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Herman & Wallace Blog

Improving Sexual Function in Women with Cognitive Behavioral Therapy

Mindfulness

In a previous post on The Pelvic Rehab Report, Sagira Vora, PT, MPT, WCS, PRPC explored the impact that pelvic floor exercises can have on arousal and orgasm in women. Today we hear part two of the conversation, and learn what factors can impact a woman's ability to achieve orgasm.

“An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.”

Wow, that sounds like paradise! The question is--how to get there? Many of our cohorts and many our female patients have not experienced this or orgasm happens for them rarely. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Some of the reasons cited for lack of orgasm are orgasm importance, sexual desire, sexual self-esteem, and openness of sexual communication with partner by Kontula el. al. in 2016. Rowland found that most commonly-endorsed reasons were stress/anxiety, insufficient arousal, and lack of time during sex, body image, pain, inadequate lubrication.

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Questions from Finding the Driver in Pelvic Pain

Elizabeth Hampton PT, DPT, WCS, BCB-PMD

I’m Elizabeth Hampton PT, DPT, WCS, BCB-PMD and I teach “Finding the Driver in Pelvic Pain”, which offers practitioners a systematic screening approach to rule in or rule out contributing factors to pelvic pain. This course helps clinicians to understand and screen for the common co-morbidities associated with pelvic floor dysfunction, like labral tears, discogenic low back pain, nerve entrapments, coccygeal dysfunction, and more. Importantly, it also coaches clinicians to organize information in a way that enables them to prioritize interventions in complex cases. I've noticed that there are some questions that course participants frequently have as they talk through common themes in their care challenges and wrote this blog to share some clinical pearls you may find to be helpful for your own practice or as an explanation to your clients.Here are some of the most common questions that I get when teaching Finding the Driver in Pelvic Pain: 1) Question: How do I even start to organize information when a client has a complex history and I am feeling overwhelmed?I write down a road map with key categories: Bowel and bladder; Spine; Sacroiliac Joint/Pubic Symphysis; Hip; Pelvic floor muscles; biomechanics; respiration; neural upregulation; whatever details can be fit into ‘big buckets’ of information. I use it to both organize my thoughts for my notes, as well as educate the client as to what my findings are and the design of their treatment program. 2) Question: How do you get your clients to do a bowel and bladder diary?I am proud to say that I can talk anyone into a 7 day bowel and bladder diary because I tell them how incredibly helpful it is to understand the way their body responds to what they eat, drink, and daily habits. It’s my secret weapon to snag clients to start connecting with their body and listening to their details, educate about defecation ergonomics and what happens in multiple systems when there is pelvic floor overactivity. It’s a great teaching tool that facilitates self-reflection and how their self-care choices impact their body’s behavior. 3) Question: How do you educate clients about pelvic floor function so they don’t focus so much on Kegels?Pelvic floor muscles do three things:

They contract gently, or powerfully, with no discomfort, and totally normal breathing; PFMs should have the same kind of nuanced control like your voice does: they should be able to do a gentle contraction, like a “whisper” or a powerful contraction, like a “shout”, depending on the task position and intent.

They relax fully and completely when the body is resting in support, or they should be able to relax to a supportive level when they are needed posturally. Relaxation should be its own celebrated event!

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Pregnancy Associated Ligamentous Laxity

Ligament Laxity Indicated with Finger Stretching

Kelly Feddema, PT, PRPC returns in a guest post on Pregnancy Associated Ligamentous Laxity. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. See her post on diastasis recti abdominis on the pelvic rehab report, and learn more about evaluating and treating pregnant patients by attending Care of the Pregnant Patient!

Pregnancy associated ligamentous laxity is something that we, as therapists, are fairly well aware of and see the ramifications of quite often in the clinic. We know the female body is changing to allow the mother to prepare for the growth and birth of the tiny (or sometimes not so tiny) human she is carrying. We also know that the body continues to evolve after the birth to eventually return to a post-partum state of hormonal balance. Do we think much about what this ligamentous laxity can mean during the actual delivery? Does laxity predispose women to other obstetric injury?

A recent study in the International Urogynecology Journal assessed ligamentous laxity from the 36th week of pregnancy to the onset of labor by measuring the passive extension of the non-dominant index finger with a torque applied to the second metacarpal phalangeal joint. They collected the occurrence and classification of perineal tears in 272 out of 300 women who ended up with vaginal deliveries and looked for a predictive level of second metacarpophalangeal joint (MCP) laxity for obstetric anal sphincter injury (OASI). They concluded that the increased ligamentous laxity did seem associated with OASI occurrence which was opposite of their initial idea that more lax ligaments would be at less of a risk of OASI.

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Positive Activities


Coaching Patients to Engage in Positive Activities to Improve Outcomes

Substantial attention has been given to the impact of negative emotional states on persistent pain conditions. The adverse effects of anger, fear, anxiety and depression on pain are well-documented. Complementing this emphasis on negative emotions, Hanssen and colleagues suggest that interventions aimed at cultivating positive emotional states may have a role to play in pain reduction and/or improved well-being in patients, despite pain. They suggest positive affect may promote adaptive function and buffer the adversities of a chronic pain condition.

Hanssen and colleagues propose positive psychology interventions could contribute to improved pain, mood and behavioral measures through various mechanisms. These include the modulation of spinal and supraspinal nociceptive pathways, buffering the stress reaction and reducing stress-induced hyperalgesia, broadening attention, decreasing negative pain-related cognitions, diminishing rigid behavioral responses and promoting behavioral flexibility.

In a feasibility trial, 96 patients were randomized to a computer-based positive activity intervention or control condition. The intervention required participants perform at least one positive activity for at least 15 minutes at least 1 day/week for 8 weeks. The positive activity included such tasks as performing good deeds for others, counting blessings, taking delight in life’s momentary wonders and pleasures, writing about best possible future selves, exercising or devoting time to pursuing a meaningful goal. The control group was instructed to be attentive to their surroundings and write about events or activities for at least 15 minutes at least 1 day/week for 8 weeks. Those in the positive activity intervention demonstrated significant improvements in pain intensity, pain interference, pain control, life satisfaction, and depression, and at program completion and 2-month follow-up. Based on these promising results, authors suggest that a full trial of the intervention is warranted.

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Dysfunction in Glans Penis

Pudendal Sacral Plexus
Male Perineum Nerves
Penis Cross Section
Pudendal Nerves Inferior

Men who present with chronic pelvic pain frequently have symptoms referred along the penis and into the tip of the penis, or glans. Symptoms may include numbness, tingling, aching, pain, or other sensitivity and discomfort. The tip of the penis, or glans, is a sensory structure, which allows for sexual stimulation and appreciation. This same capacity for valuable sensation can create severe discomfort when signals related to the glans are overactive or irritating. One of the most common complaints with this symptom is a level of annoyance and distraction, with level of bother worsening when a person is less active or not as mentally engaged with tasks. Wearing clothing that touches the tip of the penis (such as underwear, jock straps, jeans, or snug pants) may be limited and may worsen symptoms. When uncovering from where the symptoms originate, the culprit is often the dorsal nerve of the penis, which is sensible given that the glans is innervated by this branch of the pudendal nerve. If we consider this possibility (because certainly there are other potential causes) we find that there are many potential sites of pudendal nerve irritation to consider. First, let’s visualize the anatomy of the nerve.

Following the usually accepted descriptions of the dorsal nerve, we know that it is a terminal branch of the pudendal nerve that primarily is created from the mid-sacral nerves. This can lead us to include the lumbosacral region in our examination and treatment, yet in my clinical experience, there are other sites that more often reproduce pain in the glans. As the dorsal nerve branches off of the pudendal, usually after the location of the sacrotuberous ligament, it passes through and among the urogenital triangle layers of fascia where compression or irritation may generate symptoms.

As the nerve travels towards the pubic bone, it will pass inferior to the pubic bone, a location where suspensory ligaments of the penis can be found as well as pudendal vessels and fascia. This is also a site of potential compression and irritation, and palpation to this region may provide information about tissue health. Below is a cross-section of the proximal penis, allowing us to see where the pudendal nerve and vessels would travel inferior to the pubic bone.

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Putting on My Neuro “Brain”


Erica Vitek, MOT, OTR, BCB-PMD, PRPC is the author and instructor of Neurologic Conditions and Pelvic Floor Rehab, a new course coming to Grand Rapids, MI and Philadelphia, PA. This post is the next in her series on creating a course about neurologic conditions and pelvic rehabilititation.

Being a clinician, as we evaluate and treat people with pelvic health conditions, we typically take all systems of the body into account. We take the problem presented to us by the client and we examine, from all angles, how we might go about advice and treatment to best achieve their goals in alleviating the problem. We do a full review of medical history and pharmacology. We examine our client in-depth from a musculoskeletal perspective. We look at psychological contributions to the problem they are facing. We can look at their lifestyle and have them make a detailed diary to help us analyze their bladder, bowel, fluid intake and dietary habits. Do we also always include a look at the neurological components? Do we know what we are looking for? What are the best tools we can have in our toolbox as clinicians to look at our client’s problem through a “neuro brain”?

In writing each lecture of this course, I have had to step back each time I am developing a new concept and look at it with in-depth thought and contemplation about how I will use this in the clinic to assess my client’s concerns using a neuro-based approach. Taking the concepts and facts about the musculoskeletal system that we know well and then taking a look at the neurological systems contributions and relationship to that dysfunction can be challenging. The main reason for this challenge is that neuro system dysfunction is many times hard explain, presents with inconsistent or changing symptoms, may have motor or sensory deficits together or by themselves, may radiate to different locations than where the true dysfunction is located, and may have developed into central sensitization causing a hypervigilance to typically non-painful stimuli.

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Regaining sexual function after a cancer diagnosis


When a woman is given a cancer diagnosis, her entire world is turned upside down and inside out. There are so many things to think about; medical treatments, financial concerns, family concerns, and emotional upheaval. Sex may be the last thing that a woman may think about when she is actively going through treatment. However, at what rate are survivors having issues after treatment is complete?

A recent study published in the journal Cancer looked at just this. A 2-year longitudinal study was performed that tracked young adults (18-39 years old) through and after their cancer diagnosis. The most common cancers seen in the samples were leukemia, breast cancer, soft-tissue sarcoma, and non-Hodgkin lymphoma. The patients completed the Medical Outcomes Study Sexual Functioning Scale at 4 months, 6 months, and 24 months after diagnosis. At 2 years after diagnosis over 50% of the patients surveyed reported some degree of sexual dysfunction. Women that were in a committed relationship had an increased likelihood for experiencing sexual dysfunction; while men had increased rate of reporting sexual issues regardless of their relationship status.

Women that undergo cancer treatment have several reasons that could be influencing their sexual function. Fatigue is a complaint that is often expressed by cancer patients. Their body image is often altered due to surgeries that have been performed. Chemotherapy and hormonal therapy often push women into menopause which then leads to vaginal dryness. Additionally, radiation and surgical treatment can lead to scar tissue, fibrosis, and stenosis of the vagina and pelvic floor muscles.

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Multifidus size and prevalence of concussion


A couple of years ago, I wrote a blog about an interesting article by Hides and Stanton that related size and strength of the multifidus to the risk for lower extremity injury in Australian professional football players.

Now some of the same researchers are looking above. A prospective cohort study has recently been published that examined factors and their effects on concussions. Physical measurements of risk factors were taken in pre-season among Australian football players. These measurements included balance, vestibular function, and spinal control. To measure these outcomes the following tests were included: for balance the amount of sway across six test conditions were performed; vestibular function was tested with assessments of ocular-motor and vestibular ocular reflex; and for spinal control cervical joint position error, multifidus size, and contraction ability was tested. The objective measure was concussion injury obtained during the season diagnosed by the medical staff.

The findings were so interesting! Age, height, weight, and number of years playing football were not associated with concussion. Cross-sectional area of the multifidus at L5 was 10% smaller in players who went on to sustain a concussion compared to players that did not receive a concussion. There were no significant differences observed between the players that received concussion and those who did not with respect to the other physical measures that were obtained.

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Using Yoga for Post-traumatic Stress Disorder


When I mentioned to a patient I was writing a blog on yoga for post-traumatic stress disorder (PTSD), she poured out her story to me. Her ex-husband had been abusive, first verbally and emotionally, and then came the day he shook her. Violently. She considered taking her own life in the dark days that followed. Yoga, particularly the meditation aspect, as well as other counseling, brought her to a better place over time. Decades later, she is happily married and has practiced yoga faithfully ever since. Sometimes a therapy’s anecdotal evidence is so powerful academic research is merely icing on the cake.

Walker and Pacik (2017) reported 3 cases of military veterans showing positive outcomes with controlled rhythmic yogic breathing on post-traumatic stress disorder. Yoga has been theorized to impact the body’s reaction to stress by helping to modulate important physiological systems, which, when compromised, allow PTSD to develop and thrive. This particular study focuses on 3 veterans with PTSD and their responses to Sudarshan Kriya (SKY), a type of pranayama (controlled yogic breathing). Over the course of 5 days, the participants engaged in 3-4 hours/day of light stretching/yoga, group talks about self-care and self-empowerment, and SKY. There are 4 components of breathwork in SKY: (1) Ujjayi (‘‘Victorious Breath’’); (2) Bhastrika (‘‘Bellows Breath’’); (3) Chanting Om three times with very prolonged expiration; and, (4) Sudarshan Kriya, (an advanced form of rhythmic, cyclical breathing).

This study by Walker and Pacik (2017) included 3 voluntary participants: a 75 and a 72 year old male veteran and a 57 year old female veteran, all whom were experiencing a varying cluster of PTSD symptoms for longer than 6 months. Pre- and post-course scores were evaluated from the PTSD Checklist (a 20-item self-reported checklist), the Military Version (PCL-M). All the participants reported decreased symptoms of PTSD after the 5 day training course. The PCL-M scores were reduced in all 3 participants, particularly in the avoidance and increased arousal categories. Even the participant with the most severe symptoms showed impressive improvement. These authors concluded Sudarshan Kriya (SKY) seemed to decrease the symptoms of PTSD in 3 military veterans.

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The Case of a 9 Year Old Girl With Unretractable Vaginal Nerve Pain

Sciatic Nerve

Recently, I had a patient present to my practice with unretractable vaginal pain that was causing her quite a bit of suffering. Peyton (name changed) had been referred by a local osteopathic physician. For around a year, she had increasing severe vaginal pain. There was no history of assault, trauma, fall, or injury around the time of onset of symptoms. However, she had a kidney infection that caused back pain in the month prior to her pain onset.

Peyton is home schooled, but she was unable to attend outings that required longer sitting, such as field trips or church. She also was having some urinary retention with start and stop stream and resultant urinary frequency. Peyton’s mother said the pain was distressing to Peyton and would cause her to cry. She had an unremarkable medical history. However, under further questioning, we discovered she did have a history of bed wetting later than usual (until age 7) and she had persistent leg pain. With standing longer than 15 minutes, her legs would hurt and feel weak, which prevented her from performing sports or being physically active. She also had experienced some achy low back sensations since the kidney infection. Peyton had been screened by urology, her primary care, an osteopath, as well as a vulvar pains specialist who diagnosed her with nerve pain, but said there is no good viable treatment.

Objective findings revealed normal range of motion in her spine with the exception of limited forward flexion (feeling of back tightness at end range). Hip screening was negative for FABERS, labral screening or capsular pain patterns. General dural tension screening was positive for increased lower extremity and sensation of back tightness with slump c sit. Neural tension test was positive bilaterally for sciatic, R genitofemoral, L Iliohypogastric and Ilioinguinal nerves, and bilateral femoral nerves. Patient had a mild, barely perceptible lumbar scoliosis, and development of bilateral lower extremities and feet was symmetric and normal.

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