This week we get to feature Katie Tredo, DPT, PRPC, one of the first people to earn her Pelvic Rehabilitation Practitioner Certification! Katie co-owned a private practice in Maryland, and has recently relocated to the Milwaukee area to practice her trade. She was kind of enough to offer her insights with the Pelvic Rehab Report today.

Hi Katie! Tell us a little bit about your clinical practice
I recently joined the staff at Health In Balance Physical Therapy in Mequon, WI. Our team is made up of experienced physical therapists with a variety of interests and specialties. Along with two of my coworkers, my practice is focused on treating men, women, and children with pelvic dysfunctions. I think a practice with such a skilled and diverse set of physical therapists allows us to better serve our patients.

What patient population do you find most rewarding in treating and why?
I find treating patients with pelvic dysfunctions, especially pelvic pain, to be extremely rewarding. Pain, incontinence, and other pelvic dysfunctions can leave patients feeling very isolated and hopeless. Watching my patients open up about their issues then progress toward their goals, returning to their previous activities and relationships without pain or dysfunction is amazing. There are so many quality of life issues that go along with pelvic dysfunctions and I am honored to be a part of each of my patient’s journey to recovery.

Today we are so fortunate to hear from Diane Hubbard, PT, who is this week's Featured Pelvic Rehab Practitioner! Diane has completed the full Pelvic Floor Series and puts her skills to use every day. Thank you, Diane for your contributions to the field of pelvic rehabilitation, and for sharing your thoughts with us!

Tell us about your clinical practice
I am working in inpatient rehabilitation. However, I am increasing my time in pelvic rehab, as the caseload increases, in an outpatient rehab setting.

How did you get involved in the pelvic rehabilitation field?
Our hospital system was negotiating with a urology group of physicians to come and serve in our area. One of the requests of the urology group was that the hospital have a pelvic floor trained physical therapist to work with their patients as needed. Our rehab director asked if any of the PTs were interested in working with a urinary incontinence program. I said that I was very interested and was eventually given the opportunity to become trained to work with pelvic floor patients.

Do you have a burning question about pelvic rehabilitation? Herman & Wallace faculty member Michelle Lyons will be happy to help! The Pelvic Rehab Report will be conducting an interview with Michelle and we are inviting you to submit your questions. Head over to www.hermanwallace.com/michelle-lyons-question-and-answer if you are curious to hear about what it's like treating pelvic pain patients, some of Michelle's experiences practicing abroad, teaching courses to practitioners, or about her favorite pasta sauce! We will take the top 5 or 10 questions and put Michelle through the ringer.

Michelle Lyons PT, MISCP, is a graduate of University College Dublin, Ireland, with over eighteen years experience working in women's health. A firm believer in integrative healthcare, she incorporates therapeutic pilates, yoga and lifestyle advice into her treatment protocols.

Michelle has appeared in local newspapers, radio and television programs speaking on women's health issues. She has presented programs in Ireland, Canada and the U.S. including The Wise Woman weekend, The International Herbal Symposium and The New England Women's Herbal Conference and for the Irish Society of Chartered Physiotherapists.

Today we are happy to celebrate Aline Flores, PT, PRPC! Aline is one of the newly minted Certified Pelvic Rehabilitation Practitioners, having passed the exam last month. Here's what she had to say about her career in pelvic rehab. Congratulations, Aline!

Tell us about your clinical practice
This year I opened Natura Physical Therapy, a small private practice specializing in pelvic pain and breast cancer rehabilitation. Manual therapy is a big part of our approach to patient care. I often utilize myofascial release, connective tissue manipulation, trigger point therapy, and manual lymphatic drainage during treat sessions and prescribe 2-3 specific exercises for patients to complete at home. I also provide education on the neurological/physiological/emotional response to pain and teach techniques for patients to be able to modulate this response, including breathing exercises and down training techniques. The majority of my patients are high stressed, overwhelmed and extremely hard on themselves. Helping patients become more compassionate towards themselves is a huge accomplishment.

A few weeks ago, a pelvic course participant shared some sensitive and intimate thoughts about being at a course and being "the biggest girl in class." This week, we will address specific strategies for communicating with your patients and for adapting your exam techniques when appropriate. The following quote is from an educational book for Nurse Practitioners, and echoes a very healthy and realistic sentiment about our role when working with patients in pelvic rehabilitation.

"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit."

If you area clinic owner, are in a management or leadership position, one of your jobs is making sure your therapists are using best practices. This can be a challenge when best practices are continually being researched and discussed, and when systematic reviews continue to tell us that pelvic rehabilitation research lacks homogeneity and enough high-level evidence to make convincing arguments about interventions. In the absence of this, we can still integrate recommendations from clinical practice guidelines and from best practice statements. The American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) is participating in the APTA's initiative to develop clinical practice guidelines. For current guidelines, check out their page here. To see which guidelines are in development at the APTA, click here.

The American Urological Association (AUA) has also developed practice guidelines, including the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/PBS). Within this guideline, the first line treatments are listed as general relaxation/stress management, pain management, patient education, and self-care/behavioral modification. Second-line treatments include "appropriate manual physical therapy techniques", oral medications, bladder medications (administered inside the bladder), and pain management. What is very interesting about this guideline is that the authors define what types of manual therapy approaches are appropriate, and these include techniques that resolve muscle tenderness, lengthen shortened muscles, release painful scars or other connective tissue restrictions. The guidelines also define who should be working with patients who have IC/PBS and pelvic muscle tenderness: "appropriately trained clinicians". Very importantly, the authors state that pelvic floor strengthening exercises should be avoided.

Many diagnoses that live under the umbrella of "chronic pelvic pain" have similar symptoms, confounding the differential diagnosis and development of a treatment pathway. Dr. Charles Butrick, in an article published in 2007, suggested that gynecologists "…be alert to…interstitial cystitis in patients who present with chronic pelvic pain typical of endometriosis." The concurrent conditions of bladder pain syndrome (BPS) and endometriosis have been described as "evil twins syndrome" in the realm of chronic pelvic pain. Bladder pain syndrome. also known as Interstitial Cystitis (IC), is a condition commonly associated with pelvic pain, bladder pressure, and urinary dysfunction such as urgency and frequency. Endometriosis can also cause or contribute to pelvic pain, and a variety of pelvic dysfunctions including bowel, bladder, or sexual dysfunction.

A study published in the International Journal of Surgery reported on the prevalence of these two conditions. Utilizing a systematic review approach, the authors located articles reporting on the prevalence of bladder pain syndrome and endometriosis in women with chronic pelvic pain. Nine observational studies were included, and the range of endometriosis diagnosis ranged from 11%-97%, with a mean prevalence of 61%. The prevalence of endometriosis ranged from 28%-93% with a mean prevalence of 70%. The large variation in these rates were explained as potentially being due to the variations in study quality and sample selection. (The authors point out that the highest rates of prevalence for BPS and endometriosis were noted in the patient groups recruited from specialist clinics and from lists of patients from operating lists.) The study concludes that in women who present with chronic pelvic pain (CPP), screening for bladder pain syndrome is important so that appropriate treatment can be directed to all issues.

Even after teaching for a couple of decades, both in graduate level courses and in continuing education settings (live and online), I am humbled by all there is to learn and relearn about how to teach well. We all teach every day, regardless of what setting or roles we work in, and are required to share our thoughts and knowledge with respect, equanimity, and non-judgement. After teaching a course last month, I received feedback about an important topic that was not clearly addressed from an instructional or clinical standpoint, and the participant who brought it to my attention agreed to share her experience so that we as pelvic rehab providers can do a better job of addressing the issue when needed. The following post was written by Erin B. after I encouraged her to share her own thoughts about the issue.

"Having recently participated in the PF1 class after several years out of the classroom-style of continuing education, I made a few observations I felt compelled to share. (I do want to preface this with the fact that I am fully aware that my own insecurities play a role in my experiences and I recognize that they may alter my judgment of the situation.)

Today the Pelvic Rehab Report presents a conversation with Dr. Kimberlee Sullivan, DPT. Kimberlee was kind enough to share her thoughts on the importance of pelvic rehab and her experiences in the field.

Tell us about your clinical practice.

Sullivan Physical Therapy is an outpatient private practice physical therapy clinic in Austin, Texas that specializes in women's and men's health. We have seven physical therapists who evaluate and treat pelvic floor dysfunction, pre and postpartum, pediatric bladder and bowel dysfunction, and lymphedema. Our practice takes a full body approach that looks at a person from different aspects to analyze how various factors in their life may be contributing to their symptoms. We also strive to be an integrated health care practice that communicates well with both the patient and their referring physician or multiple practitioners. The physical therapists work closely with the patient's entire medical team in order to provide the best care.

Today we are happy to share an interview with Blair Green, PT! Blair brings her experience as both a practitioner and a clinic owner to the field of pelvic rehabilitation, and you can check out her insights below.

Tell us about your clinical practice

I am an owner of One on One Physical Therapy, in Atlanta, GA. My patient population is primarily patients with pelvic pain of varying degrees. I blend my skills and knowledge of pelvic health with orthopedic manual therapy and I am able to provide a comprehensive approach to treating these patients. I also work closely with postpartum women for rehabilitation following childbirth, primarily in an orthopedic sense. I like to work with women who experience diastasis recti following pregnancy and who want to return to an active lifestyle after having children. One other area that interests me is the relationship between autoimmune disorders / endocrine function / pelvic pain. I hope to expand on this in the future.