Hello friends and colleagues!

I cannot tell you how excited Dr. Meehan and I are to host the new version of Menstruation and Pelvic Health. Updated based on feedback from previous participants and from exciting updates in the field, this improved version is designed to be practical and engaging so that tomorrow you can make changes in how you take care of your patients who have a Menstrual Cycle.

If you’re like Kelsey, you may already have excitement and enthusiasm for this topic. If you’re like Taylor, this course may cause anxiety or bring up strong feelings. Don’t worry…this is a safe space, and we will walk on this journey together in a supportive and positive forum with the goal of understanding and creating solutions. If you are like Steve, you may feel a little out of your element right now. You may believe you don’t have anything to contribute to this conversation, and maybe you weren’t planning to focus on women’s health anyway. But I believe everyone has a role to play on this journey. Paying attention to other people’s experiences allows our world to grow and enables us to help our patients in ways we never realized we could.

In Part 1: Cultural aspects of the Menstrual Experience, we talk about why it can be so challenging to talk about periods and ways we can fix that problem. We discuss the many advances we have made over the years and also the challenges still left to overcome. We explore those highly elusive but very important positive aspects of the Menstrual Experience and ways to cultivate this perspective.

In Part 2: Menstrual Structures and Processes, we discuss the hormones, anatomical structures, and physiological processes that make up the normal Menstrual Cycle. We learn how the HPO Axis regulates the Menstrual Cycle, the hormones, and organs involved in preparing the uterus for a most amazing experience. Understanding the underlying anatomy and processes is critical to understanding the symptoms and disorders, and more importantly, to interventions that can help patients improve their Menstrual Experience.

In Part 3: Menstrual Symptoms and Disorders, we discuss the wide variety of symptoms such as dysmenorrhea, heavy bleeding, off-cycle spotting, emotional concerns, and challenges managing vaginal discharge. We also discuss common Menstrual Disorders such as PMS, PMDD, PME, endometriosis, adenomyosis, PCOS, and fibroids. This information helps practitioners become in tune with the symptoms our patients might be having but could be reluctant to talk about.

In Part 4: Menstrual Interventions, we discuss non-hormonal, non-prescription, and non-surgical interventions to improve the Menstrual Experience of your patients. We emphasize the use of a variety of interventions in a holistic manner to help your patients make real changes. We talk about how to conduct Menstrual Tracking and Diaries, and we design Flow Management Plans to help patients meet the challenges of life on any day of the month and communicate their concerns with medical providers. In a recorded interview with Beth Kemper, we see demonstrations of manual techniques to use during different parts of the Menstrual Cycle.

We explore important, provocative, and sometimes controversial Menstrual Topics issues such as: Chronobiology, Interoception, Menstrual Mindfulness, Menstrual Molimina, Menstrual Optimism, Menstrual Pride, Cultural Menstrual Milestones, Menstrual Seasons, If Men Could Menstruate, Toss or Keep: An Underwear Journey, What is a ‘Normal Period’ Anyway?, Prostaglandins and Period Poops, Irritable Male Syndrome, Wearing White at Wimbledon, Women are not Small Men, High Performance Cycling, Cycle Syncing, Seed Cycling, Toxic Shock Syndrome, PFAS, Menstrual Products and the Environment, Menstrual Cups and IUDs, Menstrual Cups and Uterine Prolapse, Investing in a Period Basket, a Go Bag, and a Cycle-Friendly Wardrobe, and my favorite…The Kindest Gift: A Better Menarche.

To help sift through infinite information and mis-information available on social media, we give reviews of influencers and products.

And in this second edition, we have added interviews with expert pelvic floor practitioners: Ramona Horton, Jenna Ross, and Beth Kemper to give you insight into years of experience in the field of pelvic health that you can use to help your patients.

During the live course lecture, Dr. Meehan shows us yoga and stretch poses that we can use with our patients appropriately on any day of the month. We provide demonstrations of Menstrual Volumes to help visualize the amount of blood lost on each day of a period. We have demonstrations of Menstrual Products and show their absorptive and collective capacities. We talk about the pros and cons of a variety of menstrual products:

• Liners and pads: disposable and reusable, interlabial pads
• Tampons: demonstration of different absorbency levels and shape when expanded, new technology, applicator vs no applicator, and navigating the absorbency level, number of hours inside
• Cups and discs: including insertion and removal techniques, daily washing, and cyclic ‘sterilizing’
• Period overnight wear: much-needed sleep and less anxiety about overnight flooding
• Period activewear: functional and stylish options for gym, yoga, and around town
• Period swimwear: one piece and bikini, for competition or just chillin’ in the sun

This newly updated class brings a wide variety of information to your fingertips, as pelvic floor practitioners, so that you can put the pieces together with your next patient to improve their Menstrual Experience…tomorrow. Dr. Meehan and I hope to see you during the next class on June 7th! Please feel free to contact me with any questions, concerns, or contributions.

All voices are welcome!

Nicholas Gaffga, MD, FAAFP, MPH
This email address is being protected from spambots. You need JavaScript enabled to view it.

In April, the U.S. Department of Health and Human Services and the U.S. Food and Drug Administration announced a series of new measures to phase out all petroleum-based synthetic dyes from the nation’s food supply. Studies in the 1950s were done because of concerns about petroleum-based food dyes and their potential toxicity (1). By the 1990s, it was well established that artificial colorants were harmful to humans (2). Yet here in 2025, their use remains prolific in many items, including obvious sources such as Skittles, Twizzlers, and Mountain Dew Code Red, and less obvious sources like pickles, yogurt, breakfast cereals, and processed meats.

This shocking situation is a microcosm of the chasm that often forms between scientific investigative findings and knowledge translation to practical applications. Scientists have long known these substances to be harmful, yet they have remained highly prevalent in our food supply all these years. Unfortunately, “for too long, some food producers have been feeding Americans petroleum-based chemicals without their knowledge or consent. These poisonous compounds offer no nutritional benefit and pose real, measurable dangers to our children’s health and development” (3). These artificial food dyes have been linked to cancer, inflammatory bowel diseases, neurodevelopmental disorders, and beyond (2, 4, 5).

Sometimes it’s difficult to wrap our minds around the fact that it has taken until this moment - 2025 - for the HHS and FDA to take action based on decades of research demonstrating the toxicity of these ubiquitous substances in our nation’s food supply – substances such as Red No. 40 – the most commonly used dye by the food industry that is present in over 40% of foods marketed to children (6). Many of us grew up surrounded by artificial food dyes. Today’s children are inundated with ultra-processed foods – many of them loaded with chemical ingredients, including these petroleum-based food dyes. Researchers have been looking at this issue for some time and have determined that for all populations and all exposure scenarios, the highest cumulative exposures are from FD&C Red No. 40, FD&C Yellow No. 5, and FD&C Yellow No. 6 (7). These, among others, are slated to be eliminated from our food supply by the end of next year.

A curious question might be: if so many of us have had long-term consistent exposure to such chemicals, might there be links between this and the rise in Early Onset Colorectal Cancer (EOCRC)? Attention deficit disorder? Other systemic inflammatory conditions? Current research stands firm: artificial food dyes cause DNA damage, colonic inflammation, and impact the microbiome negatively – all of which can contribute to colorectal cancer, whose incidence has been on the rise in those under 50 years of age over the last 40 years (8). Further, the underlying inflammation caused by such toxic exposure is a key mechanism triggering neurobehavioral dysregulation due to the impact on the gut-brain axis (4, 5). Correspondingly, it is well established that systemic inflammation underpins many non-communicable diseases such as Type 2 diabetes, autoimmune conditions, and even chronic pain. These dyes have been a contributor to this toxic load for years.

So, wouldn’t we want to do whatever is possible to minimize exposure to such substances - as soon as humanly possible? Even if it’s politically contentious?

It is necessary to approach such egregious missteps in the delay in safeguarding citizens’ health from an apolitical standpoint. The good news is that your cells and your microbiome, your colon, and your stomach, and even the structural part of your brain do not hold political affiliation. Whether our parts operate in health or dysfunction is a truly independent matter – from a political standpoint that is. But our health or dysfunction is highly dependent upon the foodstuffs we consume or nourishing foods we fail to consume. This phase-out of synthetic food dyes is a win for all US citizens of all ages.

The bottom line is that we as healthcare providers – now more than ever – need to have a foundational working knowledge of nutrition as it relates to overall health and a framework to take what we know from science and apply it to our patient care practices as soon as possible - vs. decades later! We must ask meaningful questions. We must share what we know to be important and relevant based on the literature. We must be curious investigators. Many of the answers we seek to the omnipresent health concerns of the 21st century await our discovery.

While we wait for the petroleum-based synthetic dyes to tiptoe quietly off of our grocery store shelves by the end of 2026, it would be wise to check food labels and leave those products with artificial food dyes at the grocers. It will be an adjustment for food producers and consumers, but the move away from highly processed ingredients such as these artificial food dyes is one critically important step toward improving the health and well-being of all.

To be ahead of the curve, please join me in my two-day remote course, Nutrition Perspectives in Pelvic Rehabilitation. The next class is scheduled for June 7-8, but you can also join me later in the year on October 11-12 or December 6-7. Remember, the food we eat impacts every system of the body, and our nourishment status directly relates to our overall health picture - affecting a multitude of conditions treated in pelvic rehabilitation. This course provides a unique opportunity to explore multi-dimensional connections between physical therapy, pelvic rehabilitation, and nutritional sciences. 

References:

1. Allmark, M. G., Grice, H. C., & Mannell, W. A. (1956). Chronic toxicity studies on food colours. II. Observations on the toxicity of FD&C green No. 2 (light green SF yellowish), FD&C orange No. 2 (orange SS) and FD&C red No. 32 (oil red XO) in rats. The Journal of pharmacy and pharmacology, 8(6), 417–424.
2. Hofseth LJ, Hebert JR, Murphy EA, Trauner E, Vikas A, Harris Q, Chumanevich AA. Allura Red AC is a xenobiotic. Is it also a carcinogen? Carcinogenesis. 2024 Oct 10;45(10):711-720. doi: 10.1093/carcin/bgae057. PMID: 39129647; PMCID: PMC11464682.
3. HHS, FDA to Phase Out Petroleum-Based Synthetic Dyes in Nation’s Food Supply. https://www.fda.gov/news-events/press-announcements/hhs-fda-phase-out-petroleum-based-synthetic-dyes-nations-food-supply  Accessed April 28, 2025.
4. He, Z., Chen, L., Catalan-Dibene, J., Bongers, G., Faith, J. J., Suebsuwong, C., DeVita, R. J., Shen, Z., Fox, J. G., Lafaille, J. J., Furtado, G. C., & Lira, S. A. (2021). Food colorants metabolized by commensal bacteria promote colitis in mice with dysregulated expression of interleukin-23. Cell metabolism, 33(7), 1358–1371.e5. https://doi.org/10.1016/j.cmet.2021.04.015
5. Sudhakaran G. (2023). Artificial food dyes are toxic: Neurobehavioral implications in children. Brain & spine, 4, 102869. https://doi.org/10.1016/j.bas.2024.102869
6. Batada, A., & Jacobson, M. F. (2016). Prevalence of Artificial Food Colors in Grocery Store Products Marketed to Children. Clinical pediatrics, 55(12), 1113–1119. https://doi.org/10.1177/0009922816651621
7. Doell, D. L., Folmer, D. E., Lee, H. S., Butts, K. M., & Carberry, S. E. (2016). Exposure estimate for FD&C colour additives for the US population. Food additives & contaminants. Part A, Chemistry, analysis, control, exposure & risk assessment, 33(5), 782–797. https://doi.org/10.1080/19440049.2016.1179536
8. Zhang, Q., Chumanevich, A. A., Nguyen, I., Chumanevich, A. A., Sartawi, N., Hogan, J., Khazan, M., Harris, Q., Massey, B., Chatzistamou, I., Buckhaults, P. J., Banister, C. E., Wirth, M., Hebert, J. R., Murphy, E. A., & Hofseth, L. J. (2023). The synthetic food dye, Red 40, causes DNA damage, causes colonic inflammation, and impacts the microbiome in mice. Toxicology reports, 11, 221–232. https://doi.org/10.1016/j.toxrep.2023.08.006
9. Potera C. (2010). The artificial food dye blues. Environmental health perspectives, 118(10), A428. https://doi.org/10.1289/ehp.118-a428

AUTHOR BIO
Megan Pribyl, PT, CMPT, CMTPT/DN, PCES

Megan Pribyl, PT, CMPT, CMTPT/DN, PCES (she/her) is a mastery-level physical therapist at the University of Kansas Health System in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic health, pregnancy, and postpartum rehabilitation – all with integration of health and wellness. She began her PT career in 2000 after graduating from the University of Colorado Health Sciences Center with her Master of Science in Physical Therapy. Prior, she earned her dual degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) in 1998 from Kansas State University. Later, she obtained her CMPT from the North American Institute of Orthopedic Manual Therapy and became certified in dry needling in 2019. Since 2015, she has been a faculty member of Herman & Wallace Pelvic Rehab Institute and enjoys both teaching and developing content. She created and instructs Nutrition Perspectives for the Pelvic Rehab Therapist offered remotely through Herman & Wallace. She also teaches Pelvic Function – Level 1, Pregnancy Rehabilitation and Postpartum Rehabilitation. She brings many years of experience and insight to all courses. As a content developer, Megan has also contributed to the Herman & Wallace Oncology Series, Pelvic Function Level 2A, as well as the Pelvic Function Series Capstone Course.

Megan’s longstanding passion for both nutritional sciences and manual therapy culminated in her creating Nutrition Perspectives for the Pelvic Rehab Therapist designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to integrate ancient and traditional practices with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation. Clinicians will come away from this course with both simple and practical integrative tools that can be immediately utilized to help clients and providers alike - along their path of healing.

Megan enjoys her many fulfilling roles as an instructor, clinician, wife, and mom to two active teenagers and owner of two rambunctious golden retrievers. She loves to read, cook, be in the great outdoors, travel, and spend time with her family and friends. She has a passion for both the mountains and the beach, exploring scientific literature, and learning all she can about the power of using nature, nurture, and nutrition to heal and sustain health.

“But nothing showed up on the MRI…”
If you’ve worked with people experiencing chronic pelvic pain, you’ve likely heard this line (or screamed it into the void yourself). Pelvic pain is complex. It’s layered. And when traditional diagnostic tools come up short, patients are left confused, discouraged, and often dismissed.

This is where pain science education becomes not just helpful—it becomes essential. Especially when we’re talking about central sensitization, a sneaky, brain-driven process that keeps the pain party going long after the tissue has healed.

Let’s dig into what this means for our pelvic pain population—and why it’s time every clinician added “pain science educator” to their superpower list.

What Is Central Sensitization?
Imagine your nervous system is like a home security system. Normally, it detects real threats—say, a break-in or fire. But in central sensitization, the system is so sensitive that it goes off when a leaf blows past the window. The brain and spinal cord amplify pain signals, misinterpreting non-threatening input (like gentle touch, muscle movement, or a full bladder) as dangerous.

In the pelvic floor world, this might look like:

• Burning with urination despite no infection
• Pain with penetration, even with no visible tissue damage
• A “tight” pelvic floor that resists every stretch and cue
• General pain or pressure that moves, shifts, or seems unprovoked

Central sensitization isn’t “in someone’s head.” It’s in their nervous system—and it’s very, very real.

Why Pain Education Matters
Pain science education helps patients reframe their experience. When someone understands that pain is a protective mechanism (not a damage report), the fear cycle begins to break.

This is huge in chronic pelvic pain. Patients often carry shame, confusion, and even trauma around their symptoms. By educating them about central sensitization, we:

• Reduce fear and catastrophizing
• Improve trust in the body
• Increase compliance with movement and manual therapy
• Promote neuroplastic healing (yes, the brain can change!)

Think of it this way: You wouldn’t start strength training a rotator cuff tear without explaining what’s happening first. The same rules apply here—except our “tear” is happening at the nervous system level.

How to Integrate Pain Science into Pelvic Floor Treatment
You don’t need to be a neuroscientist or TED Talker to do this well. Here’s how we incorporate pain education into every evaluation and treatment session:

1. Use Metaphors that Stick

The alarm system analogy is a go-to. Others include:

• “Your brain is trying to protect you, but it’s become a little overprotective.”
• “Your nervous system is on high alert like a smoke detector that’s too close to the toaster.”

2. Normalize Their Experience

Validate their symptoms without reinforcing fear. “Your body is reacting in a protective way. We can help it learn to feel safe again.”

3. Introduce the Concept of Graded Exposure

Reassure them that movement, intimacy, and bladder function can return—gradually, safely, and with support. We’re not rushing into the fire; we’re slowly turning down the alarm.

4. Keep Repeating the Message

It takes time for the nervous system—and the brain—to rewire. Repeat, reframe, and reinforce education at every visit.

The Future of Pelvic Health Is Brain-Based
Pelvic pain isn’t just a musculoskeletal issue—it’s a nervous system experience. And the more we understand central sensitization, the better we can support our patients.

Pain education isn’t fluff. It’s foundational. It’s empowering. And it may just be the first real explanation your patient has ever received.

So, let’s keep spreading the word, turning down alarms, and helping patients feel safe in their bodies again.

Because healing starts with understanding—and we’ve got a lot of explaining to do (in the best way possible).

Want to dive deeper into the why behind pain?
Learn how to distinguish between peripheral pain generators and central sensitization, understand how these mechanisms show up in the body, and gain practical strategies to address them in both pelvic pain and orthopedic patients.

Join us for our remote pain science course, Pain Science for the Chronic Pelvic Pain Population on June 21-22, where complex concepts meet clear, clinical application, even including verbatim script examples with real-life patients.

AUTHOR BIO
Tara Sullivan, PT, DPT, PRPC, WCS, IF

Dr. Tara Sullivan, PT, PRPC, WCS, IF (she/her) started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage and anatomy & physiology. During that time, she attended college at Oregon State University, earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Master of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD), treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC), deeming her an expert in the field of pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona, including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace, teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company, Mind to Body Healing (M2B), to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.

This specialty of pelvic health has given each of us so many things: purpose, community, and a means to empower and equip so many people to better understand and care for their pelvic health challenges and reach their goals.

But for the rest of the developing world, it’s not like that. Imagine a place where the field of pelvic health simply doesn’t exist. Where women have no choice but to live the rest of their lives with leaking, and community condemnation from birth-induced fistula. Where men suffer in silence with impotence and pelvic pain. Where people with all types of pelvic health conditions must go about their lives hiding and suffering in their private shame.

And then imagine that YOU had the power and influence to change this! To extend your influence, expertise and support all the way across the world to East Africa - to the Amref International University in Nairobi Kenya (AMIU), where even now two cohorts of the FIRST Masters Level Pelvic Health Therapists are busy preparing to revolutionize the understanding and delivery of pelvic rehab in East Africa: Kenya, Uganda, and Ethiopia!

Imagine though, the hurdles these professionals will have to navigate in their cultures, communities, health care systems, referral sources, families, and personal lives. Then imagine what a difference it would make for them to have encouragement, mentorship, and financial support.

The Program
Elizabeth Akincilar and I have been humbled to be a part of this movement through the leadership of the Jackson Clinics Foundation to develop curriculum, recruit teachers, mentors, volunteers, and most importantly raise financial contributions to support this fledgling program. To date, all students have had HALF of their curriculum costs covered through donations alone.

In the development of this program, both Herman & Wallace and the Pelvic Health and Rehabilitation Center generously contributed both online and didactic materials. Several colleagues added their expertise to the curriculum, including Ramona Horton, Dawn Sandalcidi, Juan Michelle Martin, Ebony Jackson, Laura McGuckin, Niko Gaffga, Carolyn Packard, and Christine Stewart.

The curriculum consists of 6 modules:

1. Introduction to Pelvic Health
2. Pregnancy/Intrapartum/Postpartum
3. Pediatrics and Marketing
4. Pelvic Pain
5. Visceral Mobilization
6. Advanced Topics within Pelvic Health

Because AMIU has a presence in over 30 countries in Africa and Asia, the potential for the curriculum to grow and spread is huge.

The Students
In East Africa, the need for pelvic health care is extraordinary, and knowledge about pelvic health conditions is minimal. There are many barriers people with pelvic health concerns encounter in receiving care, and also barriers for students to continue their studies.

Three of the students in a previous cohort had to work night shifts at the hospital for the two weeks we were in class. They spent 8 hours in class, went home to care for their families, then worked 8 hours at the hospital. For. Two. Weeks.

Another student almost dropped out because she had funds to either pay for her tuition or her daughters’ school fees. We were able to connect her with a donor who covered her expenses.

Lives are also being profoundly impacted by the care these therapists are providing in their communities: from the woman who finally bore a child after a decade of struggling with pelvic pain, to the grandmother supporting her grandchildren who was able to go back to work after getting control of her bladder and bowel leakage, to the man who never talked about the abuse he experienced as a child who is now able to have a bowel movement without pain.

The Goals
As we consider the growth of the pelvic health program in Kenya, our goals are several:

1. To equip and empower rehab specialists in providing quality pelvic health care to the country of Kenya and now other countries in East Africa.
2. To train teaching assistants and faculty members to be proficient in conducting the curriculum independently within three years
3. To reduce or eliminate barriers to pelvic health continuing education in Kenya
4. This last goal is where our pelvic health family in the US comes in. The cost for the two-year degree is equivalent to $2,000 American dollars. The average PT annual salary is less than $7,000, and participants will have to take 3 weeks off of work per calendar year to participate in the program. Many from outside of Nairobi would have to incur travel and accommodation expenses. This price tag poses a significant barrier.

The total cost of the program is $13,000. We are asking for your help in deferring the cost of the program for as many people as possible, with the goal of paying half of the tuition for the incoming class of thirty people. Our fundraising campaign in 2025 has raised $9000 thus far, with most of this coming from donations during HWConnect, which were matched by Herman & Wallace!

Here’s how you can help:

• Make a tax-deductible donation to the Pelvic Health Program through the Jackson Clinic Foundation.
  
  • Click this secure link and use the carrot to find the Pelvic Health option.
• Host a fundraising activity: perhaps a community education class where the proceeds go to this cause!
• Get on our volunteer list to lead a journal article review, a Grand Rounds discussion, or assist a student in their Legacy project.
• Become a mentor to walk beside a student on their educational journey and beyond.
• Teach an online course for our graduates!
• Donate books or supplies!

For more information on how you can get involved in fundraising or teaching an online class, you can email me (Jenna) at This email address is being protected from spambots. You need JavaScript enabled to view it. or Liz at This email address is being protected from spambots. You need JavaScript enabled to view it..

If you would like to learn more about volunteering, please connect with Ebony Jackson Clark at This email address is being protected from spambots. You need JavaScript enabled to view it..

We are so, so very humbled by your kind support.

AUTHOR BIO:
Jennafer "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 Part 1” and “Boundaries, Self-Care and Meditation Part 2” 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.

Rebuilding the Urge: Where to Start
Restoring bowel urgency is one of the most important portions of a bowel retraining program. When a patient no longer has a normal bowel movement urge due to prior postponing, the slowness of their system, chronic use of enemas, or idiopathic causation, helping the patient retore the natural bowel movement urge may be the immediate focus of the treatment.

Restoring defecatory urge is one of the first steps in the treatment process. Reviewing and understanding colon physiology and determining where the focus of treatment should start, especially in complex patients, is key. Synthesizing new treatment ideas and use of modalities to assist with colonic motility can be one of the first steps to help the patient improve their defecatory urge.

For complex cases, this can involve mapping out where motility is most compromised. Is it a problem of peristalsis? A nervous system misfire? Inflammation in the gut interfering with communication pathways? Or is it something else?

Here’s where innovative thinking and a comprehensive approach come into play.

Treatment Tools and Modalities to Restore Motility
There are many ways to support and enhance colonic motility and restore bowel urgency. These can include:

• Neuromuscular stimulation and biofeedback therapy: These help retrain the pelvic floor muscles and encourage a coordinated bowel response.
• Rectal balloon training: Assists in retraining muscle function and can also enhance patient confidence during bowel movements.
• Behavioral techniques and bowel habit training: Regular scheduling, posture optimization during defecation (hello, squatty potty!), and mindfulness around urges.
• Manual therapy and visceral mobilization: Often used by pelvic floor therapists to reduce adhesions or fascial restrictions.
• Abdominal massage and diaphragmatic breathing: Gentle but effective ways to stimulate internal movement and improve gut tone.

Gut Microbiota: The Missing Piece of the Puzzle
A healthy gut flora is essential to regular and urgent bowel movements. The microbiota helps regulate everything from stool consistency to inflammatory responses in the colon. A disrupted microbiome, such as one lacking microbial diversity or populated by too many pathogenic strains, can slow transit and dull natural urges.

Dietary diversity is key to nurturing a thriving gut ecosystem. Encouraging patients to consume the following foods can make a significant difference in restoring microbial balance and improving colon motility:

• Fiber-rich vegetables and fruits
• Fermented foods (like kefir, kimchi, sauerkraut)
• Resistant starches (like cooled potatoes or green bananas)
• Prebiotic foods (such as garlic, leeks, and onions)

Hormones and the Colon: An Overlooked Connection
Sex hormones, particularly estrogen and progesterone, have a notable impact on gut function. Many individuals report changes in bowel patterns during their menstrual cycle, and hormonal shifts during menopause or andropause can contribute to constipation or erratic bowel habits. Understanding this connection is essential when working with patients whose symptoms appear to cycle with their hormonal changes.

Hormonal imbalances or deficiencies may require a referral for endocrinological evaluation or functional medicine support, especially if gut symptoms persist despite other interventions.

What You'll Learn in the Bowel Pathology and Function Course
Bowel Pathology and Function is a remote course designed for healthcare providers looking to sharpen their skills and deepen their understanding of bowel function restoration. Through a mix of physiology review, clinical tools, and real-world strategies, participants will walk away with a clear plan for helping patients recover their natural urge to defecate.

This bowel course will help you identify where the focus of the patient’s treatment needs to be addressed. Getting to decide where their efforts should be focused and what part of the system seems to be slow or inefficient and helps the healthcare provider narrowing the treatment focus.

Session learning objectives include:

1. In-depth review of colon physiology – Understand the mechanics of motility, nervous system input, and the role of pressure gradients.
2. Use of supportive modalities – Learn how to employ tools like electrical stimulation, manual therapy, and breathwork to enhance gut movement.
3. Microbiota and diet strategies – Dive into microbial diversity and how to coach patients on food choices that support a healthy microbiome.
4. Sex steroids and gut health – Examine the influence of estrogen, progesterone, and testosterone on gut motility and bowel pattern changes.

Restoring bowel urgency isn’t just a digestive issue - it’s a quality-of-life issue. Whether you’re a clinician or a curious patient, understanding the full picture—from gut mechanics to hormones to microbes—can unlock powerful healing. And sometimes, it’s the “down and dirty” details that lead to the biggest breakthroughs. Join me June 7-8^th for Bowel Pathology and Function.

References:

Banibakhsh A, Sidhu D, Khan S, Haime H, Foster PA. Sex steroid metabolism and action in colon health and disease. J Steroid Biochem Mol Biol. 2023 Oct;233:106371. doi: 10.1016/j.jsbmb.2023.106371. Epub 2023 Jul 28. PMID: 37516405.

Barbara G, Barbaro MR, Marasco G, Cremon C. Chronic constipation: from pathophysiology to management. Minerva Gastroenterol (Torino). 2023 Jun;69(2):277-290. doi: 10.23736/S2724-5985.22.03335-6. Epub 2023 Feb 2. PMID: 36727654.

Seo M, Bae JH. [Nonpharmacologic Treatment of Chronic Constipation]. Korean J Gastroenterol. 2024 May 25;83(5):191-196. Korean. doi: 10.4166/kjg.2024.044. PMID: 38783620.

Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Neurogastroenterol Motil. 2021 Jun;33(6):e14050. doi: 10.1111/nmo.14050. Epub 2020 Dec 2. PMID: 33263938.

Yang C, Hong Q, Wu T, Fan Y, Shen X, Dong X. Association between Dietary Intake of Live Microbes and Chronic Constipation in Adults. J Nutr. 2024 Feb;154(2):526-534. doi: 10.1016/j.tjnut.2023.11.032. Epub 2023 Dec 9. PMID: 38072155.

AUTHOR BIO
Lila Bartkowski-Abbate, PT, DPT, MS, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor’s of Science (BS) in Health Sciences and a Masters of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from Herman & Wallace Institute, 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has full-time faculty experience at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Floor Series of Pelvic Floor 1, 2A and 2B and Pregnancy, Postpartum. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

As physical therapists who specialize in treating all genders and all conditions related to the niche practice of pelvic health, it has been a privilege for us to deliver whole-person care, emphasizing self-healing, nervous system regulation, and mind-body integration. We often see patients who are under high stress and anxiety, and even more so when they have no other options except surgical intervention.

One such case was a 71-year-old patient who came in with a rectal prolapse. She had experienced a 10 cm rectal prolapse post-defecation, and it had taken prolonged bed rest for half a day for spontaneous reduction to occur. This happened after every bowel movement. She was told there were no other options except surgery. She was afraid to undergo rectal surgery and was willing to try anything to avoid it. Over the course of the first visit, I also learned that she had a family member who was very ill, and she rated her stress and anxiety levels beyond 10/10.

Rectal prolapse is full thickness protrusion of the rectum through the anal canal. It can occur in both sexes, but is 6 times more likely in women. Overall, about 13% of women will undergo surgery for some form of pelvic prolapse at some point in their lives. The incidence of pelvic prolapse also increases with age, peaking in those over 70 years^1,2. Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, mucous rectal discharge, and fecal incontinence or constipation^2,3,4,5,6.

It is associated with lifestyle-limiting symptoms for the patient and frequently co-exists with other types of pelvic prolapse, making multidisciplinary management key, as it is primarily managed with surgical reconstruction². Multiple surgical approaches exist within the two broad categories of perineal and abdominal. Perineal approaches are considered less physiologically taxing but are associated with higher recurrence rates. Anterior mesh rectopexy appears to balance the best functional outcomes with the lowest risk of recurrence².

There is currently limited evidence to support non-surgical rehabilitation options for this condition. Complementary and Alternative Medicine (CAM) techniques, such as Acupressure, have shown promise in pelvic health, yet are largely underexplored in the context of rectal prolapse.

Given this patient’s high anxiety and impaired bowel function that required prolonged bed rest post-defecation, I decided to use a novel multimodal rehabilitation approach. This approach integrated Acupressure, pelvic floor muscle training (PFMT), manual therapy, breathing and mindfulness techniques, and postural and functional retraining. The goal was to address her symptoms, improve activity tolerance and function, and improve her quality of life.

Acupressure was introduced at the first visit. Over the course of 7 visits, this patient progressed through a gentle pelvic floor strengthening program and had a 90% improvement in her rectal prolapse symptoms. She was also trained to use pelvic floor Acupressure at the Governing Vessel 1 (GV 1) Acupoint to effectively and quickly reduce her rectal prolapse after every bowel movement.

The patient was also taught an Acupressure nervous system self-regulation program that consisted of Acupressure points to help her improve mind-body awareness & connection to down-regulate her nervous system. Several Acupoints, such as Conception Vessel 17 (CV17), Governing Vessel 24.5 (Yintang point), Heart 7, and Pericardium 6, were used to help her manage and control her stress and anxiety. These points were reviewed and reinforced at each session. Her functional gains included restored ability to perform ADLs without post-bowel movement limitations. She also demonstrated improved pelvic floor muscle coordination, increased standing and walking tolerance, and was very pleased that she was able to avoid surgery. Her anxiety levels significantly improved with the daily self-regulation practice, and she felt she now had physical control over her symptoms.

Acupressure is an evidence-based practice that is rooted in Acupuncture and Traditional Chinese Medicine. In Acupressure, we use gentle finger pressure instead of needles to stimulate specific points on the body known as Acupuncture points. These energy points are known to have high electrical conductivity at the surface of the skin and are embedded within the body’s vast fascial network. Because of this, they offer a unique gateway to access and influence the nervous system.

As a Holistic pelvic health practice, Acupressure can be used to:

1. Reduce Pelvic Pain
   Potent acupoints on the abdomen, pubic bone and sacrum can help to relax pelvic floor muscles, ease menstrual cramps and pelvic pain. The Bladder meridian points along the sacral spine (B27–B34) — are for back pain, pelvic tension, and reproductive organ support.
2. Enhance Blood Flow & Energy (Qi)
   Certain acupoints stimulate blood and lymph circulation in the pelvic region, supporting physiological functioning of various sexual and reproductive organs. The Kidney 1 point, located on the sole of the foot — is for grounding, calming, and helps with anxiety and stress stored in the pelvic bowl.
3. Regulate Menstrual & Reproductive Health
   Acupressure can help regulate cycles, reduce PMS symptoms, and support fertility by harmonizing hormonal pathways. The Spleen 6 – Sanyinjiao point, which is located on the inner leg, above the ankle — regulates menstrual cycles, supports fertility, and soothes menstrual cramps.
4. Promote Nervous System Regulation
   Acupressure engages the parasympathetic nervous system and can help to calm the body, improve sleep, and promote relaxation. The pelvis is often a storehouse for unprocessed emotions, especially trauma. Acupressure combined with breathwork or somatic practices can help with these symptoms.
5. Support Bladder & Bowel Function
   Pressing on meridian points associated with the bladder, kidneys, spleen, or large intestine can aid with incontinence, constipation, and other bowel & bladder symptoms. Acupressure can also help with symptoms of Rectal Prolapse as noted in this patient case.

This patient case explores a multimodal rehabilitation program integrating Acupressure with traditional pelvic floor therapy, which may serve as an effective non-surgical intervention for rectal prolapse. Improvements in symptom control, functional mobility, and self-management highlight the potential of Acupressure as a conservative approach for prolapse care.

I am so humbled to share that this patient’s Case study has been accepted at the International Urogynecological Association (IUGA) & European Urogynecological Association (EUGA) joint meeting that is being held in Barcelona, Spain in June this year. This is a great step forward to explore holistic options in pelvic health, and I am grateful to be part of this patient’s journey to wellness.

To learn more about Acupressure, please join the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for June 7- 8^th. The course will introduce participants to the basics of Traditional Chinese Medicine (TCM), Acupuncture & Acupressure. The course introduces the 12 major Meridians or energy channels, focusing on the Bladder, Kidney, Stomach, and Spleen meridians. The course is packed with key potent points that can help to self-regulate the nervous system and help with anxiety, insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, urinary dysfunctions, digestive disturbances, cancer pain, and much more. The course also offers an introduction to Yin yoga and explores Yin poses within each meridian channel that can be integrated with Acupressure and mindfulness practices.

References

1. Bordeianou L, Hicks CW, Kaiser AM, Alavi K, Sudan R, Wise PE. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies.J Gastrointest Surg. 2014;18(5):1059-1069. doi:10.1007/s11605-013-2427-7
2. Romero-Morales C, Bravo-Aguilar M, Abuín-Porras V, et al. Current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Dis Mon. 2021;67(10):101210. doi:10.1016/j.disamonth.2021.101210
3. Yang J, Do A, Mallory MJ, Wahner-Roedler DL, Chon TY, Bauer BA. Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic.& Glob Adv Health Med. 2021;10:21649561211058076. Published 2021 Dec 12. doi:10.1177/21649561211058076
4. Wen J, Chen X, Yang Y, et al. Acupuncture Medical Therapy and Its Underlying Mechanisms: A Systematic Review. Am J Chin Med. 2021;49(1):1-23. doi:10.1142/S0192415X21500014
5. Zhou YF, Zhang GL, Sun N, et al. Acupuncture for emotional disorders in patients with inflammatory bowel disease: a systematic review protocol. BMJ Open. 2022;12(9):e058568. Published 2022 Sep 27. doi:10.1136/bmjopen-2021-058568
6. Gallo G, Martellucci J, Pellino G, et al. Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse. Tech Coloproctol. 2018;22(12):919-931. doi:10.1007/s10151-018-1908-9

AUTHOR BIO
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University, New York with a Doctor of Physical Therapy degree. Rachna has since been working in outpatient hospital and private practice settings with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer county in New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. Her clinical practice has focused on an Integrative physical therapy approach blending traditional physical therapy methods with holistic practices that address the whole person - physically, mentally, emotionally, and spiritually. She specializes in working with pelvic health patients who have bowel & bladder issues with high pelvic pain which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional, and energy body.

Five years ago, the COVID-19 pandemic devastated the world on a scale not seen in nearly a century. Hospital systems became overwhelmed as the number of patients requiring hospitalization and mechanical ventilation surged. In the years since, the Centers for Disease Control and Prevention (CDC) has defined terms such as "Long COVID" and "Post-COVID Condition" to describe individuals who continue to experience symptoms well after recovering from the acute phase of the virus. As it relates to our work, a key question emerges: What are the short- and long-term effects of COVID-19 on the diaphragm?

A study by Spiesshoefer et al. (1) examined patients hospitalized with COVID-19 and assessed them approximately two years after discharge. They found that persistent diaphragm muscle weakness and exertional dyspnea remained prevalent. In their study, participants were divided into two groups—one group received six weeks of inspiratory muscle training (IMT), while the control group received a sham intervention. The IMT group demonstrated statistically significant improvements in exertional dyspnea and diaphragm function, although there was no notable change in diaphragm thickness. Importantly, these improvements persisted after the six-week intervention concluded.

Similarly, Ahmad et al. (2) compared diaphragm release techniques with conventional breathing exercises in female patients recovering from COVID-19. After just nine sessions over a three-week period, the diaphragm release group showed greater improvements in chest wall expansion, oxygen saturation, and performance on the six-minute walk test compared to the breathing exercise group.

Together, these studies highlight the importance of incorporating both breathing exercises and manual therapy techniques to optimize breathing mechanics, support chest wall mobility, enhance oxygen saturation, and reduce exertional dyspnea during walking and other functional activities.

In the Breathing and the Diaphragm course taught by Aparna Rajagopal and Leeann Taptich, a systematic and holistic approach to evaluation and treatment will be discussed, covering not only recovery from COVID-19 but also pelvic floor dysfunction, gastrointestinal disorders, and chronic low back pain. To deepen your understanding of the diaphragm’s crucial role in health and rehabilitation, register for the May 31, 2025 course through Herman & Wallace.

References:

1. Spiesshoefer J, Regmi B, Senol M, Jorn B, Gorol O, Elfetur M, Walterspacher S, Giannoni A, Kahles F, Gloeckl R, Dreher M. Potential Diaphragm Muscle Weakness-related Dyspnea Persists 2 Years after COVID-19 and Could Be Improved by Inspiratory Muscle Training. Am J Respir Crit Care Med. 2024; 210(5): 618-628.
2. Ahmad AM, Nawar NM, Dabess HM, Gallab MA. Effect of diaphragm manual release versus conventional breathing exercises in prone positioning on physical functional performance in women with COVID-19: A randomized trial. Journal of Bodywork and Movement Therapies. 2023; 35: 311-319.

AUTHOR BIO
Leeann Taptich DPT, SCS, MTC, CSCS

Leeann Taptich, PT, DPT (she/her) has been a physical therapist since 2006. She graduated with a BS in Kinesiology from Michigan State University and a Doctorate of Physical Therapy from the University of St Augustine. In 2009, she earned her Manual Therapy from the University is St Augustine and her board certification as a Sports Certified Specialist in 2018.

Leeann leads the Sports Physical Therapy team at Henry Ford Macomb Hospital in Michigan, where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital, which gives her a very unique perspective of the athlete. With her combination of credentials and her exposure to pelvic health,h she is able to use a very eclectic but complete approach in her treatment of orthopedic and sports patients. With the hospital system, she is involved with the community promoting health and wellness at local running competitions and events.

Leeann is passionate about educating and teaching and has assisted in teaching multiple courses at the local State a university PT department. She is co-chair of the continuing education committee at her hospital where she writes and develops courses. She is a co-author of the Breathing and Diaphragm class at Herman & Wallace.

Leeann lives in the metro Detroit area with her husband and 2 children. She enjoys hiking, traveling, and watching football.

Have you ever thought about how patients from diverse backgrounds face unique challenges at the intersection of their religious values—such as modesty and conservative views — and the need for pelvic and sexual health support?

Navigating this intersection of pelvic rehabilitation and religious belief systems requires a deep understanding of both the physical and emotional challenges patients may face. In many conservative religious communities, discussions around sexual health are limited, creating significant barriers to seeking care and addressing issues such as pelvic pain, sexual dysfunction, and reproductive concerns.

Let’s take a look at a past patient of mine as an example. Sarah’s case highlights the complexities that arise when religious upbringing, limited sexual education, and physical dysfunction intersect. Her story underscores the need for compassionate, culturally informed care that empowers patients to achieve their health goals while respecting their deeply held beliefs.

Case Study: Sarah
Sarah is a 23-year-old woman presenting for a pelvic health evaluation. When scheduling her appointment, she declined to disclose the specific reason for her visit.

During the patient interview, Sarah shares that she has been married for eight months and that all attempts at intercourse have been unbearably painful. She reports pain at a 14/10 intensity level and describes vocally crying out during any attempt at penetration. She expresses a deep sense of hopelessness, fearing that something is fundamentally wrong with her body, and worries that her vagina is “too small” for intercourse. Sarah admits she has never visually examined her vaginal area, stating it “grosses her out.”

Sarah is otherwise in good health but has never undergone a gynecological exam. Both she and her husband come from conservative religious backgrounds, attended religious schools with limited sex education, and received minimal information about sexual activity prior to marriage. Neither had been sexually active before their wedding. Sarah continues to adhere to her religious beliefs, including a practice that discourages conversations about sex with anyone other than her spouse. She voices a strong aversion to sexual activity, as well as to her husband’s genitalia and semen, and shares feelings of guilt over her inability to have intercourse and “make her husband happy.”

Although Sarah denies any discomfort while sitting or wearing tight-fitting clothing and reports no other general bodily pain, she has recently begun experiencing vulvar pain that precedes any attempt at intercourse. Following these attempts, she has difficulty falling asleep due to persistent pain.

Additional relevant history includes frequent urination (approximately every hour), which she attributes to having a "tiny bladder." Chronic constipation, with bowel movements occurring about once per week, often requiring significant straining (Bristol Stool Scale types 1–2). Regular menstrual cycles, though the first 2–3 days are marked by debilitating pain and the inability to successfully insert tampons.

Sarah’s personal treatment goals are to achieve pain-free intercourse and to become pregnant as soon as possible, aligning with the expectations of her close-knit, religious community.

Let’s think about our next steps with this patient.
What is your next move? Approach the patient with heightened sensitivity, cultural competence, and an awareness of how religious values can shape a patient’s experience of their body, pain, and sexuality. The next steps with Sarah should focus on creating a foundation of trust, safety, and consent while validating her experience and assuring her that treatment will proceed at her comfort level. The initial sessions could prioritize external assessment, observing breathing patterns, posture, and pelvic tension, without internal examination.

What other questions would you like to ask this patient? Gentle, respectful questioning would further clarify the nature of Sarah’s pain, emotional experiences surrounding intimacy, bladder and bowel habits, and her comfort level with educational discussions within her religious framework.

What would your treatment plan look like for this patient? Early treatment could center on pain education, diaphragmatic breathing, pelvic floor relaxation, and bladder and bowel retraining, with mirror therapy and gradual body awareness work being introduced when she is ready. The treatment plan would progress from external desensitization toward eventual internal work and dilator therapy, aimed at achieving pain-free intercourse and healthy pelvic floor function to support future pregnancy.

What other healthcare providers might you refer her to? In addition to pelvic therapy, referrals to a culturally sensitive pelvic health mental health professional, a trauma-informed gynecologist, and possibly a sex therapist and dietitian could be recommended. Throughout care, sensitivity to Sarah’s religious values, empowerment, and compassionate support would be critical to helping her meet her goals.

The Takeaway
As pelvic health providers, we choose this field because we are passionate about delivering the best possible care with sensitivity and compassion. Yet, it can feel overwhelming when we work with patients from religious or cultural backgrounds unfamiliar to us. In our efforts to be respectful, we may find ourselves hesitant to ask the crucial questions necessary for effective care.

I created a course to specifically tackle this sensitive issue; Sex and Religion is a short, one-day remote course held over Zoom that bridges the gap between the worlds of pelvic rehabilitation and religion. This course provides guidance and skills for engaging patients from religiously conservative backgrounds in a culturally sensitive manner. Participants will gain a foundational understanding of the various traditions, customs, laws, and values associated with Muslim, Jewish, Hindu, and Christian faiths as they pertain to sexuality and pelvic health.

Anyone who treats pelvic health concerns can take this course to fill their toolbox with new tools and strategies to enhance their practice. Join Rivki in her upcoming course, Sex and Religion, on May 18^th to ensure that every patient receives the thoughtful, respectful care they deserve.

AUTHOR BIO
Rivki Chudnoff, MSPT

Rivki is a Midwesterner at heart, born and raised in Chicago. At her private practice, Hamakom Physical Therapy, in Bogota, NJ. She focuses on women’s health and pelvic health rehabilitation for women and children. Rivki graduated from Stern College with a BA in Biology and from the University of Medicine and Dentistry of New Jersey (Rutgers) in 1999 with a Master of Science in Physical Therapy. Rivki started her physical therapy career in pediatrics working with children with severe disabilities.

In her practice, Rivki is privileged to work with women at different stages of life. Rivki uses a biopsychosocial approach to guide her patients through the many challenges that they encounter along their journey to healing. Rivki has written extensively on women’s health issues and has presented on pelvic health internationally to sex educators, at community events, and at marriage retreats. In her free time, she enjoys vacationing at Trader Joe’s, burning dinner, and trying to figure out new ways to embarrass her children with her professional life.

When we think of pelvic floor dysfunction, our minds often go straight to adults. We may even consider toddlers or children struggling with conditions like constipation or bedwetting. A population I frequently find missed is the infant! Many providers don’t realize that the pelvic floor issues that show up in infancy don’t have to be waited out.

As pediatric pelvic health providers, we have a unique and powerful role to play in helping babies who struggle with common challenges like reflux, colic, constipation, feeding difficulties, and even motor delays. At the root of many of these concerns lies the pelvic floor—an area often overlooked in traditional pediatric care. These parents will go to their providers, and they’ll be offered advice like “hold them upright for 20 minutes after feeding” or “try a lactation consultation,” but what happens if these interventions are not enough, OR what happens if a rehab provider wants to provide more support to a struggling family.

You may be thinking, “I don’t do pediatrics.” If that is your stance, I recommend you keep reading. You don’t have to be a dedicated pediatric therapist to provide families struggling with cranky or uncomfortable babies. Even if you don’t want to provide specific recommendations and treatment, you can still screen and offer referrals for support and even this step will create improvement in the quality of life of your families.

Understanding the Infant Pelvic Floor: More Than Just Diaper Changes
The abdominal canister in infants is still developing and is deeply interconnected with multiple systems in the body:

• The digestive system (contributing to reflux, gas, and constipation)
• The nervous system (especially for babies with difficulty calming or regulating)
• The musculoskeletal system (torticollis, body tension, abnormal movement patterns)
• The oral-motor system (especially in cases of tethered oral tissues or poor latch)

When these systems are under stress or not functioning in sync, the baby will likely be showing difficulty in performing regular functions, causing them to be uncomfortable. All babies express their discomfort differently, but this can lead to stressful symptoms such as crying, fussing, gassiness, constipation, reflux, and vomiting, leading to abnormal posturing and gross motor delays due to these adverse symptoms.

What Infant Pelvic Floor Dysfunction Looks Like
Pelvic floor issues in babies don’t always look like they do in adults. Instead, rehab providers may notice:

• Chronic straining to poop or lack of bowel movement coordination
• Irregular bowel habits, bloating, and gas
• Body tension that affects feeding or limits comfortable tummy time
• Shallow or inefficient breathing patterns
• Arching or clenching behaviors in response to gas or discomfort
• Difficulty tolerating changes in position or touch

These signs are often dismissed as “just colic” or “something they’ll grow out of,” but we know that targeted therapy can make a significant difference—not just in comfort, but in functional development.

The Role of Rehab Providers: PTs and OTs Working Together
Both physical therapists and occupational therapists play essential roles in assessing and treating infant pelvic floor dysfunction.

Physical therapists focus on:

• Core and pelvic floor coordination
• Alignment and tension patterns affecting bowel/bladder mechanics
• Breathing mechanics and diaphragm coordination
• Tummy time, head shape, and early motor development

Occupational therapists bring expertise in:

• Feeding and oral-motor function
• Sensory integration, especially around elimination and body awareness
• Nervous system regulation and co-regulation strategies for parents
• Positioning to support optimal arousal and digestion

Together, this integrative approach addresses the whole baby, not just their symptoms.

Why This Matters: Long-Term Impacts Start Early
We’re not just aiming to reduce fussiness or help with pooping (although that’s often where we start!). We’re helping to lay the foundation for:

• Healthy bowel and bladder habits
• Confident motor skill development
• Positive body awareness and sensory processing
• Easier transitions to solids and potty training down the road

Early therapy can prevent compensatory patterns and teach families tools that make everyday care easier and more connected.

A Tool for Your Toolbox: Pediatric Pelvic Floor Play Skills
To help bridge the gap between pelvic health and pediatric development, we offer a class called Pediatric Pelvic Floor Play Skills. It’s designed for rehab professionals to learn specific play skills and actionable treatment techniques for each age group of the pediatric client, from the infant to the teen/tween.

For each age category we cover:

• Age-specific considerations, tips, and tricks
• Play-based strategies to support pelvic floor coordination for each age
• How to support pelvic health treatment
• Case studies and hands-on tools for both PTs and OTs
• Problem solving for more difficult cases and situations

If you're looking to expand your skill set, collaborate across disciplines, or just get more confident in treating your littlest patients - this class is for you. Join me next weekend on May 4th!

AUTHOR BIO
Mora Pluchino, PT, DPT, PRPC

Mora Pluchino, PT, DPT, PRPC (she/her) is a graduate of Stockton University with a BS in Biology (2007) and a Doctorate of Physical Therapy (2009). She has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. She began treating Pelvic Health patients in 2016 and now has experience treating pelvises and ages with a variety of Pelvic Health dysfunctions. There is not much she has not treated since beginning this journey, and she is always happy to further her education to better help her patients meet their goals.

Dr. Pluchino strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at present. In 2020, she opened her own practice called Practically Perfect Physical Therapy to help meet the needs of more clients. She has been a guest lecturer for Rutgers University's Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Sometimes as rehab providers, we find patients have deep posterior pain, or they have a “hitting something” sensation with intimacy. Maybe they have a deep pelvic ache or nerve sensation with sitting or passing bowels.

We know the deep structures all have the word “coccygeus” in them:  iliococcygeus, pubococcygeus, and coccygeus. We also know there are ligaments that attach to this coccyx (sacrospinous ligament and sacrotuberous ligament), creating a web of support in the posterior pelvis, which has very little bony structure. When we are treating someone with deep vaginal or deep posterior pelvic pain, do we really have to “go there” and treat the coccyx internally?

Did you know that actual spinal cord fibers enter the top of the sacral foramen, travel through this tunnel in the sacrum, and come out the bottom, where they fuse with the posterior coccygeal ligament on the dorsal surface of the coccyx? They can be a tremendous source of neural and pain dysfunction in the pelvis.

In addition, the gluteus maximus attaches at the coccyx, as well as attachments from a deep bowl of fascia, called the endopelvic fascia, that lines the pelvis. The endopelvic fascia is a tremendous source of support in the pelvis but is also often a pain generator. On top of this, the massive sacrotuberous and sacrospinous ligaments also attach at the sacrococcygeal junction.

In Sacral Nerve Manual Assessment and Treatment, scheduled for May 31 through June 1, we spend time addressing how to externally treat the deep structures that attach at the posterior pelvic floor and coccyx. We address ways to treat the incredibly dense sacrotuberous and sacrospinous ligaments that attach to the coccyx from the outside. All of the nerves that supply the posterior hip, glutes, and pelvic floor squeeze between the piriformis and the sacrospinous ligament. This site where these nerves, including the pudendal, sciatic, inferior gluteal, nerve to obturator internus, and posterior femoral cutaneous, can also be a common site of dysfunction and compression. We will learn how to decompress all of this in class, as well as the surrounding soft tissues.

So, coming back to our question. With all this soft tissue and ligament work that can be external, can we forego internal rectal work? Actually….no. Both are important. The best way to treat a side-bent coccyx or an excessively flexed coccyx is internally. However, the real magic is addressing the alignment interiorly and then addressing all the softer tissues (ligaments, fascia, skin, muscle) that keep pulling the bone back into its old bad habits and misalignment.

AUTHOR BIO:
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment and Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jenna Ross, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jenna Ross. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel