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Dustienne Miller is the creator of the two-day course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. 

 

I’m one of the small business owners who has survived this difficult time. Day after day I would mask up, put on the filtration systems, and be filled with gratitude that I could still safely do my work in the world. Despite being vigilant on sleep, eating lots of veggies from the local farm, exercising, and staying well hydrated I still carry a deep covering of stress and tension.

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Dustienne Miller MSPT, WCS, CYT is a Herman & Wallace faculty member, owner of Your Pace Yoga, and the author of the course Yoga for Pelvic Pain. Join her in Columbus, OH this April 27-28, to learn how yoga can be used to treat interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. The course is also coming to Manchester, NH September 7-8, 2019, and Buffalo, NY on October 5-6, 2019.

How does a yoga program compare to a strength and stretching program for women with urinary incontinence? Dr. Allison Huang1 et al have published another research study, after publishing a pilot study2 on using group-based yoga programs to decrease urinary incontinence. Well-known yoga teachers Judith Hanson Lasater, PhD, and Leslie Howard created the yoga class and home program structure for this research study and the 2014 pilot study. The yoga program was primarily based on Iyengar yoga, which uses props to modify postures, a slower tempo to increase mindfulness, and pays special attention to alignment.

To be chosen for this study, women had to be able to walk more than 2 blocks, transfer from supine to standing independently, be at least 50 years of age, and experience stress, urge, or mixed urinary incontinence at least once daily. Participants had to be new to yoga and holding off on clinical treatment for urinary incontinence, including pelvic health occupational and physical therapy.

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As practitioners, we understand the value of a yoga practice for multiple systems. Yoga improves cardiovascular function, pulmonary function, improves flexibility, builds strength, improves balance, and cultivates resiliency. Prenatal yoga is deemed safe and widely practiced. Beyond not laying prone after the first trimester, what are modifications for practicing yoga while pregnant? Is there any evidence to demonstrate if specific yoga postures are safe from both the maternal and fetal perspective?

Polis et al set out to determine the safety of specific yoga postures using vital signs, pulse oximetry, tacometry, and fetal heart rate monitoring. The patients were diverse in age, race, BMI, gestational age, parity, and yoga experience. Exclusionary criteria included preeclampsia, placenta previa, bleeding in the 2nd or 3rd trimester, gestational diabetes, BMI greater than 35 and other medical conditions that presented contraindications.

The maternal and fetal responses were tested in 26 yoga postures. The selected postures, much like most yoga classes, offered a variety of physical positions. The standing, seated, twists and balancing postures chosen were: Easy Pose, Seated Forward Bend, Cat Pose, Cow Pose, Mountain Pose, Warrior 1, Standing Forward Bend, Warrior 2, Chair Pose, Extended Side Angle Pose, Extended Triangle Pose, Warrior 3, Upward Salute, Tree Pose, Garland Pose, Eagle Pose, Downward Facing Dog, Child’s Pose, Half Moon Pose, Bound Angle Pose, Hero Pose, Camel Pose, Legs up the Wall Pose, Happy Baby Pose, Lord of the Fishes Pose and Corpse Pose.

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You have been treating a highly motivated 24-year-old woman with a diagnosis of Interstitial Cystitis/Painful Bladder Syndrome (IC/BPS). The plan of care includes all styles of manual therapy, including joint mobilization, soft tissue mobilization, visceral mobilization, and strain counterstrain. You utilize neuromuscular reeducation techniques like postural training, breath work, PNF patterns, and body mechanics. Your therapeutic exercise prescription includes mobilizing what needs to move and strengthening what needs to stabilize. Your patient is feeling somewhat better, but you know she has the ability to feel even more at ease in their day to day. Is there anything else left in the rehab tool box to use?

Kanter et al. set out to discover if mindfulness-based stress reduction (MBSR) was a helpful treatment modality for (IC/BPS). The authors were interested in both the efficacy of a treatment centered on stress reduction and the feasibility of women adopting this holistic option.

The American Urological Association defined first-line treatments for IC/PBS to include relaxation/stress management, pain management and self-care/behavioral modification. Second-line treatment is pelvic health rehab and medications. The recruited patients had to be concurrently receiving first- and second-line treatments, and not further down the treatment cascade like cystoscopies and Botox.

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In his famous book Light on Yoga, B K S Iyengar describes pranayama as “extension of breath and its control”1.  Pranayama includes all aspects of breathwork: inhalation, exhalation, and breath retention.  As clinicians treating pelvic floor dysfunction, we emphasize the importance of breathing as a critical component of rehabilitation.  Physical therapists Paul Hodges (et al) and Julie Wiebe describe a piston-like relationship between the diaphragm and pelvic floor2,3.  Pranayama, or conscious breathing, can enhance this relationship, especially if there are holding patterns in the pelvis. On inhalation, the pelvic floor muscles and diaphragm move caudally. On exhalation, the pelvic floor muscles and diaphragm move cranially4.  As physical therapists, we instruct patients to use the breath in coordination with the pelvic floor muscles to obtain optimal stability and continence. 
 
Pelvic organ prolapse and urinary/fecal incontinence are often caused by a lack of tonic support and muscular strength of the pelvic floor, core and surrounding pelvic girdle musculature5.  Optimal pelvic floor support from adequate strength, core stability, and neuromuscular control allows for continence and organ support. For optimal core stability, there must be coordination and strength of all components of the deep core musculature – pelvic floor muscles, transverse abdominals, multifidi, and diaphragm6. The “Soda Pop Can Model of Postural Control”, conceptualized by Mary Massery, illustrates how the pressure system of an aluminum soda can maintains the stability of the structure7. Loss of support can happen at the top (i.e. tracheotomy), front (i.e. diastasis recti abdominus), back (i.e. disc herniation), or bottom (i.e. pelvic organ prolapse or incontinence). A “leak” in the structural integrity could affect postural control, core stability, and continence.  This concept underlines the importance of breath retraining as one aspect of our treatment plan.
 
Pranayama gives your patient a strategy to decrease sympathetic nervous system overactivity and encourages the parasympathetic response. According to Diane Lee, common areas of rigidity of movement/holding patterns include lateral and posterior-lateral expansion of the ribcage during inhalation8.  Mindful pranayama encourages the student to explore diaphragmatic breathing without gripping in the chest and ribcage.  
 

Examples of pranayama

 
Dirgha
Dirgha is the Three-Part Breath. Inhale, allowing the belly to fill.  If your patient finds this challenging, try a book on the belly when supine or try breathing in quadruped. The second part of dirgha is expanding the ribcage, followed by the collarbones to floating up. After trying this for 10 breath cycles, stop and recognize any new sensations or softening in the body. I recommend my patients set an alarm to go off every hour to remind them to move and breathe.
 

Ujjayi

Ujjayi is known as the Ocean breath. It sounds like you have one ear to a giant seashell. Raise one hand in front of the mouth and pretend to fog a mirror with an inhalation and exhalation.  Recreate the same action at the back of the throat, but now with the mouth closed. This breath should sound similar to the signature sound of the Star Wars villain Darth Vader.  Perform this breath with any warm-up or asana while layer this breath onto Dirgha.

 

Letting Go Breath

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Today we hear from Herman & Wallace instructor Dustienne Miller CYT, PT, MS, WCS. Dustienne instructs the Yoga for Pelvic Pain course. Join her next month at Yoga for Pelvic Pain, Cleveland, OH on July 18 and 19!

We all know yoga can help chronic headaches, insomnia, anxiety, low back pain, and a myriad of other conditions. How can we apply the principles and benefits of yoga to the treatment of chronic pelvic pain?

Breathing
As rehab professionals who treat chronic pelvic pain, we know how critical it is for our clients to learn how to downtrain the nervous system. Breath awareness and training are a useful tool in reducing sympathetic nervous system override. Some clients may not have the awareness that they are holding their breath because of pain, or even anticipation of pain. Because of the direct mechanical relationship between the diaphragm and the pelvic floor, breath holding can lead to pelvic floor muscle holding. By building awareness, which is a learned skill, the client begins to notice and eventually control non-optimal breathing patterns.

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Today on the Pelvic Rehab Report, we hear from Dustienne Miller. Dustienne wrote and teaches the Yoga for Pelvic Pain course, which is available in Cleveland, OH on July 18-19, and in Boston, MA on September 12-13.

"It feels like my pelvic floor just sighed."

Grounding in Mountain Pose

As musculoskeletal professionals, we have a sharp eye for postural dysfunction. We explain to our patients that the ribcage is sheared posteriorly to the plumb line and how gravity magnifies forces at specific structures. Some physical therapists perform the Vertical Compression Test (VCT) to allow the patient to feel the difference between their typical habitual posture and a more optimally aligned posture. This works well to “sell” your patients on why their newly aligned posture allows for more efficient weight transfer through the base of support. In addition to the VCT, I utilize Tadasana, or Mountain Pose as an additional kinesthetic approach to postural retraining.

Last week in the clinic, I was teaching my client postural awareness using Tadasana. I asked her to close her eyes, or lower her gaze if she was not comfortable closing her eyes. Working from the ground up, we started bringing awareness to her base of support. She noted that she was standing with her weight mostly in her heels. When I encouraged her to bring her weight forward, hinging from the talocrural joint, she had an “aha moment.” She said, “It feels like my pelvic floor just sighed.” She was unaware that her habitual posture was to stand with her weight mostly posterior to plumb line, thus encouraging her posterior pelvic floor to remain in an overactive state. Once she balanced her body from the ground up, she felt a major release in her holding patterns.

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H&W instructor Dustienne Miller, CYT, PT, MS, WCS wrote this post.

 

As specialists in pelvic health, we have the honor of being trusted with very private information. Our patients trust us with their secrets, their emotions, and their bodies. Sometimes patients reveal traumatic personal stories, both past and present. Even if our patients have not suffered emotional, physical, or sexual abuse, we can assume that the diagnosis of pelvic floor dysfunction is traumatic itself. Bouncing from clinician to clinician and inability to share their pain and experience with coworkers and friends is enough to increase baseline anxiety and depression levels. Yoga has proven to be an effective method in helping to heal Post Traumatic Stress Disorder and other mental comorbidities associated with pelvic floor dysfunction. But where do you start? How do you make your patient feel safe?

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Upcoming Continuing Education Courses

Mobilization of Visceral Fascia: The Urinary System - Self-Hosted (SOLD OUT)

Sep 17, 2021 - Sep 19, 2021
Location: Self-Hosted Course

Mobilization of Visceral Fascia: The Urinary System - Athens, GA Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Thrive Integrated Medicine

Mobilization of Visceral Fascia: The Urinary System - Albany, NY Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Albany Medical Center

Mobilization of Visceral Fascia: The Urinary System - Bellingham, WA Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Connect NW Physical Therapy & Wellness

Mobilization of Visceral Fascia: The Urinary System - Phoenix, AZ Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Banner Physical Therapy and Rehabilitation

Mobilization of Visceral Fascia: The Urinary System - Auburn, ME Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Select Physical Therapy - Auburn

Mobilization of Visceral Fascia: The Urinary System - Salt Lake City, UT Satellite Location (SOLD OUT)

Sep 17, 2021 - Sep 19, 2021
Location: University of Utah Orthopedic Center

Mobilization of Visceral Fascia: The Urinary System - Medford, OR Satellite Location

Sep 17, 2021 - Sep 19, 2021
Location: Asante Rogue Valley Medical Center

Athletes & Pelvic Rehabilitation - Remote Course

Sep 18, 2021 - Sep 19, 2021
Location: Replacement Remote Course

Osteoporosis Management - Remote Course

Sep 18, 2021 - Sep 19, 2021
Location: Replacement Remote Course

Pelvic Floor Level 1 - Santa Cruz, CA Satellite Course (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Alliance Physical Therapy and Rehabilitation Services Inc

Pelvic Floor Level 1 - Tempe, AZ Satellite Course (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Petersen Physical Therapy

Pelvic Floor Level 1 - Round Rock, TX Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Round Rock Medical Center

Pelvic Floor Level 1 - Nashville, TN Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Precision Physical Therapy Pilates

Pediatric Incontinence and Pelvic Floor Dysfunction Remote Course (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Replacement Remote Course

Pelvic Floor Level 1 - Kenosha, WI Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Aurora Sports Health Pershing

Pelvic Floor Level 1 - Warren, MI Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Mendelson Kornblum Physical Therapy

Pelvic Floor Level 1 - Self-Hosted

Sep 18, 2021 - Sep 19, 2021
Location: Self-Hosted Course

Pelvic Floor Level 1 - Highlands Ranch, CO Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Panorama Orthopedics and Spine

Pelvic Floor Level 1 - Muncie, IN Satellite Course (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Indiana University Health

Pelvic Floor Level 1 - Winchester, VA Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Shenandoah University

Pelvic Floor Level 1 - Egg Harbor Township, NJ Satellite Location (SOLD OUT)

Sep 18, 2021 - Sep 19, 2021
Location: Med A Quest

Bowel Pathology and Function - Remote Course

Sep 19, 2021 - Sep 20, 2021
Location: Replacement Remote Course

Yoga for Pelvic Pain - Remote Course

Sep 25, 2021 - Sep 26, 2021
Location: Replacement Remote Course

Pelvic Floor Level 2B - Wallingford, CT Satellite Course

Sep 25, 2021 - Sep 26, 2021
Location: Ivy Rehab Physical Therapy

Pelvic Floor Level 2B - Charlotte, NC Satellite Course (SOLD OUT)

Sep 25, 2021 - Sep 26, 2021
Location: Ivy Rehab Physical Therapy

Pelvic Floor Level 2B - Virginia Beach, VA Satellite Course

Sep 25, 2021 - Sep 26, 2021
Location: Southeastern Physical Therapy

Pelvic Floor Level 2B - Chamblee, GA Satellite Course

Sep 25, 2021 - Sep 26, 2021
Location: Revelle Physical Therapy Atlanta