As a small business owner, I’m grateful to have weathered the COVID-19 storm. When reflecting on the 5 year anniversary of the shutdown, I remember how we adapted day after day — masking up, running air filtration systems, and feeling grateful that we could continue to do our work safely. Yet, despite prioritizing sleep, nourishing my body with fresh food, staying active, and hydrating well, I sometimes still feel myself carrying a lingering undercurrent of stress and tension in my physical body.

We have spent years holding our breath—both literally and figuratively. The weight of collective uncertainty, change, and grief may have left some imprints on our bodies. I was reminded of this when a sudden flare of lumbopelvic pain forced me to pay closer attention to my own breath patterns. It became clear that I needed to soften, to release layer by layer of held tension, and to deepen my own breathwork and meditation practice.

As healthcare providers, our work extends beyond addressing physical concerns. We are honored to hold space for our patients' grief—whether it stems from physical trauma, medical challenges, gaslighting, or life's hardships.

They trust us, not just for guidance on optimizing their pelvic health, but as guides on their healing journeys. And yet, we too are human. We experience burnout, fatigue, and emotional strain.

We often teach our patients that breath is a bridge—connecting the nervous system, digestion, spine, pelvic floor, and our emotional state. It is one of the most powerful tools we have to remind the body that it is safe. And yet, even with this knowledge, we may find ourselves unconsciously holding our breath because we are humans living in this unpredictable and sometimes challenging world. When we resist feeling something, we don’t breathe. When we are afraid, we hold tension in our ribs. Even in moments when we think we are relaxed, we can sometimes still be bracing our jaw, back, or pelvic floor.

Let’s take a moment to pause.

Notice your body. Try not to make any adjustments to “fix” your posture.

• Where is your ribcage in relation to your pelvic floor?
• Does the breath feel deep or shallow, smooth, or restricted?
• Where do you sense movement—your chest, ribs, belly?
• What temperature is the air as it enters your nose?

What does it feel like to exhale?

• Does your breath release with ease or feel held back?
• Can you soften just a little more with each out-breath?
• Notice if there is a natural pause before your next inhale—what does that moment of stillness feel like?

If you're sitting, allow yourself to slouch for a moment.

• How does your breath feel in this position?
• Is it shallow or restricted?
• Now, gently imagine your head and spine being drawn upward, as if a magnet is lifting you toward the ceiling. Take another breath. Does it feel different? Notice any shifts in ease of expansion or softening more fully after the exhale.

Now, let’s zoom into the intercostal spaces.

• Imagine this space expanding with each inhale and softening with each exhale.
• Can you soften any more in your ribcage?
• Picture your shoulders softening, warm water is dripping down the upper trap and down the arms.
• Let your jaw unclench, your tongue relax, the space between your eyebrows melt.

Take another long, conscious breath.

• What do you notice?
• Does your body feel a little softer, a little more open, or is there still a place holding tension, waiting for a little more attention?

As practitioners, we give so much to others all day long and sometimes forget to remember to check in with ourselves. Staying connected to our own breath and body serves us just as much as it serves our patients. When we remain grounded and at ease, we can reduce fatigue, physical discomfort, and emotional exhaustion.

So, let’s remind ourselves—throughout the day—to take long easy breaths, soften our jaws, and allow our bodies to move with greater ease. It is not only a gift to ourselves to prevent burn out, but also helps us facilitate co-regulation with our patients’ nervous systems.

If you enjoyed this article, then join Dustienne in her upcoming remote course Yoga for Pelvic Health, on May 3-4, 2025. This two-day remote course offers participants an evidence-based perspective on the value of yoga for patients with chronic pelvic pain and focuses on two of the eight limbs of Patanjali’s eight-fold path: pranayama (breathing) and asana (postures) and how they can be applied for patients who have hip, back and pelvic pain. The course will describe the role of yoga within the medical model, discuss contraindicated postures, and explain how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge.

AUTHOR BIO
Dustienne Miller PT, MS, WCS, CYT

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

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

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

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

In a recent article entitled “The Effectiveness of Pelvic Floor Muscle Training in Men After Radical Prostatectomy Measured with the Insert Test,” published in the International Journal of Environmental Research and Public Health in March of 2022, the use of surface EMG biofeedback (sEMG) was one of three cohorts for men with post-operative incontinence. While all participants improved in control over micturition, the cohort of men in the group using sEMG biofeedback had the best results post-treatment./p>

So, what is it about biofeedback that improves control in patients with pelvic floor muscle dysfunction?
Biofeedback provides visual and auditory feedback of muscle activity. It is a non-invasive technique that teaches patients how to adjust muscle function, strength, and behaviors to improve pelvic floor function. The small electrical signal (EMG) provides information about an unconscious process. It is presented visually on a computer screen, giving the patient immediate knowledge of muscle function and enabling the patient to learn how to alter the physiological process through verbal and visual cues.

Kaufman states, “Without full knowledge of the use of the sEMG biofeedback equipment, many providers may miss important components to treatment.” For example, patients may inadvertently hold pelvic muscles in a chronic state of tension in an effort to avoid leakage, reducing the range of muscle excursion available for proper muscle contraction and control. Additionally, poor pelvic floor isolation can compound symptoms of incontinence when larger muscle groups such as the abdominals are co-contracting, reducing the effectiveness of the pelvic floor effort.

Importantly, biofeedback gives the skilled clinician the opportunity to evaluate proper muscle function in all three positions: supine, sitting and standing. According to Lee, “You will typically see the muscle dysfunction in the standing posture, which is not typically assessed in manual treatment.” Furthermore, in supine the muscle may not have dysfunctions and the provider will miss what happens when position is altered, and gravity negatively influences the muscle contraction.

Kaufman adds, “The only true way to determine muscle tone is through the use of sEMG biofeedback.” Manual skills alone may falsely indicate there is no muscle excursion with palpation when, in fact, the use of sEMG biofeedback reveals the presence of high tone in the pelvic muscles at rest. By restoring normal muscle resting tone the patient gains more muscle excursion and is better able to utilize and feel the muscle contract.

Case Study Example

The patient is a 63-year-old computer specialist who underwent radical prostatectomy three years ago due to prostate cancer. He has been relocated for work twice in that time and has seen two pelvic floor therapists during that period who worked exclusively with manual internal and external muscle techniques. Finally, he was referred to a biofeedback board-certified therapist who did a supine, sitting, and standing muscle assessment using two-channel sEMG biofeedback: one channel was for a rectal sensor, and the other monitored the obliques.

The "before" graph is a supine, sitting, and standing assessment. The patient is asked to perform three quick contractions, followed by a 10-second hold in each position. In the supine position, the patient demonstrated good muscle resting tone, endurance, and isolation, but once in sitting, he began to demonstrate poor pelvic floor muscle endurance, poor isolation, and higher resting tone. In standing, his pelvic floor muscle was completely overpowered by his obliques and rectus abdominis, and he had very limited pelvic muscle endurance and poor resting tone. His frustration with lack of bladder control led to withholding fluids (making symptoms worse).

Once the patient was instructed in techniques to restore normal pelvic floor muscle tone and isolated contractions using sEMG biofeedback, he began to note improved control over bladder function, and after eight visits, he was discharged from care, having achieved all treatment goals. In his "after" graph, he exhibited good muscle tone, endurance, and isolation, and did not have his abdominals overpowering his pelvic floor. He also consumed adequate water intake again but without negative effects on bladder control. He no longer needed protective undergarments.

Conclusion
A long history of scientific evidence supports using sEMG biofeedback in managing incontinence or pain symptoms. As a noninvasive, cost-effective, and powerful treatment modality, healthcare providers should consider this tool when managing pelvic floor dysfunction. Providers should be educated in adequately using this valuable modality to gain the most out of the skills and knowledge achieved through this intervention. For more information regarding courses and certification, please visit www.pelvicfloorbiofeedback.com.

Biofeedback for Pelvic Muscle Dysfunction, a self-hosted lab course scheduled for May 4, 2025, is led by Instructors Kaufman and Lee who introduce participants to the use of biofeedback when treating bladder, bowel, and pelvic floor disorders. In this course, participants learn about surface EMG biofeedback by using the equipment on themselves to experience dynamic muscle assessment in supine, sitting, and standing positions. This dynamic course also includes behavioral strategies for relearning proper muscle control for improved pelvic floor function.

Instructors Kaufman and Lee have over fifty years of combined experience using this amazing clinical tool. This treatment approach uses sEMG biofeedback to visualize muscle dysfunction, then allows for proper training and education to re-establish proper muscle movement patterns, enabling patients to gain control over function and realize they can succeed in improving symptoms. Lee adds, “Patients are constantly validating the usefulness of this modality by reaping the benefits of skilled training and behavior modification strategies.”

References:

1. Cram, J. R., & Kasman, G. S. (2011). The basics of surface electromyography. In E. Criswell (Ed.). Cram’s introduction to surface electromyography (2nd ed., pp. 3–7). Jones and Bartlett
2. Kaufman, J., Stanton, K., & Lee, T. E. (2021). Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Biofeedback, 49(3), 71-76.
3. Shelly, Beth & Kaufman, Jane (2023). Foundations of Pelvic Floor Muscle Assessment Using Surface Electromyography. APTA Academy of Pelvic Health Physical Therapy.
4. Szczygielska D, Knapik A, Pop T, Rottermund J, Saulicz E. (2022). The Effectiveness of Pelvic Floor Muscle Training in Men after Radical Prostatectomy Measured with the Insert Test. Int J Environ Res Public Health. 2022 Mar 2;19(5):2890. doi: 10.3390/ijerph19052890. PMID: 35270582; PMCID: PMC8910379.

AUTHOR BIO
Tiffany Lee, OTR, OTD, MA, BCB-PMD, PRPC

Tiffany Lee holds a BS in OT from UTMB Galveston (1996), an MA in Health Services Management, and a post-professional OTD from Texas Tech University Health Sciences Center. In 2004, she received her board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance. She is a Herman and Wallace Pelvic Rehab Institute faculty member and teaches biofeedback courses. She has been treating pelvic health patients for 25 out of her 30-year career. Her private practice in San Marcos, Texas, is exclusively dedicated to treating urinary and fecal incontinence and pelvic floor disorders. Her continuing education company, Biofeedback Training & Incontinence Solutions, offers clinical consultation and training workshops. She also enjoys mentoring healthcare professionals working toward their BCIA certification.

As rehabilitation professionals, we must ask ourselves: Are we fully educating our patients on all available rehab techniques beyond just Kegels? Here’s an evidence-based overview of penile rehabilitation following radical prostatectomy, emphasizing the importance of a comprehensive approach to restore erectile function and maintain overall penile health.

Understanding Penile Rehabilitation
Penile rehabilitation focuses on enhancing blood flow to the penis after radical prostatectomy (removal of the prostate). Even with nerve-sparing techniques, the cavernous nerves—essential for erections—can sustain trauma. This injury, known as neuropraxia, may require up to two years to recover from, potentially leading to temporary or prolonged changes in erectile function.

Why Rehabilitation Is Critical

• Preservation of Function: Rehabilitation helps sustain blood flow and minimizes the risk of venous leakage, where the veins fail to maintain blood within the penis.
• Preventing penile atrophy: The "use it or lose it" principle is fundamental in penile rehabilitation.
• Prevention of Fibrosis: Consistent treatment can reduce the formation of scar tissue (fibrosis), which may otherwise contribute to conditions such as Peyronie’s disease.
• Maintenance of Penile Length: Emerging evidence suggests that a well-structured rehabilitation program may help restore or maintain penile length, which is compromised after surgery.

Key Rehabilitation Techniques

1. Mechanical Devices:
   • Penile Pump/Vacuum Device: Utilizes negative pressure to draw blood into the penis, assisting in achieving an erection.
2. Medications:
   • Intracavernosal Injections: Direct injection of medications like Trimix or Caverject into the penis to induce an erection.
   • Low-Dose PDE5 Inhibitors: Daily administration of drugs such as Viagra or Cialis is used to enhance blood flow and protect the endothelial cells lining blood vessels. It’s important to note that these drugs depend on functional erectile nerves to produce an erection, so their role is primarily to provide vascular support.
3. Sexual Activity:
   • Regular Arousal and Orgasm: Encouraging regular sexual activity, whether through masturbation or with a partner, is beneficial. Even without an erection, achieving orgasm (which will be dry post-surgery due to the removal of the prostate and seminal vesicles) can significantly improve blood flow.
4. Pelvic Floor Exercises:
   • Strengthening Muscles: Targeting the pelvic floor muscles can enhance blood flow and support neural arousal signals, contributing to improved erectile function.
5. Cardiovascular Exercise:
   • Overall Circulation: Regular cardiovascular workouts are crucial for heart health and circulation, which in turn supports erectile health.

Remember, as rehab professionals, education is our most important treatment. Educate patients on all the available options they can be utilizing.

Final Considerations for Providers
While these strategies show considerable promise, recovery is a gradual process, and patient outcomes may vary. It is essential to have open, detailed discussions with patients about these options. Tailoring a rehabilitation program that addresses each individual’s needs and recovery trajectory can significantly impact both their sexual function and overall vascular health after prostate surgery.

By expanding our education and ensuring our patients are well-informed about all available rehabilitation options, we can optimize recovery and improve long-term outcomes.

If you would like to learn more about this topic and other topics in sexual medicine, then join Tara Sullivan in Sexual Medicine in Pelvic Rehab on May 3-4, 2025. This course provides thorough introduction to pelvic floor sexual function, dysfunction and treatment interventions for males and females of all sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Mechanical Devices (Penile Pump/Vacuum Devices)

Medications: Intracavernosal Injections and PDE5 Inhibitors (also relevant to sexual activity)

Burnett, A. L., Nehra, A., Breau, R. H., Culkin, D. J., Faraday, M. M., Hakim, L. S., Heidelbaugh, J., Khera, M., McVary, K. T., Miner, M. M., … & Shindel, A. W. (2018). Erectile dysfunction: AUA guideline. The Journal of Urology, 200(6), 633–641. https://doi.org/10.1097/JU.0000000000000626

Sexual Activity (Regular Arousal and Orgasm): This concept is also emphasized in the AUA guideline above, which supports the role of ongoing sexual activity in penile rehabilitation.

Burnett, A. L., Nehra, A., Breau, R. H., Culkin, D. J., Faraday, M. M., Hakim, L. S., Heidelbaugh, J., Khera, M., McVary, K. T., Miner, M. M., … & Shindel, A. W. (2018). Erectile dysfunction: AUA guideline. The Journal of Urology, 200(6), 633–641. https://doi.org/10.1097/JU.0000000000000626

Pelvic Floor Exercises

Cardiovascular Exercise (Physical Activity)

Silva, A. B., Sousa, N., Azevedo, L. F., & Martins, C. (2017). Physical activity and exercise for erectile dysfunction: Systematic review and meta-analysis. British Journal of Sports Medicine, 51(20), 1419–1424. https://doi.org/10.1136/bjsports-2016-096418

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 Masters 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 & Wallace, teaching continuing education courses for rehab therapists and other healthcare providers interested in the pelvic health specialty, including a course she authored - Sexual Medicine in Pelvic Rehab, and co-authored 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.

“The times they are a-changin,” Bob Dylan once sang.(1) Dylan’s song may have been from 1964, but the lyrics can be applied to the present day. Very recently, the world, and the United States in particular, has seen rapid changes in political landscapes.

For instance, America has seen an increase in anti-transgender legislation over the last several years, but also in the past few weeks and months. Many of these laws seek to ban gender-affirming care for transgender, gender non-conforming, and non-binary people, youth in particular., Another bill was introduced just 1 week prior to this post that would make it illegal to identify as transgender on legal documents in Texas, calling it “gender identity fraud,” and carrying with it potential felony charges and jail-time.(2)

What many don’t know is that in addition to charges like the one above, many of these bills also contain exceptions that allow for non-consensual surgeries to be performed on intersex infants and children. The Human Rights Watch states that these procedures on intersex children “are justified by decision-makers on the grounds that they will reduce stigma and prevent gender dysphoria, but they often have the opposite effect and also carry risks of scarring, loss of sensation, lifelong sexual dysfunction, urinary incontinence, psychological trauma, and permanent sterilization.”(3)

For example, in January 2025, an Executive Order from the United States government stated that it would “not fund, sponsor, promote, assist, or support” gender-affirming care for children under the age of 19 “and it will rigorously enforce all laws that prohibit or limit” gender-affirming procedures and treatments.(4) Many American hospitals immediately paused surgical and hormonal gender-affirming treatments for patients under the age of 19 following the order.(5) However, it was found by March 2025 that despite gender-affirming surgeries being paused, non-consensual surgeries were allowed to continue and were still being performed on Intersex infants and children during that time. These non-consensual Intersex procedures were performed by many of the same providers at hospitals who had stopped performing the gender-affirming procedures.(6)

On January 16, 2025, the United States Department of Health & Human Services released the Advancing Health Equity for Intersex Individuals report. This report affirmed the rights of Intersex people to bodily autonomy and informed consent, mentioned health equity barriers for Intersex people, and said that “health care providers and parents can work together to decide that it is in the best interest of the child to delay any non-emergent medical interventions until an intersex child is old enough to be involved in the decision-making about their sexual and reproductive health.”(7) InterACT Advocates for Intersex Youth, called the HHS report, “a victory for the right of intersex children to make their own choices about their own bodies.”(8)

Just days after the release of the HHS report, new government Executive Orders were issued that redefined words like “male,” “female,” “woman,” “man,” and “sex.”(9) This order was intended to impact the transgender and gender diverse communities. However, these Executive Orders impact the Intersex community, as well, as Intersex people can have any gender identity. InterACT says that “many grow up with a gender identity that does not align with their assigned sex at birth – meaning that there is overlap among transgender and intersex communities.”(10) These orders impact cisgender Intersex people, as well. According to InterACT, as “a woman with Complete Androgen Insensitivity (CAIS) may be assigned female at birth, and identify as a woman all her life, while having internal testes – yet the Order would define her sex by her gonads and the reproductive cells they produce.”(10)

***It’s important to note that with the introduction of the new Executive Order, the HHS report has been removed from the HHS and other government websites. InterACT saved the HHS report, and it is accessible on InterACT’s website at this time.***

As laws, reports, and orders are quickly shifting, the healthcare world is rapidly transforming with it. We may not know what local, national, or global changes are on the horizon for the world of politics, the world of healthcare, or the world in general. But one thing that we do know is that healthcare providers need to continue to be advocates for and continue to provide the best evidence-based healthcare to all of our patients, including those who are intersex or transgender.

To learn more about how to be an ally in healthcare and provide better evidence-based care to intersex folx, come take Intersex Patients: Rehab & Inclusive Care with me on May 3, 2025!

Resources

1. Dylan, B. (1964). The Times They Are A-Changin [Album]. Columbia Records.
2. Yurcaba, J. (2025, March 10). Texas Bill Would Make Identifying as Transgender a Felony Punishable By Jail. NBC News. https://www.nbcnews.com/nbc-out/out-politics-and-policy/texas-bill-identify-transgender-state-felony-rcna195642.
3. Human Rights Watch. (2022, October 26). S. Anti-Trans Bills Also Harm Intersex Children. https://www.hrw.org/news/2022/10/26/us-anti-trans-bills-also-harm-intersex-children.
4. The White House. (2025, January 28). Protecting Children from Chemical and Surgical Mutilation. https://www.whitehouse.gov/presidential-actions/2025/01/protecting-children-from-chemical-and-surgical-mutilation/.
5. Betts, A. (2025, February 3). U.S. Hospitals Suspend Healthcare for Transgender Youth After Trump Order. The Guardian. https://www.theguardian.com/us-news/2025/feb/03/trans-youth-healthcare-hospitals-trump.
6. Rodriguez, B., & Sosin, K. (2025, March 10). Hospitals that Paused Youth Gender-Affirming Care Continued Controversial Intersex Surgeries, Group Says. The 19^th*. https://19thnews.org/2025/03/hospitals-intersex-surgery-gender-affirming-care-youth/.
7. S. Department of Health & Human Services Office of the Assistant Secretary for Health. (2025, January 16). Advancing Health Equity for Intersex Individuals. InterACT Advocates for Intersex Youth. https://interactadvocates.org/wp-content/uploads/2025/01/intersex-health-equity-report.pdf.
8. (2025, January 16). Intersex Health Equity Report. https://interactadvocates.org/hhs-supports-bodily-autonomy/.
9. United States Presidential Actions. (2025, January 20). Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government Executive Order. https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/.
10. InterACT Advocates for Intersex Youth. (2025, January 21). Trump’s Executive Order Ignores Science to Push Discriminatory Agenda. https://interactadvocates.org/trumps-executive-order-ignores-science-to-push-discriminatory-agenda/.

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

Molly O’Brien-Horn, PT DPT, CLT, PCES graduated from Rutgers School of Biomedical & Health Sciences (formerly the University of Medicine & Dentistry of New Jersey) with her Doctor of Physical Therapy degree. She is a Pelvic Health Physical Therapist, a Certified Lymphedema Therapist and an LSVT BIG Parkinson’s Disease Certified Therapist. Molly is also a sex counselor, a trained childbirth doula, and a trained postpartum doula. Molly is a member of the American Physical Therapy Association Academy of Pelvic Health Physical Therapy and is also a Teaching Assistant with the Herman & Wallace Pelvic Rehabilitation Institute.

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

She also has experience in a variety of physical therapy settings over the years, including pediatric and adult oncology, school-based pediatrics, inpatient and intensive care unit hospital-based settings, skilled nursing facilities, outpatient and sports-based orthopedics, and wound care.

As of February 2025, 574 bills that restrict the rights of transgender people have been introduced in 48 states.¹ Many of these bills seek to limit the inclusion of transgender and nonbinary people, including limiting educational discussions (both anti-LGBTQ+ and gender-focused) and limitations on access to public places or services (e.g., bathrooms). Twenty-five states have now banned best practice medical and surgical treatments for transgender youth². More notably, in six of these states, providing some of these best practice treatments is now a felony².

These legislative actions directly contradict the clear positions of leading medical groups, including but not limited to the American Medical Association, the American Academy of Pediatrics, and the World Health Organization, all of which support access to gender-affirming care. The impact of these anti-transgender laws is devastating. Young transgender and nonbinary people living in these states with bans on gender-affirming care are suffering, with suicide attempts spiking by 7% to 72% over the prior year.³ Transgender adults are not immune to the effects of these regressive laws, as they are also experiencing increased rates of depression and anxiety.

Furthermore, while these laws are aimed at impacting transgender and gender diverse populations, they are negatively impacting intersex populations as well. Many of these laws restrict gender-affirming care for transgender, gender nonconforming, and nonbinary (TGD) people, but there are exceptions within these laws that allow non-consensual, non-medically necessary, usually genital-based, surgeries on intersex infants and children to continue. Per the Human Rights Watch, “These surgeries have been deemed human rights violations by the United Nations High Commissioner for Human Rights, the World Health Organization, and other authorities.”⁶

Not only are transgender laws impacting intersex youth, but recent government orders are as well. In  January 2025, the United States government released an executive order that redefined what the words “sex,” “male,” and “female” mean.⁷ InterACT Advocates for Intersex Youth issued a statement that this order “disrespects the complexity of gender by reducing it to the production of eggs and sperm, entirely fails to consider the existence of intersex people.”⁵

InterACT further mentions that even cisgender intersex folx may be impacted by this Executive Order stating “Notably, the Executive Order may invalidate a cisgender intersex person’s understanding of their own gender, too. A woman with Complete Androgen Insensitivity (CAIS) may be assigned female at birth, and identify as a woman all her life while having internal testes – yet the Order would define her sex by her gonads and the reproductive cells they produce.”⁵

Intersex folx historically have had their existence and identities erased, pathologized, and stigmatized. InterACT says that “All people, including young intersex and transgender people, deserve to be respected for who they are.”⁵ The remote course, Intersex Patients: Rehab and Inclusive Care led by Molly O'Brien-Horn, PT, DPT, CLT, addresses how to be an ally in healthcare to and how to provide better, intersex-affirming healthcare to Intersex folx. The next course offering is on May 3, 2025.

The American Civil Liberties Union (ACLU) published a research brief on the impacts of these laws and policies stating in part, “These anti-transgender laws are accomplishing exactly what they were designed to do, i.e. prevent youth from obtaining gender-affirming care, reduce gender-affirming care access for adults, prevent transgender and nonbinary people from using correct facilities or participating in sports, or censor education. These impacts are concerning enough; however, the collateral consequences of these laws are also devastating. A growing body of research indicates that these restrictive laws and the surrounding rhetoric are instilling fear, reducing safety, and increasing violence against LGBTQ+ people and their allies.“ Although it can seem frightening and daunting to step up and be an ally, it is what the world needs of all of us, especially in unprecedented times.

As access to vital care is being challenged, pelvic rehabilitation practitioners have a powerful role in supporting transgender, intersex, and gender diverse people. We can be thoughtful listeners to our patients’ stories, and we can use their chosen names and pronouns. If you’re someone new to chosen names and pronouns, be reassured that no one expects perfection from you when you start out. We all get better with practice. If you need a refresher, check out this simple refresher from the Gay, Lesbian & Straight Education Network. The Herman & Wallace course, Inclusive Care for Gender and Sexual Minorities instructed by Brianna Durand, is also an excellent starting point in learning up-to-date, in-depth knowledge of the various terminology while emphasizing clinical interactions, available research, and professional accountability.

When it comes to pelvic health interventions for trans people who have not had genital surgery, I often encourage clinicians to focus on the basics. The vast majority of pelvic health concerns improve with breathing activities, trunk coordination and strengthening, and mindfulness training. Feel empowered to reach out to rehabilitation forums or mentors for assistance in selecting or adjusting interventions. Also, know who the prescribing medical providers are in your community. Some patients need more testing than PTs and OTs can do.  Make yourself part of a strong team.

Clinicians who are ready to be leaders in gender-affirming rehabilitation can take additional training to better understand the nuances of surgery recoveries and interventions. The remote course, Transgender Health for the Rehab Professional: Genital Gender Affirming Surgery Considerations, led by Sandra Gallagher, PT, DPT, WCS and Ken McGee, PT, DPT is a great step. Typical coursework covers dilator progression after vaginoplasty, return to activity after gender-affirming surgery, and understanding the impacts of hormones on pelvic function. The next offering is on April 12, 2025.

If you are looking for more ways to get involved, consider joining the PT Proud Special Interest Group of the Academy of Leadership and Innovation. Protecting and advancing gender-affirming care requires advocacy outside the clinic. The current legislative climate might seem daunting, but the recent court rulings favoring bodily autonomy and the proliferation of shield law for healthcare workers providing gender-affirming care is heartening.

Each of us has the power to make a meaningful difference in the lives of transgender, intersex, and gender-diverse clients. Let’s commit to our ethical duty of justice—ensuring fair and equitable treatment for all, regardless of gender identity—and beneficence—promoting the well-being of every individual we serve.

References

1. 2025 Anti-Trans Bills: Trans legislation tracker. 2025 Anti-Trans Bills: Trans Legislation Tracker. Accessed February 22, 2025. https://translegislation.com/.
2. Bans on Best Practice Medical Care for Transgender Youth. Movement Advancement Project. February 2025. Accessed February 22, 2025. https://www.lgbtmap.org/equality-maps/healthcare_youth_medical_care_bans.
3. American Civil Liberties Union. (2024, September 11). The Impacts of Anti-Transgender Laws and Policies: Evidence from Empirical Research. https://www.aclu.org/publications/the-impacts-of-anti-transgender-laws-and-policies-evidence-from-empirical-
4. Lee WY, Hobbs JN, Hobaica S, DeChants JP, Price MN, Nath R. State-level anti-transgender laws increase past-year suicide attempts among transgender and non-binary young people in the USA. Nat Hum Behav. 2024;8(11):2096-2106.
5. InterACT Advocates for Intersex Youth. (2025, January 21). Trump’s Executive Order Ignores Science to Push Discriminatory Agenda. https://interactadvocates.org/trumps-executive-order-ignores-science-to-push-discriminatory-agenda/.
6. Human Rights Watch. (2022, October 26). S. Anti-Trans Bills Also Harm Intersex Children. https://www.hrw.org/news/2022/10/26/us-anti-trans-bills-also-harm-intersex-children.
7. United States Presidential Actions. (2025, January 20). Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government Executive Order. https://www.whitehouse.gov/presidential-actions/2025/01/defending-women-from-gender-ideology-extremism-and-restoring-biological-truth-to-the-federal-government/.

By taking a step BACK we can take a step FORWARD to assist individuals with eating disorders. Use your toolbox to build theirs.

Eating disorders are mental health conditions characterized by severe and persistent disturbance in eating behaviors with associated distressing thoughts and emotions that affect an individual’s physical, psychological, and social function. Eating disorders are serious mental illnesses with physical manifestations and serious and sometimes life-threatening medical complications.  Common eating disorders are Anorexia Nervosa (AN), Bulimia Nervosa (BN), Binge Eating Disorder (BED), Otherwise Specified Feeding and Eating Disorders (OSFED), and Avoidant Restrictive Food Intake Disorder (ARFID). Pica and Rumination Disorder are also included in the Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM TR).

Bowel, bladder, and pelvic dysfunction are common with individuals with eating disorders. Fertility and negative effects on both baby and birthing parent are also common.  Research is scant regarding pelvic rehabilitation interventions for this important group of individuals. More research is emerging, showing pelvic and gastrointestinal dysfunction with this population; however, pelvic-based rehabilitation has not been readily explored as an option for these individuals until last year.

Dr. Monica Williams, an Occupational Therapist, and colleagues from the ACUTE Center in Denver, Colorado published the first evidence of positive benefits from pelvic rehabilitation approaches with individuals with Anorexia Nervosa in May of 2024.  Williams et al.  performed a respective cohort study with 193 patients, which demonstrated positive effects in reducing pelvic symptomatology as indicated with improvements in the PFDI-20 (Pelvic Floor Distress Inventory) with one to only a few pelvic-focused sessions. Interventions utilized in this study were aimed at improving function of the pelvic floor musculature, including education, bladder habit retraining, pelvic floor stretches, and biofeedback.  This study is an excellent first step in demonstrating that interventions can be helpful even with limited treatment visits and intervention regions. The abdominal region was not a focus of this study.

Pelvic rehabilitation therapists have the skills to assist the patient with strategies to improve comfort and function with urinary, bowel, pelvic, and GI pain and dysfunction. We ALSO have skills to observe, ask questions, support, and advocate for our patients. We may be the first health care professionals who notice signs of an eating disorder or disordered eating. We may be the first to even ask questions to our patients. We can guide an individual to connect with helpful resources. We do NOT have to have all the answers… we just need to LISTEN, SUPPORT, and REFER OUT for additional support. We can also communicate with their permission to their health care providers to provide insight, awareness, and recommend the facilitation of a multidisciplinary team including a skilled mental wellness provider, dietician, and medical provider trained and skilled with individuals with eating disorders. We can also provide health care providers with resources about gaining more information and insight in assessment and treatment for those with suspected disordered eating or eating disorders. There are resources available for primary care providers from the Academy of Eating Disorders to assist with guidance for medical testing and recommendations for patients. (see reference below for downloadable booklet)

We, as pelvic health providers, do NOT treat eating disorders – rather, we provide support and advocate for patients, AND we are able to assist with improving function and comfort related to bowel, bladder, pelvic and gastrointestinal dysfunction and pain.  We can utilize the tools we have in our toolbox that we use in our treatments every day.

If we look at ALL individuals through the lens of a “whole package” as compared to a “pelvic box,” this will guide our treatment program…

What’s in YOUR toolbox?

Does an individual present with closed posturing and decreased excursion of the diaphragm? If so, we can work on this! We can provide chest openers, postural instruction, seated modification, costal mobility (caution with impaired bone density), breathing education, and practice. Alas, a way to allow the diaphragm to dance and move to massage the bowels and to stimulate our wonderful vagus nerve.

Does an individual present with urinary or bowel dysfunction or pelvic pain? We have tools to assist with relaxation  and re-education of pelvic floor through mindfulness, breathing, manual techniques (direct and indirect techniques), nerve gliding, modalities (heat, TENS, IFC, shockwave, dry needling, pelvic wands, vaginal trainers, etc), biofeedback (for awareness, relaxation and activation of abdominal wall and PF), anorectal balloon training,  stretching, positioning, pelvic retraining, toileting strategies, and the list goes on and on!

Does an individual present with abdominal wall dysfunction? We have tools to assist with this including (but not limited to) scar mobilization, colon massage, visceral techniques, soft tissue mobilization, fascial mobilization, strain and counterstain, nerve mobility and gliding, postural education, lymphatic stimulation, vagus nerve facilitation, modalities (heat, IFC, TENS), biofeedback on commode for effective evacuation strategies. You may have other helpful tools in your toolbox – use them!

Does an individual  have pelvic girdle or low back pain?  We have tools to assist the patient with stretching, manual soft tissue mobilization, myofascial techniques, muscle energy, education, strengthening, postural modification, taping, bracing, etc.

In summary, let’s look at all of our patients as a whole person – and a multifaceted individual. Please take the time to listen, observe, ask questions, advocate, and use YOUR TOOLS to assist building the individual’s own toolbox. Whatever you can provide these individuals to assist with bladder, pelvic, and GI/bowel dysfunction will provide additional comfort and relief. If you have the ability to pursue performing research in this area – please consider this need!

Please join me to expand your toolbox!

1. HWConnect 2025 in Seattle WA on March 28-30, 2025. I am a featured speaker on Sunday morning and will be speaking about “Eating Disorders and Disordered Eating: Putting the Pieces Together, and the Hope Pelvic Rehabilitation Can Provide.”
2. In my upcoming remote course, Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional scheduled for April 26 and 27.

References

1. American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), 5(5). https://doi.org/10.1176/appi.books.9780890425787 
2. Baenas, I., Etxandi, M., & Fernández-Aranda, F. (2023). Complicaciones médicas en anorexia y bulimia nerviosa. Medicina Clínica. https://doi.org/10.1016/j.medcli.2023.07.028 
3. Gibson, D., Watters, A., & Mehler, P. S. (2021). The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic? A systematic review. International Journal of Eating Disorders, 54(6), 1019–1054. https://doi.org/10.1002/eat.23553 
4. Guarda, A. (2023, February). What Are Eating Disorders? American Psychiatric Association. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders 
5. Inside Out Institute. (2013). DSM-5 Diagnostic criteria for Eating Disorders. https://insideoutinstitute.org.au/assets/dsm-5%20criteria.pdf 
6. Medical Care Standards Guide - Academy for Eating Disorders. (2021). Www.aedweb.org. https://www.aedweb.org/resources/publications/medical-care-standards 
7. Moore, C. A., & Bokor, B. R. (2023). Anorexia Nervosa. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459148/ 
8. National Institute of Mental Health. (2017, November). Eating disorders. Www.nimh.nih.gov. https://www.nimh.nih.gov/health/statistics/eating-disorders 
9. Ng, Q. X., Lim, Y. L., Loke, W., Chee, K. T., & Lim, D. Y. (2022). Females with Eating Disorders and Urinary Incontinence: A Psychoanalytic Perspective. International Journal of Environmental Research and Public Health, 19(8), 4874. https://doi.org/10.3390/ijerph19084874 
10. Şahmelikoğlu Onur, Ö., & Teksin, G. (2023). CLINICAL FEATURES OF WOMEN WITH GENITO-PELVIC PAIN, PENETRATION DISORDER AND DISORDERED EATING ATTITUDES: A CROSS SECTIONAL STUDY. Archives of Neuropsychiatry. https://doi.org/10.29399/npa.28313 
11. Williams, M., Blalock, D., Foster, M., Mehler, P. S., & Gibson, D. (2024). Pelvic Floor Dysfunction in People with Eating Disorders and the Acute Effect of Different Interventions – A Retrospective Cohort Study. Clinical and Experimental Obstetrics & Gynecology, 51(5). https://doi.org/10.31083/j.ceog5105116

AUTHOR BIO
Carole High Gross, PT, MS, DPT, PRPC

Carole High Gross, PT, MS, DPT, PRPC (she/her) earned her Doctorate of Physical Therapy from Arcadia University in 2015 and her Masters of Science in Physical Therapy in 1992 from Thomas Jefferson University. Carole earned her Pelvic Rehabilitation Practitioner Certification and enjoys working as a Pelvic Clinical Rehabilitation Specialist for Lehigh Valley Health Network. Carole serves as a Lead Teaching Assistant for the Herman and Wallace Pelvic Rehabilitation Institute for pelvic floor education courses. She is also an instructor with the Herman and Wallace Institute for Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole serves on the Pelvic Workgroup of the Ehlers-Danlos International Consortium. Carole has a special interest in working with individuals living with eating disorders and hypermobility throughout the pregnancy and postpartum journey. In addition, Carole enjoys working with all genders with pelvic, bowel, bladder, and abdominal issues. Carole is passionate about lifelong learning. She resides in Bucks County, Pennsylvania, and enjoys spending time with her family and pups.

Regular exercise during pregnancy offers health benefits to both the mother and baby. However, existing evidence suggests that despite being beneficial, the current recommendations of exercise are not being met by many women during pregnancy (Downs 2003, Rebelle 2022). A reason for this could be a lack of guidance. A study by Nascimento showed that less than half of women receive exercise guidance during prenatal care meetings, and nearly half of exercising women stop their participation in exercise during pregnancy.

The American College of Obstetricians and Gynecologists (ACOG) Guidelines of 1985 are still commonly recommended to patients with a hard cut-off of 15 minutes of exercise and a heart rate of 140. However, there has been a significant shift in the mindset of professionals advocating for continued exercise in pregnancy. A hard cut-off for heart rate is difficult to adhere to as maternal heart rate and cardiac output both increase in pregnancy (Tan 2013), and in 2020 the ACOG updated its Guidelines to recommend using both the BORG RPE scale and maternal heart rate. Exercise intensity should be perceived as fairly light to somewhat hard on the Borg Rating of Perceived Exertion (RPE) scale, which ranges from 0 (which is no exertion) to 20 (which is maximal exertion). An easy and practical way to monitor intensity is with the Talk Test.

The current ACOG recommendations encourage 150 minutes of moderate aerobic activity per week during pregnancy and allow for prior levels of physical activity to be continued with OB approval in the absence of medical complications and contraindications. Those initiating exercise in pregnancy need to start slowly with 5 minutes of activity per day and increase slowly by 5 minutes weekly until they are able to exercise 30 minutes per day. Contact sports, activities that may carry a risk of falling or cause the body to become overheated, skydiving, scuba diving, and activities at over 6000 feet are not encouraged during pregnancy (Gascoigne 2023, ACOG 804 opinion).

Running is one way of maintaining exercise during pregnancy, however, many runners discontinue running during pregnancy. In one study, it was found that half the participants who ran before pregnancy reported stopping during pregnancy. During a 2022 study, pregnant runners shared reasons they stopped running, including nausea, fatigue, fear of miscarriage, anxiety, nervousness, and fear. Other factors included discomfort related to baby size and position, along with symptoms of pelvic floor dysfunction (James 2022). Current data suggests that the benefits of regular physical activity in an uncomplicated pregnancy include the possibility of increased uteroplacental blood flow at rest (Clapp 2006), a positive effect on the fetus’s autonomic cardiac regulation (Son 2020), a reduction in the risk of postpartum depression (Vargas- Terrones 2019), and a positive influence on neuro and language development in the first 18 months of age (Nino Cruz 2018).

Gait biomechanics change significantly in pregnancy with a wider step width, reduced hip flexion and extension, decreased stride length, and reduced trunk ROM commonly observed. A lot of these changes are thought to be in response to changes in the center of mass/center of gravity and to maintain balance. Increased ankle stiffness is also noted but is thought to actually have beneficial effects on balance during pregnancy (Conder 2019). Not a lot of research has been conducted on the actual kinematics exhibited by pregnant runners, however, there was a recent study that showed pregnant runners not only run slower but also have decreased trunk and pelvic rotation with increased activation of the Gluteal muscles (Bagwell 2024).

When treating pregnant runners, it may be necessary to make changes to speed (decrease), cadence (increase), and trunk lean in order to continue running. Gluteal muscle function during running is especially important in the pregnant runner. There is evidence that in pregnancy, there is an increase in foot width, shoe size, and dynamic overpronation of the feet (Segal 2010, Segal 2023, Heronemus 2020, Ramachandra 2016). In light of these changes, it is very important to consider new footwear. Other changes to allow continued running include wearing suitable abdominal support garments, braces, and good breast support, especially in the second and third trimesters. Pelvic support may also be necessary and could either be internal (pessary) or external in terms of compression/pelvic support garments.

Some pregnant runners may have pelvic symptoms (incontinence, pressure, heaviness, etc.) and other factors that do not permit them to continue running through pregnancy, but pelvic therapists can do a lot to encourage and support a patient who is pregnant and wants to continue running. Pelvic therapists can not only do a pelvic floor assessment at an appropriate time but can also perform a running form assessment, hip/knee/trunk muscle strength/mobility/kinematic assessment, and offer support via braces, pressure garments, and proper footwear recommendations.

If this topic interests you, then consider signing up for The Runner and Pelvic Health on April 12th. This is a beginner-level, one-day remote course designed to expand the participants’ knowledge of the pelvic floor with running athletes. Through lecture and labs by video and participation, participants will learn what normal and abnormal running mechanics are and how the muscles work simultaneously during running. This course includes advanced assessments to help diagnose the reason for movement dysfunction and is applicable for patients who present with pelvic pain, incontinence, constipation, prolapse, postpartum, and lumbar pain.

References

1. Rebelle, Christiana & Jette, Shannon & Mills, John & Tinius, Rachel. (2022). Physical Activity Beliefs and Behaviors during Pregnancy and their Association with Provider Counseling among Women in the Southern United States. Physical Activity and Health. 6. 287. 10.5334/paah.210.
2. Symons Downs D, Hausenblas HA. Women's exercise beliefs and behaviors during their pregnancy and postpartum. J Midwifery Womens Health. 2004 Mar-Apr;49(2):138-44. doi: 10.1016/j.jmwh.2003.11.009. PMID: 15010667.
3. James, Megan & Moore, Isabel & Donnelly, Grainne & Brockwell, Emma & Perkins, Joanna & Coltman, Celeste. (2022). Running During Pregnancy and Postpartum, Part A: Why Do Women Stop Running During Pregnancy and Not Return to Running in the Postpartum Period? Journal of Women's Health Physical Therapy. Publish Ahead of Print. 10.1097/JWH.0000000000000228.
4. Physical Activity and Exercise During Pregnancy and the Postpartum Period: ACOG Committee Opinion, Number 804. Obstet Gynecol. 2020 Apr;135(4):e178-e188. doi: 10.1097/AOG.0000000000003772. PMID: 32217980.
5. Gascoigne, Emily L. et al. Physical activity and pregnancy outcomes: An expert review American Journal of Obstetrics & Gynecology MFM, January 2023, Volume 5, Issue 1, 100758
6. Tan EK, Tan EL. Alterations in physiology and anatomy during pregnancy. Best Pract Res Clin Obstet Gynaecol. 2013;27:791–802. doi: 10.1016/j.bpobgyn.2013.08.001.
7. Nascimento SL, Surita FG, Godoy AC, Kasawara KT, Morais SS. Physical Activity Patterns and Factors Related to Exercise during Pregnancy: A Cross-Sectional Study. PLoS One. 2015 Jun 17;10(6):e0128953. doi: 10.1371/journal.pone.0128953. Erratum in: PLoS One. 2015 Jul 15;10(7):e0133564. doi: 10.1371/journal.pone.0133564. PMID: 26083416; PMCID: PMC4470997.
8. Conder R, Zamani R, Akrami M. The Biomechanics of Pregnancy: A Systematic Review. J Funct Morphol Kinesiol. 2019 Dec 2;4(4):72. doi: 10.3390/jfmk4040072. PMID: 33467386; PMCID: PMC7739277.
9. ACOG Physical activity and exercise during pregnancy and the postpartum period. Obstet Gynecol. 2020;135:e178–88. doi: 10.1097/AOG.0000000000003772
10. Heronemus MJ, Rabe K, Tolstykh I, Gross KD, Wise BL, Nevitt MC, Lewis CE, Hillstrom HJ, Segal NA; MOST Study Group. The Association of Parity with Greater Dynamic Pronation of the Feet. PM R. 2021 Feb;13(2):144-152. doi: 10.1002/pmrj.12381. Epub 2020 May 11. PMID: 32281293; PMCID: PMC7554144.
11. Segal N, Eagles MS. The effects of pregnancy on shoe size and knee laxity. Am J Phys Med Rehabil 2010; 89:S41.
12. Rabe KG, Segal NA, Waheed S, Anderson DD. The Effect of Arch Drop on Tibial Rotation and Tibiofemoral Contact Stress in Postpartum Women. PM R 2018; 10(11):1137–1144.
13. Segal NA, Boyer ER, Teran-Yengle P, Glass NA, Hillstrom HJ, Yack HJ. Pregnancy leads to lasting changes in foot structure. Am J Phys Med Rehabil 2013; 92(3):232–240.
14. Ramachandra, Preetha & Kumar, Pratap & Kamath, Asha & Maiya, Arun. (2016). Do Structural Changes of the Foot Influence Plantar Pressure Patterns During Various Stages of Pregnancy and Postpartum? Foot & ankle specialist. 10. 1938640016685150. 10.1177/1938640016685150
15. Clapp JF. Influence of endurance exercise and diet on human placental development and fetal growth. Placenta. 2006. Jun‐Jul;27(6‐7):527‐34.
16. Son JS, Zhao L, Chen Y, et al. Maternal exercise via exerkine apelin enhances brown adipogenesis and prevents metabolic dysfunction in offspring mice. Sci Adv. 2020;6(16).
17. Niño Cruz GI, Ramirez Varela A, da Silva ICM, Hallal PC, Santos IS. Physical activity during pregnancy and offspring neurodevelopment: A systematic review. Paediatr Perinat Epidemiol. 2018. 32(4):369‐79
18. Vargas‐Terrones M, Barakat R, Santacruz B, Fernandez‐Buhigas I, Mottola MF. Physical exercise programme during pregnancy decreases perinatal depression risk: a randomised controlled trial. Br J Sports Med. 2019. 53(6):348‐53.

AUTHOR BIO
Aparna Rajagopal, PT, MHS, WCS, PRPC, CAPP-OB-Certified

Aparna Rajagopal PT, MHS, WCS, PRPC, Capp -OB Certified (she/her) holds a Bachelor of Science degree in Physical Therapy from India and a Master of Health Sciences from the University of Indianapolis. She developed a growing interest in treating pregnant and postpartum patients in 2003. The birth of her daughter in 2006 served as the driving force behind her passion for the field of pelvic dysfunction. She treats men, women, and children with urological, gynecological, and colorectal issues. Her work with female athletes led her to realize the importance of correct breathing techniques in rehabilitation and led her to co-author the breathing and diaphragm class.

She serves as lead therapist for the pelvic dysfunction program at Henry Ford Macomb Hospital, where she mentors and teaches other pelvic therapists. She is a consultant for the hospital's Sports Therapy team for the athletic triad syndrome. She frequently presents and educates physicians, residents, physical therapists, and community support groups on physical therapy treatment for pelvic floor dysfunction. She serves as co-chair of the continuing education committee at her hospital system, where she helps to write and develop courses.

One of my favorite things as the instructor of the Menopause Transitions course is when participants ask questions. Whether it is something about their own menopause journey or when a patient is struggling with symptoms, it thrills me to provide resources and clarity to help them make informed decisions.

The following are some of the questions that have come up in class or that have been brought to my attention via email after participants are back in the clinic:

Given the many benefits of hormone therapy, should every patient take it during or after perimenopause for the prevention of chronic disease?
This is an excellent question! Based on recommendations from The Menopause Society, hormone therapy is approved for the treatment of vasomotor symptoms, genitourinary symptoms, and the prevention of osteoporosis.

Hormones are often lauded as a benefit for reducing both heart disease and dementia. While it has shown some benefit for heart disease, it is not recommended as a preventative treatment. The same holds true for prevention of neurodegenerative disease. The research on the benefits of hormones in cardiovascular and neurodegenerative disease reductions is often looking a different outcomes.

Each study may use a different type of estrogen. An oral estrogen blend (Premarin), an estradiol patch, and an oral estradiol can all have different effects on the body. You simply cannot extrapolate data from one study to the next if the type of estrogen studied was different. In addition, some research shows no benefit. Based on the current data, hormones are not a slam dunk for the prevention of heart disease and dementia. More studies with the types of hormones that are currently being prescribed are needed before recommending them as prevention.

Hormone therapy is very effective for improving bone density. Osteoporosis is a painless process of bone loss. If a person is not experiencing hot flashes and is concerned about their risk for osteoporosis, they could opt for a DEXA scan and then make an informed decision with their provider regarding hormone therapy.

Is there a dose of estrogen that is more beneficial for treating osteoporosis?
In the 2021 position statement for the management of osteoporosis, the Menopause Society cites a study that shows improved bone density with increased dosage. Oral estradiol doses of .02mg, .05mg, and .075mg after 2 years of treatment correlated with an improvement in lumbar spine bone density of .4%, 2.3%, and 2.7% (Greenwald et.al, 2005). While improvement can be gained from a smaller dose, a higher dose does have more benefit. Once again, informed decision-making with a knowledgeable provider is needed.

What are your go-to resources for all things menopause?
Based on the answers to the two previous questions, I think you can see that The Menopause Society is the gold standard when it comes to all things menopause. The position statements are available on their website and can be accessed for free. This includes guidelines on hormones, non-hormonal treatments, genitourinary syndrome of menopause, and osteoporosis. They also have monthly practice pearls, which include many pertinent topics on current treatments and health concerns for the patient in the transition.

Another great resource is Jen Gutner’s The Vagenda. While complete articles require a subscription to her Substack, she does offer a free email version that shares information about many of the topics flying around in the social media sphere. Her opinions are not always popular, but they are always research-based.

A final resource would be Women Living Better. This website was started by women frustrated with their own perimenopause experience and has resources for patients wanting to know more about options for treatment and symptoms experienced during this time. The founders have also been responsible for some interesting research regarding a survey of 3200 women in perimenopause. This is also available on their website.

Keep in mind that there are many social media influencers with millions of followers who also offer information. They have YouTube channels, Instagram, and websites. Menopause seems to be everywhere! While it is extremely valuable to get the message out there, the conclusions offered are often oversimplified in the attempt to push a quick and easy narrative. If I have learned anything in my knowledge journey, it is that there is no one-size-fits-all answer. Treatment is very individualized based on health status, risk factors, and personal preferences. Nuance is the key when it comes to offering the best outcomes.

If you would like to learn more on this topic, then join me on April 26-27, 2025, in Menopause Transitions and Pelvic Rehabilitation to understand more about the physiological consequences to the body as hormones decline and how to assist our patients in lifestyle habits for successful aging.

References:

1. The 2020 genitourinary syndrome of menopause position statement of The North American Menopause Society. Menopause, 2020. 27(9): p. 976-992.
2. Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause, 2021. 28(9): p. 973-997.
3. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 2022. 29(7): p. 767-794.
4. Greenwald, M.W., et al., Oral hormone therapy with 17beta-estradiol and 17beta-estradiol in combination with norethindrone acetate in the prevention of bone loss in early postmenopausal women: dose-dependent effects. Menopause, 2005. 12(6): p. 741-8.
5. The Nonhormone Therapy Position Statement of The North American Menopause Society" Advisory, P., The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 2023. 30(6): p. 573-590.

AUTHOR BIO
Christine Stewart, PT, CMPT

Christine Stewart, PT, CMPT (she/her) graduated from Kansas State University in 1992 and went on to pursue her master’s degree in physical therapy from the University of Kansas Medical Center, graduating in 1994. She began her career specializing in orthopedics and manual therapy, then became interested in women’s health after the birth of her second child.

Christine developed her pelvic health practice in a local hospital with a focus on urinary incontinence and prolapse. She left the practice in 2010 to work at Olathe Health to further focus on pelvic rehabilitation for all genders and obtain her CMPT from the North American Institute of Manual Therapy. She completed Diane Lee’s Integrated Systems Model education series in 2018. Her passion is empowering patients through education and treatment options for the betterment of their health throughout their lifespan. She enjoys speaking to physicians and to community-based organizations on pelvic health physical therapy.

What do you know about the Americans with Disabilities Act (ADA)? You may be thinking that you are a pelvic health provider, so you don’t need to worry about laws, rules, and regulations. You may need to know more about the ADA than you thought.

Scenario: Your patient calls and requests an American Sign Language interpreter during their pelvic health evaluation. You don’t know much about this. You start to research online, and here is what you find…

Google search answer: “Yes, under the Americans with Disabilities Act (ADA), if your practice is a place of public accommodation (e.g., a healthcare provider), you are generally required to provide effective communication, which may include an ASL interpreter when necessary. However, the law considers "undue burden," meaning if the cost is too high relative to your resources, alternative accommodations (like written communication or remote video interpreting) may be acceptable. You cannot charge the patient for the interpreter.”

You do more research and find out the Americans with Disabilities Act (ADA) is a landmark civil rights law enacted in 1990 that prohibits discrimination against individuals with disabilities in various aspects of public life. It ensures that people with disabilities have the same rights and opportunities as everyone else, covering areas such as employment, public accommodations, transportation, government services, and telecommunications.

Under the ADA, as a pelvic health provider, you will have to provide public accommodations. You may work for a location or be a private business owner, but in either setting, you’ll have to be able to make accommodations. This means being ready to cover physical accessibility (ramps, elevators, bathrooms) and accommodations for people with visual, hearing, or other impairments.

How does this relate to ethics?
Consider the scenario above. You find out that in-person ASL interpreters charge $60 - 90/hour, have a two-hour minimum, and also include paid travel. This means that each visit will cost you between $130 and $250 for just the interpreter. Virtual visits are $1.99 - $2.99 per minute, and the company tells you most deaf people prefer in-person when given the option. The companies you talk to explain that not all deaf people can even use a virtual interpreter. The cancellation windows vary from 48 business hours to 5 business days. You now know that based on the ADA, you have to provide this if you take on this patient, AND you have to pay for this service. What do you do?

An ethical dilemma is the choice between two “right” options. There isn’t a straightforward right versus wrong as there is with an ethical problem. This puts more pressure on the therapist or manager (if the therapist is in a larger organization) to make a judgment call.

The decision you make will likely be based on a few different factors. These are the questions that come to mind for making a decision on this ethical dilemma.

• What is my practice model - fee for service or insurance based?
• How much will I be reimbursed for the therapy session?
• Will this session take more time than other sessions?
• What is my profit margin like?
• Do I have the financial cushion to take on a patient that may actually have my practice losing money?
• How long will the patient need to be seen?
• Is there anyone else in the community I can refer this patient to who may have better resources to accommodate this patient?
• Is the interpreter going to be HIPPA compliant?
• Is the patient going to be comfortable with the interpreter in the room?
• Am I confident the patient will attend appointments regularly?

What would you do as a provider?
I can tell you what our clinic did when this happened. When this patient called, we told them we’d need to take a moment to do some research to find out if we were able to accommodate them. We did our research and were able to find a friend of a friend who was qualified but had better rates than the bigger agencies. We looked at what we HAD to provide and compared that to what we COULD provide, and we decided to take on this patient. Financially, the visit would “net zero,” meaning we wouldn’t make any money, but we also wouldn’t lose money if the patient attended regularly. We felt our clinic was best able to accommodate this patient of the providers in the area. We weighed the pros for the clinic vs. the cons and did the same for the patient and made our decision. That is what we must do every day as a providers. Choosing to refer the patient to an equally qualified location that could accommodate the patient might also have been a good choice.

For pelvic health practitioners, understanding the ADA is crucial when working with individuals who may have disabilities. Some key considerations include:

• Ensuring clinic accessibility (ramps, door widths, exam tables) for individuals with mobility challenges
• Providing communication accommodations for those with speech, hearing, or cognitive impairments
• Offering reasonable modifications to treatment plans for patients with disabilities
• Knowing how legal protections apply when treating patients and ensuring compliance in documentation and practice policies

Ethical dilemmas don’t come with easy answers.
That’s why ongoing education is critical for pelvic health providers. Understanding both the ethical and legal implications of our work ensures that we protect our patients, our licenses, and our professional integrity.

For those looking to deepen their knowledge in this area, the Ethical Considerations from a Legal Lens course is a must-attend event. Taking place remotely on April 12, 2025, this course is designed to provide pelvic health practitioners with the tools they need to navigate real-world ethical challenges with confidence.

What You’ll Gain from the Course

• A deeper understanding of legal considerations in pelvic health practice
• Strategies to navigate informed consent and patient autonomy
• Insights into trauma-informed care and how to approach sensitive patient cases
• Tools to manage professional boundaries and ethical decision-making
• Interactive discussions and case studies to help apply concepts in real scenarios

As providers, we want to deliver the best care possible while ensuring that our practice remains ethical, respectful, and legally sound. Education is the key to making that happen. If you’re ready to strengthen your ethical knowledge and enhance your practice, sign up for the Ethical Considerations from a Legal Lens course today!

Freebie:
ADA Compliance for Pelvic Health Providers - Free Download Reference

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.

Pilates has always had a place in rehab and was used frequently by those (think ballet dancers and performers) who needed a system of exercise that could challenge the neuromuscular system to bring them back to a high level of function. But Joseph Pilates created his “Method” to heal himself—he suffered from asthma, rickets, and rheumatic fever—and in doing so, made it suitable for all types of people at all stages of health and wellness.

Do you long to try that Reformer in your clinic but feel you have not had the training necessary to use it safely beyond a glorified squat machine? Come experience Pilates movement in my new course, Pilates Therapeutic Exercise in Pelvic Health, scheduled for May 3-4, 2025. By using your therapeutic exercise training, we will choose appropriate traditional Pilates exercises to apply to common pelvic floor and pelvic girdle dysfunction. This course is meant to focus on specific diagnoses like prolapse prevention, urinary incontinence, and postpartum abdominal wall activation. This is not Pilates training—there are many suitable courses for this goal - but rather it is to whet your appetite to further your training and give you explicit examples of Pilates exercises to help your patient.

We will review how to safely set up the reformer for patients and see how select exercises can transform core activation by doing rather than telling folks about the movement. Using the Reformer is a wonderful neuro reeducation tool -- utilizing springs, one can instantly create tension that will act as an active assist for muscle groups or modify it to be one that is resistive, creating activation of muscle contraction. Additionally, you can access many developmental postures on the Reformer that can help your patient succeed. Combined with good verbal and tactile cues, the Reformer is a go-to for my pelvic floor patients with pain, ROM issues, and/or weakness, and I can’t wait to share!

AUTHOR BIO
Pam Downey, PT, MSPT, DPT, WCS, BCB-PMD, PRPC

Pam Downey, PT, MSPT, DPT, WCS, BCB-PMD, PRPC (she/her) is a Board Certified Clinical Specialist in Women’s Health Physical Therapy and Board Certified in Biofeedback for Pelvic Muscle Dysfunction. Owner of Partnership in Therapy, a private practice in Coral Gables, Florida, she treats pelvic floor dysfunction, related urogynecological and colorectal issues, spine dysfunction, osteoporosis, and complaints associated with pregnancy and the postpartum period. Her mission is to educate and integrate healthy lifestyles for patients on the road to wellness.

Dr. Downey has been honored to teach with the Herman & Wallace Institute since 2006. She is an Adjunct Professor in the Physical Therapy Program at the University Of Miami Miller School of Medicine in Coral Gables, Florida, and Nova Southeastern University in Fort Lauderdale, Florida. A certified Polestar Pilates Educator, she utilizes Pilates and therapeutic exercise interventions specifically designed for patients with pre/post-natal, pelvic floor muscle, and other lumbo-pelvic pain-related dysfunctions.

Dr. Downey received her Bachelor of Arts from Sarah Lawrence College and her Master of Science and Doctorate in Physical Therapy from the University of Miami School of Medicine. She is actively involved in professional activities of the Section on Women’s Health of the American Physical Therapy Association, presently sitting as Coordinator of Research Submissions for annual meetings and as a manuscript reviewer for the Journal of Women’s Health. Dr. Downey has lectured nationally and internationally at professional conferences and is the author of multiple published research articles and a book chapter on chronic pelvic pain in the medical text, Women’s Health in Physical Therapy.