Herman & Wallace Blog

Earlier this year, Herman & Wallace sponsored the first ever pelvic rehab course for physios in Nairobi, Kenya in partnership with The Jackson Clinics Foundation. After returning from that course, Kathy Golic, PT spent months writing a new course, adapting information from Pelvic Floor Level 1, Level 2A, and the Pregnancy and Postpartum series. This October, Kathy returned to teach her follow-up course that expanded on the first module, introducing lectures and labs tailored to the community of pelvic physios in Kenya. This dispatch comes from instructor Kathy Golic, PT, who sent in this article shortly after returning from the course. Huge thanks to Kathy and her colleagues Sherine Aubert and Casie Danenhauer for doing this important work!

It has been a week now, and as I type looking out on the windy rainy day, it is hard to believe that I was so recently in a warm, sheltered classroom sequestered from the hustle and bustle of Nairobi. A place which has captured my heart. Really it is the people, especially my new “sisters” who I spent so much time with during this last two-week course module. Once again, I experienced chill bumps every day from witnessing the growth, the stories, the wisdom and the compassion of these bright, motivated, committed physiotherapists who came back for the 2nd module in our series to help them become experts in the field of Pelvic Health. This module covered topics of Pregnancy, Postpartum care, Prolapse, Colorectal Conditions including fecal incontinence and constipation, and Coccydynia. We had a terrific printed course manual for this 2nd in the series, thanks to the partnership of Herman and Wallace and Jackson Clinics Foundation. With my wonderful and resourceful, skilled colleagues from LA, Casie Danenhaur, and Sherine Aubert, we included comprehensive lectures, lively demonstrations, hands on creative experiential learning opportunities, and awesome supervised lab training sessions. We also had a lot of case study discussions, and live case studies where we assisted the students, who are practicing physiotherapists, in conducting thorough assessments and clinical reasoning processes to treat and make plans to further the progress of their patients.

All of this in itself was incredibly rewarding. But there was more. The power of sacrifice we witnessed. The power of solidarity and true generosity. Most of these women continued to have to work after class even while in this two-week module; in class from 8-4, but then going on their way, some of them through heavy Nairobi traffic, to treat patients in their offices, or to work hospital shifts. One student heading out after a Wed. afternoon class told me that she was going to work from 7- midnight, then would sleep until 4am, then back to work until 7 am, before returning to class at 8 am. She also had to miss one class to participate in her mentorship for her ortho advanced diploma, so had to make up a test with us the next day. (she aced the test!) Now for the generosity. I will share just 1 of many stories. One of the physios asked a patient of hers whom she felt she could use some help with, if she would mind traveling to the KMTC classroom where we were teaching so the other students could learn, while we the visiting instructors, would help guide in her assessment and care. This woman agreed, and got up at 3:30 am, traveled by bus for 3 hours to come for her treatment. She willingly shared her story, and it was tough to hear. She worked as a vegetable vendor carrying produce on her back, lifting it, and sitting on a stone for hours each day. She, a mother of 5 grown children with an unemployed husband. Her physio and the class did quite well in their assessment and with treatment and suggestions. She seemed pleased. Then as she prepared to leave, some of the physio students “passed the hat” and collected 7,000 kshillings (about $70.00) and presented this humble lady with the money so that she could afford transportation home. It is my understanding that most Kenyans spend 50% of their income on food, so sharing with this patient was a true sacrifice. But for these ladies, there was no question about it. This is how they live and how they work. They are themselves so grateful for the knowledge, skills and experience that they are getting through this program, and they will pay it backwards and forwards. My colleagues this time and last time, are also indebted to them for all they have taught us. It is truly an honor and privilege to be part of this great program, and I too am thankful for all the team players in this venture.

Pelvic pain can often involve adverse neural tension. The hip and pelvic nerves wrap around like spaghetti, making diagnosis and treatment difficult. Is the pain driver boney, capsular, muscle or neurovascular? Luckily, impingement and labral tears are fairly easy to diagnosis. Nerve entrapment can be a little bit tricky to diagnosis and treat. Part of being a good pelvic floor physical therapist is appropriately diagnosing and then partnering with patients to treat symptoms, pain, and movement dysfunction.

The authors of this study focused on hip, so this blog focuses on sciatic and pudendal nerve entrapment in the athletic population. Nerve entrapment occurs when the normal slide and glide is limited. That can be from any structure in the pelvis and hip region that cause strain or compression on the nerves in the area. Often patient’s descriptions of pain can be the first sign with complaints of ‘burning’, ‘sharp’, or changes in sensation. Evaluation for changes in reflexes and motor function are helpful. Other signs of nerve entrapment are tenderness to palpation and reproduction of pain with movements that elongate the nerve. Medical management to confirm diagnosis include nerve blocks, and diagnostic imaging, and nerve conduction velocity tests.

Specific locations of pain can help determine where the nerve is being squished. The sciatic nerve (L4-S3) can be entrapped as it passes between the piriformis and deep hip rotators. This often presents with a history of trauma to the gluteal area and limited sitting tolerance (>30 minutes). As the sciatic nerve moves down it can have ischiofemoral impingement, when the nerve gets compressed between lateral ischial tuberosity and greater trochanter at level of quadratus femoris muscle. This will often present as pain during mid- to terminal-stance during walking. Then, once the sciatic nerve clears the pelvis it can become entrapped by the proximal hamstring. There can be hamstring trauma in the history, and possible partial avulsion or thickening of the hamstring may entrap the sciatic nerve.

The pudendal nerve (S2-S4) can become entrapped in several areas and symptoms often include pain medial to the ischium and can include genital regions for all genders, perineum, and peri-rectal regions. The most common areas consist of the space between the posterior pelvic ligaments (sacrospinous and sacrotuberous) and the obturator internus muscle. History often includes bike riding, and a common complaint is pain with sitting, except a toilet seat.

Differential diagnosis for posterior nerves physical examination can include the following tests:

Sciatic Nerve

• Seated palpation: where the clinician palpates the subgluteal space (between sacrum and deep hip rotators), ischial tuberosity and hamstring attachment, and in the area medial to ischial.
• Seated piriformis stretch - involved lower extremity is adducted and internally rotated while palpating posterior hip region.
• Active piriformis - resisted lateral abduction and external rotation while palpating posterior hip region.
• Ischiofemoral impingement: the involved is placed in extension with adduction and external rotation
• Active knee flexion: this test is done seated with knee at 30° and 90° flexion. Clinician palpates ischial canal while providing knee flexion resistance for 5 seconds in both positions.

Pudendal Nerve

• Palpation around sciatic notch, region medial ischium
• Internal palpation for obturator internus tenderness
• Internal palpation of alcocks canal

Consertative treatment including physical therapy can be helpful. Manual therapy including nerve glides and soft tissue mobilization. Nerve mobilizations require anatomical nerve pathway knowledge. Mobilizing the nerves is thought to improve blood flow within and around the nerve, decrease adhesions, and also may affect central sensitivity. Soft tissue mobilization is geared towards positively affecting scar tissue and encouraging movement that may be restricting neural movement.

Therapeutic exercises for strengthening and stretching are also helpful, however use caution to avoid aggressive stretching as it may aggravate nerves. Exercises to promote load transfer through the pelvis and lower extremities can be helpful. The authors also suggest lower extremity passive PNF (proprioceptive neurofacilitation) diagonal movements. The authors also suggest aerobic conditioning, cognitive behavioral therapy, and for the chronic pelvic pain population, pelvic floor muscle training that does not provoke symptoms.

When conservative treatment including injections produces limited results, surgical treatments are often the next step. Often surgeries where the nerves are decompressed, neurolysis, or removed, neurectomy can be helpful.

To learn more nerve assessment and treatment techniques, join Nari Clemons, PT, PRPC in her course Sacral Nerve Manual Assessment and Treatment in Tampa, FL this December 6-8, 2019!

Martin R, Martin HD1, Kivlan BR 2.Nerve Entrapment In The Hip Region: Current Concepts Review.Int J Sports Phys Ther. 2017 Dec;12(7):1163-1173.

Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has just joined the Herman & Wallace faculty and co-authored the new course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.
Aparna was kind enough to introduce herself to us here on The Pelvic Rehab Report.

Thank you for your time Aparna! To start, tell us a little bit about yourself.
My name is Aparna. I’ve been a physical therapist for 22 years. About 16 years ago I switched focus from orthopedics to treating pregnancy and postpartum patients and that’s where my initial interest in pelvic care started. In 2006 following my pregnancy and birth of my daughter, my interest in pelvic care grew with my special interest becoming pelvic pain.

I teach and mentor the pelvic health therapists within the fairly large hospital system that I work at and collaborate with our spine center team and our sports team.

What can you tell us about this new breathing course that is not mentioned in the “course description” and “objectives” that are posted online?
Physical therapy has evolved and continues to evolve as we speak. Regional inter dependence, wherein the different systems interplay, and one structure influences another, is fascinating. No longer is the body considered and treated as independent fragmented pieces. The ‘core’ with the contribution of the Diaphragm and the pelvic floor is so much more than just the Transverse Abdominis and the Multifidus working together. Fascial restrictions of the lower abdomen and the pelvis can influence how the low back feels, thoracic stiffness can influence the interplay between the various abdominal muscles by way on their insertion into the lower ribs, musculo- skeletal pain and postural deviations can stem from incorrect breathing patterns etc.

Normal breathing rate is about 10 times every minute. Breathing incorrectly reinforces wrong movement patterns tens of thousand times a day with negative consequences on the musculoskeletal system.

This course offers an in depth look at the diaphragm from the perspective of both orthopedic and pelvic therapists and attempts to tie in the diaphragm to the thoracic spine, the ribs, the pelvic floor, the core, posture and finally the athlete.

What essential skills does the breath course add to a practitioner’s toolkit?
The practitioner will walk away with the ability to view the patient as a “whole”. It offers a different perspective on neck and back pain, posture/ alignment along with the ability to assess for and connect breathing and the diaphragm to stability/ the core, continence issues and the Autonomic Nervous System.

As therapists we already do a great job of addressing strength issues, assessing and correcting posture, mobilizing etc. You can add to your treatment options by learning how the diaphragm works in concert with other muscles (especially the abdominals) and systems, identifying breathing pattern dysfunctions and postures, and movement patterns which may be linked to breathing pattern dysfunctions. This understanding is beneficial for both orthopedic and pelvic patients.

What inspired you to create this course? What void does this new offering fill?
I have used breathing and evaluation of the diaphragm as a part of pelvic care for several years now. As the mentor for the pelvic program at my hospital, and as a part of the spine team and sports team, I work with pelvic therapists, orthopedic therapists, manual certified therapists, and sports certified therapists. Through my interactions I have come to realize that although many of the therapists are aware that the Diaphragm and breathing are important, they are unsure of how to assess for dysfunctions and address those dysfunctions. I initially started conducting classes within the hospital system. At the same time Leeann who is a sports certified therapist and holds a manual therapy certificate and I started collaborating on our patients. Using a combination of her knowledge and effective manual techniques with my pelvic care and breathing techniques we realized that along with my pelvic patients; our back and neck patients, and her sports patients were all benefitting from this combined approach. We realized along the way that we had information worth sharing with our colleagues that would benefit them in treating their patients, and started classes within the hospital system and that is how this class was born!

What was your process like creating this course?
As a trained pelvic therapist, I have incorporated and used breath and the diaphragm in my treatment for over a decade. Leeann and I have created this course using a combination of our clinical experiences, our education in our respective chosen paths of patient care, and most importantly using recent and relevant research articles from journals to guide us extensively in creating this course.

Breathing and the Diaphragm: Pelvic and Orthopedic Therapists is a new course being offered next March 27-29, 2020 in Sterling Heights, MI, and again on December 11-13, 2020 in Princeton, NJ. It is created and taught by Aparna Rajagopal, PT, MHS and Leeann Taptich, PT, DPT. Come learn how the diaphragm and breathing can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi component system that works together.

Do you work with osteoporosis patients? This may be a trick question because you probably do whether you know it or not- even if you are a pediatric therapist! Osteoporosis is defined by the World Health Organization¹ as a systematic skeletal disease characterized by:

• Low bone mass
• Micro-architectural deterioration of bone tissue
• Consequent increase in bone fragility and susceptibility to a fracture

Osteoporosis occurs in men, women and even children. It is sometimes called the “silent disease” because often people don’t know they have it until they break a bone. And even then, compression fractures are painful only 20-30% of the time. Old fractures are often found on x-rays when a person is imaged for illnesses such as pneumonia. According to the National Osteoporosis Foundation², about one in two women and one in four men over the age of 50 will suffer a fracture due to bone fragility. At this point in time, it is estimated 80% of patients entering Emergency Departments with a fragility fracture (a fall from a standing height) are never followed up for care.

As therapists, we see patients for a variety of diagnoses with co-morbidities but osteoporosis may not be listed. This could be because they have never been identified. We are in a prime position to screen for signs associated with the disorder. Below are the top 3 signs to look for:

• History of fracture from minimal trauma (fall from a standing height, sneeze, lifting groceries, etc.) The typical fracture areas are wrist, hip, and spine although fragility fractures can happen anywhere in the body.
• Hyper-kyphosis. Note, I said hyper-kyphosis, not kyphosis. We are meant to have a thoracic kyphosis but an excessive curve, particularly when it hinges around T8 area may indicate a collapse of the anterior portion of the vertebral bodies. This is the pie shaped wedging seen on x-rays and further increases the stress on the anterior aspect of the spine. Observe your patients’ sagittal posture for proper alignment.
• Loss of height. Ask your patient their tallest height remembered; then measure them. A loss of 4 cm (1.5 inches) or more may indicate fractures in the spine.

Remember pain may or may not accompany a compression fracture. Patients may complain of a “catch” or muscle spasm or nothing at all. These quick and simple screens can alert the healthcare provider and may help prevent further disintegration of the bones. Research is showing that not only weight bearing exercises but a site specific back and hip strengthening program decreases the risk of fracture.³

1. World Health Organization. www.who.int
2. National Osteoporosis Foundation. www.nof.org
3. Current Osteoporosis Reports. Sept, 2010. The Role of Exercise in the Treatment of Osteoporosis. Sinaki M, Pfeifer M, Preisinger E, Itoi E, Rissoli R, Boonen S, Geusens P, Minne HW.

Part 3: Carefully Choosing to Say Yes or No (or The Summer that Almost Wasn’t)

*Disclaimer: this essay is meant to be read in a voice of complete transparency and humility.

Two summers ago I was anxiously anticipating a break. I was wrapping up home school for my girls and had scheduled some down time from writing my contribution to “Boundaries, Meditation and Self-Care” when I got the call…

Rewind a bit. Two years prior I also got a call. Would I be interested in writing a chapter in a Urology textbook on alternative care for pelvic pain conditions…edited by and partnering with a big name in pelvic floor rehab? Oh yes indeed I would! I have always dreamed of seeing my name in print. Was I scared out of my mind? Heck yes! I was working 20 hours a week, part time home schooling my girls and teaching for Herman & Wallace. I had one day a week to myself for cleaning, errands, the occasional book reading or interacting with friends. I decided I could spend my next year of Fridays researching, writing and editing said chapter. Oh, I also started therapy for the anxiety increase that came with the project. My therapist suggested I hire help with house cleaning, which I did. She also suggested meditation, mindfulness and using essential oils. I opted not to enact these suggestions. It was a crazy year, but I learned a ton and was proud of my contribution to the publication.

In the brief time that I caught my breath from the book chapter, I was invited to be part of the team writing the Pelvic Floor Capstone course. What an honor! I had always wanted to try writing a course and this would be a perfect opportunity to collaborate with others on such a big project. I committed, worsening my anxiety with heart palpitations which escalated to a level that required medication. My Fridays and evenings were again occupied for quite some time. Luckily, I still had the cleaning help and the therapist which were really just the skinniest strings that were maintaining my sanity.

While teaching our first Capstone class, although both of us were struggling with burnout, Nari Clemons and I had a moment of euphoria, seeing everything come together and watching students learn. We decided we would design and write another course and put together an outline and a plan for Boundaries, Self-Care and Meditation.

I think you might be getting a picture of my prior lifestyle. If there was time, I filled it. If there was an opportunity, I took it. If I did something once, I could do it again. But applying the concepts of our boundaries course to myself changed everything.

Nari and I knew we were burning out and needed change. I have always had anxiety, but it had escalated to the point of requiring both therapy and medication. I was giving my all, my best, to everyone else and my family got my scrappy leftovers, the worse of me. I had been functioning in these patterns my whole life and had no idea how to get off the hamster wheel.

As we developed Boundaries, Meditation and Self Care I became my own research study, incorporating the material we would be teaching into my own life. I finally started setting priorities and boundaries that helped put my family first and give them the best of me. I said no to a variety of opportunities that I then delegated to colleagues who were delighted to step up. I started meditating, practicing mindfulness and using essential oils as part of my self-care as my therapist suggested a year ago. I even enrolled my kids in full time school for the upcoming year. I was feeling so much better!

So when the next call came, I was prepared.

The editor and famous pelvic floor PT I had worked with on the book chapter was in need of an editor for an article that was going to be published in a medical journal. There was a lot of editing that needed to be done and time was of the essence. My contribution as editor would list me as a co-author. How many of you also dream of seeing your name attached to an article in a peer reviewed medical journal? Because of what I had learned through therapy and practiced with meditation I had the ability to pause, reflect, and make an informed choice that considered how this opportunity lined up with my priorities. I replied with much gratitude for the offer, but this time I said no. It was difficult to say no, and I had to work through some regret, but in the end I made the right choice and we had a great summer.

Life is funny sometimes and lessons in humility are plentiful. Back track again to when the urology text came out a few years ago. I excitedly ordered a print copy. When I opened to the chapter which I contributed, I discovered another person’s name had accidently been printed where mine should have been. The mistake was corrected for the ebooks but more paper copies were not printed. I may never see my name in print, but the Summer That Almost Wasn’t taught me that there are more important things in life.

If you find yourself struggling with boundaries, saying no, and prioritizing the things that are important to you personally and as a therapist, know that you are not alone, and you can get support. Consider talking with your supervisor, a counselor, reading a good book on the subject or taking Boundaries, Meditation and Self Care, a course offering through Herman and Wallace that was designed to help pelvic health professionals stay healthy and inspired while equipping therapists with new tools to share with their patients.

We hope you will join us for Boundaries, Meditation and Self Care this November 9-11, 2019 in San Diego, CA.

Childbirth fear is associated with lower labor pain tolerance and worse postpartum adjustment.^1,2 In addition, psychological distress during pregnancy is associated with adverse consequences in offspring, including detrimental birth outcomes, long-term defects in cognitive development, behavioral problems during childhood and high levels of stress-related hormones.³ These negative consequences of fear and stress during pregnancy have inspired both interest and research into the role of mindfulness training during pregnancy to reduce fear and stress and improve outcomes.

In a randomized controlled trial, first-time mothers in the late 3rd trimester of pregnancy were randomized to attend either a 2.5-day mindfulness-based childbirth preparation course offered as a weekend workshop or a standard childbirth preparation course with no mind-body focus.⁴ Participants completed self-report assessments pre-intervention, post-intervention, and post-birth, and medical record data were collected. Compared to standard childbirth education, those in the mindfulness-based workshop showed greater childbirth self-efficacy and mindful body awareness, reduced pain catastrophizing and lower post-course depression symptoms that were maintained through postpartum follow-up. Participants in the mindfulness workshop also demonstrated a trend toward a lower rate of opioid analgesia use in labor.

In a qualitative study, researchers conducted in-depth interviews at four to six months postpartum with ten mothers at increased risk of perinatal stress, anxiety and depression and six fathers who had participated in a Mindfulness Based Childbirth and Parenting Program (MBCP).⁵ The MBCP program integrates mindfulness training into childbirth education. Participants meet for eight 2 hour and 15 minute weekly sessions and a reunion after babies are born. Specific mindfulness practices introduced include body scan, mindful movement, sitting meditation and walking meditation. Also, methods to integrate mindfulness into pain management, parenting and activities of daily living are introduced. Participants are asked to practice at home for 30 min per day in between sessions supported by audio guided instructions and informative texts.

Participants in the MBCP Program described gaining new skills for coping with stress, anxiety and pain, as well as developing insight and self-compassion and improving communication. Participants attributed these improvements to an increased ability to focus and gain a wider perspective as well as adopt attitudes of curiosity, non-judging and acceptance. In addition, they described mindfulness training to be helpful for coping with childbirth and parenting, including breastfeeding troubles, sleep deprivation and stressful moments with the baby.

These findings demonstrate potential therapeutic outcomes of integrating mindfulness training into childbirth preparation. Although this is a young field and more research is warranted, there is substantial research demonstrating mindfulness training improves stress management, pain management and decreases physiological markers of stress in a wide range of patient populations.^{6, 7} While the interventions in the above two studies introduce mindfulness in a group format, I have also found that patients can greatly benefit from being taught mindful principles and practices in one-on-one treatment sessions.

Carolyn will share her over-30 years of training and experience teaching mindfulness to patients both individually and in group settings in her course, Mindfulness-Based Pain Treatment, coming up on October 26 and 27 in Houston, TX. Participants will return to the clinic with skills to not only help patients, but to also help themselves be less stressed, more mindful providers!

1. Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand. 2001;80(4): 315–320.
2. Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish national birth cohort. Br J Obstet Gynaecol. 2009:116(10): 1350–1355.
3. Isgut M, Smith AK, Reimann. The impact of psychological distress during pregnancy on the developing fetus: Biological mechanisms and potential benefits of mindfulness interventions. J Perinat Med. 2017 Dec 20;45(9):999-1011.
4. Duncan LG, Cohn MA, Chao MT. The benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with an active comparison. BMC Pregnancy Childbirth. 2017. May 12;17(1):140.
5. Lonnberg G, Nissen E, Niemi M. What is learned from Mindfulness-Based Childbirth and Parenting Education? – Participants’ experiences. BMC Pregnancy Childbirth. 2018; 18: 466.
6. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
7. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.

Often pelvic floor therapists see men for post-prostatectomy urinary leakage. However, at least for me, that quickly led to seeing male patients for pelvic pain and sexual dysfunction. Male sexual dysfunction is a broad category and can consist of erectile dysfunction (ED), ejaculation disorders including premature ejaculation (PE), and low libido -- often there is a pelvic floor muscle (PFM) dysfunction component. Conservative treatment frequently consists of pharmacological and lifestyle changes for this population.

In normal sexual function, the male superficial pelvic floor musculature (bulbocavernosus and ischiocavernosus) work together to create increased intracavernosus pressure by limiting venous return, resulting in an erection. Ejaculation is created by rhythmic contractions of the bulbocavernosus muscle.

The authors of this systematic review were curious if pelvic floor muscle training was effective for treating erectile dysfunction and premature ejaculation diagnoses, and if so to determine whether there is a treatment protocol. Ten studies were found that met the inclusion criteria, five that focused on ED and five that focused on PE. In total, there were 668 participants ranging in age from 30-59 years old. Studies were excluded if participants were post-prostatectomy and/or had a neurological diagnosis. The intervention was a pelvic floor program, and pelvic floor muscle contractions were either taught or supervised. Studies also included supportive treatment including biofeedback, lifestyle changes, and electrical stimulation.

The studies focused on erectile dysfunction listed a combination of hormonal, psychogenic, arteriogenic, and venogenic causes. The pelvic floor training ranged from 5-20 visits over 3-4 months and included a home exercise program. Pelvic floor training was similar in all studies and consisted of maximal quick contractions over one second and submaximal endurance holds over 6-10 seconds. Compliance to home exercise program was not assessed. Between 35% and 47% of participants reported a full resolution of symptoms. Subjective improvements were supported by improved maximal anal pressure and intracavernosus pressure. One study used the International Index of Erectile Function (IIEF) and showed significant improvement (p<0.05).

The studies focused on premature ejaculation noted participants had either lifelong or secondary PE. The pelvic floor training in these studies ranged from 12-20 sessions over 1-3 months. All studies used electrical stimulation as part of the pelvic floor muscle training. Four studies also used biofeedback. Only one study listed a home exercise program but did not report on compliance. The pelvic floor muscle training was compared to nothing in three studies, and to a selective serotonin reuptake inhibitor (SSRI) in the other two studies. Patient reported full resolution of symptoms was 55-83% in two studies, and there was a significant improvement in delay in heterosexual penetrative ejaculation (p<0.05) in three studies.

For both erectile dysfunction and premature ejaculation, pelvic floor muscle exercise prescription was 2-3 times per week with pelvic floor muscle contractions both maximal quick contractions and submaximal endurance holds. Significant results were shown with participants who were taught pelvic floor muscle contractions through a combination of verbal and physical means (typically biofeedback). Specific verbal cues were not reported. The authors suggest that electrical stimulation was helpful for training recruitment patterns; however, there was not a significant difference in outcomes for those with ED when using electrical stimulation. The authors suggest that pelvic floor muscle training can be part of a conservative treatment. It may be used with oral pharmacology for quick results, and may be beneficial with electrical stimulation and biofeedback, though more research is indicated.

If you are interested in learning more about treating male patients, consider attending Male Pelvic Floor: Function, Dysfunction, and Treatment!

Myers, C., Smith, M. “Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review” Physiotherapy 105 (2019) 235–243

As more and more patients seek care for pelvic floor dysfunction, the need for more qualified practitioners is becoming apparent. Many patients prefer to see a clinician who they identify with, which is why it is important for practitioners of all genders to learn to treat pelvic floor dysfunction. Because much of the public's awareness of pelvic rehab comes out of women's health, the vast majority of pelvic health practitioners are women.

There is currently a shortage of male pelvic health practitioners. To help us understand why it is so important to fix that, we reached out to several male clinicians who have attended the Male Pelvic Floor: Function, Dysfunction, and Treatment course to ask them about the need for more men in the field. Here are some answers to the question:

“Why is it important to have male providers available to treat male patients in the field of pelvic health?”

Grant Headley of Bridgetown Physical Therapy of Portland, Oregon (www.bridgetownpt.com)
While as PT’s we all approach our patients with interest in helping them as individuals, some of our patients feel more comfortable sharing certain details with a provider of the same gender. Many of the hang-ups some men have about receiving care from a female provider are related to an older generation, to certain traditional or religious cultural beliefs, or to certain beliefs about propriety related to receiving care.

As acknowledged in our coursework, generally men have cultural barriers that traditionally do not permit sharing of vulnerability or weakness, especially in the sexual domain. Here are a few unsolicited statements I feel encapsulate what my own male patients have told me: Some heterosexual men feel more comfortable sharing the details of their dysfunction with a man because they find it difficult to admit vulnerability in the presence of a female. Some men prefer not to relay the clinically pertinent details of dysfunctional sexual encounters with a female because they do not wish to make the female practitioner uncomfortable. Many men feel that they can relay more detail about the mechanics of the sexual dysfunction or signs of improvement to a male provider. Some men have told me that they felt their sexual dysfunction was minimized or that they have been treated with patronizing language by a female pelvic PT in the past. Unfortunately, these patients attribute this negative experience to the PT being female, and they are not comfortable having a second opinion with a female.

Although we strive to present as open-minded and neutral to our patients, they may have an affinity for a male provider. This could foster a more constructive clinical partnership towards working on their goals if they perceive fewer communication barriers. I can offer my own experience as a past patient suffering with pelvic floor dysfunction; I was so desperate for help and I felt so grateful that there was a physical therapist in my city at all that was willing to help me. I did not care that she was female and that I had to receive treatment at a women's health clinic for new mothers in the University Hospital. Many female therapists reading this article have likely transferred lifesaving PT care to scores of men. This organization of H&W that does so much good for a sensitive aspect of men's care is dominated by women- this needs to be acknowledged as a net positive but also appreciated that much of the education and application of care is an adaptation from what has worked for women in the past. Many men will be so grateful to receive care and get better. Some men unfortunately will have barriers to receiving care and for those patients, we can seek out and encourage our male colleagues to get involved in pelvic rehab so we can all provide more access to care.

Lance Frank of Flex Physical Therapy in Atlanta (www.flexptatl.com)
Personally, as a male provider in pelvic health, I find that the men I treat are much more comfortable and at ease discussing topics like erections (or lack thereof) and sexual dysfunction, as well as incontinence, or pelvic pain. In a female dominated sub-specialty of physical therapy, sometimes as a male it can be intimidating and even embarrassing for some men to discuss these topics at all, let alone with a female; so having the option to speak and be treated by another male who may better understand the changes, anatomy, and problems they’re experiencing may feel a bit less daunting. Our culture has made male masculinity fragile and I think some populations of men who need pelvic floor rehab may feel embarrassed to be treated by a female clinician if their perception of being seen by a female is emasculating. Ultimately, I think there needs to be more men in this field because there needs to be better visibility of male pelvic health providers in general, as well as better representation of men acknowledging that male pelvic floor disorders exist and are willing and able to treat them.

Eddie Gordon of Flow Rehab in Seattle (www.flowrehab.com)
There are far fewer male physiotherapists treating men with pelvic floor dysfunctions, but I am hopeful this will change for the better. Lack of access to male pelvic physios is a relative barrier to care because some men are more comfortable seeing a male pelvic provider the same way most women would prefer seeing a female pelvic physio. In general, men do not typically seek treatment as frequently or early enough the way most women do. If male pelvic physios are not available, then men may more likely delay treatment, which could potentially worsen their problem. Ironically, when it comes to men with pelvic floor dysfunctions, men are underrepresented, but I am hopeful that more male PT’s will be joining the movement to educate the male population.

Milan Patel of Comprehensive Therapy Services in San Diego (comprehensivetherapy.com)
I believe it's important to have male providers in the pelvic health field for many reasons, one being the opportunity for connection. I think we connect best with reflections of ourselves and for men seeking out a pelvic health provider that can be hard to find. In my experience, pelvic physical therapy works best when your patient can be open and honest, and establishing a strong connection between therapist and patient is the first step. Another reason is that people should have options for the provider they want. In San Diego I am the only male pelvic physical therapy provider which means most men seeking pelvic floor therapy have no choice but to see a female. If you switched the genders in the last sentence you could see how that is problematic. Many women prefer to have their pelvic PT be a female, I just think guys should get the same choice.

Steven Lavender of The Physical Therapy Practice NYC in New York (thephysicaltherapypractice.nyc)
In my experience as a gay male practitioner practicing pelvic floor physio on only men:

Gay male patients usually prefer a gay provider because they feel like they don’t have to explain lifestyle issues and choices, they may be unused to being touched by women, and maybe misogynistic.

Some straight men have told me that they think a male practitioner would know more about their pelvic issues than a woman. Some men don’t think women are strong enough nor have long enough fingers to get to the places they need to be. Some straight men report they might be attracted to a female therapist and get an erection or feel embarrassed about appearing unmanly with their particular pelvic condition.

For some men being touched by a woman is a religious issue so many males of the Jewish and Muslim faiths prefer to see a male practitioner.

Some men could not care less who sees them as long as they get better.

One woman called me for advice or for an appointment from some distance because they "figured a gay man in New York City just might know more about my ass and ass pain than any local jack-assed doctor in my neck of the woods." True story.

If you are interested in learning to treat male patients, the Male Pelvic Floor: Function, Dysfunction, and Treatment course is a great place to start! The course is taking place twice more in 2019, this September 13-15, 2019 in Pasadena, CA, and again in Fort Myers, FL on October 19-21, 2019. We are already booked four times in 2020 as well, so be sure to check out the full course schedule for all available dates.

I recently found this article from the Psychology Research and Behavior Management Journal. I found myself curious about how other healthcare disciplines treat a diagnosis that often presents in conjunction with pelvic floor dysfunction. Irritable bowel syndrome, or IBS, affects nearly 35 million Americans. It is considered a ‘functional’ condition meaning that symptoms occur without structural or biochemical pathology. There is often a stigma with functional diagnosis that the symptoms are “all in their heads”, and while there are many theories about what predisposes individuals to IBS, the experts now think of IBS as a “disorder of gut brain interaction”. Generally, there are 3 subtypes of IBS where people note either constipation dominant, diarrhea dominant or mixed. In order to be diagnosed an individual must report abdominal pain at least 1 day per week in the last 3 months which is related to stooling and a change in frequency or form. Other symptoms that are common are bloating, nausea, incomplete emptying, and urgency.

The author suggests a biopsychosocial framework to help understand IBS. An interdependent relationship between biology (gut microbiota, inflammation, genes), behavior (symptom avoidance, behaviors), cognitive processes (“brain-gut dysregulation, visceral anxiety, coping skills”), and environment (trauma, stress). The brain-gut connection by a variety of nerve pathways is how the brain and gut communicate in either direction; top down or bottom up. Stress and trauma can dysregulate gut function and can contribute to IBS symptoms.

Stress affects the autonomic nervous system that contributes to sympathetic (fight/flight) and parasympathetic (rest/digest). Patients with IBS may have dysfunction with autonomic nervous system regulation. Symptoms of dysregulated gut function can present as visceral hypersensitivity, visceral sensitivity, and visceral anxiety. Visceral hypersensitivity is explained as an upregulation of nerve pathways. The author sites studies that note that IBS patients have a lower pain tolerance to rectal balloon distention than healthy controls. Visceral sensitivity is another sign of upregulation where IBS patients have a greater emotional arousal to visceral stimulation and are less able to downregulate pain. The author notes that the IBS population show particular patterns of anxiety with visceral anxiety and catastrophizing. Visceral anxiety is described hypervigilance to bowel movements and fear avoidance of situational symptoms. For example, fear of not knowing where the bathroom is located.

Cognitive behavioral therapy (CBT) has been shown to be an effective treatment to decrease the impact of IBS symptoms. CBT is focused on modifying behaviors and challenging dysfunctional beliefs. CBT can be presented in a variety of ways, however most include techniques consisting of education of how behaviors and physiology interplay for example the gut and stress response; relaxation strategies, usually diaphragmatic breathing and progressive relaxation; cognitive restructuring to help individuals see the relationship between thought patterns and stress responses; problem-solving skills with shift to emotion focused strategies (“acceptance, diaphragmatic breathing, cognitive restructuring, exercise, social support”) instead of problem focused strategies, and finally exposure techniques to help the individual slowly face fear avoidance behaviors. So much of the techniques are similar to what pelvic floor therapists try to educate our patients in. It is reassuring to me that through we may be different disciplines we are on the same team are moving towards the same goal. The author recommends a 10 session treatment duration, and notes that may be a barrier for some. Integrated practice with other healthcare professionals is also recommended. The more we can know about what our other team members are doing to help support patients the more effective we all are.

Kinsinger, Sarah W. “Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights” Psychology research and behavior management vol. 10 231-237. 19 Jul. 2017, doi:10.2147/PRBM. S120817

Ultrasound imaging is being used more frequently in the physical therapy clinical setting. Physical therapists are using ultrasound (US) imaging in varying ways. Some are using it as a training tool for the patient to learn neuromuscular control. Others are using it to guide needle placement while performing dry needling. In a recent article authored by several well-known physiotherapists, the various uses of US imaging were defined, as well as discussions regarding the scope of practice, and training for physiotherapists using ultrasound imaging.

Four uses of US imaging have been reported by physical therapists. The first and most common use of US imaging is the evaluation of muscle structure and function to aid in neuromuscular control. Essentially, the US images are being used as a source of biofeedback. This has been coined Rehabilitative Ultrasound Imaging (RUSI). Additional uses have emerged in recent years including Diagnostic US imaging which is the diagnosis and monitoring of pathology; and interventional US imaging which is using the US images to guide percutaneous procedures involving dry or wet needling. These three categories are performed during clinical care and fall under the umbrella term “point of care ultrasound.” The last category of US imaging use in physical therapy is paired with performing research.

In this article, some thoughts and areas for improvement were brought to light regarding each type of US imaging as well as the scope of practice and training for each type of US use. It was mentioned that RUSI sits almost entirely within the scope of the physical therapy profession, however, it can be difficult for therapists to receive training for this use. Therapists interested in learning diagnostic or interventional US imaging have more options for training because these uses of US have established criteria for training, competence, and regulation outlined by the World Health Organization (WHO), as well as oversight from the World Federation for Ultrasound in Medicine and Biology. These programs often are intended for other healthcare practitioners (radiologists, and sonographers), but physical therapists are able to take the courses. However, it was stated that both diagnostic and interventional US imaging do not fall within the scope of practice for a majority of physical therapists around the world. So, although training may be more available for these types of US use; therapists taking these courses gain increased experience with non-physical therapy applications, and therefore are at risk for operating outside the scope of their practice.

The authors continued with distinct recommendations for needed training for the four different types of US imaging. Several of the listed skills were fundamental knowledge that a therapist should obtain before utilizing any of the four types of US into their practice such as basic physics for US, terminology, safety, among other knowledge. Then there were skills that were specific to the particular type of US being performed. Since point-of-care use of US is generally not included as part of entry level physical therapy education programs, this knowledge needs to be obtained in a postgraduate education format. For therapists who wish to learn diagnostic application of US imaging, there are multiple courses available from schools that train sonographers. However, according to this article, the form of US imaging that sits more within the scope of practice for physical therapists, rehabilitative ultrasound imaging, does not have as many educational opportunities as diagnostic US imaging does.

Herman & Wallace offers a course that provides fundamental skills of US imaging (such as history, and knowledge of the physics needed for US imaging), as well as specific skills for real-time ultrasound imaging. The schedule of the course includes a lot of lab time with multiple US units available so the ratio of participant to US unit low. You will leave the course being able to interpret US images and use it as an assessment tool or biofeedback tool for the patient. Using RUSI will change how you treat patients! The Rehabilitative Ultrasound Imaging course is offered three more times this year. Join me in Columbia, MO this August; Madison, WI in September; or Chicago, IL in December to learn how to use this form of ultrasound imaging in your clinical practice!

Whittaker J, Ellis R, Hodges P, et al. Imaging with ultrasound in physical therapy: what is the PT’s scope of practice a competency-based educational model and training recommendations. Br. J Sports Med. Apr. 2019; 0:1-7.