Anorectal balloon catheter training is one of the most underrated but helpful treatments for people with pelvic floor symptoms related to bowel dysfunction. This is a tool that many clinicians don’t know about or are afraid to initiate with their clients. Clinicians wonder if clients will be receptive, how to use an anorectal balloon catheter efficiently, and frequently wonder what cases are appropriate for this specific modality. Anorectal balloon catheter training is a versatile treatment helping patients with pelvic floor conditions that stem from hyposensitivity or hypersensitivity in the rectal canal.

Rehab clinicians can use anorectal balloon catheters to help with defecation training, anorectal sensory training, coordination training, and resistance training that can improve symptoms for individuals with fecal incontinence, fecal urgency, and chronic constipation as well as other colorectal diagnoses. This modality can be used to improve the coordination between the pelvic floor muscles and the abdominal muscles to assist in defecation training. It also can help a patient learn what the urge to have a bowel movement should feel like, especially if they have altered sensation in the anal canal. 

An anorectal balloon is a form of biofeedback to use with pelvic floor patients. During treatment, an anorectal balloon is placed in the rectal canal. The balloon can hold 400 mL but filling volumes are typically much lower. The balloon is then filled with air and the amount of air is altered in order to help retrain sensation in the anorectal area. Before implementing this treatment technique in a patient’s plan of care, there are a few steps a rehabilitation provider should take.

First, patients should be screened to make sure they are good candidates for this treatment. This includes internal muscle assessment of the rectal canal prior to implementing training. Detailed patient education on the purpose and procedure of training with an anorectal balloon catheter should be provided. Patients may have some experience with anorectal manometry and may need their therapist to differentiate how manometry testing is for assessment purposes, but balloon training is a biofeedback tool. 

Once this treatment is decided upon, the therapist will begin by getting some baseline measurements. These include the first feeling of sensation of the balloon filling, the first urge to defecate, and then their maximum tolerance. These baselines give a provider information on how to proceed with treatment. It is helpful to have norms readily available to be able to compare your patient’s readings to. Caution should be taken when working with patients who have had lower bowel surgeries and pediatric patients, avoiding maximum values beyond a certain value.

With proper consideration of the baseline measurements of sensation levels, a treatment plan can be developed with the use of anorectal balloon training to improve sensation and awareness in the anorectal area. Sensation is trained via inflations and deflations of the balloon to assist in feedback to allow the patient to recognize what normal range values feel like.

Anorectal Balloon Catheters - Intro and Practical Application is a mini-course offered by Herman & Wallace to help providers feel comfortable screening patients for their eligibility for this intervention. The course will assist in helping practitioners to feel confident in providing this treatment with appropriate patients. This class is built with treatment in mind, and intended for therapists who have some exposure to the concept of anorectal assessment and treatment but want to learn more ways to apply this technique to their clients. This class includes didactic information and hands-on lab practice in the privacy of participant’s own space, to help bring this skill to their clinical practice. The next offering of this course is:

https://hermanwallace.com/continuing-education-courses/anorectal-balloon-catheters/

Abdominal bloating and distension are common symptoms reported in pelvic health practice. While many individuals experience occasional bloating that resolves without intervention, persistent or long-standing distension can significantly impact quality of life. Patients often report discomfort, sleep disruption, dietary restrictions, and frustration when symptoms persist without clear answers.

One condition associated with these symptoms is abdomino-phrenic dyssynergia, a disorder involving a paradoxical relationship between the diaphragm and abdominal wall.

Under normal conditions, when intraluminal gas increases in the gastrointestinal tract, the body responds with a coordinated pattern:

• the diaphragm relaxes, and
• the abdominal wall contracts

This response helps maintain abdominal shape and pressure regulation.

However, in abdomino-phrenic dyssynergia, the opposite pattern occurs. The diaphragm contracts downward while the abdominal musculature relaxes, leading to visible abdominal distension and discomfort. Dysfunction of the pelvic floor is also frequently associated with this condition, reinforcing the importance of a comprehensive evaluation of the entire pressure management system.

Traditional management strategies include biofeedback therapy and breathing retraining, both aimed at restoring appropriate neuromuscular coordination.

A Clinical Case Example

In our clinic, we are seeing an increasing number of referrals for patients diagnosed with abdomino-phrenic dyssynergia. One recent patient illustrates how breathing mechanics and musculoskeletal restrictions can contribute to these symptoms.

The patient was a 72-year-old female with a long-standing history of abdominal bloating and distension.

She reported:

• Bloating and abdominal distension throughout the day, worsening toward evening
• Limiting evening food intake due to abdominal discomfort and “tightness”
• Pain rated 3–5/10 in the morning, increasing to 8/10 by late evening
• Difficulty sleeping due to the abdomen feeling “hard and tight” at bedtime

Examination Findings

Physical examination revealed several contributing factors:

• Significant tightness in the posterior chain and erector spinae in the thoracic and lumbar regions
• Reduced thoracic rotation and mobility
• Connective tissue restrictions in the upper abdominal quadrants, especially the epigastric region and inferior rib cage
• Decreased lower rib cage mobility
• Difficulty producing a prolonged or forceful exhale
• Reduced ability to relax the pelvic floor following contraction

These findings highlighted the interaction between breathing mechanics, rib cage mobility, myofascial restrictions, and pelvic floor coordination.

Treatment Approach

Treatment included a multi-system approach addressing breathing, mobility, and neuromuscular coordination.

Interventions included:

• Biofeedback therapy
• Visceral mobilization techniques
• Thoracic spine and rib joint mobilizations
• Soft tissue techniques, including gentle diaphragm release
• Breathing retraining
• Techniques focused on pelvic floor relaxation

The patient completed nine treatment sessions, combined with a structured home maintenance program that she followed consistently.

Outcomes

By the end of treatment, the patient reported:

• 70% overall improvement in symptoms
• Ability to eat evening meals without discomfort
• Restful sleep through the night without abdominal tightness

This case highlights how restoring efficient breathing mechanics and rib cage mobility can significantly influence abdominal pressure regulation, pelvic floor function, and patient comfort.

Why Breathing Matters for Pelvic and Orthopedic Therapists

Breathing is far more than a respiratory function. The diaphragm plays a central role in:

• pressure regulation
• core stability
• pelvic floor coordination
• movement efficiency

Understanding how breathing integrates with the musculoskeletal system can significantly expand a clinician’s ability to address persistent symptoms that may otherwise be overlooked.

In the course Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, we explore these relationships in depth and provide clinicians with practical tools to assess and treat dysfunctional breathing patterns.

Participants will learn how to:

• Explain normal diaphragmatic breathing and the role of the internal and external oblique musculature
• Assess and treat dysfunctional breathing patterns including chest, abdominal, and paradoxical breathing
• Understand the role of intra-abdominal pressure (IAP) in spinal stability
• Apply the concept of regional interdependence in patients with pelvic or back pain
• Recognize how postural patterns influence diaphragm and pelvic floor function
• Identify myofascial contributors to dysfunctional breathing and apply appropriate treatment techniques
• Perform rib and thoracic spine mobilizations to improve respiratory mechanics
• Develop exercise progressions for breathing retraining in clinic and home programs
• Integrate diaphragmatic breathing strategies into athletic rehabilitation

Understanding the relationship between breathing mechanics, mobility, and pelvic floor function allows clinicians to address dysfunction from a more integrated perspective and can lead to meaningful improvements in patient outcomes.

Aparna Rajagopal, PT, MHS, WCS, PRPC, Capp-OB Certified is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interest in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction.

Leeann Taptich DPT, SCS, MTC, CSCS leads the Sports Physical Therapy team at Henry Ford Macomb Hospital where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital which gives her a very unique perspective of the athlete.

Aparna and Leeann co-authored the course, Breathing and the Diaphragm: Pelvic and Orthopedic Therapists, which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.

Course Dates: March 14, 2026

Price: $450
Experience Level: Beginner
Contact Hours: 13.5

Description: This remote course is an integrated approach where participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes while looking at structures from the glottis and the cervical region to the pelvic floor.

This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. Instructed techniques are applicable to patients who present with Diastasis Rectus Abdominis, pelvic pain, incontinence, and prolapse, as well as cervical, thoracic, scapular, and lumbar pain.

I recently evaluated a 75 y.o patient who presented with significant urinary urgency and frequency, voiding approximately every hour. She reported disrupted sleep due to nocturia, stating, “I can’t sleep at night because I keep getting up to go to the bathroom. They gave me medication to help me sleep, but it doesn’t work.”

Over the course of the visit, it became clear that she was also experiencing chronic anxiety. Anxiety permeated multiple aspects of her daily life, she worried about day-to-day events as well as events in the future. She reported that her urinary symptoms worsened during periods of heightened anxiety, and she had difficulty relaxing both her body and mind.

My initial clinical focus was nervous system regulation. I guided her to sit back comfortably and take several gentle breaths, emphasizing a prolonged exhalation with an audible sigh. She was instructed to consciously release tension throughout her body while maintaining attention on her breath. After only a few breaths, she smiled and reported that she already felt calmer.

In addition to a home program that included diaphragmatic breathing, self–abdominal massage, and pelvic girdle mobility exercises, I introduced two Acupressure points for nervous system self-regulation: Conception Vessel 17 (CV17) and Yintang (EX-HN 3).

CV17, located at the center of the chest, is traditionally associated with emotional regulation and calming of the heart-mind connection. Yintang, located between the eyebrows, is described in Traditional Chinese Medicine (TCM) as having a mentally stabilizing and calming effect.¹

At her subsequent visit, the patient reported feeling calmer overall and noted that she was able to use the Acupressure points independently to regulate her anxiety. Over the course of several visits, an integrative plan addressing hip mobility, bladder training, behavioral modification and nervous system regulation resulted in measurable improvement. Her daytime voiding interval increased to approximately 2.5 hours, and nocturnal voiding frequency also decreased.

Acupressure as an Evidence-Informed Integrative practice

Acupressure, rooted in Traditional Chinese Medicine, is increasingly recognized as an evidence-informed, integrative, and trauma-informed intervention. Integrative health and medicine approaches intentionally combine conventional physical therapy interventions with holistic strategies that address the whole person - physically, mentally, emotionally, and spiritually (Justice et al).

The use of Acupressure for anxiety is well established in integrative medicine. Acupoints such as Yin Tang (EX-HN3), Shenmen (HT7), Neiguan (P6), Hegu (LI4), Taichong (LV3), Jianjing (GB21), Zu San Li (ST36) and Sanyinjiao (SP6) are some of the most frequently used points to treat anxiety2. Yintang (EX-HN 3), in particular, has demonstrated anxiolytic effects and has also been associated with improvements in depressive symptoms.³

Beyond mental health applications, Acupressure has also been used as an effective non-pharmacological therapy for the management of a host of conditions such as insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, digestive disorders and urinary dysfunctions. Emerging research suggests that Acupressure influences neural networks across multiple systems, supporting emotional regulation and multisystem healing

Physiologically, Acupressure has been shown to improve heart rate variability and reduce sympathetic nervous system activity. This downregulation is associated with decreased release of stress hormones such as epinephrine and cortisol, facilitating the relaxation response and correlating with reductions in anxiety and pain.

Why Acupressure Matters in Pelvic Health Rehabilitation

The pelvic floor is highly responsive to stress, anxiety, and unresolved trauma, often demonstrating increased tone or guarding in response to perceived threat. This can contribute to pelvic pain, urinary dysfunction, dyspareunia, constipation, and other pelvic health conditions.

These presentations are not purely musculoskeletal, they frequently reflect underlying nervous system dysregulation. Incorporating Acupressure into pelvic health rehabilitation can meaningfully support patients by:

· Calming hyperactive pelvic and autonomic nerves

· Improving circulation and tissue mobility in the pelvic region

· Releasing stored muscular tension and trauma

· Supporting emotional grounding, safety, and resilience

Acupressure can be particularly beneficial during or after pregnancy, childbirth, surgery, or emotionally traumatic experiences, offering a gentle, patient-empowering approach to healing.

Acupressure as a Hands-On Self-Regulation Tool

Acupressure involves the application of gentle, intentional pressure to specific points along the body’s meridian system. These points correspond with key organ systems, including the nervous, digestive, and reproductive systems and can influence both physical and emotional health.

Clinical benefits of acupressure include:

· Vagal nerve modulation and stress reduction

· Decreased muscle tension and chronic pain

· Enhanced emotional regulation and trauma support

· Promotion of relaxation and improved sleep

Integrating acupressure into pelvic health physical therapy supports whole-person healing, restoring not only movement and function, but also a sense of safety, stability, and emotional balance.

Commonly Used Acupressure Points for Anxiety, Pain, and Pelvic Health

· CV 17 (Conception Vessel 17) – Located at the center of the chest Main point for Emotional healing

· Yintang (EX-HN 3) – Located between the eyebrows Mentally stabilizing effect, calming point

· H 7 ( Heart 7) – Located on the ulnar side of the hand, in the joint space) Helps with Insomnia, reduces anxiety

· P 6 (Pericardium 6) – Inner forearm Calms the heart, reduces anxiety and nausea

· Sp 6 (Spleen 6) – Above the inner ankle Regulates reproductive health

· CV 6 (Conception Vessel) – Below the navel Supports core energy, fatigue and abdominal tension

These points can be gently stimulated during therapy or taught as part of a home program, offering patients the tools for emotional self-regulation. To explore these concepts further, please join us for the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for Feb 7th & 8th . This course introduces participants to foundational principles of Traditional Chinese Medicine, Acupuncture, and Acupressure, with a focused exploration of the Bladder, Kidney, Stomach, and Spleen meridians.

Participants will also learn additional nervous system–regulating points for managing anxiety, pain, and related symptoms, as well as two comprehensive acupressure-based home and wellness programs. The course further integrates Yin yoga as a complementary practice, offering an evidence-informed perspective on how Yin postures associated with specific meridians may influence neurodynamic pathways and support multidimensional healing.

References

1. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256

2. Yang J, Do A, Mallory MJ, Wahner-Roedler DL, Chon TY, Bauer BA. Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic. Glob Adv Health Med. 2021;10:21649561211058076. Published 2021 Dec 12. doi:10.1177/21649561211058076

3. Kwon CY, Lee B. Acupuncture or Acupressure on Yintang (EX-HN 3) for Anxiety: A Preliminary Review. Med Acupunct. 2018;30(2):73-79. doi:10.1089/acu.2017.1268

4. Justice C, Sullivan MB, Van Demark CB, Davis CM, Erb M. Guiding Principles for the Practice of Integrative Physical Therapy. Phys Ther. 2023;103(12):pzad138. doi:10.1093/ptj/pzad138

5. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.

6. Abaraogu UO, Igwe SE, Tabansi-Ochiogu CS. Effectiveness of SP6 (Sanyinjiao) acupressure for relief of primary dysmenorrhea symptoms: A systematic review with meta- and sensitivity analyses. Complement Ther Clin Pract. 2016;25:92-105

7. He Y, Guo X, May BH, et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233

8. Hasanin ME, Elsayed SH, Taha MM. Effect of Acupressure on Anxiety and Pain Levels in Primiparous Women During Normal Labor: A Randomized Controlled Trial. J Integr Complement Med. 2024;30(7):654-661. doi:10.1089/jicm.2023.0072

Pain shows up in almost every pelvic health plan of care, but a lot of providers were never actually trained to teach pain in a way that changes outcomes. We learn how to assess tissues, strength, tone, and pathology, but pain is not a simple “damage meter.” It’s a protective output of the nervous system, shaped by context, perceived threat, inflammation, prior experiences, hormones, and learned responses. When we skip pain science education (or keep it vague), patients often stay fearful, hypervigilant, and stuck, especially when imaging is normal or symptoms don’t “match” what we see.

Endometriosis, among other pelvic pain conditions, is one of the clearest examples of why this matters. Endometriosis is characterized by lesions containing endometrium-like epithelium and stroma that develop outside the uterus and are biologically distinct from normal uterine endometrium. Endo is a real inflammatory disease with lesions that can be found on the bowel, bladder, ureters, abdominal wall, and peritoneum commonly. And yet pain severity doesn’t reliably correlate with lesion size, number, or location. Some patients with extensive disease report minimal pain, while others with smaller disease experience life-altering symptoms. Pain science helps us explain that gap: the nervous system can become sensitized over time, turning up the volume on danger signals even when tissues are stable or after the primary driver has been addressed.

Clinically, one of the most important skills is being able to distinguish peripheral pain generators from sensitization. Peripheral drivers include things like active lesions/inflammation, adhesions, pelvic floor overactivity, tissue irritation, and organ-specific contributors. Sensitization shows up when pain persists beyond expected healing, spreads, becomes disproportionate to findings, or is paired with hypervigilance, fear-avoidance, and strong symptom reactivity to stress, sleep disruption, and attention. In pelvic health, cross-talk between organs adds another layer, bladder, bowel, uterus, and pelvic floor can share neural pathways, so symptoms don’t always point neatly to the true source.

This is where pain science education becomes a part of treatment. For endometriosis, an example of pain science education starting point could be: “Endo can absolutely create pain through inflammation and lesion activity, but pain isn’t always a direct reflection of how much disease is present. Over time, your nervous system can become extra protective, like an alarm system that’s gotten too sensitive. That doesn’t mean the pain is in your head. It means your pain IS real, and your nervous system is amplifying signals. The good news is the system can be retrained through the right combination of medical care, pelvic rehab, graded exposure, and nervous system regulation.”

When providers can explain pain clearly, patients stop interpreting every symptom spike as damage. They become more confident with movement, more consistent with rehab, and more resilient during flares. And that’s why pain science education is so important, because with endometriosis, IC/PBS, prostatitis, IBS, vaginismus/dyspareunia, and primary dysmenorrhea, your hands matter, but what you do with your words can be the turning point.

If you’re treating endometriosis, or any chronic pelvic pain condition, and you’re not sure whether you’re addressing the “spark” (peripheral drivers) versus the “fuel” (sensitization), this Pain Science class is designed to make that clinical reasoning practical, teachable, and immediately usable in your sessions.

Dr. Tara Sullivan, PT, DPT, PRPC, WCS, IF Sexual Medicine in Pelvic Rehabilitation - Remote Course - March 14-15 2026 

Learn More: Sexual Medicine in Pelvic Rehab March 14-15, 2026

When we think of sports rehab, we typically envision athletes returning to the court after an ankle sprain or knee injury. But what if the same principles of rigorous assessment, load transfer optimization, movement education, and functional stability could apply to one of the body’s most critical yet under‑appreciated joints: the sacroiliac joint (SIJ)?

For clinicians working in pelvic health, embracing a sports‑rehab mindset can transform how we evaluate and treat SIJ dysfunction and pain, and recent research supports this crossover approach. Now might just be the ideal time to integrate these strategies into your practice.

Why Sports Rehab Principles Matter for SIJ/Pelvic Health

• High prevalence of SIJ issues in athletic populations: A 2024 systematic review found that among athletes, average prevalence of SIJP or SIJD was ~10.7%, with rates much higher (32–36%) in those presenting with low back or pelvic pain. (Mirdamadi et al, 2025)
• SIJ dysfunction often coexists with lower extremity injuries: In a 2023 study of basketball players, those with SIJ pain or dysfunction reported significantly more lower-limb and pelvic‑girdle injuries, both acute and overuse, than their peers without SIJ complaints. (Abdollahi et al, 2023)
• Biomechanics and load transfer matter: The SIJ plays a key role in transmitting loads between the spine and lower extremities. Disruption in force transmission, whether from muscular imbalance, altered movement patterns, or pelvic instability, may contribute not just to SIJ pain, but to secondary injuries elsewhere. (Prather, 2000; Abdollahi et al, 2023)

These findings align closely with core sports‑rehab principles: assessing mechanical and neuromuscular impairments, correct faulty movement or load patterns, and restore stability and function before returning to high‑demand activity.

Translating Sports‑Rehab Strategies into Pelvic Health Practice
Here are some of the evidence-based crossover strategies that pelvic rehab clinicians can begin using:

• Comprehensive Functional Assessment: Rather than isolating the SIJ, consider the entire kinetic chain. For instance, when evaluating an athlete (or active individual) with lower extremity complaints, include SIJ screening - given its association with lower‑limb injuries. (Abdollahi et al, 2023)
• Dynamic & Stabilization Exercises: Inspired by sports rehab protocols, incorporating exercises that challenge stability, proprioception, and dynamic load transfer can be effective. A case study combining Swiss‑ball training, mobilization with movement, and taping demonstrated promising results in an athlete with concurrent SIJD and ankle sprain. (Shedge et al, 2024)
• Manual Therapy + Movement Integration: While manual therapy alone has mixed evidence, a recent meta‑analysis found that SIJ manual therapy did not significantly reduce pain vs. non-manual interventions but did improve disability moderately. Combining manual therapy with functional movement and exercise tends to align with best-practice sports rehab philosophy. (Trager at al, 2024)
• Holistic, Movement‑Based Rehab Over “Fixing” Passive Structures: Rather than focusing solely on static “joint alignment” or joint‑centric correction, prioritize restoring functional movement, load capacity, and neuromuscular control - all principles that athletic trainers and sports PTs rely on routinely.

Why This Matters - For Both Clinicians and Clients
Adapting a sports‑rehab informed paradigm for SIJ/pelvic health offers several advantages:

• Broader applicability: Whether your client is a weekend runner, a postpartum individual, or a competitive athlete, a functional, movement‑based SIJ rehabilitation model supports real‑world demands.
• Better injury prevention and reduced recurrence: By addressing underlying load‑transfer dysfunction and neuromuscular control, not just symptoms, you may reduce the risk of future pelvic or lower‑extremity injuries.
• Improved patient buy-in: Clients often resonate with language around “stability,” “function,” and “return to activity.” Familiar terms from sports rehab, which can increase compliance and perceived relevance.

Connect the Dots Between Sports Rehab & Pelvic Rehab - Take the 4‑Hour Course
If you’re ready to bridge the gap between sports rehab and pelvic health, I invite you to join the upcoming four‑hour remote course, Sacroiliac Joint Current Concepts, taught by experienced former NHL physical therapist and athletic trainer Steve Dischiavi, PT, PhD, DPT, MPT, SCS, ATC, COMT.

📅 Date: January 25, 2026
📚 You’ll receive:

• A full, easy‑to-follow SIJ exam sequence - optimized for a pelvic‑health context.
• Treatment strategies aligned with current evidence and sports rehab biomechanics.
• Practical tools you can integrate into your clinical practice immediately (Monday morning!)

Transform your approach and help clients move, perform, and heal better. Register today to reserve your spot.

References

1. Mirdamadi N, Khadembashiri MM, Moghadam N, Kordi R. Prevalence and Risk Factors of Sacroiliac Joint Pain in Athletes: A Systematic Review and Proportional Meta-Analysis. Clin J Sport Med. 2025 Mar 26;35(4):514-525. doi: 10.1097/JSM.0000000000001341. PMID: 40135982.
2. Abdollahi, S., Sheikhhoseini, R., Rahimi, M. et al. The sacroiliac dysfunction and pain is associated with history of lower extremity sport related injuries. BMC Sports Sci Med Rehabil 15, 36 (2023). https://doi.org/10.1186/s13102-023-00648-w
3. Prather H. Pelvis and sacral dysfunction in sports and exercise. Phys Med Rehabil Clin N Am. 2000 Nov;11(4):805-36, viii. PMID: 11092020.
4. Shedge SS, Ramteke SU, Samal S. Integrated Rehabilitation Approach Utilizing Swiss Ball Training, Mulligan Taping, and Mobilization With Movement for Simultaneous Management of Sacroiliac Joint Dysfunction and Lateral Ankle Sprain in a Badminton Athlete: A Case Study. Cureus. 2024 Mar 26;16(3):e56942. doi: 10.7759/cureus.56942. PMID: 38665699; PMCID: PMC11044192.
5. Trager RJ, Baumann AN, Rogers H, Tidd J, Orellana K, Preston G, Baldwin K. Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials. J Man Manip Ther. 2024 Dec;32(6):561-572. doi: 10.1080/10669817.2024.2316420. Epub 2024 Feb 14. PMID: 38353102; PMCID: PMC11578406.

Pelvic floor rehabilitation is often associated with urinary continence or pelvic support, but recent research highlights its broader role, including significant impacts on respiratory health. Studies now suggest that combining pelvic floor muscle (PFM) training with pulmonary rehabilitation can enhance lung function, particularly in elderly patients recovering from orthopedic surgery.

Pelvic Floor Muscle Training and Pulmonary Function
A 2025 randomized controlled trial investigated the effects of combining pelvic floor muscle training with pulmonary rehabilitation in elderly patients following surgery for intertrochanteric femur fractures (Ji et al., 2025). Fifty patients were randomly assigned to either pulmonary rehabilitation alone or pulmonary rehabilitation combined with PFM training. After four weeks, both groups showed improvements in forced vital capacity (FVC), peak expiratory flow (PEF), and the FEV1/FVC ratio, with the combined intervention group demonstrating significantly greater gains. Diaphragm excursion and thickening fraction were also improved, suggesting a synergistic relationship between the diaphragm and pelvic floor muscles that enhances respiratory mechanics.

Supporting Evidence
Additional studies support the connection between PFM function and respiratory performance. A recent study using sensor-based diaphragm exercises combined with PFM training in women with stress urinary incontinence demonstrated improvements in both pelvic floor function and respiratory parameters (Yakıt Yeşilyurt et al., 2025). Similarly, pelvic floor electrical stimulation has been shown to enhance diaphragm excursion and rib-cage movement during tidal and forceful breathing and coughing (Hwang et al., 2021). Foundational work also demonstrated that co-activation of abdominal and pelvic floor muscles contributes to improved expiratory function and intra-abdominal pressure regulation (Sapsford et al., 2001). Together, these studies highlight the physiological link between the pelvic floor, diaphragm, and respiratory system.

Why This Matters
For elderly patients recovering from hip fractures, optimizing lung function is critical to reducing postoperative complications such as pneumonia and supporting overall recovery. Integrating PFM training with pulmonary rehabilitation provides a novel and underutilized approach to enhance respiratory efficiency and accelerate functional recovery. Moreover, these findings expand the role of pelvic floor rehabilitation beyond traditional urogenital outcomes, emphasizing its value in multidisciplinary rehabilitation programs.

Takeaway
The pelvic floor contributes significantly to respiratory mechanics. Combining pelvic floor muscle training with pulmonary rehabilitation can improve lung function in elderly post-surgical patients and may support broader recovery goals. As research evolves, pelvic floor specialists have the potential to play a key role in integrated rehabilitation approaches.

Practical Next Step: Elevate your clinical expertise by enrolling in Breathing and the Diaphragm, scheduled for December 6. This course covers diaphragm anatomy, breathing mechanics, and how the diaphragm, abdominals, and pelvic floor interact to regulate intra‑abdominal pressure, support core stability, and influence posture. Lab sessions include assessment and treatment of dysfunctional breathing patterns, ribcage and thoracic-spine restrictions, and practical strategies for clinical integration. While broadly applicable to pelvic pain, incontinence, prolapse, and core/abdominal issues, these techniques can be adapted for elderly post-hip-fracture patients to optimize lung function and recovery.

References

• Yakıt Yeşilyurt S, Şahiner Pıçak G, Başol Göksülük M, Balıkoğlu M, Özengin N. Investigating the Effectiveness of Pelvic Floor Muscle Training, Including Sensor-Based Diaphragm Exercises in Women With Stress Urinary Incontinence: A Randomized Controlled Study. Arch Phys Med Rehabil. 2025 Jul 11:S0003-9993(25)00796-8. doi: 10.1016/j.apmr.2025.06.019. Epub ahead of print. PMID: 40653184. https://pubmed.ncbi.nlm.nih.gov/40653184/
• Ji D, Fu Y, Wu L, Tian C, Jin S. Effect of pelvic floor muscle combined with pulmonary rehabilitation training on lung function in elderly patients after surgery for intertrochanteric fractures of the femur: a randomized controlled trial. Eur J Med Res. 2025 May 14;30(1):381. doi: 10.1186/s40001-025-02610-7. PMID: 40369675; PMCID: PMC12076919. https://pubmed.ncbi.nlm.nih.gov/40369675/
• Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial. Medicine (Baltimore). 2021 Jan 8;100(1):e24158. doi: 10.1097/MD.0000000000024158. PMID: 33429797; PMCID: PMC7793445. https://pubmed.ncbi.nlm.nih.gov/33429797/
• Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn. 2001;20(1):31-42. doi: 10.1002/1520-6777(2001)20:1<31::aid-nau5>3.0.co;2-p. PMID: 11135380. https://pubmed.ncbi.nlm.nih.gov/11135380/

As the holiday season approaches, Thanksgiving reminds us to pause and reflect on what we are grateful for in our personal lives and in our professional practice. For pelvic health practitioners, one of the greatest sources of gratitude is the opportunity to guide patients toward meaningful progress in their rehabilitation journeys.

Recognizing Small Wins Makes a Big Difference
Pelvic rehabilitation is often a journey of incremental improvements. While some changes may be subtle, each step forward is a win. Whether it’s a patient regaining core strength, experiencing reduced pain, improving bladder or bowel control, or building confidence in their body, these victories deserve recognition.

Celebrating small milestones can empower patients, reinforcing that their effort and consistency are yielding real results. Acknowledging progress, even the tiniest, can make a difference in adherence, motivation, and long-term outcomes.

Ways to Celebrate Patient Progress

• Track measurable improvements: Use objective measures like strength, endurance, or symptom diaries to show patients how far they’ve come.
• Highlight functional achievements: Celebrate when a patient reaches a daily-life goal, like returning to exercise, sitting comfortably, or managing symptoms during work or travel.
• Share success stories (with permission): Patient testimonials can motivate others and reinforce a culture of positivity and gratitude in your clinic.
• Verbal acknowledgment: Never underestimate the power of simply saying, “You’ve made great progress!”

Simple Pelvic Floor-Friendly Tips for the Holidays
The holiday season often brings long hours of cooking, hosting, or traveling. Activities that can challenge posture, core stability, and pelvic floor engagement. Here are some short, actionable tips patients can use to stay mindful of their pelvic health:

1. Engage the core while standing: While chopping vegetables or stirring a pot, gently draw the belly button toward the spine and lift the pelvic floor to maintain activation.
2. Shift weight regularly: Avoid standing in one position for too long. Step side to side or gently march in place while waiting for the oven timer.
3. Practice deep breathing: Encourage diaphragmatic breathing while seated or standing to release tension and coordinate with the pelvic floor.
4. Take micro-breaks: Every 30–60 minutes, sit or stand with good posture, roll the shoulders, and gently lengthen the spine.
5. Travel-friendly stretches: While on the road or sitting for long periods, gently lift and lower the pelvic floor or do seated pelvic tilts to maintain mobility.

These simple practices can help patients maintain pelvic floor awareness, reduce tension, and feel more comfortable throughout the holiday festivities.

Fostering Gratitude in Your Practice
Showing gratitude to your patients strengthens the therapeutic relationship. A simple thank-you note, a personalized follow-up, or acknowledging their dedication in session can help them feel seen and appreciated. Gratitude flows both ways: as you recognize patients’ efforts, you’re also reminded why you chose this profession - the opportunity to make a meaningful impact in people’s lives.

Looking Ahead with Appreciation
Thanksgiving is a perfect time to reflect on the wins from the past year, both big and small. Take a moment to appreciate the resilience of your patients and the progress you’ve helped facilitate. As we guide patients toward healthier, more empowered lives, celebrating these victories reminds us of the profound value of pelvic rehabilitation work.

Pelvic rehabilitation is a constantly evolving specialty, and your ability to offer high-quality care grows when you have access to a diverse set of tools. Modalities play a significant role in strengthening clinical precision, improving neuromuscular learning, enhancing patient engagement, and expanding treatment possibilities. When you integrate evidence-based modalities into your practice, you elevate the effectiveness and individualization of your patient care.

Here are the top five reasons modalities matter in pelvic rehabilitation, along with examples of tools that can support your work

1. Modalities Improve Your Clinical Precision

Pelvic health presentations often involve complex relationships between muscle tone, coordination, pain, biomechanics, breathing patterns, and emotional factors. Modalities help you see these interactions more clearly and treat them more effectively.

Tools that support clinical precision include:

• Surface EMG biofeedback for assessing activation, resting tone, and timing.
• Real Time Ultrasound Imaging (RUSI) for observing deep core mechanics, pelvic floor movement, and breathing synergy.
• Myofascial tools that help you identify tissue restrictions and monitor tissue response.
• Postural support belts and braces clarify how external stabilization influences symptoms.

With these tools, you gain insights that strengthen your clinical decisions and give patients a clearer understanding of what is happening in their bodies.

2. Modalities Support Both Uptraining and Down Training

Pelvic rehabilitation patients often need help with improving activation, reducing overactivity, coordinating movement, or building endurance. Modalities help you guide the nervous system in the direction that best supports each patient’s goals.

Examples include:

• Surface EMG biofeedback for awareness, facilitation, and relaxation.
• Electrical stimulation to support neuromuscular firing for those with inhibition or weakness.
• Real Time Ultrasound Imaging to help patients visualize diaphragmatic motion and pelvic floor excursion.
• Myofascial tools such as soft tissue instruments to reduce guarding and improve mobility.
• Breath training accessories like visual feedback tools that support better coordination.

Using modalities for both uptraining and down training gives patients more ways to understand and feel the changes you are guiding them toward.

3. Modalities Enhance Patient Understanding and Self-Efficacy

Education and behavior change are central to pelvic rehabilitation. Many patients struggle to conceptualize pelvic floor movement, pressure systems, or muscle relaxation. Modalities make these invisible processes visible and actionable.

Tools that promote self-efficacy include:

• Biofeedback displays that show contraction and relaxation in real time.
• Real-time ultrasound images that reveal how the pelvic floor, transversus abdominis, and diaphragm work together.
• Myofascial release tools that patients can use safely at home.
• Lubricants, dilators, and pelvic wands that support sexual wellness, tissue tolerance, and desensitization.
• Pelvic support belts that help patients feel stable and confident during daily activities.

When patients understand what they are doing and feel empowered by their progress, they become stronger partners in their own recovery.

4. Modalities Expand What Is Possible in Your Treatment Sessions

You already rely on your hands, your knowledge, and your clinical reasoning. Modalities add another layer that allows you to address diverse needs in more targeted ways.

Examples include:

• Myofascial tools for reducing soft tissue restrictions and improving movement.
• Electrical stimulation for supporting continence or reducing pelvic pain.
• Light therapy devices that can help with tissue healing.
• RUSI for assessing pressure management and facilitating motor learning.
• Belts, braces, and supports that can help reduce pain and improve load transfer during movement.
• Lubricants and moisturizers support tissue comfort and sexual function.

Your treatment sessions become more versatile, adaptable, and responsive to the patient in front of you.

5. Modalities Improve Outcomes Across Many Pelvic Health Conditions

The evidence for modality use continues to grow. When you broaden your clinical toolkit, you are better equipped to support patients with varied needs.

Modalities can enhance care for:

• Stress and urge incontinence
• Pelvic pain and overactive pelvic floor conditions
• Bowel dysfunction and dyssynergia
• Dyspareunia and sexual dysfunction
• Postpartum recovery
• Post-prostatectomy rehabilitation
• Vulvodynia and vestibulodynia
• Coordination impairments and breathing dysfunction
• Lumbopelvic instability and load transfer issues

From myofascial support tools to electrical stimulation to imaging and external supports, modalities allow you to tailor interventions with greater specificity and effectiveness.

Build Your Skills with a Hands-On Course Focused on Modalities
If you want clear guidance, supported practice time, and evidence-based instruction on using modalities safely and effectively, Modalities and Pelvic Function was designed for you.

The course combines pre-course video lectures with two days of hands-on lab and dedicated instruction. You will learn how to select and apply modalities, interpret findings, support neuromuscular learning, and integrate tools such as biofeedback, electrical stimulation, myofascial instruments, RUSI, and patient support devices.

Join the Upcoming Boston Course
Venue: Current Medical Technologies
Address: 14 Kendrick Road, Unit 1, Wareham, MA 02571
Dates: January 24 through 25, 2026
Elevate your pelvic rehabilitation practice. Register now to reserve your seat.

Male pelvic cancer survivors, including those treated for prostate, bladder, penile, and testicular cancers, face a range of ongoing functional challenges that affect quality of life. Treatments such as radical prostatectomy, radiation therapy, chemotherapy, and reconstructive surgery can lead to urinary incontinence, erectile dysfunction, bowel irregularity, pelvic pain, and changes in body image or hormonal balance. These effects often overlap and require an integrated rehabilitation approach.

Prostate cancer survivors frequently report urinary leakage, urgency, and reduced bladder control. Bladder cancer patients, particularly those who undergo urinary diversion or neobladder reconstruction, may struggle with altered storage and emptying patterns. Colorectal cancer survivors treated with low anterior resection often develop low anterior resection syndrome, which is characterized by stool clustering, urgency, and incontinence (Jones et al., 2024; Kim & Oh, 2023). Penile and testicular cancer survivors may experience sexual dysfunction and hormonal disruptions that influence pelvic floor function and psychosocial well-being. Across these diagnoses, common contributors to dysfunction include pelvic floor muscle weakness or discoordination, neural disruption, scar tissue and fibrosis, and the cumulative impact of cancer treatment on mobility, confidence, and daily function.

The Role of Pelvic Floor Rehabilitation
Pelvic floor rehabilitation is an essential component of survivorship care. Randomized trials and systematic reviews consistently support structured pelvic floor muscle training to improve urinary continence after prostatectomy (Fernández et al., 2015; Chen et al., 2023; Gerlegiz et al., 2025). Supervised PFMT produces better outcomes than unsupervised exercise, particularly when initiated before surgery or early postoperatively. Confirming accurate pelvic floor activation through biofeedback or palpation is critical for optimizing treatment success (Gerlegiz et al., 2025).

For men treated with pelvic radiation, long-term changes in muscle structure and neural control can contribute to urinary or bowel dysfunction and pelvic pain. Morphological and functional assessments using MRI, surface electromyography, and palpation have demonstrated reduced pelvic floor muscle endurance and altered activation patterns years after treatment (Ribeiro et al., 2021). These findings highlight the importance of ongoing rehabilitation to restore motor control, manage fibrosis, and reduce symptom burden.

Colorectal cancer survivors with low anterior resection syndrome benefit from targeted pelvic floor rehabilitation. Structured programs including pelvic floor muscle training, coordination exercises, and biofeedback have demonstrated improvements in bowel function, urgency, and quality of life (Jones et al., 2024; Kim & Oh, 2023). Programs delivered over multiple sessions, with patient adherence to home exercises, provide the most consistent benefit.

Sexual health is another domain where pelvic rehabilitation is important. Pelvic floor muscle training can improve erectile function, particularly when initiated preoperatively or in high-volume programs (Milios et al., 2020; Wong et al., 2020). Pelvic therapists can also address pelvic pain, scar sensitivity, and coordination deficits that contribute to sexual discomfort. Multidisciplinary collaboration with urology, sexual medicine, and mental health professionals provides comprehensive support for survivors navigating intimacy and relationship challenges.

Practical Rehabilitation Strategies
Evidence-based rehabilitation for male pelvic cancer survivors should include the following components:

Assessment and activation  - Confirm voluntary pelvic floor contraction using digital palpation, biofeedback, or ultrasound. Accurate assessment allows for individualized exercise prescription and objective tracking of progress (Gerlegiz et al., 2025; Ribeiro et al., 2021).

Structured exercise prescription - High-volume pelvic floor muscle training incorporating both slow- and fast-twitch fibers is recommended. Supervised sessions ensure correct technique, increase adherence, and improve outcomes (Fernández et al., 2015; Chen et al., 2023).

Biofeedback and adjunct modalities - Biofeedback supports motor learning and awareness. Electrical stimulation may be used selectively in patients unable to contract muscles effectively (Fernández et al., 2015).

Bowel retraining and coordination exercises - Strategies such as urge suppression, stool consistency management, scheduled toileting, and coordination exercises improve function in patients with low anterior resection syndrome (Jones et al., 2024; Kim & Oh, 2023).

Manual therapy and scar management - Hands-on techniques address fibrosis, scarring, restricted mobility, and pain. Scar desensitization and soft tissue mobilization support improved muscle recruitment and pelvic comfort.

Sexual rehabilitation integration - Pelvic floor muscle training can complement medical penile rehabilitation, graded exposure, and sensory retraining to improve sexual function and comfort (Milios et al., 2020; Wong et al., 2020).

Psychosocial support - Addressing body image, anxiety, and intimacy concerns is essential. Counseling referrals and supportive communication improve adherence and quality of life.

Prehabilitation and telehealth - Preoperative pelvic floor training can improve postoperative outcomes (Chen et al., 2023). Telehealth facilitates remote guidance, adherence monitoring, and access to specialized pelvic rehabilitation services.

Takeaway
Functional impairments after male pelvic cancer treatment are common, but rehabilitation can significantly improve urinary continence, bowel control, sexual function, pain, and overall quality of life. Evidence strongly supports structured, supervised pelvic floor muscle training for urinary incontinence after prostatectomy, with growing support for bowel and sexual rehabilitation in this population. Early, individualized, and evidence-based intervention is key to maximizing recovery.

Clinicians seeking to deepen their skills in treating male pelvic and colorectal cancer survivors are encouraged to register for the Oncology of the Pelvic Floor Level 2A: Male Pelvic and Colorectal Cancers course on December 6–7. This two-day training provides hands-on learning, case-based discussions, and practical strategies for evidence-based assessment and intervention.

References

1. Fernández RA, García-Hermoso A, Solera-Martínez M, Correa MT, Morales AF, Martínez-Vizcaíno V. Improvement of continence rate with pelvic floor muscle training post-prostatectomy: a meta-analysis of randomized controlled trials. Urol Int. 2015;94(2):125-32. doi: 10.1159/000368618. PMID: 25427689.
2. Ribeiro AM, Nammur LG, Mateus-Vasconcelos ECL, Ferreira CHJ, Muglia VF, de Oliveira HF. Pelvic floor muscles after prostate radiation therapy: morpho-functional assessment by magnetic resonance imaging, surface electromyography and digital anal palpation. Int Braz J Urol. 2021 Jan-Feb;47(1):120-130. doi: 10.1590/S1677-5538.IBJU.2019.0765. PMID: 33047917; PMCID: PMC7712707.
3. Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. Sex Med. 2020 Sep;8(3):414-421. doi: 10.1016/j.esxm.2020.03.005. Epub 2020 May 14. PMID: 32418881; PMCID: PMC7471070.
4. Chen, Yi-Hsuan1; Juan, Yung-Shun1,2,3,4; Wei, Wei-Chi1; Geng, Jiun-Hung5; Chueh, Kuang-Shun1,4; Lee, Hsiang-Ying1,2,3,4,*. Effects of Early Pelvic Floor Muscle Training on Early Recovery of Urinary Incontinence after Prostate Surgery. Urological Science 34(1):p 39-45, Jan–Mar 2023. | DOI: 10.4103/UROS.UROS_59_22
5. Wong C, Louie DR, Beach C. A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research. J Sex Med. 2020 Apr;17(4):737-748. doi: 10.1016/j.jsxm.2020.01.008. Epub 2020 Feb 3. PMID: 32029399.
6. Jones S, Edie A, Troop E, Hill JS, Thompson JA. The Effect of Pelvic Floor Rehabilitation on Low Anterior Resection Syndrome After Colorectal Cancer Treatment. J Adv Pract Oncol. 2024 May 22:1-12. doi: 10.6004/jadpro.2024.15.8.4. Epub ahead of print. PMID: 39802528; PMCID: PMC11715399.
7. Kim YM, Oh EG. Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs. 2023 Mar-Apr 01;50(2):142-150. doi: 10.1097/WON.0000000000000958. PMID: 36867038.
8. Gerlegiz ENA, Öztürk D, Gürşen C, Akbayrak T, Özgül S. Structured and supervised pelvic floor muscle training following confirmed contraction in post-prostatectomy urinary incontinence: a systematic review of randomized controlled trials. J Cancer Surviv. 2025 Aug 28. doi: 10.1007/s11764-025-01882-6. Epub ahead of print. PMID: 40877548.

Pelvic rehabilitation practitioners often focus on mechanical concerns such as diastasis recti, pelvic floor weakness, and altered load transfer. However, one foundational element that deserves equal attention in the postpartum period is the ongoing effect of hormonal shifts on connective tissues and joints.

Even after delivery, hormones such as relaxin, estrogen, and progesterone continue to influence tissue behavior, joint mobility, and the body's response to rehabilitation. Understanding how these hormones affect ligament laxity, collagen turnover, and neuromuscular control helps clinicians design safer and more effective recovery programs.

Hormonal Changes in Pregnancy and Early Postpartum
Relaxin is produced by the corpus luteum and placenta, and rises significantly during pregnancy. It is known for its role in “relaxing” muscles and ligaments, especially in the pelvis, to facilitate childbirth. Estrogen and progesterone also rise and modulate connective-tissue metabolism and receptor expression in ligaments.

A recent review highlights that pregnancy-associated hormonal fluctuations (relaxin, estrogen, progesterone) contribute to increased joint laxity (Yalçınkaya et al., 2025). These hormonal effects do not cease abruptly at delivery; they taper variably and may persist for months postpartum, meaning joint and tissue behavior remains altered during rehab.

Hormones Affect Connective Tissue and Joint Mechanics
At the cellular level, relaxin increases the activity of matrix metalloproteinases (MMPs) such as MMP-1, -9, and -13, which degrade collagen and weaken ligament/tendon architecture (Parker et al., 2-22). Estrogen and progesterone increase expression of relaxin receptors in ligaments, amplifying these effects (Yalçınkaya et al., 2025).

In animal and human tendon studies, both relaxin and estrogen have been shown to reduce tendon stiffness and increase compliance, which can reduce load tolerance (Danos et al., 2023). The net mechanical effect is increased joint mobility (or perceived laxity), reduced passive stability, and a greater need for neuromuscular control to compensate.

Clinically, this manifests as more “loose-feeling” joints, increased cushioning of movement, greater reliance on muscular control for stability, and potentially slower progress of load-transfer training. A prospective cohort during pregnancy found associations between estrogen changes and increased low-back/pelvic-girdle pain and disability (Daneau et al., 2025). Although postpartum longitudinal data are sparse, the same mechanisms are likely to persist into the early postpartum period and influence rehab.

Implications for postpartum rehabilitation of joints

1. Assessment and monitoring: Include joint laxity screening (e.g., Beighton score or joint-specific tests) and ask the client about subjective joint “giveness” or instability. Recognize that normal endpoints may be slower to return.
2. Loading progression: Because connective tissues are in a transiently weakened state, adopt more conservative load progressions. Emphasize neuromuscular control (motor control, stability) before heavy mechanical loading. Use subsets such as closed-chain, low-velocity, high-control activities.
3. Tailored timeline: Do not assume pre-pregnancy tissue behavior has returned simply because the organ-based recovery period has ended. A busy schedule, hormonal fluctuations (including lactation, menses return) may continue to modulate tissue mechanics.
4. Patient education: Explain that “it’s not just about the tummy and pelvic floor” but that “your ligaments and joints are still adjusting.” This can help set realistic expectations and foster adherence to graded rehab.
5. Coordination with other practitioners: Ensure communication with obstetric, primary-care, and sports-medicine colleagues about longer-term musculoskeletal implications of hormonal and biomechanical changes. As one review concluded, many women are at elevated risk for persistent joint instability and possible long-term sequelae such as early osteoarthritis (Yalçınkaya et al.., 2025).

Case example
A 34-year-old primipara at 10 weeks postpartum presents with “clicking” in the pubic symphysis region when lifting her 9-month-old toddler and reports a sense of “unstable hips” when stepping sideways. On assessment, she has a Beighton score of 5/9 (with bilateral thumb-to-forearm and elbow hyperextension). She also reports previous hip discomfort in adolescence.

Given her history and findings, you design a graduated program: phase 1 focused on pelvic-floor activation + hip stability in non-weight-bearing by week 12; phase 2 at week 16, introducing unilateral step-downs with low amplitude; phase 3 at week 20, adding higher load functional tasks (carrying child + step).

You monitor joint symptoms, ensure neuromuscular control precedes full load, and educate her regarding ligamentous recovery timeline (~6-12 months). You explain that although the baby is 9 months old, her connective tissues may still be adjusting to hormone-mediated changes.

Conclusion
Hormonal recovery is a critical but sometimes overlooked element of postpartum rehabilitation. The lingering influence of relaxin, estrogen, and progesterone shapes how connective tissues behave and respond to loading. By integrating hormonal awareness into clinical decision-making, pelvic health practitioners can enhance precision, promote safety, and improve long-term functional outcomes. Recovery after childbirth is not limited to muscle or fascia; it is a systemic process involving hormones, tissues, and time.

For clinicians interested in expanding their postpartum rehabilitation skills, consider registering for the upcoming Postpartum Rehabilitation Remote Course scheduled for December 13-14. This course covers acute postpartum management, mental health screening, and musculoskeletal considerations. Participants will learn to modify examinations and interventions for the relevant stages of postpartum recovery. In addition to abdominal wall considerations, typical spine and extremity dysfunctions will be addressed. The course includes instruction on postpartum exercise and return to fitness, with labs covering external perineal screening as well as techniques for the abdominal wall, spine, and ribs, and upper and lower quarter dysfunction.

References

1. Yalçınkaya, B., Sezgin, E. A., Saçıntı, K. G., & Özçakar, L. (2025). Neuromusculoskeletal disorders in pregnancy revisited. Journal of Joint Diseases and Related Surgery, 36(3), 741-750.
2. Parker, E. A., Meyer, A. M., Goetz, J. E., Willey, M. C., & Westermann, R. W. (2022). Do Relaxin Levels Impact Hip Injury Incidence in Women? A Scoping Review. Frontiers in Endocrinology, 13, 827512. https://doi.org/10.3389/fendo.2022.827512
3. Danos, N., Patrick, M., Barretto, J., Bilotta, F., & Lee, M. (2023). Effects of pregnancy and lactation on muscle-tendon morphology. Journal of Anatomy, 243(5), 860-869. https://doi.org/10.1111/joa.13916
4. Daneau, C., Nougarou, F., Abboud, J., Ruchat, M., & Descarreaux, M. (2025). Changes in pregnancy-related hormones, neuromechanical adaptations and clinical pain status throughout pregnancy: A prospective cohort study. PLOS ONE, 20(2), e0314158. https://doi.org/10.1371/journal.pone.0314158