Constipation, which includes rectal evacuation disorders, slow transit constipation, and IBS to name a few is one of the most common gastrointestinal disorders worldwide (1,2). The complexity of constipation and its impact on a person’s health and quality of life is often misunderstood and common treatment strategies such as diet, exercise, hydration, and stress management can be an oversimplification of what is necessary to effectively manage the disorder (1). From a rehabilitation lens, it is pivotal to prioritize the function of the nervous system when developing a treatment strategy for constipation, considering the nervous system is the central control mechanism of all functions and processes in the human body.

Dry needling, specifically, dry needling with electrical stimulation, is one of the most impactful tools we have in rehabilitation to improve the health and function of the nervous system. Dry needling has evolved from a procedure that utilizes a monofilament needle to deliver mechanical input into “trigger points” in muscle tissue to include the use of a monofilament needle for the delivery of electrical stimulation, which is often described as percutaneous electrical stimulation or neuromodulation. The use of electrical stimulation with dry needling can have a profound effect on improving the healing capacity of tissues and the overall functional recovery of the human body primarily due to the impact it has on the nervous system. Therefore, we must have a sound understanding of the neuroanatomy and physiology of any region of the body and the associated dysfunction to effectively develop and implement a treatment plan.

The gastrointestinal system is considered the most complicated system in our body in terms of the number of structures involved in function and regulation and the enormity of neurons that innervate the gastrointestinal tract, and it is yet to be fully understood (3). The enteric nervous system, which is commonly considered the third branch of the autonomic nervous system, is at the center of regulatory control of the gastrointestinal (GI) tract and precisely coordinates the function of GI neurons, glial cells, macrophages, interstitial cells, and enteroendocrine cells which drives gut motility and secretions (3). It is interesting to note that the sophistication of the enteric nervous system allows the GI tract to be able to function independently of any neural inputs from the central nervous system (3,4). However, normal physiologic functioning of the GI tract is influenced by bidirectional neuronal connections between the enteric and central nervous systems which is known as the “brain-gut-axis” (3).

Embedded in the walls of the GI tract are the myenteric and submucosal plexuses of the enteric nervous system, which innervate the GI tract and uniquely provide both excitatory and inhibitory motor neurons (4). The myenteric plexus lies between the longitudinal and circular muscle layers of the GI tract and coordinates smooth muscle movements or gut propulsions (“motility”) while the submucosal plexus is found within the connective tissues of the submucosa and regulates secretion, absorption, and blood flow in the GI tract (3,4).

The sympathetic and parasympathetic nervous systems influence the function of the GI tract primarily through integrated neuronal activity with the enteric nervous system versus direct innervation to the wall of the gut, with the exception of blood vessels and sphincters which receive direct sympathetic innervation (3).

Sympathetic inputs to the GI tract regulate secretion and motility and parasympathetic inputs to the distal colon are important for colonic motility and defecation (3).

The function of the somatic nervous system innervating key structures involved with defecation should be equally prioritized to comprehensively evaluate factors contributing to constipation. This may include spinal nerves from the thoracolumbar and sacral vertebral segments, the iliohypogastric and ilioinguinal nerves, the pudendal nerve, the levator ani nerve, and even the phrenic nerve if we are considering the innervation and function of the diaphragm and the importance of breathing mechanics and control of intraabdominal pressure during voiding.

From a treatment perspective, the most impactful window of access to modulate activity in the gastrointestinal tract using dry needling with electrical stimulation is targeting spinal nerves and associated peripheral nerves and their target organs (primarily muscle tissue) that converge with our autonomic nervous system innervating the gut (5). Additionally, electrical stimulation applied directly over the involved target tissue in the GI tract can help facilitate changes in GI function because the enteric nervous system is embedded in the wall of the GI lumen. The rationale for the use of neuromodulation to impact the function of the gastrointestinal tract is that our system is a bioelectric system, therefore, the application of electrical stimulation can have a profound impact on neuromuscular function which is interrelated with neurovascular, neuroimmune function, neuroinflammatory function, neuroendocrine function and so on (5, 6, 7). There is even evidence that electrical stimulation can impact the concentration of bacterial populations in the GI tract which can influence the overall function of the gut. Lastly, ongoing dysfunction in gastrointestinal tissue or any visceral tissue can create neuromotor dysfunction in associated somatic tissues that may include pain, tissue sensitization, abnormal muscle tone, and abnormal motor control strategies which can be effectively and efficiently treated with dry needling and electrical stimulation.

In conclusion, dry needling with electrical stimulation is one the best tools used in conjunction with traditional rehabilitation strategies to create meaningful, sustainable improvements in the function of the human body. If you want to learn more about the implementation of dry needling into your practice as it relates to constipation or gastrointestinal disorders, join us on an upcoming course!

Dry Needling and Pelvic Health: Foundational Concepts and Techniques 

• Galloway NJ - March 21 - 23 2025
  
• Atlanta GA - June 21-22, 2025
• Dayton OH - September 13-14, 2025

Dry Needling and Pelvic Health 2: Advanced Concepts and Neuromodulation

• Seattle WA - May 17-18, 2025

Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations

References

1. Forootan M, Bagheri N, Darvishi M. Chronic constipation: A review of literature. Medicine (Baltimore). 2018;97(20):e10631. doi:10.1097/MD.0000000000010631
2. Black CJ, Ford AC. Chronic idiopathic constipation in adults: epidemiology, pathophysiology, diagnosis and clinical management. Med J Aust. 2018;209(2):86-91. doi:10.5694/mja18.00241
3. Sharkey KA, Mawe GM. The enteric nervous system. Physiol Rev. 2023;103(2):1487-1564. doi:10.1152/physrev.00018.2022
4. Spencer NJ, Hu H. Enteric nervous system: sensory transduction, neural circuits and gastrointestinal motility. Nat Rev Gastroenterol Hepatol. 2020;17(6):338-351. doi:10.1038/s41575-020-0271-2
5. Larauche M, Wang Y, Wang PM, et al. The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs. Neurogastroenterol Motil. 2020;32(11):e13925. doi:10.1111/nmo.13925
6. Zhang C, Chen T, Fan M, et al. Electroacupuncture improves gastrointestinal motility through a central-cholinergic pathway-mediated GDNF releasing from intestinal glial cells to protect intestinal neurons in Parkinson's disease rats. Neurotherapeutics. 2024;21(4):e00369.
7. Jacobson A, Yang D, Vella M, Chiu IM. The intestinal neuro-immune axis: crosstalk between neurons, immune cells, and microbes. Mucosal Immunol. 2021;14(3):555-565. doi:10.1038/s41385-020-00368-1

AUTHOR BIO:
Tina Anderson, MS PT

Tina Anderson (she/her) received her Master of Science in Physical Therapy in 2001 from Grand Valley State University located in Grand Rapids, Michigan. She graduated from Michigan State University in 1996 with a Bachelor of Science in Kinesiology. Tina specializes in treating patients with complex neuromusculoskeletal dysfunction including dysfunctions of the pelvic floor. Tina earned her dry-needling certification in 2006 and has been teaching dry-needling nationwide since 2008. Tina was integral in pioneering dry-needling techniques for the pelvic floor and surrounding neuroanatomical structures. She currently owns and operates a private physical therapy practice in Aspen, Colorado. Tina and her family, including their new “fur” child Beatrice, love living and playing in the Rocky Mountains!

Pessaries and Pelvic Rehab includes 6 hours of pre-course video lectures that cover relevant pelvic anatomy, types of prolapse, indications and contraindications for prolapse, and medical-legal considerations for pessary fitting. The in-person portion will include labs on advanced POP assessment and assessment of vaginal dimensions, as well as provide participants the opportunity to fit various pessary types under the supervision of an instructor.

This two-day in-person course is targeted to pelvic therapists who are interested in adding pessary fitting to their clinical practice and have completed Pelvic Function Level 1 and Level 2B.

Attendees will:

• -Identify Which Patients to Refer to medical providers for pessary assessment and fitting
  -Learn Indications and Contraindications for pessary fitting
  -Assess Perineal and Vaginal Dimensions to determine pessary choices and fitting
  -Perform a Pessary Fitting for 4 types of pessaries including ring, dish, donut, and cube
  -Screen for Complications of pessary fitting and use
  -Create Plans of Care that consider lifespan issues, the role of hormones, and other pelvic functions including, but not limited to, bowel, bladder, and sexual health.

Pessaries and Pelvic Rehab is perfect for practitioners eager to add pessary fitting to their clinical practice. Look for this course to be scheduled for 2025!

If you haven’t registered yet then consider this your personal invitation to join us at HWConnect 2025 in beautiful Seattle, Washington. Take advantage of this golden opportunity to network, learn, and expand your toolkit. The conference will be here before you realize it – and tickets are limited! PLUS, if you register now, you can reserve your room at a special discounted rate. 

FRIDAY  SPEAKER LINEUP
Ramona Horton, MPT, DPT - "The Do Not Miss List: What many pelvic rehab therapists overlook"
Ramona Horton, MPT, DPT developed and instructs the visceral and fascial mobilization courses for HW and frequently presents at local, national, and international venues – including International Pelvic Pain Society, CSM and HWConnect- on topics relating to women’s health, pelvic floor dysfunction, and manual therapy.

KEYNOTE SPEAKER
Dawn Sandalcidi PT, RCMT, BCB-PMD - “Development of Continence Through The Lens of The Diaphragm, Ribcage, and Pelvic Floor.”
Dawn Sandalcidi PT, RCMT, BCB-PMD is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. Dawn has spoken at the World Physical Therapy Conference about pediatric pelvic floor dysfunction and incontinence, has 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. 

SATURDAY SPEAKER LINEUP
Ken McGee, PT, DPT - "Five Lessons from Gender-Affirming Care for All Your Clients"
Ken McGee, PT, DPT (they/he) is a white, queer transmasculine physical therapist. They have helped hundreds of people overcome conditions related to gender affirmation and pregnancy. Ken has lectured nationally and internationally on conditions related to gender affirmation and birth tears. Their practice, B3 Physical Therapy, centers on transgender and perinatal rehabilitation.

Dr. Cindy Mossbrucker - "Endometriosis and the Evil Triplets: IC, IBS, and Levator Spasm"
Dr. Cindy Mosbrucker is a nationally recognized expert in minimally invasive excision of endometriosis, as well as the diagnosis and treatment of pelvic pain in women. Dr. Mosbrucker is a sought-after resource for women with pelvic pain from all causes, including pudendal neuralgia, levator spasm, hip impingement and labral tears, and interstitial cystitis.

KEYNOTE SPEAKER
Nancy Norton, RN - “The Power of Humor for Pelvic Healers.”
Nancy Norton, RN is a Registered Nurse and comedian and has been featured on A&E, Netflix, Amazon Prime, and tours nationally - headlining clubs, festivals, conferences, and events - performing both standup comedy and delivering keynote presentations. Nancy has also toured internationally on several USO tours entertaining the troops in Europe, Asia, Iceland, and the Pacific. Nancy also hosts a weekly Podcast called "Tromedy", aimed at helping to transmute trauma responses with comedy.

SUNDAY SPEAKER LINEUP
 Carole High Gross, PT, DPT, PRPC - "Eating Disorders and Disordered Eating: Putting the Pieces Together, and the Hope Pelvic Rehabilitation Can Provide"
Carole High Gross, PT, MS, DPT, PRPC serves on the APTA Pelvic Workgroup of the Ehlers-Danlos International Consortium. Carole has a special interest in working with individuals living with eating disorders, hypermobility, and throughout the pregnancy and postpartum journey.

KEYNOTE SPEAKER
Leticia Nieto, PsyD, LMFT, TEP - “Working Well: Trauma Responsive Care for Those We Work With and for Us.”
Leticia Nieto, PsyD, LMFT, TEP is a leadership coach, psychotherapist, and educator specializing in liberation and equity, cultural responsiveness, motivational patterning, and evolutionary creativity. Dr. Nieto is internationally recognized for her expertise in addressing social justice concerns from a developmental ecological perspective including orienting to systemic transformation, survivance, song and poetry, relational repair, joy, radical rest, intersectional coalition, and reparative and restorative justice. Her 2010 book, Beyond Inclusion, Beyond Empowerment: A Developmental Strategy to Liberate Everyone, is an accessible analysis of the dynamics of oppression and supremacy that offers readers ways to develop skills to promote social justice.

Discounted Hotel Rooms Available Until January 1, 2025
HWConnect 2025 will take place entirely at the Hilton Seattle Airport & Conference Center in Seattle, WA, and we would love for you to stay at the hotel for ease of attending all sessions and social events and have secured a room block and special pricing for conference attendees starting at $167.

The hotel is accessible from the Seattle-Tacoma Airport by walling across the skybridge by the SeaTac light rail station, making it very convenient for those flying in or attending from the greater Seattle area. We Look Forward to Seeing You at HWConnect!

HWConnect 2025 is scheduled for March 28-30, 2025 in Seattle Washington.

When it comes to treating defecatory disorders, particularly fecal incontinence and chronic constipation, innovation can be a game changer. Enter rectal balloon catheters—a tool that, despite initial discomforting imagery, offers significant benefits for patients struggling with these conditions.

At first glance, the thought of a balloon being inserted into the anus may provoke apprehension. However, it's essential to understand that the size of these balloons is smaller than that of an average bowel movement, making their use far more manageable than one might expect. The primary role of these catheters is to provide sensory retraining in the anal canal, an aspect of treatment that is otherwise challenging to achieve.

Numerous studies have highlighted the effectiveness of rectal balloon catheters. For instance, research by Bright et al. in 2005 showed that when patients squeeze to retain a balloon, it effectively mimics the physiology of defecation. This process aids in improving maximal anal squeeze pressures, a vital aspect of bowel control.

As the study states, “External anal sphincter contraction is difficult for some patients to perform on request. With traction on a balloon catheter, anal squeeze pressures improved in most patients. This indicates that many patients perform maximal anal squeeze pressures better once that muscle group has been tested in a more normal physiological function.”

This revelation underscores the potential of balloon catheters in not only retraining muscle function but also in enhancing patient confidence during bowel movements.

The key to success with rectal balloon catheters lies in careful patient selection. Not every patient will benefit from this approach, but for those who do, the results can be transformative. Many have reported significant improvements in their ability to manage symptoms and regain control over their bowel functions.

Are you still feeling apprehensive about integrating balloon catheters into your practice?
It’s understandable. Take a course to build your confidence and learn how to use this remarkable clinical tool. In Anorectal Balloons: Introduction and Practical Applications you will learn the research that supports the use of balloon catheters, as well as evaluation and treatment techniques using anorectal balloons. You will participate in a lab to ensure proper handling. Anorectal Balloons: Introduction and Practical Applications is an online course lasting 5.5 hours. Join me on December 14 to learn more about anorectal balloon catheters so that you can add this tool to your clinical repertoire.

Rectal balloon catheters may initially seem daunting, but they represent an essential advancement in the treatment of defecatory disorders. With the right training and patient selection, you can add this remarkable clinical tool to your repertoire and make a profound difference in your patients' lives.

Resources:

Bright T, Kapoor R, Voyvodich F, Schloithe A, Wattchow D. The use of a balloon catheter to improve evaluation in anorectal manometry. Colorectal Dis. 2005 Jan;7(1):4-7. doi: 10.1111/j.1463-1318.2004.00698.x. PMID: 15606577.

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 & 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.

Prostate cancer remains one of the most commonly diagnosed cancers among men, yet the pathway to effective screening can be fraught with confusion and uncertainty. With varying recommendations from different health organizations and a multitude of testing options available, patients often find themselves unsure about when and how to pursue screening. Two of the screening methods often recommended are the Prostate-Specific Antigen (PSA) test and MRI.

Prostate-Specific Antigen (PSA) Testing
Screening for prostate cancer has been confusing for some patients in terms of what is recommended. Prostate-Specific Antigen (PSA) is used by some providers, but some patients are unsure when to proceed with testing. The US Preventative Services Task CDC recommends that the use of PSA screening between in men aged 55 to 69 should be an individual choice, however, it should not be performed in men over the age of 70. Other websites recommend having a discussion for screening between individuals and their medical provider, which may include PSA testing, starting at 50, earlier if there is a risk present.

Some of the issues for screening for prostate cancer with PSA include false positives that require additional testing and biopsy, overdiagnosis, and overtreatment. The treatment for prostate cancer has a lot of side effects including urinary incontinence, erectile dysfunction, and bowel issues. This is concerning when quality of life can be greatly influenced by these side effects.

MRI
With improved technology, MRI is emerging as a nice screening tool for prostate cancer. MRI has shown promising results. MRI does identify cancer before it is too advanced. It also is decreasing the number of patients that are diagnosed with clinically insignificant cancer, which means fewer patients are being overtreated. According to Hugosoon et al in 2024, using MRI to decide if a biopsy should be performed “eliminated more than half of diagnoses of clinically insignificant prostate cancer,” while the risk of being diagnosed at an incurable stage was “very low.”¹ The use of MRI is more than for diagnosis at the pre-biopsy stage but is progressing to screening, active surveillance, clinical staging, and detection of recurrent disease. ² Artificial intelligence (AI) based algorithms are being explored for the use of detecting and characterizing prostate cancer on an MRI. These are showing promising results as well, particularly with decreasing false positives.³

As the landscape of prostate cancer screening evolves, it is crucial for patients and healthcare providers alike to remain informed and engaged in discussions about the best approaches to diagnosis and treatment. The decision to undergo screening should not be taken lightly; it requires a thorough understanding of the benefits and risks associated with various testing methods, including PSA testing and the promising role of MRI.

In an era where technology, including artificial intelligence, is reshaping how we approach cancer detection, it’s imperative to remain proactive and adaptable. By prioritizing education and open communication, we can ensure that the journey through prostate cancer screening and treatment is navigated with confidence and clarity.

Join us in Oncology of the Pelvic Floor Level 1 (OPF1) to receive an introduction to oncology of the pelvic floor, or Oncology of the Pelvic Floor Level 2A (OPF2A) for a deeper understanding of prostate cancer and empower yourself or your patients with the knowledge needed for informed health choices. In OPF1, we address issues that are commonly seen in a patient who has been diagnosed with cancer such as cardiotoxicity, peripheral neuropathy, and radiation fibrosis while in OPF2A, we cover topics of prostate cancer, testicular and penile cancers, as well as colorectal and anal cancers. You will learn the latest diagnostic testing for each type of cancer as well as medical treatment and how that treatment can influence our patients’ bodies. Hands-on treatment techniques that can be used in the rehabilitation process are learned. Join us to learn more about prostate cancer and more!

Oncology of the Pelvic Floor Level 1 is next offered January 11-12, 2025.
Oncology of the Pelvic Floor Level 2A is next offered March 8-9, 2025.

Resources

1. Hugosson J, Godtman RA, Wallstrom J, et al. (2024). Results after four years of screening for prostate cancer with PSA and MRI. New England Journal of Medicine. 391; 1083-1095.
2. Trecarten S, Sunnapwar AG, Clarke GD, Liss MA. (2024). Chapter Three- Prostate MRI for the detection of clinically significant prostate cancer: update and future directions. Advances in Cancer Research. Vol 161. 71-118.
3. Roubiere O, Jaouen T, Baseilhac P, et al. (2023). Artificial intelligence algorithms aimed at characterizing or detecting prostate cancer on MRI: How accurate are they when tested on independent cohorts?- A systematic review. Diagnostic and Interventional Imaging. Vol 104 (5): 221-234.

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 & 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.

In 2024, the Journal of Women’s and Pelvic Health Physical Therapy published an article on stress urinary incontinence (SUI) and parous runners. It specifically looked at functional lower extremity strength along with running mechanics. The study had 22 participants who performed functional strength tests, including a 30-second single-leg sit-to-stand test and a 10-minute treadmill run with a cadence assessment, and also filled out SUI questionnaires. The higher questionnaire scores had a positive correlation between increased ground contact times and slower cadences.

There was no correlation between the 30-second single-limb sit-to-stand test and higher SUI questionnaire scores. However, multiple other studies referenced in this article have shown increased SUI with decreased hip external rotation and abduction strength compared to those without SUI. The 30-second single-limb sit-to-stand test has not been validated as a good measure of hip strength at this time.

In the remote course The Runner and Pelvic Health by Leeann Taptich and Aparna Rajagopal, they will discuss running mechanics, faults of running including ground reaction forces, contact times, and cadence along with functional strength assessments that can be performed for parous female runners with reported SUI. Please join them on December 14, 2024 for this course.

Reference:

Ron NJ, Dolbinski SC, Hodonicky EG, Middlebrook DO, Olmstead SR, Olsen SL, Ron ED. Hollman JH. Associations between running mechanics, functional lower extremity strength, and stress urinary incontinence in parous female runners. Journal of Women’s & Pelvic Health Physical Therapy. 2024; 48(3): 147-153.

AUTHOR BIO:
Leeann Taptich DPT, SCS, MTC

Leeann Taptich (she/her) has been a physical therapist since 2006. She graduated with a BS in Kinesiology from Michigan State University and a Doctorate of Physical Therapy from the University of St Augustine. In 2009, she earned her Manual Therapy from the University is St Augustine and her board certification as a Sports Certified Specialist in 2018.

Leeann leads the Sports Physical Therapy team at Henry Ford Macomb Hospital in Michigan where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital which gives her a very unique perspective of the athlete. With her combination of credentials and her exposure to pelvic health, she is able to use a very eclectic but complete approach in her treatment of orthopedic and sports patients. With the hospital system, she is involved with the community promoting health and wellness at local running competitions and events.

Leeann is passionate about educating and teaching and has assisted in teaching multiple courses at the local State University PT department. She is co-chair of the continuing education committee at her hospital where she writes and develops courses. Leeann lives in the metro Detroit area with her husband and 2 children. She enjoys hiking, traveling, and watching football.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sitting to standing. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence: (1)

• Anterior Tip: Iliococcygeus and pubococcygeus, Sacrococcygeal ligament
• Lateral: Coccygeal muscles that run parallel with the sacrospinous ligament
• Posteriorly: Fibers of gluteus maximus and sacrotuberous ligament

Along with serving as a major attachment site for the above structures it provides support for weight bearing in the seated position and provides structural support for the anus. However, the coccyx is only 10% weight-bearing, so what seems to go wrong that this bone is taking the brunt of the weight-bearing? Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall or an internal trauma like a difficult childbirth (1,2).

In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulted in coccyx pain were from the use of instruments such as forceps delivery or vacuum-assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth (3). Other causes of coccyx pain can be non-traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction (1).

When assessing a patient with coccyx pain, it is also of the utmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retro rectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign and if excision is necessary. Quite often, these masses can be felt as a bulge on rectal examination (4, 5).

A multidisciplinary approach including physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with prolonged coccyx pain (1). Special wedge-shaped sitting cushions can provide relief for patients in sitting and help return them to their social activities during treatment. Physical therapy includes manual manipulation and internal work to the pelvic floor muscles to alleviate internal spasms and ligament pain.

Intrarectal coccyx manipulation can potentially realign a dislocated sacrococcygeal joint or coccyx (1). Unique taping methods demonstrated in video by Dr. Abbate can be used as a follow-up to coccyx manipulation to help hold the coccyx in the new position and allow for optimal healing. Often coccyx pain patients have concomitant pathologies such as pelvic floor muscle dysfunction, sacroiliac or lumbar spine pain, and various other orthopedic findings that are beneficial to address. When conservative treatments fail, injections or a possible coccygectomy may be considered. Luckily, conservative treatment is successful in about 90% of cases (1).

Join Lila Abbate in her upcoming Coccydynia and Painful Sitting remote course on December 14th. By learning how to treat coccyx pain appropriately, you will be a key provider in solving many unresolved sitting pain cases that are not resolved with traditional orthopedic physical therapy.

References:

1. Lirette L, Chaiban G, Tolba R, et al. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal. 2014; 14:84-87.
   Marinko L, Pecci M. Clinical Decision Making for the Evaluation and Management of Coccydynia: 2 Case Reports. JOSPT. 2014; 44(8): 615
   3. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012; 48 (3): 387-392.
   4. Levine R, Qu Z, Wasvary H. Retrorectal Teratoma. A rare cause of pain in the tailbone. Indian J Surg. 2013; 75(2): 147-148.
   5. Suhani K, Ali S, Aggarwal L, et al. Retrorectal cystic hamartoma: A problematic tail. J Surg Tech Case Rep. 2104; 6(2): 56-60.

AUTHOR BIO
Lila Abbate, PT, DPT, OCS, WCS, PRPC

Lila Abbate (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations in Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series and the Pregnancy and Postpartum Rehabilitation courses. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

Pain with sitting is a common complaint that patients may present to the clinic with. While excess sitting has been shown to be detrimental to the human body, sitting is part of our everyday culture ranging from sitting at a meal, traveling in the car, or doing work at a desk. Often, physical therapists disregard the coccyx or tailbone as the possible pain generator, simply because they are fearful of assessing it, have no idea where it is, or have never learned about it being a pain generator in their education.

Coccydynia is the general term for “pain over the coccyx.” Patients with coccydynia will complain of pain with sitting or transitioning from sitting to standing. Despite the coccyx being such a small bone at the end of the spine, it serves as a large attachment site for many important structures of interest that are important in pelvic floor support and continence: (1)

• Anterior Tip: Iliococcygeus and pubococcygeus, Sacrococcygeal ligament
• Lateral: Coccygeal muscles that run parallel with the sacrospinous ligament
• Posteriorly: Fibers of gluteus maximus and sacrotuberous ligament

Along with serving as a major attachment site for the above structures it provides support for weight bearing in the seated position and provides structural support for the anus. However, the coccyx is only 10% weight-bearing, so what seems to go wrong that this bone is taking the brunt of the weight-bearing? Women are five times more likely to develop coccydynia than men, with the most common cause being an external trauma like a fall or an internal trauma like a difficult childbirth (1,2).

In a study of 57 women suffering from postpartum coccydynia, most deliveries that resulted in coccyx pain were from the use of instruments such as forceps delivery or vacuum-assisted delivery. A BMI over 27 and having greater than or equal to 2 vaginal deliveries resulted in a higher rate of coccyx luxation during birth (3). Other causes of coccyx pain can be non-traumatic such as rapid weight loss leading to loss of cushioning in sitting, hypermobility or hypomobility of the sacrococcygeal joint, infections like a pilonidal cyst, or pelvic floor muscle dysfunction (1).

When assessing a patient with coccyx pain, it is also of the utmost importance to rule out red flags, as there are multiple cases cited in the literature of tumors such as retro rectal tumors or cysts being the cause of coccyx pain. These masses must be examined by a doctor to determine if they are malignant or benign and if excision is necessary. Quite often, these masses can be felt as a bulge on rectal examination (4, 5).

A multidisciplinary approach including physical therapy, ergonomic adaptations, medications, injections, and, possibly, psychotherapy leads to the greatest chance of success in patients with prolonged coccyx pain (1). Special wedge-shaped sitting cushions can provide relief for patients in sitting and help return them to their social activities during treatment. Physical therapy includes manual manipulation and internal work to the pelvic floor muscles to alleviate internal spasms and ligament pain.

Intrarectal coccyx manipulation can potentially realign a dislocated sacrococcygeal joint or coccyx (1). Unique taping methods demonstrated in video by Dr. Abbate can be used as a follow-up to coccyx manipulation to help hold the coccyx in the new position and allow for optimal healing. Often coccyx pain patients have concomitant pathologies such as pelvic floor muscle dysfunction, sacroiliac or lumbar spine pain, and various other orthopedic findings that are beneficial to address. When conservative treatments fail, injections or a possible coccygectomy may be considered. Luckily, conservative treatment is successful in about 90% of cases (1).

Join Lila Abbate in her upcoming Coccydynia and Painful Sitting remote course on December 14th. By learning how to treat coccyx pain appropriately, you will be a key provider in solving many unresolved sitting pain cases that are not resolved with traditional orthopedic physical therapy.

References:

1. Lirette L, Chaiban G, Tolba R, et al. Coccydynia: An overview of the anatomy, etiology, and treatment of coccyx pain. The Ochsner Journal. 2014; 14:84-87.
   Marinko L, Pecci M. Clinical Decision Making for the Evaluation and Management of Coccydynia: 2 Case Reports. JOSPT. 2014; 44(8): 615
   3. Maigne JY, Rusakiewicz F, Diouf M. Postpartum coccydynia: a case series study of 57 women. Eur J Phys Rehabil Med. 2012; 48 (3): 387-392.
   4. Levine R, Qu Z, Wasvary H. Retrorectal Teratoma. A rare cause of pain in the tailbone. Indian J Surg. 2013; 75(2): 147-148.
   5. Suhani K, Ali S, Aggarwal L, et al. Retrorectal cystic hamartoma: A problematic tail. J Surg Tech Case Rep. 2104; 6(2): 56-60.

AUTHOR BIO
Lila Abbate, PT, DPT, OCS, WCS, PRPC

Lila Abbate (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations in Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series and the Pregnancy and Postpartum Rehabilitation courses. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

The year was 1998 - my fellow classmates and I converged upon our journey in graduate school to become physical therapists. In our first semester, we shouldered a heavy load of coursework and were memorably immersed in a battle between courses taught by our anatomy and histology professors. Both professors claimed stake to the title of teaching the “most important course in the curriculum.” The connection between anatomy and physical therapy was clear and specific. But there were moments when the connection between histology and physical therapy seemed less relevant and the demands from our histology professor obtuse. The battle between courses played out in both the cadaver lab and the histology slide viewing rooms. My classmates and I found ourselves compelled to pour over both anatomy and histology with focused intensity; the figurative competition became a grind.

We shared in collective moans and groans surrounding the challenge of having a histology professor who thought so highly of cellular structure and function and insisted our appreciation of the topic should equal that of learning anatomy. This professor made exceedingly clear to each of us: “You MUST know what a normal cell looks like to understand basic anatomy and physiology. If you don’t know what normal looks like, then you’ll never know what abnormal looks like.”  We studied muscle slides, fibrocartilage slides, hyaline cartilage slides, endothelium slides, neuron slides, bone slides, tendon slides….and on and on and on. We counted mitochondria. We compared normal and abnormal. Over and over again.

Little did I know - our future understanding of health would literally hinge upon such things. Normal and abnormal cellular health. Intra- and Inter-cellular (mis)communication. Inter-cellular barrier integrity. Mitochondrial (dys)function.

In September 2024, Dr. Casey Means shined a spotlight on our country’s health crises by participating in a non-partisan roundtable discussion titled “American Health and Nutrition – a Second Opinion” – elucidating in a national forum the stark reality of the dismal nutrition situation that plagues our country resulting in equally dismal national health statistics. We are all witnesses to this health catastrophe. She also recently published “Good Energy,” a call-to-action she co-authored with her brother Cally Means. In the roundtable discussion and in the book, Dr. Means eloquently describes the driver of all health and disease states - the status of cellular function – and that this is foundationally driven by nutrition or lack thereof. Based on the overwhelming evidence in the literature I’ve read through the years, and compiled to create “Nutrition Perspectives in Pelvic Rehab,” I couldn’t agree with her more.

And I guess this is where I admit our histology professor was on to something.

As rehab professionals, we absolutely care about what cells look like, act like, move like, and feel like. We may not realize it, but cellular health or dysfunction can dictate if our patients have low energy, metabolic dysregulation (diabetes, obesity, fatty liver disease), neurodegenerative diseases like Parkinson’s, Alzheimer’s, dementia & peripheral neuropathy (Qiao et.al., 2024; Sabui et.al., 2022), neurocognitive changes, (Shatalina et.al., 2024) cancer, chronic pain, or even dysregulation of the gut-brain axis (found in conditions such as IBS). Cellular dysfunction is at the foundation of all of these conditions and their sequelae. We also may not realize it, but when we palpate tissue that is painful, inflamed, tense, tight, dyscoordinated, or find joints to be irritated (Seewald et.al. 2023) cellular dysfunction may be making itself manifest. Sarcopenia, muscle degeneration and weakness, also has underpinnings in metabolic and thus cellular dysregulation (Daily &Park, 2022;  Xie & Huang, 2024). Chronic systemic inflammation is by definition cellular dysregulation. (Kharrazian, 2022)

And finally, we also may not fully realize the decidedly negative impact our standard American diet has on each and every condition just listed, or more precisely, on our cellular health. Without normal cellular function our bodies will devolve into chaos - otherwise known as disease states.

As rehab professionals, we need to know all we can about anatomy, biomechanics, and therapeutic intervention. In my journey, it was the requisite histological training combined with my studies in nutritional sciences that allowed me to see how the “peripheral” topics of nutrition, health, and cellular function intersected in vivid clarity early in my career. This fueled my long-standing passion to share this information with other healthcare providers through the creation of “Nutrition Perspectives.”

This intersection should inform our intention as we steer towards solutions to the overarching American health crisis while helping our clients – one conversation at a time. “Nutrition Perspectives in Pelvic Rehab” (NPPR) provides practical steps to navigate a path forward to improve digestive health, gut health, and overall health. First, we must bravely confront the magnitude and complexity of the problem as we equip ourselves with working knowledge of functional nutrition as shared in NPPR.

Optimizing cellular health can positively influence everything we care about as rehab providers. I might argue in this context – that learning about functional nutrition may be equivalent in importance to anatomy and histology! More fairly – the intersection of anatomy, histology & nutrition will be the foundation upon which the future of health and wellness, and hopefully healthcare will eventually be built.

Nutrition Perspectives in Pelvic Rehab is nearing its 10th anniversary– 10 years of sharing profoundly important nutritional concepts that impact each one of us and the clients we serve. As the body of evidence explodes, the essence of the message within NPPR is unwavering and may just become your “most important course in the curriculum.” Nutrition matters deeply – all the way down to the cellular level.

Come learn the hows and whys in an upcoming offering of Nutrition Perspectives in Pelvic Rehab – available in remote format on the following dates:  Dec 7-8, 2024; Feb 22-23, 2025; June 7-8, 2025; Oct 11-12, 2025 & Dec 6-7, 2025.

Resources:

• American Health and Nutrition – A Second Opinion. https://rumble.com/v5fy7bv-american-health-and-nutrition-a-second-opinion.html
• Daily JW, Park S. Sarcopenia Is a Cause and Consequence of Metabolic Dysregulation in Aging Humans: Effects of Gut Dysbiosis, Glucose Dysregulation, Diet and Lifestyle. Cells. 2022 Jan 20;11(3):338. doi: 10.3390/cells11030338. PMID: 35159148; PMCID: PMC8834403.
• Kharrazian D. Functional Medicine Approaches to Neurodegeneration. Phys Med Rehabil Clin N Am. 2022 Aug;33(3):733-743. doi: 10.1016/j.pmr.2022.04.011. PMID: 35989061.
• Means, C;  Means, C. Good Energy – the Surprising Connection between Metabolism and Limitless Health. Avery. May 2024.
• Qiao L, Yang G, Wang P, Xu C. The Potential Role of Mitochondria in the Microbiota-Gut-Brain Axis: Implications for Brain Health. Pharmacol Res. 2024 Sep 25:107434. doi: 10.1016/j.phrs.2024.107434. Epub ahead of print. PMID: 39332752.
• Sabui A, Biswas M, Somvanshi PR, Kandagiri P, Gorla M, Mohammed F, Tammineni P. Decreased anterograde transport coupled with sustained retrograde transport contributes to reduced axonal mitochondrial density in tauopathy neurons. Front Mol Neurosci. 2022 Sep 30;15:927195. doi: 10.3389/fnmol.2022.927195. PMID: 36245925; PMCID: PMC9561864.
• Seewald LA, Sabino IG, Montney KL, Delco ML. Synovial fluid mitochondrial DNA concentration reflects the degree of cartilage damage after naturally occurring articular injury. Osteoarthritis Cartilage. 2023 Aug;31(8):1056-1065. doi: 10.1016/j.joca.2023.03.013. Epub 2023 Apr 6. PMID: 37028640; PMCID: PMC10524327.
• Shatalina E, Whitehurst TS, Onwordi EC, Gilbert BJ, Rizzo G, Whittington A, Mansur A, Tsukada H, Marques TR, Natesan S, Rabiner EA, Wall MB, Howes OD. Mitochondrial complex I density is associated with IQ and cognition in cognitively healthy adults: an in vivo [¹⁸F]BCPP-EF PET study. EJNMMI Res. 2024 Apr 17;14(1):41. doi: 10.1186/s13550-024-01099-1. PMID: 38632153; PMCID: PMC11024075.
• Xie X, Huang C. Role of the gut-muscle axis in mitochondrial function of aging muscle under different exercise modes. Ageing Res Rev. 2024 Jul;98:102316. doi: 10.1016/j.arr.2024.102316. Epub 2024 May 3. PMID: 38703951.

AUTHOR BIO
Megan Pribyl, PT, CMPT, CMTPT/DN, PCES

Megan Pribyl, PT, CMPT, CMTPT/DN, PCES (she/her) is a mastery-level physical therapist at the University of Kansas Health System in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic health, pregnancy, and postpartum rehabilitation – all with integration of health and wellness. She began her PT career in 2000 after graduating from the University of Colorado Health Sciences Center with her Master of Science in Physical Therapy. Prior, she earned her dual degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) in 1998 from Kansas State University. Later, she obtained her CMPT from the North American Institute of Orthopedic Manual Therapy and became certified in dry needling in 2019. Since 2015, she has been a faculty member of Herman & Wallace Pelvic Rehab Institute and enjoys both teaching and developing content. She created and instructs Nutrition Perspectives for the Pelvic Rehab Therapist offered remotely through Herman & Wallace. She also teaches Pelvic Function – Level 1, Pregnancy Rehabilitation and Postpartum Rehabilitation. She brings many years of experience and insight to all courses. As a content developer, Megan has also contributed to the Herman & Wallace Oncology Series, Pelvic Function Level 2A, as well as the Pelvic Function Series Capstone Course.

Megan’s longstanding passion for both nutritional sciences and manual therapy culminated in her creating Nutrition Perspectives for the Pelvic Rehab Therapist designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to integrate ancient and traditional practices with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation. Clinicians will come away from this course with both simple and practical integrative tools that can be immediately utilized to help clients and providers alike - along their path of healing.

Megan enjoys her many fulfilling roles as an instructor, clinician, wife, and mom to two active teenagers and owner of two rambunctious golden retrievers. She loves to read, cook, be in the great outdoors, travel, and spend time with her family and friends. She has a passion for both the mountains and the beach, exploring scientific literature, and learning all she can about the power of using nature, nurture, and nutrition to heal and sustain health.

Overall prevalence of pelvic floor dysfunction (PFD) ranges from 14.7%-45% within the athletic population (Culleon-Quinn 2022). Additional evidence supports the incidence of PFD within this population (Culleon-Quinn 2022, Rebullido et al 2021, Rodríguez-López et al 2020, Nygaard & Shaw 2016). The athletic population is disproportionately in need of pelvic health services – but much like the general population, many athletes are not aware of the signs and symptoms of PFD, so they may not know to seek care (Bosch-Donate et al, 2024, Cardoso et al, 2018).

In a recent publication in the International Journal of Sports Physical Therapy, a group of student and faculty researchers investigated a method of screening collegiate athletes for PFD as a component of the DPT students’ project to promote health in their communities. The intent of the study was to identify the incidence of PFD in collegiate athletes, assess for awareness of PFD, and explore psychosocial factors related to PFD in athletes.

Taking place at the DPT students’ university, student-athletes were recruited from multiple sports teams to participate in a generalized pelvic floor screening in two phases. In the first phase, students completed a demographics section as well as the Cozean Pelvic Dysfunction Screening Tool, a ten-item subjective screening tool. Athletes who scored a “3” or greater on the Cozean Pelvic Dysfunction Screening Tool were then invited to participate in the second phase of screening: a simple, external pelvic floor muscle (PFM) function assessment, performed by the researchers. The researchers chose this score due to the 91% specificity indicating possible PFD in individuals who score 3 or greater on the tool. (Cozean, N 2018)

The researchers performed an external PFM function assessment that included palpation of the coccyx over clothing. This external assessment allowed for improved comfort of the athletes as well as improved efficiency in the performance of the assessment. Coccygeal motion palpation was previously found to be valid when performed by clinicians without formal pelvic health training and was correlated with activation patterns shown via real-time ultrasound, demonstrating 94% sensitivity and 79% specificity in identifying PFM activation patterns (Maher & Iberle, 2020).

For the PFM function assessment, the researchers palpated the tip of the coccyx with the athlete in a seated position as described in the original 2020 study. Participants were then instructed to contract, release, and lengthen their pelvic floor muscles while the student researchers palpated the motion of the coccyx. As described in the validity study, student researchers identified whether or not the coccyx moved anteriorly, posteriorly, or not at all to infer the activity of the PFM. If the student researchers were unsure, the faculty research leader, a Board-Certified Women’s Health Clinical Specialist, and a Certified Pelvic Rehabilitation Practitioner were available on-site to confirm findings.

Once the coccygeal motion palpation was completed, the researchers assigned the athletes into one of three classifications of suspected PFM impairment:

• “normal PFM activity” indicating that the coccyx moved posteriorly with PFM lengthening and anteriorly with PFM contraction
• “increased tone/overactive PFM activity” indicating that the coccyx did not move posteriorly during lengthening, but did move anteriorly with contraction
• “decreased tone/underactive PFM activity” indicating that the coccyx moved posteriorly with lengthening, but did not move anteriorly with contraction

The researchers then shared information with the student athletes pertaining specifically to the suspected PFM impairment identified. Athletes were given information about the PFM, general exercises to consider, as well as resources for finding a trained PT if they desired more formal assessment and interventions.

A quarter (24.5%) of participants scored a “3” or greater on the subjective screening tool, with positive correlations with increased age, self-identified female gender, and increased knowledge of PFD. Swimming athletes were also found to have an increased incidence of positive screening scores as compared to other sports. Following coccygeal motion testing, 54% of the participants were identified as demonstrating “decreased tone/underactive PFM activity” and 39% were identified as demonstrating “increased tone/overactive PFM activity”.

Of the 13 athletes who scored positive on the Cozean Pelvic Dysfunction Screening Tool, 12 also demonstrated objective signs of increased or decreased tone of the PFM during coccygeal motion palpation, (92.3%) reinforcing the Cozean tool’s effectiveness as a simple subjective screening tool for PFD. Additionally, coccygeal motion palpation is a simple, non-invasive, objective screening method that can be taught to clinicians who do not have formal training in pelvic health, allowing for screening to be performed efficiently by all clinicians, and addressing a critical barrier to receiving care.

The results of this study highlight that PFD is often present in physically fit individuals who are competitive athletes. Additionally, 69% of the athlete participants presenting with suspected PFD reported feelings of embarrassment, anxiety, worry, or annoyance with regard to their symptoms, and 62% reported feelings of frustration. 69% of the athletes presenting with suspected PFD reported feeling as though PFD had an effect on athletic performance and 77% reported that PFD had an impact on their personal life. These qualitative findings illustrate that beyond the physical impact of PFD, there is a psychosocial impact as well. By implementing a PFD screening process for athletes, clinicians without formal pelvic health training can help identify athletes who may be experiencing PFD and serve as the initial point of contact to help athletes function better, both on and off the playing field.

By performing screening with a subjective screening tool and an external pelvic floor muscle assessment, the researchers were able to identify athletes demonstrating subjective and objective characteristics of PFD efficiently, while also emphasizing participant comfort. Taking this innovative approach to PFM assessment, it is much more feasible to integrate pelvic floor screening into a standard sports screening performed by a general physical therapist or athletic trainer. Once identified, those professionals can facilitate referral to a physical therapist with pelvic health training for more thorough assessment and treatment. This would allow more athletes with PFD to receive access to care and could have implications for both athletic performance as well as quality of life.

Interested in learning more? Come and see this group speak at APTA’s Combined Sections Meeting in 2025 where they’ll present an educational session about the study and discuss the implementation of this screening process to help ensure that athletes with PFD are identified sooner and receive access to care efficiently.

You can read the published research article, "Screening for Incidence and Effect of Pelvic Floor Dysfunction in College-Aged Athletes," here: https://ijspt.org/screening-for-incidence-and-effect-of-pelvic-floor-dysfunction-in-college-aged-athletes/.

AUTHOR BIO
Ashlie Crewe Campitella, PT, DPT, WCS, PRPC

Dr. Ashlie Crewe Campitella earned her Bachelor of Psychology and Doctorate of Physical Therapy at Gannon University prior to beginning her pelvic health training. She is a board-certified women’s health clinical specialist (WCS) and has her certification as a pelvic health practitioner (PRPC) through the Herman and Wallace Pelvic Rehabilitation Institute. 

Ashlie has developed pelvic health continuing education that is comprehensive and inclusive of all genders through the Institute of Advanced Musculoskeletal Treatments, where she is now a lead instructor. She also serves as the Pelvic Health Development Program Coordinator for Upstream Rehabilitation Institute. Additionally, Ashlie is a member of the International Pelvic Pain Society, and the Global Pelvic Health Alliance and serves as an adjunct faculty member at Lebanon Valley College, as well as on the medical advisory board for the Lichen Sclerosus Support Network. She remains in clinical practice in Harrisburg, Pennsylvania, treating patients of all ages and genders with pelvic health complaints, with a special focus on implementing a pain neuroscience and trauma-informed approach to pelvic health treatment.

Boundaries, Self-Care, and Meditation Part 1 and Boundaries, Self-Care and Meditation Part 2, scheduled for November 23, are instructed by Nari Clemons, PT, PRPC and Jenna Ross, MSPT, BCB-PMD, PRPC.

Women are often socialized to be these kinds of words: sweet, likable, giving, generous, helpful, and accommodating. If that bend of conditioning is particularly strong, it shapes our relationships and our career choices. We often choose a career that makes us feel like we are being sweet, helpful, and generous. These traits serve others around us well, and they may increase our likability with others. We begin to see our likability as how much we embody these traits, and we can see our worth to others and ourselves as how much we show up in this one-dimensional way to others.

Taken to an extreme, this starts to look like being uber-available for patients calling them on our own time, emailing from home, running over in sessions to give the patient everything they could possibly get from a session, adding in hours to accommodate a patient, writing our notes during our lunchtime, and finding that resource for our patient by searching the web for an hour.

“Tis better to give than receive” or “giving them the shirt off our back” may be mantras we use or grew up with. But is it really true? Is giving more than we receive actually sustainable as a model? And if you give someone the shirt off your back, what would you wear? So many of the models we are raised to see as virtuous are actually rooted in martyrdom and are the hallmarks of poor boundaries.

When we hyper-inflate the “likable” characteristics of ourselves, it is often because we are deeply afraid of being seen as selfish, unlikable, or worst of all, a bi#ch. But why? We make these traits shadows…the traits to deny in ourselves and go to extreme lengths to hide from ourselves and others. Maybe instead, these are the very traits that can help us to understand where we need to set a boundary, rest, or realize we really don’t want to say yes to that added demand.

They can remind us of our energy limits and draw lines that help us have more room for joy, fun, and self-care. If we could honor these shadow traits as helpful protectors of ourselves, we could consider our happiness and balance equally as important as our patients’ happiness and balance. We could find ways to leave work on time to make it to that fun dance class, and we could empower our patients to have greater self-sufficiency. Often, when we are conflicted or tired, we can do well to ask ourselves, “What would a selfish bi#ch do?” The answer is usually what our being needs for balance, but we are too afraid to embrace our shadow to acknowledge our deeper needs and wants.

By ridding ourselves of the need to be seen as syrupy sweet (and utterly drained) and by embracing self-care that may look harsh or selfish to others, we can empower ourselves to have better boundaries. This can also help our patients as we model balanced caregiving, without self-sacrifice. By embracing and honoring these important traits of self-care, self-protection, and acknowledging our needs, we set the stage for less burnout and more healthy relationships in life. So, next time you are overwhelmed by the number of obligations you have or the time you are bleeding energy for others, ask yourself “What would my selfish bi#ch do?” And, if you manage to hear and honor her, high-five yourself as you strut to better self-care and integrated self-love.

Enter the course I co-wrote and teach with Jenna Ross - Boundaries, Self-Care, and Meditation Part 2. This course was born out of our own personal and professional struggles and our journey to having a life and a practice that we love and can sustain. This class provides a safe space to facilitate deep, personal, and professional transformation through evidence-based information and practices. Join us in Boundaries, Self-Care, and Meditation Part 2 on November 23 to learn new strategies to address both oneself and one's patients with a mind, body, and spirit approach.

AUTHOR BIO
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment, as well as Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jen Vande Vegte, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jen Vandevegte. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel successful. She also is an advocate for therapists learning how to feel well and thrive as they care for others, which is a skill that can be developed. “Basically, I love helping therapists learn to help themselves and others more while having a lot of fun doing it”. Nari lives in Portland Oregon, where she runs a local study/mentoring group and has a private practice, Portland Pelvic Therapy. Her interests include meditation, working out, nature, and being constantly humbled from raising her three amazing teenagers!