is an exciting development, especially for those of us working in hospital settings! The ability to visit patients shortly after childbirth and begin pelvic floor rehabilitation right away presents a major opportunity. It allows us to reach more patients early, provide essential education, and address potential issues before they progress. With today’s smaller, more portable ultrasound units, which can even connect to a smartphone or tablet, therapists can easily bring them onto the labor and delivery unit to examine patients within the first few days after delivery.

The Course: Rehabilitative Ultrasound Imaging: Pelvic Health & Orthopedic Topics
This course examines how rehabilitative ultrasound imaging can benefit various patient populations. You'll learn how to apply ultrasound in both orthopedic and pelvic health settings. There are two course options: a two-day version tailored for orthopedic therapists, and a three-day version designed for pelvic floor therapists, which includes deeper training on pelvic floor-specific conditions. Join me September 5–7 to learn how to integrate ultrasound imaging into your clinical practice. Satellite Options for the September 5-7 course date include:

• Rehabilitative Ultrasound: Orthopedic Topics - September 5-6
  Indianapolis IN
  Seattle WA
  Self-Hosted
• Rehabilitative Ultrasound Imaging Pelvic Health - September 5-7
  Indianapolis IN
  Seattle WA
  Self-Hosted

 

AUTHOR BIO
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC (she/her) has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health, including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion to help oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include: “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman and Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies and physicians.

One of the most important concepts in working with people with low bone density (osteopenia or osteoporosis) is reducing the hyper-kyphosis of the spine. Notice I’m saying HYPER-kyphosis, not just kyphosis which should be present in the thoracic spine. Because the anterior portion of the vertebral bodies is where most spinal fractures occur, an increase in the Cobb angle beyond 40-50 degrees places increased pressure on that area. This can result in increased risk of fractures or may be an indication that a fracture has previously occurred.

There are several ways to measure an individual’s thoracic hyper-kyphosis with x-rays being the gold standard. However, we as clinicians can use the Flexicurve, a protocol advanced by physical therapist, Carleen Lindsey. (1)

The Flexicurve ruler is a tool used to measure thoracic kyphosis and can help identify hyper-kyphosis. It is available on Amazon or found in some fabric stores. To use the Flexicurve, the ruler is molded to the patient's thoracic and lumbar curves in standing and then the curves are traced on graph paper. Measurements of the curves are then taken by measuring the width of the T curve, divided by the length of the T curve X 100. A kyphosis index is calculated to quantify the curvature. An index greater than 13 is often considered hyper-kyphotic, according to a study from the NIH. (2)

One of the advantages that I love is that after the measurement is traced on graph paper and dated, the patient has a visual of their spine which helps with exercise compliance. It also helps to explain why we are targeting specific muscles and areas of the spine, not just general strengthening. Following our exercise program, the patient can be re-measured, and the new drawing placed adjacent to the initial one. Patients can see the improvement which further motivates them to keep exercising Typically, with the reduction in thoracic hyper-kyphosis come a subsequent increase in height!

So how do we reduce the curve? By strengthening the upper back extensors. First you must make sure the individual is trained in neutral lumbar spine and core control. Many people with hyper-kyphosis compensate by increased lumbar lordosis which often results in lumbar hypermobility and resultant pain. And doesn’t strengthen the upper back.

Once they understand and can maintain neutral lumbar spine, we proceed with the Decompression and Re-alignment Routine developed by Sara Meeks, PT. This is practiced in the supine position and progressed to prone. Using visuals is a great way to “get your ideas of movement” into your patient’s body. I like to use the “person being shot out of a cannon” as my visual. The abdominal stabilization, spinal elongation, and activation of scapulo-thoracic musculature are all embodied in the image.

Educating patients and giving them visuals to see the improvement goes a long way toward helping them remain compliant with their exercise program.

My colleague and partner, Dr. Frank Ciuba and I would welcome you to our upcoming remote course, Osteoporosis Management: An Introductory Course for Healthcare Professionals where you will learn additional assessments and exercises for people with low bone density. Our next courses are scheduled for September 6 or November 8.

References:

1. https://www.researchgate.net/figure/Flexicurve-ruler-measurement-of-kyphosis-A-Mark-the-C7-spinous-process-and-the-L5-S1_fig3_44639136
2. J Lam, T Mukhdomi. Kyphosis, Stat Pearls, NIH. (Aug 2023

 

AUTHOR BIO
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT (she/her) has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete, where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.

Over the last few years, a growing body of studies has expanded our understanding of male pelvic floor dysfunction and refined the approach to treatment within pelvic rehabilitation. The latest evidence supports a multifaceted, neuro-muscular strategy grounded in early intervention, individualized care, and integration of tools like electrical stimulation and manual therapy. Below, are a few key findings that are reshaping clinical protocols and outcomes in male pelvic rehab.

Post-Prostatectomy Urinary Incontinence
Pelvic floor muscle training (PFMT) remains the first-line therapy for post-prostatectomy incontinence (PPI). A 2022 meta-analysis by Park et al, involving 21 randomized controlled trials, found that PFMT nearly tripled continence rates compared to no PFMT. Patients also showed significant improvements in both objective measures (e.g., pad counts) and subjective continence scores.

While long-term benefits are well established, recent research emphasizes the importance of early initiation. Multiple studies support beginning PFMT preoperatively or immediately postoperatively to optimize outcomes, particularly after nerve-sparing robotic-assisted radical prostatectomy. Timed, progressive PFMT, especially when started early, is essential for maximizing continence recovery, even more so in cases involving nerve-sparing approaches that may affect pelvic floor coordination.

Combining PFMT with Electrical Stimulation
A 2025 meta-analysis by Lunardi et al examined 885 female patients and found that pelvic floor muscle training (PFMT) combined with electrical stimulation significantly outperformed PFMT alone in improving continence, pelvic floor strength, and quality of life. However, these findings are limited to women and do not directly translate to male populations.

In contrast, evidence in male patients, particularly those with post-prostatectomy incontinence, is more mixed. A randomized, placebo-controlled trial by Yamanishi et al. in 2010 that involved 56 men found that PFMT combined with anal electrical stimulation significantly improved continence rates during the early recovery period (1–6 months) compared to “sham” stimulation. However, by 12 months, the difference between groups was no longer statistically significant, suggesting that the benefits may be short-term.

While adjunctive electrical stimulation appears to provide early benefit in some men, especially those with severe leakage or poor initial voluntary contraction, the long-term advantage remains uncertain. Patients with limited neuromuscular control may benefit from neuromuscular electrical stimulation (NMES) to enhance recruitment and early adherence, but expectations should be managed regarding sustained continence outcomes beyond the first 6–12 months.

Pelvic Floor Therapy for Sexual Dysfunction
Emerging literature from Pastore et al. (2021) supports pelvic rehab in the management of erectile dysfunction, premature ejaculation, and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Integration of manual therapy, PFMT, and behavioral retraining has yielded meaningful gains in function and reduction in nociceptive signaling.

A 2024 study utilizing High-Intensity Focused Electromagnetic (HIFEM) therapy further points to new frontiers in non-invasive intervention for erectile dysfunction and male urinary control.

These findings highlight the evolving role of pelvic floor therapy as a cornerstone in the multidisciplinary management of male sexual dysfunction. Whether through traditional rehabilitation approaches—such as PFMT, manual therapy, and behavioral retraining—or through emerging technologies like HIFEM, pelvic health interventions demonstrate tangible benefits in improving sexual function, alleviating pelvic pain, and restoring urinary control.

Clinical Patterns Worth Noting
In clinical practice, several common patterns emerge when treating male pelvic floor dysfunction. Patients with chronic pelvic pain frequently present with pelvic floor overactivity, often accompanied by restrictions in the obturator internus, adductor magnus, and piriformis muscles. This hypertonicity is commonly associated with neural sensitization and can be exacerbated by postural imbalances or stress-related bracing strategies.

Men recovering from prostatectomy may exhibit compensatory recruitment of accessory muscles, such as the gluteal and abdominal muscles, due to impaired pelvic floor motor control. This can reduce the effectiveness of voluntary pelvic floor muscle contractions and contribute to persistent urinary leakage despite exercise adherence. Thorough neuromuscular re-education is often required to facilitate isolated pelvic floor activation and restore continence.

Erectile dysfunction in this population is frequently compounded by contributing factors such as pelvic asymmetry, altered respiratory diaphragm coordination, and increased thoracolumbar tension. These findings emphasize the importance of a whole-body biomechanical and neuro-myofascial assessment, as pelvic floor dysfunction in men rarely presents in isolation. Recognizing and addressing these interrelated impairments is key to achieving lasting functional outcomes.

August Satellite Lab: Pelvic Function Level 2C
Herman & Wallace invites you to refine your clinical reasoning and hands-on skills at the upcoming Pelvic Function Level 2C Satellite Lab Course, held August 16–17.

This intermediate-level course emphasizes:

• Recognizing the key signs and symptoms that lead to impairment, functional limitations, and disabilities in men’s health
• Use of an evaluation/outcome tool relating to patient condition(s)
• Designing a multi-modal plan of care for pelvic rehabilitation
• Performing clinical interventions based on the patient's presentation and goals

Clinical treatment interventions include patient education, neuro re-education, therapeutic exercise, manual therapy, therapeutic activities, instruction in self-care, and recommendations for relevant modalities.

It’s essential that pelvic rehabilitation continues to evolve beyond the historically female-centered framework to address the full spectrum of pelvic dysfunction, including the complex needs of male patients. Evidence indicates that targeted, neuromuscular-driven rehabilitation strategies can significantly improve outcomes for men experiencing urinary, sexual, and pain-related pelvic conditions.

The August course is available in 9 different satellite locations as well as self-hosted. Satellite locations for Pelvic Function Level 2C: Men’s Pelvic Health and Rehabilitation include:

• Columbus OH
• Danvers MA
• Katy TX
• Milwaukee WI
• New Orleans LA
• New York NY
• Palm Beach FL
• Paso Robles CA
• Tacoma WA
• Self-Hosted

 

References

1. Park JJ, Kwon A, Park JY, Shim SR, Kim JH. Efficacy of Pelvic Floor Exercise for Post-prostatectomy Incontinence: Systematic Review and Meta-analysis. 2022 Oct;168:175-182. doi: 10.1016/j.urology.2022.04.023. Epub 2022 May 5. PMID: 35526757. https://pubmed.ncbi.nlm.nih.gov/35526757/
2. Lunardi AC, Foltran GC, Carro DF, Silveira LTY, Haddad JM, Ferreira EAG. Efficacy of electrical stimulation in comparison to active training of pelvic floor muscles on stress urinary incontinence symptoms in women: a systematic review with meta-analysis. Disabil Rehabil. 2025 Jun;47(13):3256-3267. doi: 10.1080/09638288.2024.2419424. Epub 2024 Oct 28. PMID: 39467254. https://pubmed.ncbi.nlm.nih.gov/39467254/
3. Yamanishi T, Mizuno T, Watanabe M, Honda M, Yoshida K. Randomized, placebo-controlled study of electrical stimulation with pelvic floor muscle training for severe urinary incontinence after radical prostatectomy. J Urol. 2010 Nov;184(5):2007-12. doi: 10.1016/j.juro.2010.06.103. Epub 2010 Sep 20. PMID: 20850831. https://pubmed.ncbi.nlm.nih.gov/20850831/
4. Pastore AL, Palleschi G, Fuschi A, Maggioni C, Rago R, Zucchi A, Costantini E, Carbone A. Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach. Ther Adv Urol. 2014 Jun;6(3):83-8. doi: 10.1177/1756287214523329. PMID: 24883105; PMCID: PMC4003840. https://pmc.ncbi.nlm.nih.gov/articles/PMC4003840/
5. Yaacov D, Nelinger G, Kalichman L. The Effect of Pelvic Floor Rehabilitation on Males with Sexual Dysfunction: A Narrative Review. Sex Med Rev. 2022 Jan;10(1):162-167. doi: 10.1016/j.sxmr.2021.02.001. Epub 2021 Apr 27. PMID: 33931383. https://pubmed.ncbi.nlm.nih.gov/33931383/
6. Brandeis J. Improving Male Pelvic Health: Efficacy of HIFEM Muscle Stimulation for Urinary Function and Sexual Dysfunction in Men. Reproductive System & Sexual Disorders: Current Research. Research Article. 2024; 13(1). ISSN: 2161-038X. https://www.longdom.org/open-access/improving-male-pelvic-health-efficacy-of-hifem-muscle-stimulation-for-urinary-function-and-sexual-dysfunction-in-men-106497.html

Have you ever wanted to show LGBTQIA+ patients your allyship and that your health care facility is an inclusive and welcoming environment, but have never been sure how? You're not alone! Many healthcare professionals feel uncertain about how best to support LGBTQIA+ individuals, especially given the diverse and evolving nature of these communities. Below are 3 simple yet impactful ways to make your office a more inclusive space for LGBTQIA+ and Intersex patients.

As healthcare professionals, we have the responsibility to create environments where every patient feels safe, seen, and understood. While it may seem like a lot to consider, small adjustments can have a lasting impact on the experiences of LGBTQIA+ patients. To dive deeper into building an inclusive practice, including how to be an ally to LGBTQIA+ folx, join the upcoming session on Intersex Patients: Rehab & Inclusive Care with Dr. Molly O’Brien-Horn on August 23, 2025!

Inclusive Documentation and Forms
When it comes to making a space truly inclusive, one of the first areas to look at is documentation. While many healthcare facilities have begun to add spaces for patients to share their pronouns or gender identity on intake forms, there’s always more that can be done to reflect the diversity of your patients.

• Gender Identity: Include options beyond just "Male" or "Female." Consider adding options like “Non-binary,” “Genderqueer,” “Prefer not to answer,” or a free text field where patients can write in their gender identity.
• Sexual Orientation: Instead of only asking for heterosexual or homosexual orientations, provide a range of options, including "Bisexual," "Pansexual," "Asexual," and “Queer.” Also, give patients the space to self-identify if their sexual orientation doesn’t fall within these options.
• Intersex and Variations in Sex Characteristics: Patients may have unique needs based on intersex traits or variations in sex characteristics. Including a question about whether a patient identifies as intersex or has a variation in sex characteristics can provide vital context for care. This helps in creating an affirming space and avoids erasure of intersex experiences.

Why This Matters: By offering these inclusive options, you make it clear that your office recognizes the unique experiences and identities of all patients. This not only fosters trust but also improves healthcare outcomes by tailoring care to the individual’s specific needs.

Inclusive Signs, Flags, and Pins
Visually demonstrating your commitment to inclusivity can be incredibly powerful, but it’s important to go beyond just a rainbow pride flag.

• LGBTQIA+ and Intersex Pride Flags: While the rainbow pride flag is commonly associated with LGBTQ+ inclusion, it's important to acknowledge that not all LGBTQIA+ individuals are represented by that flag. For example, the Intersex Inclusive Progressive Pride Flag includes the yellow and purple circle, which is a symbol for intersex people. Displaying this flag or using intersex pride pins in your office makes a visible statement of support for Intersex patients, who are often marginalized within LGBTQIA+ spaces.
• Gender-Neutral Bathrooms: Clear signage for gender-neutral or all-gender bathrooms is another way to show inclusivity. These spaces are especially important for transgender, non-binary, and gender-nonconforming individuals, who may feel uncomfortable or unsafe using gendered restrooms.

Why This Matters: These small but meaningful symbols signal to your patients that they are seen, valued, and respected. The presence of inclusive symbols like flags, stickers, or signs also helps to ease the anxieties of patients who may be concerned about facing discrimination in a healthcare setting.

Accessibility
Creating an accessible office environment is an essential component of inclusivity, as it helps ensure that everyone, including LGBTQIA+ individuals with disabilities, feels welcome. Accessibility goes beyond just physical ramps and elevators—it includes how your office accommodates people from all backgrounds and experiences.

• ADA Compliance: Make sure that your office is fully compliant with the Americans with Disabilities Act (ADA). This includes wheelchair ramps, accessible parking spaces, Braille signage, and elevators. For LGBTQIA+ folx with disabilities, these elements are especially important as they can help create a more comfortable, dignified experience while accessing care.
• Training and Language: Accessibility also involves educating staff on respectful and inclusive language when interacting with patients with disabilities or chronic health conditions. It’s important that everyone from front desk staff to physicians understands how to communicate effectively with people who have hearing, visual, mobility, or cognitive impairments.
• Transgender and Non-Binary Specific Care: Many transgender and non-binary individuals face unique healthcare challenges when it comes to physical accessibility. For example, accessible dressing rooms and changing areas that respect gender identity are critical. You could also consider gender-neutral fitting rooms and patient rooms, making sure your spaces are accommodating for all genders.

Why This Matters: Ensuring that your office is accessible and compliant helps every patient feel like they belong. Accessibility is not just about physical space but also about creating an environment where LGBTQIA+ individuals can communicate their needs without fear of judgment or misunderstanding.

Incorporating these simple strategies into your practice can make a profound difference for LGBTQIA+ and Intersex patients. From creating inclusive forms to displaying pride flags that acknowledge diverse identities, and ensuring your office is accessible for all, every step you take toward inclusivity helps build trust and improve patient care.

As healthcare providers, we must continually educate ourselves, listen to our patients, and strive to create spaces where every individual feels affirmed and respected. Join us for the upcoming course with Dr. Molly O’Brien-Horn on August 23rd for Intersex Patients: Rehab & Inclusive Care to take your allyship to the next level! Together, we can make healthcare environments more supportive for everyone.

Resources:

1. National LGBTQIA+ Health Education Center. (2016, February 17). Providing Inclusive Services and Care for LGBT People. https://www.lgbtqiahealtheducation.org/wp-content/uploads/Providing-Inclusive-Services-and-Care-for-LGBT-People.pdf.

2. National LGBTQIA+ Health Education Center. (2020). Affirming Primary Care for Intersex People 2020. https://www.lgbtqiahealtheducation.org/wp-content/uploads/2020/08/Affirming-Primary-Care-for-Intersex-People-2020.pdf.

3. Lambda Legal & InterACT. (2018, July 19.) Intersex-Affirming Hospital Policy Guide: Providing Ethical and Compassionate Health Care to Intersex Patients. https://www.lambdalegal.org/publications/intersex-affirming.

4. Pride in Diversity & OII Australia. (2014). Employers’ Guide to Intersex Inclusion. https://ihra.org.au/wp-content/uploads/key/Employer-Guide-Intersex-Inclusion.pdf.

 

AUTHOR BIO
Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI

Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI graduated from Rutgers School of Biomedical & Health Sciences with her Doctor of Physical Therapy degree. She is a Pelvic Health Physical Therapist, a Certified Lymphedema Therapist, a Pregnancy & Postpartum Corrective Exercise Specialist, an LSVT BIG Parkinson’s Disease Certified Therapist, and an APTA Credentialed Clinical Instructor. She is also a trained childbirth and postpartum doula. Molly is a member of the APTA Academy of Pelvic Health Physical Therapy and is also a Teaching Assistant with the Herman & Wallace Pelvic Rehabilitation Institute.

Molly is passionate about providing accessible healthcare to pelvic health patients of all age ranges, gender identities, sexualities, body variations, and all ability levels.

Advanced maternal age (AMA) is typically defined as pregnancy in women aged 35 years or older. Being of advanced maternal age doesn’t necessarily make postpartum recovery harder. However, it can be associated with factors that may impact the trajectory of the recovery process.

Today, let’s explore a question that I often encounter when teaching the peripartum series (Pregnancy Rehabilitation and Postpartum Rehabilitation): Does Pelvic floor function and recovery look different in women of advanced maternal age compared to younger birth parents?

In a 2024 study by Swenson et al.,¹ their objective was to determine the differences, by maternal age, at first vaginal birth, in genital hiatus (GH) from late pregnancy through one year postpartum. They were investigating this question because older maternal age at the time of first vaginal birth can increase the risk for pelvic organ prolapse (POP). Genital hiatus (GH) enlargement seems to precipitate POP. (A larger measurement of the levator hiatus is associated with POP.) They offer a possible explanation for this increased POP risk with AMA, suggesting that older age may impair the recovery of the connective tissue and pelvic floor muscles (PFMs) that help maintain normal GH closure. This study included POP-Q exams in the third trimester, 8 weeks postpartum, and 1 year postpartum. In this study, they defined AMA as pregnancy in women aged 33 years or older, and there were 593 participants with a mean age of 28.8 years old.

What they found was that there was no significant difference in GH between age groups in the third trimester or at 8 weeks postpartum; however, at one year postpartum, the GH was significantly larger in the older group. These authors concluded that “ongoing PF changes continue past the traditional 6-week postpartum period and that older women may follow an impaired recovery trajectory that could lead to anatomic POP.”

How interesting! This conclusion suggests that the increase in size of the GH is happening during the first year postpartum, so this seems like an optimal time to participate in pelvic floor therapy.

The authors further suggest that identifying postpartum women in an impaired recovery trajectory could advance efforts to develop preventative strategies and early interventions. A study like this may help us advocate for women of “AMA” and the strong need for early, routine pelvic rehab to perhaps prevent or minimize POP.

In an observational prospective study in 2013, Yoshida et al.², aimed to show differences in temporal recovery of pelvic floor function within the first 6 months postpartum between women having their first birth at AMA and those having their first birth at a younger age. Following vaginal birth at 6 weeks, 3 months, and 6 months, 17 women were studied. Urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire Short Form, and PFM function was assessed by the anteroposterior diameter of the levator hiatus using transperineal ultrasound. They found that more of the women who reported urinary incontinence were of the advanced maternal age group, and that the diameter of the levator hiatus, at rest, was larger in the AMA group compared to the younger group. Therefore, they concluded that recovery of pelvic floor function following birth may be delayed in women of AMA.

This study was older and smaller than the previous one we looked at by Swenson et al. However, both seem to echo a similar message that first-time birthers of advanced maternal age may have a different recovery trajectory than someone who births for the first time at a younger age.

Let’s look at one more study regarding interventions. In a randomized controlled trial in 2024, by Huang et al.³, they aimed to investigate the efficacy of postpartum nursing guidance in the treatment of early pelvic floor dysfunction (PFD). This study had 146 women of AMA, divided into control and intervention groups. Both groups were given routine pelvic floor rehabilitation treatment, including low-frequency estim, individualized biofeedback, and postpartum rehabilitation guidance with instruction on PF rehab to enhance their self-care awareness and self-management skills for 30 minutes, 2x/week for 15 sessions over 3 months. In addition to the routine pelvic floor rehabilitation treatment, the experimental group was given “postpartum nursing guidance, “which was an individualized program consisting of health education tailored to the individual’s education levels/background (consisting of visual aids, images, brochures, one-on-one counseling sessions). They also had psychological counseling, progressive and more specific PF muscle training (contracting PFM’s on exhale and relaxing on inhale, integrating use of PFM’s with daily activities, PFM contractions were progressed by position, duration over time with specificity, from 5 minutes to 15-25 minutes per day and 2-3x/day).

Lastly, the experimental group had regular follow-up visits. To summarize, the experimental group had more of a comprehensive, individualized, wholistic approach to treatment compared to the controls. In the study, they compared the two groups before and after the interventions for PFM strength, urinary incontinence, prolapse, and nursing satisfaction (satisfaction with their care). There was no statistical significance between the two groups before the interventions; however, 3 months after the intervention, the experimental group had significantly lower incidence of urinary incontinence & POP and significantly higher PFM strength and higher nursing satisfaction scores than the control group.

After synthesizing these three articles, let’s think about what we would change with our rehabilitation approach for patients of advanced maternal age. 

• -It may be helpful to identify the patients who are 35 and over following their first birth for prevention and treatment of PFD.
• -We should be educating perinatal providers in our area and advocating PF rehabilitation for those who have birthed, but particularly those over 35.
• -We should advocate for early PF rehab, hopefully before 1 year postpartum.
• -When setting goals and expectations for recovery, recognize that patients of advanced maternal age may need longer.
• -The individualization approach to PFM interventions seems to be superior to general advice.
• -A wholistic treatment or comprehensive/team approach may lead to better outcomes.

Hopefully, this challenges you to think a little deeper when treating patients of advanced maternal age!

Whether you're currently supporting patients through their pregnancy journey or guiding them through recovery after birth, Herman & Wallace’s Peripartum Series offers essential tools for evidence-based, compassionate care. Start with Postpartum Rehabilitation on August 16-17 to strengthen your foundation in pelvic floor recovery and core reactivation. Then, deepen your clinical skill set by joining Pregnancy Rehabilitation on September 13-14, where you’ll gain strategies to support prenatal adaptations, manage musculoskeletal pain, and optimize function throughout pregnancy.

Together, these courses provide a comprehensive path for clinicians committed to advancing care for the perinatal population.

References:

1. Swenson, C. W., Hendrickson, W. K., Allshouse, A. A., & Nygaard, I. E. (2024). Older maternal age at first vaginal delivery is associated with increased genital hiatus size at 1 year postpartum. American Journal of Obstetrics & Gynecology, 230(6), e110-e112.
2. Yoshida, M., Murayama, R., Nakata, M., Haruna, M., Matsuzaki, M., Shiraishi, M., & Sanada, H. (2013). Pelvic floor function and advanced maternal age at first vaginal delivery. Open Journal of Obstetrics and Gynecology, 3(4), 28-34.
3. Huang, Q., Tang, J., Zeng, D., Zhang, Y., & Ying, T. (2024). The effect of postpartum nursing guidance on early pelvic floor dysfunction recovery in women of advanced maternal age: a randomized controlled trial. Frontiers in Medicine, 11, 1397258.

 

AUTHOR BIO
Rachel Kilgore, DPT, OCS, COMT, PRPC

Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES (she/her) graduated from Central Washington University with a Bachelor of Science (BS) in exercise science and a minor in nutrition in 2004 where she also captained the collegiate soccer team. Rachel completed her Doctor of Physical Therapy (DPT) at University of Washington in 2007. She has worked in out patient orthopedics and pelvic health since 2007. She furthered her physical therapy training earning Certified Orthopedic Manual Therapist (COMT), Physical Therapy Board-Certified Specialist in Orthopedics (OCS), and Pelvic Rehabilitation Practitioner Certification (PRPC). She is a member of the American Physical Therapy Association (APTA), Section of Orthopedics and Section of Women’s Health, and the Physical Therapy Association of Washington (PTWA).

Currently, Rachel practices in Seattle at Flow Rehab in the Freemont Neighborhood with Holly Tanner and Jake Bartholomy. Her patient care focuses on orthopedics, female athletes, and women’s health conditions for bladder & bowel dysfunctions, pelvic, pain, pregnancy and post-partum issues. Since giving birth to her daughter in 2016, Rachel has held a special place in her heart to treat and encourage new mothers, helping them to achieve their health and fitness goals. She enjoys working with many of the local mother’s fitness groups and neighborhood peripartum practitioners.

In her free time Rachel enjoys cheering on her local Seattle sports teams the Seahawks, the Sounders, and the Husky Football team with her friends and family. She loves living in the Northwest and enjoying all it has to offer outdoors with hiking, running, cycling, and playing soccer.