September is Ovarian Cancer Awareness Month. Ovarian cancer is the seventh most common type of malignant neoplasm in women and the eighth cause of mortality for women (Gaona-Luviano et al, 2020). In women who have died from gynecological cancers, ovarian cancer is the leading cause of death (Arora et al., 2021). This type of cancer can originate from any of the ovary's three main components, including the epithelium, stroma, and germinal cells. Per Gaona-Luviano et al., 2020, “epidemiology of this cancer shows differences between races and countries due to several factors including genetic and economic.” Detection of ovarian cancer is problematic because there is no standardized screening process and most cases of ovarian cancer are found in the advanced stages (Gaona-Luviano et al, 2020).

How is ovarian cancer diagnosed?
Sadly, the existing screening tests have a low predictive value. A gynecological evaluation, transvaginal ultrasound, and tumor marker testing (cancer antigen-125/CA-125 assay) can help with early detection strategies but this has not shown a significant effect on the morbidity or mortality of this cancer (Arora et al., 2021).

How is ovarian cancer treated medically?

Research shows that the standard line of care treatment includes surgery and platinum-based chemotherapy. Additional options including anti-angiogenic bevacizumab and Poly(ADP-ribose) polymerase (PARP) inhibitors have also been used more recently. (Arora et al., 2021)

What are the outcomes of an ovarian cancer diagnosis?
There is a high rate of recurrence after the initial detection treatment. Many of the cases re-occurred and these secondary cases were less curable with increased incidence of treatment failures (Arora et al., 2021).

What are ovarian cancer risk factors?
Some risk factors include advanced age, early menarche, late menopause, family history, nulliparity, obesity, perineal talc use, smoking, endometriosis, and hormone replacement therapy (Arora et al., 2021). Some protective factors include oral contraceptives, bilateral tubal ligation or salpingectomy, breastfeeding, and multiparity (Arora et al., 2021).

Some research shows there may be some health disparities in the diagnoses between Non-Hispanic Black women compared to Non-Hispanic White women. In a study by Washington et al. in 2023 53,367 women were included in the analysis with the profile being 82% Non-Hispanic White, 8.7% Non-Hispanic Black, 5.7% Hispanic, and 2.7% Non-Hispanic Asian/Pacific Islander. They found that the Non-Hispanic Black race was associated with a higher risk of death than Non-Hispanic White race and Non-Hispanic Black women versus Non-Hispanic White women had an increased risk of mortality among those with low and mid socioeconomic status groups.

In response to this potential inequity, the National Cancer Institute has launched 3 studies to look at these patterns to “better understand the causes of racial and ethnic disparities among women with ovarian cancer.” These studies will examine whether the treatments with these patient populations were consistent with standard clinical guidelines and ensure all patients received quality care. Additional studies will look at a “cells-to-society approach” to assess the biology behind these trends. In both cases, the researchers will assess a range of potential factors that can affect disparities, from the molecular makeup of tumors to environmental factors, and comorbidities (NCI, 2024).

What can pelvic health providers do to help?
As pelvic health providers, we can educate ourselves on how best to screen and refer our patients to ensure early diagnosis and medical treatment if we hear anything suspicious. It is difficult to self-advocate in this current medical climate and having a skilled provider guiding the questions to ask and the support to seek is invaluable. If a patient is already into their treatment journey, we can provide the needed rehabilitation support including things like coordination and strengthening of the core and pelvic floor, stretching and positioning to lengthen tight areas, scar mobilization, patient education, and symptom management with the patient for any symptoms that may pop up throughout their course of care.

If you’re unsure that you have these skills in your skill set, please check out the Oncology of the Pelvic Floor Series to gain more knowledge and experience in these areas to better help patients with these diagnoses. Certified Lymphatic Therapists may skip this course and move on to the level Oncology of the Pelvic Floor Level 2A and Level 2B courses.

• Oncology of the Pelvic Floor Level 1, next scheduled for November 2-3, 2024, is the first course in the series and focuses on topics that prepare practitioners to be part of the interdisciplinary oncology team. Topics will include the basics of cancer: terminology, staging, medical treatment, and the sequelae of these medical treatments. These topics include the lymphatic system as well as issues that are commonly seen in a patient who has been diagnosed with cancer such as cardiotoxicity, peripheral neuropathy, and radiation fibrosis.
• Oncology of the Pelvic Floor Level 2A, (not yet scheduled for 2025), builds on information presented in Oncology of the Pelvic Floor Level 1 and focuses on male pelvic cancers (prostate cancer, penile cancer, and testicular cancer), colorectal cancer, and anal cancer including risk factors, diagnosis, and prognosis. Topics discussed include sequelae of the medical treatment of cancer and how this can impact a patient’s body and quality of life, rehabilitation, and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy. Participants MUST register with a partner, or plan to have a volunteer available to work on during course labs.
• Oncology of the Pelvic Floor Level 2B, next scheduled for December 7-8, 2024, builds on information presented in Oncology of the Pelvic Floor Level 1 and focuses on gynecological and bladder cancers including risk factors, diagnosis, and prognosis. Topics discussed include sequelae of the medical treatment of cancer and how this can impact a patient’s body and quality of life, rehabilitation, and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy. Participants MUST register with a partner, or plan to have a volunteer available to work on during course labs.

References:

• Arora, T., Mullangi, S., & Lekkala, M. R. (2021). Ovarian cancer.
• Gaona-Luviano, P., Medina-Gaona, L. A., & Magaña-Pérez, K. (2020). Epidemiology of ovarian cancer. Chinese Clinical Oncology, 9(4), 47-47.
• NCI. Ovarian cancer studies aim to reduce racial disparities. Ovarian Cancer Studies Aim to Reduce Racial Disparities - NCI. (2024, June). https://www.cancer.gov/news-events/cancer-currents-blog/2020/ovarian-cancer-racial-disparities-studies#:~:text=Credit:%20iStock,impeded%20research%20in%20this%20area.
• Washington, C. J., Karanth, S. D., Wheeler, M., Aduse-Poku, L., Braithwaite, D., & Akinyemiju, T. F. (2024). Racial and socioeconomic disparities in survival among women with advanced-stage ovarian cancer who received systemic therapy. Cancer Causes & Control, 35(3), 487-496.

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 women, men, and children with a variety of Pelvic Health dysfunction. 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.

She 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 the present time. In 2020, She opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University 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.

If you saw Ethical Considerations for Pediatric Pelvic Health and thought “Why are they making ANOTHER ethics class?” please let me take a moment to explain its origin and purpose in the Herman and Wallace course offerings. I wrote my Pediatric Pelvic Floor Play Skills course when I had colleagues asking for ways to play with their patients. When I started teaching this class, some of the most common questions that came up seemed like ETHICAL questions. How do we handle pediatric care in different settings? How do we get consent from minors? If a child says no but their legal guardian wants the assessment done, what does the provider do?

Pediatric Pelvic Floor Play Skills is a class written to help providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. One of the tricky parts of working with children is including the child in their care plan and coordinating with caregivers. In this course, talk about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective. While in Ethical Considerations for Pediatric Pelvic Health, we review the different overall milestones, as well as what age-appropriate expressions of sexuality may look like as children develop toward adulthood.

Let's talk about Pediatric Care
When we say “pediatric” this can span from infants to teenage age groups. Dealing with a crying baby will be different decision-making versus a toddler in a tantrum or a defiant teen. The pediatric population is a vulnerable group because they can’t advocate for themselves, their own interests, and their health to protect themselves from harm. When we consider decision-making with a child, a therapist should consider things like their development, family structure, competence, and education levels. Children develop in a variety of areas including their fine and gross motor skills, language, cognitive, social, emotional, and behavior.

In pediatric care, obtaining informed consent has two parts because it requires therapists to secure consent from caregivers and to seek assent from the child. Once they have obtained the parent’s permission, therapists should explain the procedures, potential benefits, and risks in an age-appropriate manner to the child. Therapists have to make sure the child feels comfortable and involved in their care at each step.

Pelvic health providers should establish clear guidelines about what information will be shared with caregivers and what will remain confidential when working with children, especially tweens and teens. This helps the therapist to build trust with the patient and encourages open communication with the patient. We must also consider what the caregivers are entitled to hear about their child’s life and medical care. For example, if a tween wants to talk to you about sex, do you feel equipped with the ethical implications for yourself in your practice? What about if a child discloses a sexual assault at school? What about if a teenager tells you they are pregnant but hasn’t told their parents? This class will give some guidelines to make these decisions and provide a peer “think tank” to further discuss.

One of the easiest ways to be an effective pediatric provider includes communication with the patient and their support system. Make sure to review topics like the condition, treatment options, and expected outcomes to empower them to make informed decisions. Keep your communication clear and provide educational materials that are accessible and understandable. Make sure to check with caregivers about what words and pictures they are comfortable with the child seeing and hearing. Some children or caregivers may have personal, religious, or cultural implications that may limit what education they want the child to be exposed to.

Every child is unique, and their treatment should reflect their individual needs, preferences, and circumstances. Therapists should listen to the child and their support network, and incorporate their feedback into the plan of care. Consider their life and routine to make sure their care and homework fit into their daily schedule. Advocating for the needs and rights of pediatric patients is a critical aspect of ethical care. Therapists may need to recommend resources, treatments, and accommodations, and promote awareness and education about pediatric pelvic health issues within the broader community. This may include coordinating with a child’s daycare, school, or other medical providers.

What course is right for you?

• Ethical Considerations for Pediatric Pelvic Health on October 13th - Learn more about the ethical challenges pediatric pelvic health practitioners may experience including consent, managing situations of trauma and abuse, and managing autonomy for minors. If you work with pediatric patients on a regular basis, this class can be an additional step in your practice. It will review topics like consent, abuse, education, communication, and diagnoses that tend to have more ethical considerations with pediatric patients. Join us to review background information and then discuss, as a group, different cases and ethical situations to help further your pediatric clinical practice.
• Pediatric Pelvic Floor Play Skills on October 20th - This is a beginner-level course and is a good fit for providers who do not have a lot of experience treating pediatric patients and want to learn how to make sessions enjoyable and effective. In this course, we discuss specific concerns and considerations by age, strategies to bring to a provider's practice, sample home programs, equipment purchase lists (with a budget in mind), tips for helping get families on board with the implementation of care, and resources such as outcomes measures, developmental milestone checklists, and recommendations things parents ask for like how to talk about periods and sex.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

I am a graduate of Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my 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 the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman and Wallace since 2020 and have over 150 hours of lab instruction experience.

Dawn Sandalcidi will be a keynote speaker at HWConnect 2025 on March 28-30, 2025. You can also join her in upcoming courses: Pediatric Pelvic Floor, Diaphragm, and Postural Development: Intro to Core Function and Continence in Children on September 29th, Pediatrics Level 1 -Treatment of Bowel and Bladder Disorders on October 26-27, or Pediatrics Level 2 - Advanced Pediatric Bowel and Bladder Disorders on November 2-3.

As physical and occupational therapists, we aim to provide the best possible care for our young patients by understanding and addressing the underlying mechanisms affecting their health. The diaphragm is one of the most important yet often overlooked structures. This muscle plays critical roles in both respiratory and postural functions and has far-reaching implications for the stability and health of children.

In this blog, we’ll explore the anatomy, function, and clinical relevance of the diaphragm, its connections to the pelvic floor muscles, and the broader implications for pediatric therapy.

Anatomy Of The Diaphragm

In order to appreciate the functions that the diaphragm plays in breathing and movement, you must first understand the anatomy. The diaphragm is the thin, dome-shaped muscle that separates the thoracic and abdominal cavities. Its structure is divided into two primary components:

1. The Crural (Vertebral) Portion: The crural portion, or muscular “legs” of the diaphragm, originates from vertebrae of the lumbar spine, providing stability and anchoring the diaphragm in place.
2. The Costal Portion: The costal portion originates from the xiphoid process of the sternum and the upper margins of the lower rib pairs.

At the center of the diaphragm lies the “central tendon”, the non-muscular aponeurosis at which the muscular fibers converge. This tendon acts as a pivotal point during the contraction of the diaphragm.

When the diaphragm contracts during inspiration, the dome of the diaphragm descends, shortening the muscle fibers and increasing the volume of the thoracic cavity. This action decreases intrapleural pressure, allowing the lungs to expand and fill with air. At the same time, abdominal pressure increases as the diaphragm displaces the rib cage and moves downward.

The relationship between the diaphragm and the rib cage is vital for effective breathing and functional movement. Keep this in mind when working with kids who have low tone or poor strength. Breathing mechanics and diaphragm optimization are essential to assess. Proper contraction of the diaphragm not only facilitates lung expansion but also ensures that the core and extremities are stabilized, leading to efficient and stable movement patterns.

Let’s take a closer look at these functional connections.

The Diaphragm’s Connections To Posture And Pelvic Floor

A critical concept in understanding the diaphragm’s function is the Zone of Apposition (ZOA). The ZOA is the vertical area of the diaphragm that extends from the inside of the lower ribs to the top of the diaphragm. This zone maintains the diaphragm's dome shape, which is important for effective breathing.

When the ZOA is well-maintained, the diaphragm can contract efficiently without the need for accessory muscle recruitment. This efficiency prevents compensatory breathing patterns that can lead to respiratory and postural issues.

Conversely, a decreased ZOA can result in poor diaphragm contraction, leading to inefficient breathing and overuse of accessory muscles. Musculoskeletal effects on posture can include issues such as:

• Anterior rib flare
• Lung hyperinflation
• Hyperlordosis
• Protruding abdomen
• Weakness of the anterior core muscles with poor pressure system management

The diaphragm works in close coordination with the pelvic floor muscles (PFM) and the abdominal muscles. This interaction is vital for managing intra-abdominal pressure (IAP) and maintaining stability in both the thoracic and abdominal cavities when breathing.

1. During inspiration, the diaphragm descends, causing an eccentric lengthening of the abdominals and the PFM, which stabilizes the core.
2. During exhalation, the diaphragm relaxes and ascends, while the abdominals and PFM contract concentrically.

This basic overview of the diaphragm's connections is expanded upon in my live online course, Pediatric Pelvic Floor Diaphragm and Postural Development, where I delve deeper into how these relationships impact children with pelvic floor issues like constipation, diastasis rectus, and even cystic fibrosis.

The diaphragm, in coordination with the abdominal muscles and the PFM, helps to stabilize the spine and pelvis during movement. This stabilization is essential for maintaining balance and posture when learning developmental motor skills.

This coordination also ensures that pressure within the thoracic and abdominal cavities is managed effectively, influencing respiratory capacity and lymphatic drainage.

Furthermore, the fascial connections from the diaphragm establish healthy function of many organ systems. Let’s take a look at this in more detail, so you can understand how this directly affects your practice as a pediatric therapist.

The Diaphragm’s Fascial Connections To Organ Systems
Beyond its muscular and respiratory functions, the diaphragm is also deeply interconnected with the body’s fascial system. Fascia surrounds every structure in the body, providing support and facilitating movement. Fascia has contractile properties, so a problem with the diaphragm or its related structures can cause dysfunction along the entire fascial chain.

The diaphragm has direct fascial connections to several key organs, including:

• Heart
• Lungs
• Liver and Colon
• Esophagus

These fascial connections highlight the diaphragm’s role in managing information between the chest and abdomen, as well as its influence on organ function. When kids have dysfunction in their diaphragm or its associated fascial structures, this can lead to a range of issues, such as digestive, breathing, and swallowing problems.

The diaphragm also influences postural stability through its relationship with the glottis, which controls airflow through the vocal cords. Engagement of the glottis during upright perturbations or stability tasks enhances thoracic stability. The proper function of the glottis needs to be considered when working with kids on breathing mechanics, trunk stability, or pelvic floor engagement.

You must also look at neurological connections to the diaphragm, such as those involving the phrenic, vagus, trigeminal, and hypoglossal nerves. What many therapists often see as classic mechanical issues or classic digestive issues, can actually have distal neurological origins. This includes mechanical conditions such as headaches and thoracic outlet syndrome, and autonomic digestive conditions such as gastroesophageal reflux, aerophagia, and functional gastrointestinal disorders.

Get good at connecting the pieces and understanding the root causes of dysfunction, rather than simply treating the kids’ symptoms.

Clinical Implications For Pediatric Therapy
For pediatric therapists, understanding the diaphragm’s role in respiration, postural stability, and its broader connections within the body is essential for effective treatment. Children with conditions such as cerebral palsy (CP), respiratory issues, constipation, and musculoskeletal pain can benefit significantly from interventions that target the diaphragm and its associated structures.

For example, in children with CP, research has shown that kids with better diaphragmatic function exhibit greater ambulatory mobility, abdominal expansion, and respiratory function compared to kids with impaired diaphragmatic function. You should prioritize treatment of the diaphragm for children with CP, especially those who are non-ambulatory. [1]

Similarly, addressing diaphragmatic function can play a critical role in managing pediatric patients with respiratory conditions, such as asthma. Ensuring that the diaphragm maintains its dome shape and ZOA can improve the child’s breathing efficiency, reduce the reliance on accessory muscles, and enhance overall respiratory function.

Lastly, the diaphragm’s role in maintaining intra-abdominal pressure and coordinating with the pelvic floor muscles is crucial for managing conditions like constipation and urinary incontinence. By optimizing diaphragmatic function, you can support children’s pelvic floor function and help improve their bowel motility and urinary continence.

There are many widespread health implications that you have the power to influence as a pediatric therapist! If you are looking to deepen your understanding of the diaphragm and its role in pediatric health, join me virtually for my live Pediatric Pelvic Floor Diaphragm and Postural Development course on September 29, 2024.

This course will provide you with the knowledge and tools you need to enhance your practice and improve outcomes for your young patients. Don't miss this opportunity to expand your skill set and make a meaningful difference in the lives of the children you treat.

Reference:

1. Bennett S, Siritaratiwat W, Tanrangka N, Bennett MJ, Kanpittaya J. Diaphragmatic mobility in children with spastic cerebral palsy and differing motor performance levels. Respir Physiol Neurobiol. 2019 Aug;266:163-170. doi: 10.1016/j.resp.2019.05.010. Epub 2019 May 21. PMID: 31125702.

AUTHOR BIO

Dawn Sandalcidi PT, RCMT, BCB-PMD

Dawn Sandalcidi is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. She graduated from SUNY Upstate Medical Center in 1982 and is actively seeing patients in her clinic Physical Therapy Specialists, Centennial CO.

Dawn is a national and international speaker in the field, and she has gained so much from sharing experiences with her colleagues around the globe. In addition to lecturing internationally on pediatric bowel and bladder disorders, Dawn is also a faculty instructor at the Herman & Wallace Pelvic Rehab Institute. Additionally, she runs an online teaching and mentoring platform for parents and professionals.

In 2017, Dawn was invited to speak at the World Physical Therapy Conference in South Africa about pediatric pelvic floor dysfunction and incontinence. Dawn is also Board-Certified Biofeedback in Pelvic Muscle Dysfunction (BCB-PMD). She has also been published in the Journals of Urologic Nursing and Section of Women’s Health.

In 2018, Dawn was awarded the Elizabeth Noble Award by the American Physical Therapy Association Section on Women's Health for providing Extraordinary and Exemplary Service to the Field of Physical Therapy for Children.

Movement competence (or Movement Literacy) is defined as the development of sufficient skills to ensure successful performance in different physical activities. Often used in the world of sports and youth, it also applies to our everyday activities. For example, standing up from a chair or toilet, getting in/out of a car, moving our body from Point A to Point B (and the difference between the ground being even and dry vs uneven and icy).

In our course, Osteoporosis Management: An Introductory Course for Healthcare Professionals, Dr Frank Ciuba and I approach the starting point for individuals with low bone mass (osteopenia or osteoporosis), from an “optimal alignment position.” Patients start supine with hips and knees flexed and are educated on what optimal alignment feels like. Many need to be propped using pillows, towels, or blocks behind their heads, forearms, or between their knees to achieve “their optimal alignment.” Breathing and awareness play a huge role in activating core musculature to sustain this alignment when moving to a vertical position such as sitting or standing. In vertical, our weight-bearing forces and gravity should pass down through the skeleton to take advantage of bone-building benefits. We use dowel rods, broom handles, and walls to give feedback. Optimal alignment can and should be taught in a variety of positions: side-lying, prone, hands and knees, ½ kneeling as we move up the developmental chain.

Hip Hinging, a well-known concept by therapists, must be practiced and mastered for patients with low bone mass to reduce the risk of vertebral fractures. Activities that involve bending at the waist such as brushing teeth, making a bed, and putting dishes in the dishwasher all place the anterior portion of the vertebral bodies under pressure and increase fracture risk.

Advancing from static optimal alignment postures to dynamic optimal alignment is a whole different ballgame; akin to advancing from sitting in a car to driving a car. There are many moving parts - pun intended.

Just as in athletics, mastery comes from repetition. It is not enough to teach patients a safe movement pattern one time, hand them a sheet of paper with pictures, and expect them to be able to comply and gain competence. Reinforcing proper technique and helping them become aware of compensation strategies (hunching shoulders when lifting objects, overarching the back when reaching overhead, etc.) are critical if Movement Competency is to “stick.”

I like to think of movement competency as building a house. First, you need a firm foundation before putting up the walls and roof. Our patients require that foundation to be able to layer on more complicated patterns of movement.

Please join us for this one-day course on September 14th or November 2nd to learn more Osteoporosis-safe exercises, balance and gait activities, and additional ways to help your patients build a strong foundation for movement competence!

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.

Did you know that September is prostate cancer awareness month? As of 2020, prostate cancer is the most common cancer in men worldwide. Prostate cancer accounts for one in every 14 cancer diagnoses globally, and 15% of all cancers in patients born with a prostate. It ranks second in terms of cancer mortality in this population, second only to lung cancer.(1) A recent Lancet Commission on prostate cancer is projecting a significant increase in the number of new cases of prostate cancer annually. They are projecting that the number of new cases will rise from 1.4 million annually worldwide in 2020 to 2.9 million by 2040. This is due to changing age structures within the population and improved life expectancy.(1) This projected rise in prostate cancer cannot be prevented by lifestyle changes or public health interventions. Due to this projected increase in new cases, screening is a must and will be critical to better prognosis and survival for these patients. Along with a rise in prostate cancer, it is expected that other conditions such as diabetes and heart disease will mirror the projected increase in prostate cancer. It is recommended that screening and early diagnosis programs should not only focus on prostate cancer but “men’s health more broadly.”(1)

The Commission also recommended outreach programs to educate the population about prostate cancer. Social media and traditional media were both recommended to be used to reach individuals who may not be accessing medical care as frequently. This is something that we as rehabilitation clinicians can help with! As a rehabilitation clinician, we are expert educators for our patients. So much of what we do with patients is educate them about their bodies and things that can be done to assist in healing. We can take it a step further and educate them to have general health checks that would include screening for prostate cancer, among other screens such as for heart disease, and diabetes. We may also be able to reach other individuals by educating our patients to encourage their family and friends about the importance of general health screens. Many of us are also very adept at using social media to reach the community. Can we post something about Prostate Cancer Awareness Month? How easy is it to post a quick word about the expected rise in prostate cancer diagnoses and encourage patients to see their doctor for their annual health exam? Let’s all try to reach a few additional individuals this month in honor of Prostate Cancer Awareness Month! If we each are able to get a few more individuals in for screening, what impact could we make? This is something we should continue to do over the next several decades to encourage our patients to health screens! Mark your calendars every September to honor this month and educate our patients and their families!

To learn more about prostate cancer and how to treat this population, take Oncology of the Pelvic Floor Level 2A. This is an online course where you can learn specific techniques to help patients who have been diagnosed with pelvic cancers and colorectal cancers. It is offered September 7-8. Register today!

Reference:

1. James N, Tannock I, N’Dow J, et al. (2024). The Lancet Commission on prostate cancer: planning for the surge in cases.  The Lancet Commissions. 403(10437): P1683-1722. DOI:https://doi.org/10.1016/S0140-6736(24)00651-2

AUTHOR BIO:
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion for helping oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include: “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman and Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies, and physicians.

Outside of work, Allison enjoys spending time with her family, caring for her animals, reading, traveling, and most importantly of all, being a mom! She lives in the Denver metro area with her family.

The Herman & Wallace course catalog does not include a pessary-focused course at the time of posting. Pelvic Organ Prolapse is discussed in Pelvic Function Level 1 and more in-depth in Pelvic Function Level 2B.

A pessary is a device that is placed in the vaginal canal to support the pelvic organs. They have been used by humans for millennia to treat pelvic organ prolapse (POP), being crafted of various materials from pomegranate to cork¹. Most modern-day pessaries are made of silicone, although some medical pessaries are even engineered to release estrogen. Recent research suggests that combining pessary use with pelvic floor muscle training for treating POP may be even more effective than pelvic floor muscle training alone².

A pessary can be worn only during an activity that typically provokes symptoms, such as running, or used almost continuously with periodic cleaning. People looking to avoid or delay pelvic organ prolapse surgery, such as those planning to give birth, may especially benefit from pessary use. Many transgender and nonbinary people with a front canal also find pessary use helpful for reducing POP symptoms.

Pessaries have additional benefits beyond improving prolapse symptoms. For example, some pessaries are designed to mitigate urinary incontinence by applying pressure to the urethra¹. A 2024 study even indicated that they may improve sexual wellness in people with pelvic organ prolapse². One case study series suggests that intersex people who have undergone vaginoplasty or neovaginoplasty may also benefit from pessary use for maintaining the patency of the canal⁵.

Traditionally in the United States, pessaries have been placed by medical professionals rather than rehabilitation professionals (although some PTs at the Veteran Affairs were involved in fitting pessaries under the guidance of urogynecologists). In 2021, the American Physical Therapy Association’s Academy of Pelvic Health convened a Pessary Task Force to look at the feasibility of physical therapists fitting and managing pessaries. In 2022, the Academy of Pelvic Health released its position statement to include pessary fitting and management in the scope of practice of pelvic health physical therapists in the United States and its five territories. By the end of 2022, the Academy of Pelvic Health hosted its first pessary fitting course. Several more courses have been offered since then.

If you are looking to include pessary fitting and management in your clinical toolkit, first check with your state physical therapy board to ensure that it is permitted where you practice. If your state does allow pessary fitting, select a class that ideally includes both didactic and lab-based coursework. Be aware that most will require a pelvic health fundamentals class with internal examination as a prerequisite. Once you have passed your pessary class, it will be important to maintain solid connections with advanced clinicians (i.e., trusted urogynecologists and gynecologists) who you can coordinate with on more complex cases, such as those that present with vaginal dermatoses or genitourinary syndrome of menopause.

Physical therapists specialize in showing clients how to tend and support their bodies. Active participation in pessary fitting and management is a way to help the nearly 40% of people with vaginal canals who are expected to develop pelvic organ prolapse⁷.

Note: The author does not currently know of any occupational therapists fitting pessaries in the United States, but they hope that this becomes a part of OT scope in the future.

References

1. Shah SM, Sultan AH, Thakar R. The history and evolution of pessaries for pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct. 2006;17(2):170-175.
2. Jin C, Yan H, Shang Y, et al. Real-world clinical effectiveness of nonsurgical treatments for female with POP-Q stage II cystocele: a retrospective analysis of therapeutic efficacy. Transl Androl Urol. 2024;13(4):483-492.
3. Petter Rodrigues M, Bérubé MÈ, Charette M, McLean L. Conservative interventions for female exercise-induced urinary incontinence: a systematic review. BJU Int. Published online July 23, 2024.
4. Nemeth Z, Vida P, Markovic P, Gubas P, Kovacs K, Farkas B. Long-term self-management of vaginal cube pessaries can improve sexual life in patients with pelvic organ prolapse, results from a secondary analysis. Int Urogynecol J. Published online August 5, 2024.
5. Mensah V, Christianson MS, Yates M, Tobler K, Kolp LA. Novel use of a pessary to maintain vaginal patency following vaginoplasty or neovaginoplasty for mullerian anomalies or agenesis. Fertility and Sterility. 2013;99(3):S37.
6. Wang B, Chen Y, Zhu X, et al. Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Front Public Health. 2022;10:975829.

AUTHOR BIO
Ken McGee, PT, DPT

Ken McGee, PT, DPT, (they/he) is a queer transmasculine pelvic health physical therapist based in Seattle. Their mission is to bring greater awareness to the pelvic health needs of the LGBTQIA2S community. They enjoy mentoring other rehabilitation professionals to better care for people of all genders.

Ken received their Doctor of Physical Therapy from the University of Washington in 2014 and their board certification as a Women’s Health Clinic Specialist (WCS) in 2018. Ken has lectured nationally and internationally on birth tears. Their practice, B3 Physical Therapy and Wellness, centers on transgender and perinatal rehabilitation. Ken also provides peer bodyfeeding support and doula care.

As musculoskeletal specialists, we are adept at identifying postural dysfunction. I often explain to patients how their ribcage might shift posteriorly relative to the plumb line and how gravity can amplify forces on specific structures. To help patients understand the difference between their habitual non-optimal posture and a more optimally aligned posture, many occupational and physical therapists use the IPA’s Vertical Compression Test (VCT). This test effectively demonstrates how improved alignment facilitates better weight transfer through the base of support. Sometimes this test reproduces back or pelvic pain which allows the patient to understand how their posture might be a contributing factor to them not feeling their best. In addition to the VCT, I incorporate Mountain Pose as an additional kinesthetic tool for postural retraining.

Many moons ago, I was working with a lovely client on embodied postural awareness using Mountain Pose. I suggested she could close her eyes if she felt comfortable (some people will feel safer lowering their gaze instead of closing their eyes). Working from the ground up, she realized her weight was predominantly in her heels. When I guided her to shift her weight forward by hinging from the talocrural joint, she experienced an “aha moment,” saying, “It feels like my pelvic floor just sighed.” She hadn’t been aware that her habitual posture involved standing with her weight behind the plumb line, which contributed to overactivity of the posterior pelvic floor. Once she adjusted her base of support from the ground up, she felt a significant release in her habitual tension.

At our follow-up visit, the client noted an increase in her postural awareness. She was surprised by how frequently she noticed her pelvic floor gripping in a state of overactivity. She also reported enhanced awareness during her standing yoga postures in class. Grounding down through the feet, cued as imagining the soles of the feet getting magnetically drawn into the floor, can be a useful verbal cue to assist with letting go of unnecessary gripping. The experience of achieving embodied optimal alignment has given her greater self-efficacy, and she’s successfully translated this improved postural awareness into her daily life. Self-awareness and empowerment are central goals in my physical therapy practice, and integrating yoga into this process makes my clinical work even more fulfilling.

To learn more, join Dustienne in her remote course Yoga for Pelvic Pain this September 14-15! This course discusses a variety of pelvic conditions including interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Dustienne also describes the role of yoga within the medical model, contraindicated postures, and how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge in this course.

Author Bio:
Dustienne Miller PT, MS, WCS, CYT

Dustienne Miller 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 Radio City Christmas Spectacular. She is an assistant professor of musical theater and jazz dance at the 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.

Trauma. The word holds so many meanings. Say the word and depending on your perspective - it could mean Trauma (like trauma center which is physical injury focused) or trauma (like unwanted experience causing adverse socioemotional consequences). In medical environments, the former would be qualified as ‘Big T’ Trauma, and the latter would be ‘little t’ trauma. Once you are immersed in the ‘little t’ trauma field, the Big and little traumas change meanings. The Big T Trauma would describe a significant event, whereas the little t trauma would include multiple, smaller microaggressions accumulating into adverse effects.

I have worked in trauma since 1996. And the changes have been vast. Thankfully, long gone are the days that I am educating physicians in the ER on how to complete a rape kit and how to perform care that is patient-focused and empowering. I would like to think that advocates are no longer having to explain to medical providers that RU22 is not an ‘abortion pill’ but a medicine that is required to be offered BY LAW in Illinois (SASETA) to reduce the risk of implantation after a rape. I started working in ERs advocating for the medical and legal rights of sexual assault survivors BEFORE Law-and-Order SVU brought these patients into mainstream culture in 1999. Thank you, Olivia and Elliot for bringing this awareness into our living rooms.

When I was a mental health counselor in the 90s and 2000s, it was quite remarkable that trauma was not included in mental health services. PTSD definitions were changing frequently within the DSM (Diagnostic Statistical Manual) during this time. Definitions and inclusion of trauma within mental health continue to change frequently to this day. In the 90s, I was working with youth in lower socioeconomic populations and their trauma was both palpable and unseen. Also, during this time, education and awareness of developmentally appropriate sexual health were not a thing! I remember my supervisor calling me and asking me what to do with a teenage female who was masturbating with a brush. And I was like OK - which side of the brush… is she masturbating for pleasure which is normal/appropriate or is she hurting herself and we need to screen her for sexual abuse? I screened her for abuse (my supervisor was not comfortable- she ended up disclosing her own abuse) and the teenager did not disclose abuse or self-harming behaviors, so it was normal sexual behavior. I could go on about cultural and gender taboos, but that is literally power for the course.

When I made the change from mental health to physical therapy in the mid-late 2000s it soon became apparent that trauma was not considered within rehabilitation. In 2011, I created the first in-service on trauma - focusing on education, awareness, and teaching Polyvagal theory. Stephen Porges introduced Polyvagal much earlier in 1994 and I am looking forward to the day he receives the Nobel Prize for his work, as he should. I am ecstatic that Polyvagal is no longer an obscure construct. I see many friends and fellow clinicians normalizing the terms neuroception and interoception, and I am elated. This is quite different from when ten ten-plus years ago, the response to my course was a not-so-friendly ‘Stay in your lane, PT’ (and this is not addressing the fact that our fellow OT and SLP comrades are doing this challenging work). I am so glad that is not the case anymore. Trauma-informed care (TIC) is becoming the norm, not the exception. And I am so happy to see what other rehabilitation specialists are doing within the field! There is so much space for us all.

Here is an outline of what we expand upon within the course Trauma Awareness for the Pelvic Therapist:
Trauma-informed care (TIC) is a universal approach within healthcare that recognizes and responds to the impact of traumatic experiences on individuals. It aims to create a supportive environment that promotes healing and recovery while minimizing the risk of re-traumatization. The core principles of trauma-informed care include understanding the prevalence and effects of trauma, recognizing the signs and symptoms of trauma in patients and staff, and integrating knowledge about trauma into practices, policies, and procedures. In order to understand the effects of trauma, an understanding of neurobiology of the brain and function of the autonomic nervous system are foundational.

Key Principles of Trauma-Informed Care:
Safety:
Ensuring physical and emotional safety for the CLINICIAN, clients, and staff. This involves creating an environment where individuals feel secure and respected.

Trustworthiness and Transparency:
Building trust through clear, consistent, and transparent practices. Ensuring that decision-making processes are transparent, and that information is shared openly.

Peer Support:
Encouraging and incorporating peer support and mutual self-help as essential components of trauma-informed care. Peer support helps to build trust, enhance collaboration, and promote recovery.

Collaboration and Mutuality:
Emphasizing partnership and the leveling of power differences between staff and clients. Everyone involved in the care process collaborates and shares in the decision-making.

Empowerment, Voice, and Choice:
Prioritizing the empowerment of individuals and recognizing their strengths. Offering choices and supporting individuals in their decisions helps to foster autonomy and resilience.

Cultural, Historical, and Gender Issues:
Being responsive to cultural, historical, and gender contexts. This involves recognizing and addressing the impact of systemic oppression and discrimination and promoting cultural competence among staff.

Implementation Strategies
Training and Education:
Providing ongoing training for EVERYONE on the principles of trauma-informed care and the impact of trauma. This includes recognizing trauma responses and learning how to create a supportive environment.

Policy and Procedure Review:
Introducing TIC and revising organizational policies and procedures to ensure they reflect trauma-informed principles. This includes practices related to intake, assessment, treatment planning, and discharge.

Environment Modification:
Creating physical spaces that promote a sense of safety and calm. This can involve changes to the layout, lighting, noise levels, and decor.

Client/Patient Involvement:
Involving clients in the planning and evaluation of services to ensure their perspectives and needs are considered.

Support Systems:
Providing support for EVERYONE to prevent burnout and secondary traumatic stress. This can include supervision, debriefing sessions, and access to mental health resources.

Trauma is personal and individualized. There is no one size fits all or one technique can be used for all.

Benefits of Trauma-Informed Care:
Improved Outcomes:
Trauma-informed care can lead to better engagement, adherence to treatment, and overall outcomes for clients/patients.

Reduced Re-traumatization:
By creating a supportive and understanding environment, the risk of re-traumatizing individuals (read: ALL of us) is minimized.

Enhanced Trust:
Building trust between clients/patients and providers fosters better communication and a stronger therapeutic relationship.

Empowerment and Recovery:
Empowering individuals to take an active role in their care promotes recovery and resilience.

Remember, trauma-informed care is a comprehensive approach that involves understanding, recognizing, and responding to the effects of trauma. By integrating trauma-informed principles into practice as UNIVERSAL PRECAUTIONS, we can create safer, more supportive environments that promote healing and recovery for ourselves and all individuals.

It has been an honor to bring this course, Trauma Awareness for the Pelvic Therapist, into the rehabilitation space. In the last 10 years, and especially since COVID-19, it is beautiful to see how TIC has become mainstream. One word of caution: We need to watch out for end-of-spectrum gas lighting. We all have seen patients whose symptoms and experiences have been minimized when their trauma has not been taken into consideration. This can also happen at the other end of the spectrum. I had a patient who sought out gynecological treatment from a ‘trauma-focused gynecologist.’  This patient we all know - chronic pelvic pain with a history of endo, PCOS, IBS-M, and IC. When she went to this clinician, she was told that her pain was caused by trauma, whether she remembered the trauma or not. The patient is a counselor and has been doing much work with her mental health team. She was open to ‘unknown trauma’ but we both thought she should seek another provider. Two weeks later, she had surgery for appendicitis.

TIC allows us to refocus on our work within rehabilitation and is open and supportive towards all people. This work is AMAZING. This work is HARD. This work is quite frankly one of the reasons we were placed on this earth. To be present for another person’s pain, whatever type of pain that is - is one of the most special care one can give to another.

Please be so proud of all the work you have done. Know that you are enough. And that you can be present for others. I hope you find even more support and knowledge with any trauma course that you choose to take, I just hope to meet you in mine on September 21-22!

AUTHOR BIO:
Lauren Mansell DPT, CLT, PRPC

Lauren received her Doctor of Physical Therapy degree from Governors State University and a Bachelor's Degree in Psychology and Sociology from Northwestern University. Before becoming a physical therapist, Lauren counseled suicidal and homicidal SES at-risk youth who had survived sexual violence. Lauren was certified as a medical and legal advocate for sexual assault survivors in 1999 and has advocated for over 130 sexual assault survivors of all ages in the ED. Lauren's physical therapy specialty certifications include Certified Lymphedema Therapist (CLT), Pelvic Rehabilitation Professional Certificate (PRPC), and Certified Yoga Therapist (CYT). She is a board member of the Chicagoland Pelvic Floor Research Consortium, American Physical Therapy Association Section of Women's Health and Section of Oncology.

As adjunct faculty, Lauren teaches Special Topics: Pelvic Rehabilitation Physical Therapy at Governors State University. Lauren works at the University of Chicago providing pelvic rehabilitation, lymphedema, and oncological physical therapy within Therapy Services and the Center of Supportive Oncology. She treats pelvic pain, urinary incontinence, bowel dysfunction, sexual dysfunction, lymphedema, lymph node transfer/bypass, stem cell transplant, and bowel/bladder/sexual/functional concerns of patients undergoing HIPEC (hyperthermal intraperitoneal chemotherapy). Lauren is a 2017 Fellow of the Chicago Trauma Collective. As a trauma-sensitive practitioner, her goal is to empower patients to create meaningful, healthful lifestyle changes to improve their physiology and wellness

Lifelong vaginismus is a condition where a person experiences pain or difficulty with vaginal insertion from the first attempt. This could include the insertion of a tampon, gynecologic speculum, finger, penis, or sex toy. Many patients report, "I always had trouble with tampons" and may avoid using them altogether. They might also avoid pelvic exams and face significant challenges with receptive sexual activity.

Pelvic trainers, also known as dilators, vaginal trainers, or accommodators, can be effective tools for addressing lifelong vaginismus. However, as a pelvic health clinician, you may have noticed that some patients reach a plateau, getting "stuck" at a certain size trainer. Lifelong vaginismus is believed to be due to uncontrolled spasms of the pelvic floor muscles surrounding the vaginal opening. These spasms can hinder the insertion of progressively larger trainers and are not easily managed through passive stretching alone.

Instead, combining passive stretching with techniques like breathing and contract-relax exercises can be beneficial. Using muscle contractions may seem counterintuitive, but they can effectively promote muscle relaxation and control. Let's explore four scientific perspectives on how this works.

1. Physiology of Skeletal Muscle

Skeletal muscle, which includes the pelvic floor muscles, responds to isometric contractions by activating Golgi Tendon Organs (GTOs) embedded in the muscle fibers. When GTOs are activated, they send signals to the spinal cord, triggering a reflex that inhibits the same muscle. Essentially, an isometric contraction causes the muscle to inhibit itself. This technique, known as "hold-relax" in Proprioceptive Neuromuscular Facilitation (PNF) stretching, may increase flexibility in the pelvic floor muscles when performed around the trainers.

2. Neurological Effects

Repeated, sub-maximal contractions followed by gentle stretching and intentional relaxation can increase corticospinal excitability, promoting motor learning and performance (Christiansen et al., 2018). Over time, practicing voluntary contraction and relaxation, along with breathing exercises, helps patients gain more control over the muscles surrounding the vagina.

3. Pain Science Perspective

Voluntary contractions activate the motor cortex in the brain, which has two effects on inhibiting pain (Lopes et al., 2019):

1. Inhibition of the thalamic nuclei (lateral spinothalamic tract), limiting nociceptive messages.
2. Activation of the periaqueductal gray, which contains enkephalin-producing cells that release endogenous opioids to suppress pain.

These effects reduce pain and facilitate the progressive insertion of vaginal trainers.

4. Graded Exposure

Graded exposure involves gradually increasing exposure to an activity that causes fear or anxiety. Starting with the smallest size, trainers are inserted to the "just the start of discomfort" point (not to pain). This is followed by breathing exercises and gentle voluntary contractions and relaxations ("hold-relax" technique) along with passive stretching. As discomfort lessens, the trainer can be inserted further, repeating the steps. This process, over several sessions, allows progression to larger trainer sizes, reducing fear and anxiety while increasing functional insertion and decreasing pain.

Practical Application

During a session, a patient may insert a trainer just to the point of discomfort. The clinician can then guide them through the hold-relax routine:

1. Take a breath in.
2. Exhale and gently squeeze the pelvic floor muscles around the trainer – hold, hold, hold (through the full exhale).
3. Release the muscles while inhaling again.

Repeat for 3-5 repetitions. After the last hold-relax, keep the muscles relaxed while gently pressing the trainer to stretch along the vaginal wall for 30-60 seconds, maintaining the same insertion depth. Repeat these steps for the posterior, left, and right vaginal walls (avoiding the anterior wall to prevent irritation of the urethra). These instructions can be adapted based on the individual patient.

In the Vaginismus and Vulvovaginal Dyspareunia course, participants learn and practice these steps, along with other techniques for addressing painful vaginal intercourse. The course covers selecting trainers, using lubricants, sexual positions, props and aids, perineal scar massage, and specific manual therapy treatments. It also provides guidance on discussing sexual activity with patients, including when to pause or continue, and how to involve partners. A rehabilitative treatment decision-making algorithm based on examination findings helps clinicians determine the most effective treatment combinations for each patient. Join us in the next Vaginismus and Vulvovaginal Dyspareunia course, scheduled for September 14, 2024.

For patients struggling with vaginal trainer progression, try these breathing, hold-relax, and gentle stretching techniques in your clinic this week. It may transform trainers from a frustrating obstacle into a useful and functional tool.

References:

Christiansen, L., Madsen, M. J., Bojsen-Møller, E., Thomas, R., Nielsen, J. B., & Lundbye-Jensen, J. (2018). Progressive practice promotes motor learning and repeated transient increases in corticospinal excitability across multiple days. Brain stimulation, 11(2), 346-357.

Lopes, P. S. S., Campos, A. C. P., Fonoff, E. T., Britto, L. R. G., & Pagano, R. L. (2019). Motor cortex and pain control: exploring the descending relay analgesic pathways and spinal nociceptive neurons in healthy conscious rats. Behavioral and Brain Functions, 15(1), 1-13.

AUTHOR BIO

Darla Cathcart, PT, DPT, PhD, WCS, CLT

Darla graduated from Louisiana State University (Shreveport, LA) with her physical therapy degree, performed residency training in Women’s Health PT at Duke University, and completed a Ph.D. at the University of Arkansas Medical Sciences. Her dissertation research focused on using non-invasive brain stimulation to augment behavioral interventions for women with lifelong vaginismus, and her ongoing line of research focuses on painful intercourse and post-Cesarean rehabilitation.

Darla’s certifications and training include Women’s Health Certified Specialist (WCS, board certification through the American Board of Physical Therapy Specialties). Certificate of Achievement in Pelvic Physical Therapy (CAPP-Pelvic). Certificate of Achievement in Pregnancy & Postpartum Physical Therapy (CAPP-OB). Certified Lymphedema Therapist (CLT).

Darla began her women’s health physical therapy career in her first job while working with pregnant women with musculoskeletal problems in a private outpatient therapy clinic in Shreveport, LA (with a focus on spine rehab). While there, she developed and hosted an exercise class for pregnant women. She would go on to develop a mom-and-baby postpartum exercise class while in her Duke residency in Durham, NC. She went on to develop the pelvic, pregnancy, and post-breast cancer/lymphedema PT program at Christus-Schumpert Health System in Shreveport, LA. During this time, she participated in educating women in the labor and birth preparatory classes hosted by the hospital; she also taught the women’s health course for physical therapy students at LSU-Shreveport. Darla went on to serve as a full-time faculty member in the physical therapy program at the University of Central Arkansas in Conway, AR, where she taught women’s health topics, documentation, therapeutic exercise, professional development, and human physiology. She recently owned a private PT practice that is dedicated to pelvic (bowel, bladder, and pelvic pain) and pregnancy/postpartum conditions in Conway, AR. Darla now is a full-time faculty member in the entry-level Physical Therapy program at Graceland University.

Darla currently serves as the President of the Academy of Pelvic Health of the American Physical Therapy Association. She has several peer-reviewed and non-peer-reviewed scientific publications. Amongst some of these, she co-authored “Clinical Summary: Urinary Incontinence” for PTNow.org in April 2015. She authored the chapter titled “The Female Hip and Pelvis” in Orthopedic Management of the Hip and Pelvis (S Cheatham, M Kolber, Elsevier, 2015). She chaired the committee for and participated heavily in the development of the Certificate of Achievement in Pregnancy/Postpartum (CAPP-OB) course series for the Section on Women’s Health of the American Physical Therapy Association. Darla has spoken and instructed many courses in local, national, and international settings on a variety of pelvic, pregnancy/postpartum, and other women’s health physical therapy topics. Darla has served as the Director of Education (2011-2014) and as Vice President (2015-2016) for the Section on Women’s Health, American Physical Therapy Association. She also served as a technical expert panel member on Treatments for Fecal Incontinence, Agency for Healthcare Research and Quality in 2014-2015. She also volunteered as a Women’s Health Certified Specialist Exam Standardization Task Force member in May 2013. Darla received several awards from the Section on Women’s Health: CAPP-OB Instructor of the Year (2017); Course Site Hostess of the Year (2018); and Volunteer of the Year (2015). She also received Clinical Instructor of the Year while serving as a clinical instructor a pelvic health physical therapy student from Elon University in 2011.

Do you feel you lack a firm understanding of how to comprehensively treat pregnant and postpartum athletes? Maybe you don’t feel confident in knowing how to modify activity for this population, or you feel that most high-intensity activity should be ceased during pregnancy and early postpartum.

If this is you, might I encourage you to take our upcoming course on special considerations for Pregnant and Postpartum High-Intensity Athletes?

While this patient population is like the general population in many ways, there is a certain nuance in evaluating pregnant and postpartum athletes. This is especially true for elite or high-intensity athletes. Considering the demands of many of these high-intensity sports (running, powerlifting, CrossFit, Orange Theory) it is imperative that pelvic therapists also understand orthopedics, and vice versa. In bridging this gap between specialties, we have the opportunity to optimize performance, while ensuring our patients also remain healthy.

Keeping this in mind, our evaluation will look a bit different than traditional pelvic and orthopedic evaluations. Specifically, each respective specialty should be screening the other. If you are a pelvic therapist, you should also be screening the lumbar spine, SI joint, Hip joint, and mid-thoracic spine. You should also be performing a functional movement analysis that is specific to their desired sport. If you are an orthopedic therapist, you should also be screening for diastasis recti, pressure management capability, and pelvic floor tension and/or weakness. While orthopedic therapists will not be performing an internal exam like their pelvic therapist counterparts, there are still several screening methods that can be used to determine if a patient requires referral to a pelvic PT. And that is exactly what this course aims to do.

Pregnancy and Postpartum Considerations for High-Intensity Athletics aims to bridge the gap between pelvic and orthopedic therapists and to help educate providers on how to evaluate this patient population with confidence. We will cover special medical considerations for this patient population, ways in which to modify activity for this population, and how to keep them doing what they love safely throughout pregnancy and postpartum. So, if you would like to learn more about working with pregnant and postpartum athletes, go ahead and sign up for our September 15th course offering. We’d love to have you!

AUTHOR BIO
Emily McElrath PT, DPT, MTC, CIDN

Emily McElrath is a native of New Orleans and received her undergraduate degree in Athletic Training at the University of Southern Mississippi and went on to receive her Doctorate of Physical Therapy from the University of St. Augustine for Health Sciences. She is highly trained in Sports and Orthopedics and has a passion for helping women achieve optimal sports performance. Emily is certified in manual therapy and dry needling, which allows her to provide a wide range of treatment skills including joint and soft tissue mobilization. She is an avid runner and Cross-fitter and has personal experience modifying these activities during pregnancy and postpartum. While not working, Emily enjoys time with her husband and two kids.