Electrostimulation is a conservative treatment of improving bladder function. This can be performed parasacrally, intravaginally or by stimulation of the tibial nerve (Wang and Liu, 2022, Jacomo et al, 2020, Bhide et al 2019, Padilha et al., 2020).

Tibial Nerve Stimulation (TNS) is performed to assist patients to improve bowel and bladder function such as fecal incontinence, constipation, overactive bladder (OAB), painful bladder syndrome, pediatric voiding dysfunction, neurogenic bladder, urinary urgency (UU), and enuresis. Today we are going to explore tibial nerve stimulation for overactive bladder symptoms.

A 2025 systematic review and meta-analysis reviewed transcutaneous tibial nerve stimulation with OAB. All the studies reviewed revealed improvements in urinary symptoms through improved quality of life and OAB functional outcome scores or improvements with 3-day voiding diary measures such as urinary incontinence, urgency, frequency and nocturia (Vaca-Benavides et al., 2025).

How does TNS work for OAB?

Although research is still determining exact pathways, TNS is thought to work through retrograde neuromodulation of the sacral nerve plexus (L4-S3) via transmission of electrical signals from the ankle (distally) along the path of the posterior tibial nerve (more proximally) to the spinal cord, which is believed to suppress excessive or abnormal afferent signaling at the detrusor muscle, thereby inhibiting involuntary spasms and/or contractions (Shang et al., 2026, Vaca-Benavides et al., 2025, Sapouna, 2024).

TNS likely modulates neural pathways by stimulating peripheral somatic afferent nerves which to calm the bladder and inhibit the micturition reflex (Al-Danakh et al., 2022). Utilizing TNS long-term may reprocess the signals received by the bladder by inducing neural plastic changes over a longer period with repeated nerve stimulation (Kovacevic and Yoo, 2015). Repeated TNS sessions may also potentially assist with reorganization of the central nervous system’s sensory processing relieving detrusor overactivity (Sapouna, 2024).

Animal models also suggest a reduction of mast cells, which may reduce sensitivity and inflammation (Gaviev et al., 2013, Sapouna, 2024). In addition, stimulation in the animal models have reduced the expression of C-fos in the spinal cord, which is a marker of neuronal metabolic activity, which may lead to a downregulation in neuronal pathways (Sapouna, 2024).

What are different types of Tibial Nerve Stimulation (TNS)?

Shang et al, describe 3 main types of TNS utilized clinically.

The first type is Percutaneous Tibial Nerve Stimulation (PTNS), involves delivering low-voltage stimulation through the insertion of a needle-shaped electrode approximately 3-4cm above the medial malleolus.

The second type, Transcutaneous Tibial Nerve Stimulation (TTNS), is something we are more familiar with. This involves placing non-invasive use of electrode pads on the skin and utilizing a TENS unit to provide stimulation on the route of the posterior tibial nerve.

The third type is Implantable Tibial Nerve Stimulation (ITNS / iTNM), which involves surgically implanting electrodes near the tibial nerve for chronic stimulation with special units.

How can I learn to use TTNS?

To learn more about TTNS, as well as other forms of neuromodulation, take Modalities and Pelvic Function: The Pelvic Health Toolkit. In this course you learn how to integrate into your treatments numerous types of modalities including neuromodulation, biofeedback, estim, release tools, tools for sexual health, and modalities for urinary and fecal incontinence. Participants are introduced to many examples of modalities with hands on labs to practice the application of these tools. Join us June 27 and 28 in Milwaukee, Wisconsin for Modalities and Pelvic Function to learn more about frequently used modalities in pelvic health.

https://www.hermanwallace.com/continuing-education-courses/modalities-and-pelvic-function

References

Al-Danakh, A., Safi, M., Alradhi, M., Almoiliqy, M., Chen, Q., Al-Nusaif, M., Yang, X., Al-Dherasi, A., Zhu, X., & Yang, D. (2022). Posterior Tibial Nerve Stimulation for Overactive Bladder: Mechanism, Classification, and Management Outlines. Parkinson’s disease, 2022, 2700227. https://doi.org/10.1155/2022/270022

Barroso, U., Jr, & Lordêlo, P. (2011). Electrical nerve stimulation for overactive bladder in children. Nature reviews. Urology, 8(7), 402–407. https://doi.org/10.1038/nrurol.2011.68

Bhide, A. A., Tailor, V., Fernando, R., Khullar, V., & Digesu, G. A. (2020). Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy. International urogynecology journal, 31(5), 865–870. https://doi.org/10.1007/s00192-019-04186-3

Cava, R., & Orlin, Y. (2022). Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized, controlled study. International urology and nephrology, 54(8), 1825–1835. https://doi.org/10.1007/s11255-022-03235-z

Gaziev, G., Topazio, L., Iacovelli, V., Asimakopoulos, A., Di Santo, A., De Nunzio, C., & Finazzi-Agrò, E. (2013). Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC urology, 13, 61. https://doi.org/10.1186/1471-2490-13-61

Jacomo, R. H., Alves, A. T., Lucio, A., Garcia, P. A., Lorena, D. C. R., & de Sousa, J. B. (2020). Transcutaneous tibial nerve stimulation versus parasacral stimulation in the treatment of overactive bladder in elderly people: a triple-blinded randomized controlled trial. Clinics (Sao Paulo, Brazil), 75, e1477. https://doi.org/10.6061/clinics/2020/e1477

Kovacevic, M., & Yoo, P. B. (2015). Reflex neuromodulation of bladder function elicited by posterior tibial nerve stimulation in anesthetized rats. American journal of physiology. Renal physiology, 308(4), F320–F329. https://doi.org/10.1152/ajprenal.00212.2014

Padilha, J. F., Avila, M. A., Seidel, E. J., & Driusso, P. (2020). Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial. Trials, 21(1), 166. https://doi.org/10.1186/s13063-020-4096-7

Sapouna, V., Zikopoulos, A., Thanopoulou, S., Zachariou, D., Giannakis, I., Kaltsas, A., Sopheap, B., Sofikitis, N., & Zachariou, A. (2024). Posterior Tibial Nerve Stimulation for the Treatment of Detrusor Overactivity in Multiple Sclerosis Patients: A Narrative Review. Journal of personalized medicine, 14(4), 355. https://doi.org/10.3390/jpm14040355

Shang, D., Deng, H., Li, C., Wang, Z., Jin, L., & Li, X. (2026). Tibial nerve stimulation for overactive bladder: a literature review of stimulation parameters. Translational andrology and urology, 15(2), 67. https://doi.org/10.21037/tau-2025-aw-774

Vaca-Benavides, D. A., Ju, W., Gonzalez, C., Aitken, P., Appukuttan Nair Syamala Amma, A. K., Mitra, S., & Shenkin, S. D. (2025). The importance of electrical parameters on transcutaneous tibial nerve stimulation for overactive bladder syndrome: a systematic review and meta-analysis. Age and ageing, 54(7), afaf203.

Wang, Z. H., & Liu, Z. H. (2022). Treatment for overactive bladder: A meta-analysis of tibial versus parasacral neuromodulation. Medicine, 101(41), e31165. https://doi.org/10.1097/MD.0000000000031165

Candido, T. A., Ribeiro, B. M., de Araújo, C. R. C., Pinto, R. M. C., Resende, A. P. M., & Pereira-Baldon, V. S. (2020). Effects of tibial and parasacral nerve electrostimulation techniques on women with poststroke overactive bladder: study protocol for a randomized controlled trial. Trials, 21(1), 936. https://doi.org/10.1186/s13063-020-04856-4

There are faculty members who teach courses, and then there are faculty members who help define the standard of education in an entire specialty. Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC, is the latter. A Senior Faculty member at Herman & Wallace since 2006, Dr. Downey has spent nearly two decades shaping how clinicians learn to assess and treat pelvic floor dysfunction, and she shows no signs of slowing down.

We are proud to spotlight one of the longest-serving and most accomplished educators in our institute.

A Clinician and Educator Since 1991

Dr. Downey has been a physical therapist for more than 30 years. She is a Board-Certified Specialist in Pelvic Health Physical Therapy (WCS), Board-Certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD), and a Certified Pelvic Rehabilitation Practitioner (PRPC). She brings more than 25 years of focused experience treating individuals with pelvic pain, including neuralgias of the lumbosacral plexus, voiding and sexual dysfunction, pregnancy-related and postpartum musculoskeletal dysfunction, diastasis recti, sacroiliac joint pain, and dyspareunia.

She is the owner of Partnership in Therapy, a private practice in Coral Gables, Florida, where she provides personalized one-on-one care to patients of all genders, from adolescents to octogenarians. Her mission is to educate and integrate healthy lifestyles for patients on the road to wellness.

From Sarah Lawrence to the University of Miami

Dr. Downey earned her Bachelor of Arts from Sarah Lawrence College and her Master of Science and Doctorate in Physical Therapy from the University of Miami Miller School of Medicine. She currently serves as an Adjunct Professor in the Physical Therapy Program at both the University of Miami Miller School of Medicine and Nova Southeastern University in Fort Lauderdale, Florida.

Her academic career runs alongside her clinical and continuing education work. She is actively involved in the Academy of Pelvic Health of the American Physical Therapy Association, where she has served as Coordinator of Research Submissions for annual meetings and as a manuscript reviewer for the Journal of Women’s Health.

Pilates as a Clinical Tool

One of the hallmarks of Dr. Downey’s practice is her integration of Pilates therapeutic movement into pelvic health rehabilitation. A certified Polestar Pilates Educator since 2000, she has spent more than two decades using Pilates and therapeutic exercise interventions specifically designed for patients with prenatal and postnatal conditions, pelvic floor muscle dysfunction, and lumbo-pelvic pain.

Her Herman & Wallace course, Pilates Therapeutic Exercise for Pelvic Health, introduces clinicians to the Pilates Method with an emphasis on clinical application and patient empowerment. The course covers the original 34 mat exercises and select Reformer activities, giving clinicians tools to move patients beyond passive treatment and into active, neuromuscular integration. For Dr. Downey, the philosophy is simple: patients who understand and feel how their muscles work become active participants in their own healing.

A Published Author and International Speaker

Dr. Downey has lectured nationally and internationally at professional conferences and has authored multiple published research articles. She is the author of a book chapter on chronic pelvic pain in the medical text Women’s Health in Physical Therapy, contributing to the academic body of knowledge that informs how clinicians approach complex pelvic pain cases.

Her expertise is sought beyond the continuing education classroom. Most recently, Dr. Downey was invited to present at a virtual pop-up session co-hosted by the International Pelvic Pain Society (IPPS) and the APTA Academy of Pelvic Health. Her presentation, “What About Ken? Sexual Dysfunction and Pain in Younger Men,” addressed the musculoskeletal side of sexual pain and dysfunction in younger males and the positive outcomes that can be achieved through collaborative, multidisciplinary care. It is a topic that remains underrepresented in pelvic health education, and Dr. Downey’s willingness to bring it to the forefront reflects her commitment to advancing the field for all patient populations.

Senior Faculty at Herman & Wallace

Dr. Downey has been teaching with Herman & Wallace since 2006, making her one of the institute’s longest-serving faculty members. She teaches across the Pelvic Floor Series as well as her own Pilates course, bringing a combination of clinical depth, movement expertise, and patient-centered philosophy to every course she leads.

Her role as Senior Faculty reflects not just longevity, but the sustained impact she has had on the quality and direction of pelvic health education at Herman & Wallace. Clinicians who train under Dr. Downey consistently describe her as thorough, passionate, and deeply invested in helping them translate what they learn in the classroom into meaningful results for their patients.

About Dr. Downey

Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC (she/her) is a Board-Certified Specialist in Pelvic Health Physical Therapy, Board-Certified in Biofeedback for Pelvic Muscle Dysfunction, and a Certified Pelvic Rehabilitation Practitioner. She is the owner of Partnership in Therapy in Coral Gables, Florida, and an Adjunct Professor at the University of Miami Miller School of Medicine and Nova Southeastern University. A Polestar Pilates Educator since 2000, she has more than 25 years of experience treating pelvic pain, voiding and sexual dysfunction, and pregnancy-related musculoskeletal conditions. She has been Senior Faculty at Herman & Wallace since 2006 and is the author of a book chapter on chronic pelvic pain in Women’s Health in Physical Therapy.

Learn From Dr. Downey

Whether you are looking to build your foundation in pelvic health or integrate Pilates into your clinical practice, Dr. Downey’s courses offer the depth, clinical precision, and hands-on learning that define the Herman & Wallace experience.

May 30-31, 2026: Pilates Therapeutic Exercise for Pelvic Health 

Pelvic Floor Series (Levels 1, 2A, and 2B)

Multiple dates and locations available | Satellite, In-Person, and Self-Hosted formats

Your patients deserve comprehensive care, and you deserve the knowledge to deliver it. View upcoming course dates and register at hermanwallace.com. Courses fill quickly, so register early to secure your spot.

Half the world's population experiences a menstrual cycle, yet social stigma, clinical discomfort, and gaps in provider training often leave patients without the information, tools, or permission they need to manage it well. Pelvic rehab clinicians frequently find themselves on the receiving end of questions no one else has been willing to answer. What is a normal period? Why does my cycle affect my pelvic floor symptoms so much? What products actually work, and how do I choose the right one? Is this amount of pain something I should just live with?

These are the questions Nicholas Gaffga, MD, MPH, FAAFP and Amy Meehan, PT, DPT, MTC set out to address when they built the Herman & Wallace remote course Menstruation and Pelvic Health. The course is designed for pelvic rehab providers who want to go beyond treating isolated symptoms and instead help patients reshape the menstrual experience itself through non-hormonal, non-prescription, and non-surgical interventions.

What the Course Covers

The curriculum is organized into four parts. Part 1, Cultural Aspects of the Menstrual Experience, examines how historical and cultural narratives shape the way menstruation is discussed, clinically managed, and personally experienced. Part 2, Menstrual Structures and Processes, covers the hormones, anatomy, and physiology of the cycle, including the HPO axis and the organs involved in preparing the uterus throughout each phase. Part 3, Menstrual Symptoms and Disorders, addresses dysmenorrhea, heavy bleeding, off-cycle spotting, emotional concerns, and vaginal discharge, along with common disorders including premenstrual disorders, endometriosis, adenomyosis, PCOS, and fibroids. Part 4, Menstrual Interventions, focuses on holistic strategies clinicians can introduce in practice today.

The second edition of the course includes new interviews with expert pelvic floor practitioners Ramona Horton, Jenna Ross, and Beth Kemper, whose clinical experience adds depth to the discussion of how the menstrual cycle intersects with pelvic floor dysfunction across the lifespan. Provocative topics run throughout, including chronobiology, interoception, menstrual mindfulness, menstrual molimina, cultural milestones, prostaglandins and period symptoms, and what a normal period actually looks like.

Why It Matters for Pelvic Rehab

In the live remote session, Dr. Meehan demonstrates yoga and stretch poses tailored to different phases of the cycle, along with a detailed walkthrough of menstrual products from liners and tampons to cups, discs, period underwear, overnightwear, activewear, and swimwear. Participants learn to build a flow management plan with patients, identify when to refer for physician evaluation, and help patients develop an individual action plan to reduce negative symptoms and work with the natural rhythms of their cycle.

Past participants describe the course as one that changes how they practice. Clinicians leave with a deeper understanding of their patients' experience, a broader set of tools to offer in the clinic, and language that makes a historically taboo topic feel approachable in the treatment room.

Upcoming Dates

The next live remote session of Menstruation and Pelvic Health is May 9, 2026. Additional dates are offered throughout the year for clinicians who want to schedule the course alongside their summer and fall continuing education plans.

Register for the Course

Menstruation and Pelvic Health

Next Session: May 9, 2026

Remote Course via Zoom

Additional dates available throughout 2026

Register here: https://hermanwallace.com/continuing-education-courses/menstruation-and-pelvic-health

Few modalities have generated as much clinical conversation in the last five years as low-intensity extracorporeal shockwave therapy. Once reserved for kidney stones and elite sports medicine clinics, shockwave has now crossed into pelvic health, with growing applications for chronic pelvic pain, erectile dysfunction, genitourinary syndrome of menopause, and stress urinary incontinence. For clinicians considering whether to add this tool to their practice, the first question is always the same. Does the research support what the marketing claims?

Stacey Roberts, PT, RN, MSN has built her teaching career around answering that question with rigor. Her Herman & Wallace remote course, Shockwave Treatment, gives pelvic rehab clinicians a clear-eyed look at the evidence, the device landscape, and the clinical protocols that actually work.

Why the Research Matters

The evidence base for shockwave therapy in pelvic health is deeper than many clinicians realize, and it is growing quickly. Three studies in particular have shaped the conversation.

First, the landmark randomized, double-blind, placebo-controlled trial by Zimmermann and colleagues, published in European Urology in 2009, established shockwave as a viable treatment for male chronic pelvic pain syndrome.1 Men who received four weekly sessions of perineal shockwave showed statistically significant improvements in pain, quality of life, and urinary symptoms compared to sham controls, with effects sustained at twelve weeks. This study is still cited today as the foundational clinical trial for shockwave in the pelvis.

Second, a 2021 systematic review and meta-analysis by Zeng and Ye in Translational Andrology and Urology pooled data from six controlled trials covering more than three hundred patients with chronic pelvic pain syndrome.2 The analysis confirmed that low-intensity extracorporeal shockwave therapy produced meaningful improvements in total National Institutes of Health Chronic Prostatitis Symptom Index scores, pain subscores, urinary function, and quality of life at twelve weeks post-treatment. The authors concluded that shockwave has a reproducible clinical effect and warrants continued investigation as a first-line conservative intervention.

Third, a 2022 randomized, double-blind, placebo-controlled study by Kim and colleagues in the World Journal of Men's Health applied multi-focal low-intensity shockwave weekly for eight weeks in men with category III chronic prostatitis.3 The treatment group showed significant improvements in symptom index scores, erectile function, and pain compared to placebo, with no reported adverse events. This study helped establish that the benefits extend beyond pain relief into sexual function, which has important implications for patients dealing with post-prostatectomy concerns, pelvic floor hypertonicity, and partner intimacy issues.

Taken together, these studies move shockwave from anecdote to evidence. They also raise the bar for clinical application. As Stacey emphasizes in her course, not all devices produce true shockwaves, not all protocols deliver equivalent doses, and not all patients are appropriate candidates.

What Sets This Course Apart

Where shockwave marketing tends to oversimplify, the Herman & Wallace course focuses on precision. Stacey walks participants through the physics of focused versus radial devices, the differences between electrohydraulic, electromagnetic, and piezoelectric shockwave generation, and how each influences tissue depth and clinical indication. She unpacks the research terminology so clinicians can read a study and immediately know whether the device tested was a true shockwave or a radial pressure wave, a distinction that matters enormously when translating findings to clinical practice.

The course also covers case studies, treatment protocols for common pelvic health indications, and practical business considerations for clinicians weighing whether to invest in a device for their practice.

About Stacey Roberts

Stacey Roberts, PT, RN, MSN has been a physical therapist specializing in outpatient orthopedics and sports medicine since 1990. She has been analyzing shockwave research extensively since 2020 to develop clear and concise therapeutic applications and protocols for pelvic health, sexual health, and musculoskeletal patients. Stacey is the owner of New You Health and Wellness, a cash-based clinic where she integrates wellness, hormone health, and musculoskeletal care. She is a co-principal investigator on an IRB-approved study related to shockwave and dyspareunia, and she joined the Herman & Wallace faculty in 2021.

Learn From Stacey Roberts

Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research

May 3, 2026

Remote Course via Zoom

Register here: https://hermanwallace.com/continuing-education-courses/shockwave-treatment/remote-course-may-3-2026

References

1. Zimmermann R, Cumpanas A, Miclea F, Janetschek G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study. Eur Urol. 2009;56(3):418-424. doi:10.1016/j.eururo.2009.03.043
2. Zeng X, Ye Z. Low-intensity extracorporeal shock wave therapy for male chronic pelvic pain syndrome: a systematic review and meta-analysis. Transl Androl Urol. 2021;10(4):1543-1556. doi:10.21037/tau-20-1423
3. Kim KS, Choi YS, Bae WJ, et al. Clinical efficacy of multi-focal low-intensity extracorporeal shockwave therapy in the treatment of chronic prostatitis/chronic pelvic pain syndrome: prospective-randomized, double-blind, placebo-controlled study. World J Mens Health. 2022;40(2):298-305. doi:10.5534/wjmh.210078
4. Vahdatpour B, Alizadeh F, Moayednia A, Emadi M, Khorami MH, Haghdani S. Efficacy of extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome: a randomized, controlled trial. ISRN Urol. 2013;2013:972601. doi:10.1155/2013/972601
5. Marszalek M, Berger I, Madersbacher S. Low-energy extracorporeal shock wave therapy for chronic pelvic pain syndrome: finally, the magic bullet? Eur Urol. 2009;56(3):425-426. doi:10.1016/j.eururo.2009.06.026

From Home Care to Pelvic Health: A Journey Guided by Faith, Mentorship, and Resilience

Sometimes the most meaningful career paths aren’t the ones we plan. For Herman & Wallace faculty member Carole High Gross, PT, MS, DPT, PRPC, the road to becoming a leader in pelvic health rehabilitation was shaped by unexpected challenges, pivotal relationships, and a willingness to trust the journey even when the destination wasn’t yet visible.

We recently sat down with Carole to talk about her career, her calling, and the work that drives her. What unfolded was one of the most compelling stories of resilience and purpose we’ve heard.

A Career Built on Breadth

Carole’s career in physical therapy spans more than three decades. After earning her Master of Science in Physical Therapy from Thomas Jefferson University in 1992, she worked across nearly every clinical setting imaginable: pediatrics, aquatics, outpatient orthopedics, inpatient rehab, contract work, and home care, which she loved most. She built a deep clinical foundation long before pelvic health was on her radar.

Then life intervened.

Carole was diagnosed with breast cancer, followed by a rare chronic leukemia called hairy cell leukemia. She also lives with CIDP, a neurological condition that significantly impacted her mobility. At one point, she was using a walker, a wheelchair, and a scooter for community outings. Clinical work, at least the way she’d always done it, was no longer an option.

But Carole’s response was characteristically forward-looking: her brain was still working, so she went back for her doctorate.

Getting Back Into the Swing of Things

When Carole enrolled in her Doctor of Physical Therapy program at Arcadia University, the same institution where she’d started her undergraduate education years earlier (she lovingly calls them her “bookend university”), the transition wasn’t easy. She recalls sitting on her bed, textbooks in hand, wondering why she was putting herself through it.

But she found a way to reframe the challenge. She hadn’t forgotten how to learn. She’d simply had a very long summer. That simple mindset shift became a guiding mantra. Every time Carole faces a challenge in her health, her career, or her education, she reminds herself that she’s just getting back into the swing of things.

Walking Through the Door

As Carole neared the end of her DPT, she knew she couldn’t return to home care. She felt pulled toward something but didn’t know what it was. She describes it as trusting a GPS where someone else can see the full route, but she can only see the next turn on the screen.

Then, in a matter of days, a series of small, seemingly random events changed the trajectory of her career.

A friend convinced her to stop by a retirement party. There, she bumped into Kathy Sumner, a PT she’d worked with 20 years earlier. Kathy invited Carole to visit a pelvic health clinic she ran with Janet Whelan Drake, who Carole now works alongside as a Lead Teaching Assistant at Herman & Wallace.

When Carole walked through the clinic door, the feeling was immediate and unmistakable. She was home.

Kathy and Janet became Carole’s mentors. Weekends of hands-on training. Patients brought in for teaching opportunities. Encouragement to pursue coursework. The small-room private practice setting turned out to be the perfect environment for someone navigating mobility challenges, a place where Carole could not only survive, but thrive.

The timing was ideal. Her DPT program required a semester-long research project on a topic of interest, and Carole channeled everything into developing her Belly After Baby program for postpartum women, with Kathy and Janet guiding her every step of the way.

Eating Disorders and Pelvic Health: A Critical Connection

Today, Carole is a Pelvic Clinical Rehabilitation Specialist at Jefferson Health Lehigh Valley in Pennsylvania, where she treats patients of all genders with pelvic, bowel, bladder, and abdominal concerns. She holds her Pelvic Rehabilitation Practitioner Certification (PRPC) and serves as both an instructor and Lead Teaching Assistant at Herman & Wallace.

Her course, Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional, fills a critical gap in pelvic health education. Individuals with eating disorders frequently present with the exact symptoms pelvic rehab professionals treat every day: constipation, bloating, abdominal pain, pelvic organ prolapse, urinary dysfunction, and pelvic pain. Yet the connection between eating disorders and pelvic health is often overlooked.

As Carole explains, pelvic health providers aren’t going to diagnose or treat eating disorders, but they absolutely can and should be asking the right questions. They can observe, support, refer, and provide manual and educational tools that make a real difference in someone’s recovery journey. Sometimes, a pelvic health clinician is the first provider to notice the signs and gently guide someone toward help.

The course has received outstanding reviews, with clinicians praising its depth and Carole’s ability to connect the bigger picture, the multidisciplinary web of providers that supports individuals with eating disorders, with the specific, actionable skills pelvic health professionals can bring to the table.

Research at the International Level

Beyond Herman & Wallace, Carole serves on the Pelvic Workgroup of the International Consortium on the Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society. In 2024, the workgroup published a landmark paper in PLOS ONE, a multidisciplinary, multinational effort co-creating evidence-based clinical guidelines for the management of pregnancy, birth, and postpartum recovery in individuals with hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD).

The workgroup is currently finalizing a paper focused on pelvic health concerns in individuals with hEDS and HSD, with additional publications expected through 2026 and into 2027, including updates to diagnostic criteria and guidance across multiple clinical domains.

Carole is passionate about the screening role pelvic health professionals can play for hypermobility. As she describes it, asking just a few simple questions about a history of joint subluxations, dislocations, or being “super bendy” can start to connect dots that no one else has connected. Many individuals with hypermobility present with pelvic dysfunction, GI issues, chronic pain, skin changes, and temperature sensitivities. Pelvic health clinicians may be the first to notice that these seemingly unrelated issues share a common thread.

A Philosophy of Mentorship

One theme that runs through every chapter of Carole’s story is mentorship. She was mentored into pelvic health by Kathy and Janet. She was encouraged to take that first Pelvic Floor Level 1 course by people who believed in her when she wasn’t sure she believed in herself. And now, she pays it forward: mentoring new clinicians, serving as boots on the ground at satellite courses, and fostering the collaborative, family-like learning environment that she believes is the heart of what Herman & Wallace does best.

Her advice to clinicians who feel overwhelmed by the breadth of pelvic health education?

“Keep your focus on the step you’re on. Don’t look up at the full staircase. There’s no timeline. One course, one skill, one patient at a time, and before you know it, you’ll have built something incredible underneath you.”

About Carole

Carole High Gross, PT, MS, DPT, PRPC (she/her) earned her Doctorate of Physical Therapy from Arcadia University in 2015 and her Master of Science in Physical Therapy from Thomas Jefferson University in 1992. She works as a Pelvic Clinical Rehabilitation Specialist at Jefferson Health Lehigh Valley and serves as a Lead Teaching Assistant and instructor at Herman & Wallace, where she created and teaches Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole is a member of the Pelvic Workgroup of the Ehlers-Danlos International Consortium and has a special interest in working with individuals living with eating disorders and hypermobility throughout the pregnancy and postpartum journey. She is a dedicated mentor for growing pelvic professionals and focuses on team building and program development.

Learn From Carole

Ready to explore the intersection of eating disorders and pelvic health rehabilitation? Carole’s course is designed to expand your clinical lens, build your confidence in screening and observation, and equip you with practical tools to support individuals with eating disorders on their recovery journey.

Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional

Remote Course | October 4–5, 2025 | Live via Zoom

Your patients deserve comprehensive care, and you deserve the knowledge to deliver it. Register today at hermanwallace.com. Spots are limited.

Rehabilitative ultrasound imaging is a clinical tool that can change the way you practice. I have often shared with other clinicians how much the use of ultrasound imaging has influenced how I approach patients with chronic back or sacroiliac joint pain. Using ultrasound imaging allows for a way to assess the deeper core muscles, which may be more difficult to palpate on some individuals. Being able to view the activation in these muscles can inform the therapist whether the patient is properly activating their core or relying on a less ideal strategy.

Seeing the Core Muscles That Are Hard to Reach

One of the most valuable things about rehabilitative ultrasound imaging in pelvic health is what it shows us about the deeper core muscles. These are muscles that conventional palpation simply cannot reach reliably in every patient. With ultrasound imaging, we can observe in real time whether a patient is using a proper activation strategy or compensating in a way that looks adequate on the surface but is not providing the stability they need.

That kind of information changes treatment. It gives both the clinician and the patient something concrete to work with, and it often unlocks progress that had stalled.

A Game Changer for Incontinence and Prolapse

The use of rehabilitative ultrasound imaging has also been a game changer in treating incontinence and prolapse patients. Not only does it enable me to view activation in the pelvic floor, but also the supportive function of the pelvic floor. For some patients, that supportive function is exactly what has been missing. Being able to show them what is happening in their own body, in real time, is often what finally moves treatment forward.

When Ultrasound Made All the Difference: A Patient Story

I recently began working with a patient who is a semi-professional athlete. She was 14 months postpartum and seeking care for prolapse symptoms and discomfort. This patient understood the importance of the pelvic floor and had sought out pelvic floor rehab immediately following delivery. She was approved to return to exercise and at the sixth minute of activity felt a prolapse occur.

After returning and continuing with pelvic health therapy, she still was not seeing progress with respect to her symptoms. There was real pressure mounting because she had qualified for an international level event in her sport that was six months away.

When I evaluated her, I identified that she was able to activate her pelvic floor while in a supine position, but not when standing or during a motor task. Using rehabilitative ultrasound imaging allowed her to visualize what it felt like to do a proper contraction while in standing. This was transformative. It helped her learn to engage her pelvic floor in a weight bearing position, which improved the supportive function of the pelvic floor and allowed her to begin engaging it during her sports activity.

It did take time and a lot of practice. But the addition of ultrasound imaging was what made the difference between her earlier attempts at pelvic rehab and this course of treatment.

About the Instructor: Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC is the creator of the Rehabilitative Ultrasound Imaging courses at Herman & Wallace and currently serves as Director of Education. A physical therapist since 1999, Allison holds a Doctor of Physical Therapy from Boston University. She is board certified by the Lymphology Association of North America (2011), board certified in Biofeedback Pelvic Muscle Dysfunction (2012), and earned her Pelvic Rehabilitation Practitioner Certification in 2014. She is a published researcher, a co-author in Healing in Urology, and a nationally recognized lecturer on ultrasound imaging, lymphedema, and pelvic floor dysfunction. Allison practices at Inspire Physical Therapy and Wellness in the Denver metro area, treating men, women, and children across a wide range of pelvic health conditions.

Join Us in Edmond, Oklahoma: April 17 to 19, 2026

This three-day course covers transabdominal viewing of the pelvic floor, abdominal wall, and spinal muscles as well as transperineal imaging that allows us to view the supportive function of the pelvic floor. Topics include:

• Real-time imaging of the transverse abdominals, rectus abdominis, deep multifidus, levator ani, bladder, bladder neck, urethra, and vagina
• Transabdominal and transperineal viewing methods
• Hands-on lab time with ultrasound machines provided by course sponsors
• Clinical application for lumbopelvic pain, pelvic organ prolapse, and urinary incontinence

You will love learning to use this clinical tool and seeing the changes it makes for your patients. Register for Rehabilitative Ultrasound Imaging: Pelvic Health and Orthopedic Topics in Edmond, OK at hermanwallace.com.

Pelvic health physical therapy sits at the intersection of multiple body systems: musculoskeletal, neuromuscular, gastrointestinal, urologic, reproductive, and psychological. Yet one critical piece is consistently underemphasized in clinical training: pharmacology.

As pelvic health providers, we routinely treat patients who are taking medications that directly influence bladder function, bowel motility, hormonal balance, tissue integrity, pain perception, sexual function, and autonomic regulation. If we are not confident in our understanding of those medications, we risk missing key contributors to our patients' symptoms — or worse, misinterpreting clinical presentation altogether.

Expanding pharmacologic literacy for pelvic health providers isn't optional anymore. It's essential.

Medications Influence the Pelvic Floor More Than We Think

Consider how commonly our patients are prescribed medications like these:

• Anticholinergics for overactive bladder
• Beta-3 agonists for urinary urgency
• Hormonal contraceptives or menopausal hormone therapy
• SSRIs and SNRIs
• Muscle relaxants
• Opioids
• Laxatives or stool softeners

Each of these medications can alter tissue quality, muscle tone, coordination, libido, arousal, bowel patterns, or pain processing. For example, oxybutynin (an anticholinergic) may reduce bladder urgency but contribute to constipation — which in turn increases pelvic floor strain. Hormonal changes driven by oral contraceptives or menopause can affect collagen integrity, vaginal tissue health, and load tolerance. Antidepressants may improve mood while simultaneously influencing sexual function or arousal.

When we assess biomechanics without considering pharmacology for pelvic health, we are seeing only part of the picture.

Medication Side Effects Can Mimic or Exacerbate Dysfunction

Patients frequently present with symptoms such as:

• Constipation or bowel irregularity
• Urinary retention, urgency, or frequency
• Sexual dysfunction or decreased arousal
• Vaginal dryness or tissue irritation
• Fatigue or dizziness affecting exercise tolerance

How often are these attributed solely to pelvic floor dysfunction when medication side effects may be a primary contributor? Understanding pharmacodynamics and pharmacokinetics allows us to recognize red flags early, identify medication-induced symptoms, modify exercise dosing appropriately, and collaborate more effectively with prescribing providers. This elevates our clinical reasoning from symptom management to genuinely comprehensive pelvic health care.

Interdisciplinary Collaboration Starts with Pharmacologic Fluency

Pelvic health PTs frequently collaborate with OB-GYNs, urogynecologists, urologists, gastroenterologists, pain specialists, and primary care providers. When we understand the indications for common pelvic medications — their mechanisms of action, contraindications, and side effect profiles — we can communicate clearly, advocate effectively for our patients, and participate meaningfully in care decisions.

This isn't about prescribing. It's about being an informed provider within a multidisciplinary team. Pharmacologic literacy is what allows pelvic health providers to show up at that table as true clinical partners.

Meet the Faculty: Kristina Koch, PT, DPT, CLT, PCES

Kristina Koch, PT, DPT, CLT, PCES is a board-certified specialist in women's health physical therapy and the creator of this course. With over two decades of clinical experience treating pelvic floor dysfunction across all genders and ages, Kristina brings unparalleled depth to this subject. She earned her doctorate from The College of St. Scholastica in 2021 and currently practices in Colorado Springs, CO, where she also serves as a guest lecturer for graduate PT students at Regis University in Denver and provides educational sessions for medical providers and community groups. Kristina has developed this course because she believes pharmacologic literacy is a professional responsibility — not just a clinical nice-to-have.

Invest in the Provider You're Becoming

Pelvic health is evolving rapidly. Our patients are complex. Our role is expanding. To practice at a high level, we must think beyond muscles and manual therapy — we must understand the biochemical and systemic influences that shape pelvic function, including the medications our patients take every day.

If you are ready to deepen your expertise, improve patient outcomes, and elevate your confidence in pharmacology for pelvic health, this is the course you've been waiting for.

Pharmacologic Considerations for the Pelvic Health Provider

Remote Course — Saturday, April 4, 2026 | 8:00 AM Pacific | Live via Zoom

This one-day remote course is designed specifically for pelvic health rehabilitation professionals and covers:

• Urologic medications and their effects on pelvic floor function
• Gastrointestinal pharmacology
• Hormonal therapies including gender-affirming care medications
• Pain medications and their impact on neuromuscular function
• Psychotropic medications and pelvic health
• Medication side effects that influence pelvic function
• Clinical decision-making and interdisciplinary communication
• Non-medication treatment alternatives

Your patients deserve comprehensive care, and you deserve the knowledge to deliver it. Register today at hermanwallace.com — spots are limited.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Acupressure as an Evidence-Informed Integrative practice

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

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

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

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

Why Acupressure Matters in Pelvic Health Rehabilitation

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

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

· Calming hyperactive pelvic and autonomic nerves

· Improving circulation and tissue mobility in the pelvic region

· Releasing stored muscular tension and trauma

· Supporting emotional grounding, safety, and resilience

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

Acupressure as a Hands-On Self-Regulation Tool

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

Clinical benefits of acupressure include:

· Vagal nerve modulation and stress reduction

· Decreased muscle tension and chronic pain

· Enhanced emotional regulation and trauma support

· Promotion of relaxation and improved sleep

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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