A prostate cancer diagnosis often brings more than concerns about survival. It can impact urinary control, sexual function, pelvic comfort, and overall quality of life. Men who undergo radical prostatectomy or radiation therapy frequently experience urinary incontinence and erectile dysfunction, sometimes lasting months or years. Pelvic rehabilitation offers structured, evidence-based strategies to restore function, manage symptoms, and rebuild confidence during recovery.

Understanding Prostate Cancer and Its Impact on Pelvic Health
Prostate cancer is among the most common cancers in men. Risk factors include advancing age, family history, genetic predispositions (such as BRCA2 mutations), race or ethnicity, and lifestyle factors including diet and obesity. Diagnosis typically involves PSA screening, biopsy, and imaging to determine disease stage.

Treatment for localized disease often includes radical prostatectomy, external beam radiation therapy (EBRT), or brachytherapy. Each approach carries potential side effects that can affect urinary, sexual, and pelvic function. Even a nerve-sparing prostatectomy can lead to neuropraxia and disruption of pelvic structures, resulting in urinary leakage and erectile dysfunction (5). Radiation therapy can induce fibrosis, vascular injury, and tissue changes that affect erectile function, bladder, and bowel coordination (3). Combined or salvage treatments can further compound these effects (2).

Urinary Incontinence: The Role of Pelvic Floor Training
Urinary incontinence is one of the most common and distressing post-prostatectomy complications. Pelvic floor muscle training (PFMT) is widely recommended as a first-line intervention. Evidence demonstrates that men who engage in PFMT pre- or early postoperatively regain continence faster and experience less severe leakage than those who do not (3).

Effective PFMT focuses on both slow- and fast-twitch muscle contractions, integrating exercises into functional activities, and employing biofeedback or ultrasound to ensure proper engagement (4). Although differences in long-term continence may diminish, early training significantly improves quality of life and independence during the initial recovery months.

Addressing Erectile Dysfunction Through Rehabilitation
Erectile dysfunction (ED) affects 30–80% of men after prostate cancer treatment, depending on nerve-sparing technique, age, baseline function, and comorbidities. Neurovascular damage, fibrosis, and ischemia are key contributors.

Radiation therapy further increases risk over time (1).

Penile rehabilitation, initiated early, promotes tissue health and functional recovery. Strategies include PDE5 inhibitors, vacuum erection devices, intracavernosal injections, and emerging techniques such as low-intensity shockwave therapy. PFMT complements these strategies by strengthening pelvic floor support, reducing coexisting muscle hypertonicity, and enhancing neuromuscular coordination. Combined interventions yield better outcomes than single-modality approaches.

Managing Pain, Fibrosis, and Pelvic Discomfort
Men may also experience pelvic pain, scar adhesions, muscle hypertonicity, or radiation-induced fibrosis, which can interfere with mobility and rehabilitation adherence. Pelvic rehabilitation addresses these challenges through manual therapy, myofascial release, scar mobilization, neural desensitization, stretching, and relaxation techniques. A holistic approach ensures that pain and fibrosis do not amplify guarding or disrupt neuromuscular coordination, allowing patients to regain functional independence.

Integrating Rehabilitation into Recovery
Prehabilitation by initiating pelvic floor training before surgery can “prime” the neuromuscular system, improving early outcomes. Interventions should be individualized, taking into account anatomy, treatment modality, and comorbidities. Functional progression from isolated contractions to daily activities ensures that strength and coordination translate into meaningful improvements in continence, sexual function, and mobility.

Interdisciplinary collaboration with urologists, radiation oncologists, sexual medicine specialists, psychologists, and nurses enhances recovery, supports timely referrals, and addresses psychosocial aspects of treatment. Realistic expectations and patient education about recovery timelines are critical; while continence may return within months, sexual function may take longer.

Case Example: A 62-year-old man undergoing nerve-sparing robotic prostatectomy began PFMT preoperatively and continued structured pelvic rehabilitation postoperatively. Eight weeks after surgery, he initiated penile rehabilitation with PDE5 inhibitors and vacuum devices alongside ongoing PFMT. At six months, he regained urinary continence, and by 12 months reported meaningful improvements in erectile function. This phased, individualized approach exemplifies how rehabilitation supports functional recovery and quality of life.

Conclusion
Prostate cancer treatment affects multiple systems: neuromuscular, vascular, connective tissue, and psychological. Pelvic rehabilitation offers structured strategies to address urinary incontinence, erectile dysfunction, pelvic pain, and mobility deficits. By combining PFMT, penile rehabilitation, manual therapy, and individualized functional progression, rehabilitation professionals play a crucial role in helping men regain independence and confidence.

References:

1. Nicolai, M., Urkmez, A., Sarikaya, S., Fode, M., Falcone, M., Albersen, M., Gul, M., Hatzichristodoulou, G., Capogrosso, P., & Russo, G. I. (2021). Penile Rehabilitation and Treatment Options for Erectile Dysfunction Following Radical Prostatectomy and Radiotherapy: A Systematic Review. Frontiers in Surgery, 8, 636974. https://doi.org/10.3389/fsurg.2021.636974
2. Al Hussein Al Awamlh B, Wallis CJD, Penson DF, et al. Functional Outcomes After Localized Prostate Cancer Treatment. JAMA. 2024; 331(4): 302–317. doi:10.1001/jama.2023.26491. https://jamanetwork.com/journals/jama/fullarticle/2814131
3. Milios, J.E., Ackland, T.R. & Green, D.J. Pelvic floor muscle training in radical prostatectomy: a randomized controlled trial of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urol 19, 116 (2019). https://doi.org/10.1186/s12894-019-0546-5
4. Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. Sex Med. 2020 Sep; 8 (3): 414-421. doi: 10.1016/j.esxm.2020.03.005. Epub 2020 May 14. PMID: 32418881; PMCID: PMC7471070. https://pmc.ncbi.nlm.nih.gov/articles/PMC7471070/
5. Newman, D. (2024, December 9). Pelvic muscle rehabilitation after radical prostatectomy. UroToday. https://www.urotoday.com/video-lectures/localized-prostate-cancer/video/4446-pelvic-muscle-rehabilitation-after-radical-prostatectomy-diane-newman.html

The sacroiliac joint (SIJ) has long been a focus of debate within musculoskeletal rehabilitation. Traditionally, clinicians were taught to view the SIJ as an isolated structure. A structure that could become “out of alignment” or “stuck,” requiring manual correction. However, emerging evidence challenges this perspective, suggesting that the SIJ functions as a dynamic part of the larger kinetic chain rather than an independent pain generator. As research continues to evolve, clinicians are being called to adopt a more contemporary, evidence-based pain science model that recognizes the interdependence of the SIJ, spine, hips, and lower limbs.

The SIJ plays a critical role in load transfer between the spine and lower extremities. As Vleeming et al. (2012) describe, effective force transmission across the pelvis depends on the coordinated function of surrounding musculature and connective tissues, rather than the mobility of the SIJ itself. This understanding aligns with the concept of regional interdependence, which proposes that impairments in one region, such as the hips, lumbar spine, or even the feet, can contribute to dysfunction elsewhere. When considering SIJ pain, clinicians should therefore assess not only the joint itself but also how altered movement patterns in the kinetic chain may influence pelvic mechanics.

Recent research supports this integrated approach. Abdollahi et al. (2023) found that athletes with SIJ pain or dysfunction had a significantly higher prevalence of prior lower-limb and pelvic-girdle injuries, emphasizing the relationship between distal mechanics and pelvic load transfer. Similarly, Yan et al. (2024) demonstrated that combining core stability exercises with manual therapy improved outcomes for patients with SIJ dysfunction, reinforcing the need for both regional mobility and neuromuscular control. Meanwhile, a 2023 systematic review by Liu et al. concluded that no single isolated intervention showed clear superiority for SIJ pain, further highlighting the importance of multimodal, functional rehabilitation approaches.

The contemporary pain science model departs from outdated narratives that emphasize positional faults or misalignments. Instead, it promotes a systems-based view of the SIJ that values load management, motor control, and functional reintegration. Clinicians adopting this paradigm focus on restoring the body’s natural ability to transfer and absorb forces efficiently, rather than attempting to “realign” a joint that exhibits minimal movement. This shift reflects a broader professional evolution: moving from structure-based explanations toward a biopsychosocial understanding of pain that integrates mechanical, neurological, and contextual factors.

For rehabilitation specialists, applying the kinetic-chain model in clinical practice begins with a comprehensive assessment strategy. This includes provocative tests for SIJ involvement, movement analysis of the hips and lumbar spine, and screening for contributing factors such as limited ankle mobility or impaired gluteal activation. Treatment then flows logically from these findings by addressing the specific impairments that disrupt load transfer. For example, a clinician might improve hip mobility and gluteal strength to enhance pelvic stability, or restore ankle dorsiflexion to reduce compensatory shear forces through the SIJ. Motor control retraining, particularly of the transversus abdominis, multifidus, and pelvic floor, completes the continuum of care.

Clinicians interested in refining their SIJ evaluation and treatment skills can gain hands-on guidance in Sacroiliac Joint Current Concepts, a half-day course offered on November 8, taught by former NHL physical therapist and athletic trainer Steve Dischiavi, PT, PhD, DPT, MPT, SCS, ATC, COMT. This course provides a succinct, evidence-informed framework for SIJ assessment and intervention. Participants will explore why shifting away from an outdated mechanical narrative aligns better with contemporary pain science and how this transition can elevate clinical reasoning and patient outcomes. The course features a full, easy-to-follow exam sequence and corresponding treatment strategies, ensuring that attendees leave with practical tools they can implement immediately in the clinic.

As the evidence continues to grow, one theme remains clear: the SIJ cannot be understood, or treated, in isolation. A modern, kinetic-chain approach recognizes the interrelationship of structure, movement, and neuromuscular control across the pelvis and lower body. By embracing this integrative model, clinicians not only enhance their diagnostic precision but also improve their ability to deliver meaningful, functional outcomes for patients.

Join us on November 8 for Sacroiliac Joint Current Concepts and take the next step toward mastering a contemporary, evidence-based approach to SIJ rehabilitation.

Resources

• Abdollahi, S., Sheikhhoseini, R., Rahimi, M. et al.The sacroiliac dysfunction and pain is associated with history of lower extremity sport related injuries. BMC Sports Sci Med Rehabil 15, 36 (2023). https://doi.org/10.1186/s13102-023-00648-w
• Liu, Y., Suvithayasiri, S., & Kim, J.-S. (2023). Comparative efficacy of clinical interventions for sacroiliac joint pain: Systematic review and network meta-analysis with preliminary design of treatment algorithm. Neurospine, 20(3), 997–1010. https://doi.org/10.14245/ns.2346586.293
• Vleeming, A., Schuenke, M. D., Masi, A. T., Carreiro, J. E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: An overview of its anatomy, function and potential clinical implications. Journal of Anatomy, 221(6), 537-567. https://doi.org/10.1111/j.1469-7580.2012.01564.
• Yan, H., Zhao, P., Guo, X., & Zhou, X. (2024). The effects of Core Stability Exercises and Mulligan’s mobilization with movement techniques on sacroiliac joint dysfunction. Frontiers in Physiology, 15, 1337754. https://doi.org/10.3389/fphys.2024.1337754

When physical therapists think about core stability, the focus often turns to individual muscles such as the transversus abdominis, multifidus, or pelvic floor. Yet at the center of this intricate system lies the diaphragm, a key player in the generation and modulation of intra-abdominal pressure (IAP). The ability to coordinate the diaphragm with the abdominals and pelvic floor through effective IAP regulation is critical not only for postural control but also for spine protection and efficient movement strategies.

IAP refers to the pressure within the abdominal cavity, bounded superiorly by the diaphragm, inferiorly by the pelvic floor, and circumferentially by the abdominal wall and spine. As the diaphragm contracts and descends during inhalation, it compresses the abdominal contents, while the pelvic floor and abdominal wall counteract this pressure to maintain balance. This pressurization acts as an internal stabilizer, creating a dynamic support system that reduces shear and bending stress on the lumbar spine. Recent biomechanical modeling by Murray and colleagues (2025) highlighted that IAP’s stabilizing role becomes particularly significant when external mechanical loads shift rapidly, emphasizing its importance for both daily and athletic movements.

Emerging evidence reinforces that IAP is not a passive byproduct of breathing; it is an active mechanism of stabilization. Kawabata and Shima (2023) demonstrated that breathing patterns and postural orientation strongly influence IAP and abdominal muscle recruitment. Their cross-sectional study revealed that forced exhalation in supine produced significant transversus abdominis and internal oblique activation, while exertion inhalation during a plank posture elicited similar effects, confirming that posture and breath type dictate how effectively the core musculature contributes to trunk stiffness.

Sembera et al. (2023) added an intriguing layer by showing that abdominal bracing, although stabilizing, can compromise respiration during lifting tasks. Their findings indicated that bracing reduces lung volumes even when diaphragmatic excursion increases, suggesting a necessary balance between spinal stability and ventilatory function. Clinically, this underscores the need to coach patients on modulating (not maximizing) IAP, to avoid respiratory compromise while preserving spinal support.

When the diaphragm, abdominal wall, and pelvic floor fail to coordinate efficiently, IAP regulation becomes dysfunctional. Patients with chronic low back pain often exhibit altered breathing strategies or underuse IAP mechanisms, relying instead on excessive paraspinal activation. Similarly, postpartum individuals with diastasis recti or individuals with pelvic floor dysfunction may struggle to modulate IAP effectively, resulting in impaired load transfer and increased spinal demand. In patients with respiratory disorders such as asthma or COPD, restricted diaphragmatic excursion can further limit the ability to generate stabilizing intra-abdominal pressure.

Recent clinical studies support the integration of breathing and core training in rehabilitation. Li et al. (2025) found that individuals with chronic non-specific low back pain who engaged in core training combined with breathing exercises demonstrated greater improvements in pain, function, and strength than those performing core training alone.

Likewise, Seo et al. (2024) reported that diaphragmatic strengthening within a core training protocol enhanced diaphragm thickness, respiratory pressure, and postural stability compared to traditional training methods. Together, these findings affirm that targeted interventions to optimize IAP and diaphragmatic coordination can yield meaningful functional benefits.

While the science of IAP is growing, the clinical application remains refreshingly practical. The following cues can help practitioners integrate IAP-based interventions into patient care.

Clinical Cues & Strategies: How to “Use IAP” Without Overdoing It

1. Start with breathing awareness
   • Use diaphragmatic or “belly” breathing cues in supine/recumbent first, encouraging gentle expansion in all directions.
     Use ultrasound or palpation (if available) to see diaphragm descent or amplitude changes.
2. Introduce gentle co-activation
   • Once diaphragm movement seems adequate, cue light abdominal engagement (e.g., light TrA) while breathing to gently harness IAP.
     Avoid immediate high bracing; the goal is dynamic modulation, not always maximal stiffening.
3. Progress posture + load
   • Move from supine → quadruped → half-kneel → standing → loaded tasks (bird-dog, dead bug, split stance).
     In each, cue breathing + abdominal co-activation together in a coordinated rhythm, not sequentially.
4. Load under breathing constraints
   • Challenge patients to maintain coordinated breathing + IAP during functional tasks: lifts, carries, squats.
     Use feedback (tactile cue, visual diaphragm ultrasound, breathing sensors) if possible.
5. Monitor for compensation
   • Watch for breath holds, neck accessory overuse, scapular shrugging, or paradoxical breathing.
     If compensations appear, regress posture or reduce load.
6. Balance ventilation and stability
   • Be cautious in populations with respiratory compromise, too much bracing may reduce lung capacity.
     When in doubt, prioritize breathing first, then layer in stabilization.

In summary, intra-abdominal pressure serves as a powerful yet nuanced mechanism of spinal protection. The coordinated activity of the diaphragm, abdominals, and pelvic floor forms an adaptable cylinder that stabilizes the spine, enhances postural control, and supports efficient movement. Current research emphasizes that effective IAP regulation requires both breath control and muscular timing, skills that can be refined through intentional training. Clinicians who integrate IAP strategies into their treatment approaches are better positioned to optimize function and alleviate pain across a wide spectrum of patients, from postpartum individuals to high-performance athletes.

Register Now: Breathing and the Diaphragm - December 6
For clinicians ready to deepen their understanding of the diaphragm and its vital relationship with IAP, join us on December 6 for Breathing and the Diaphragm, an interactive Zoom-based continuing education course.

Learn evidence-based assessment and treatment techniques that connect the diaphragm, abdominals, and pelvic floor to optimize intra-abdominal pressure, postural control, and functional performance. Perfect for clinicians treating patients with pelvic pain, diastasis, incontinence, spinal dysfunction, or athletes seeking enhanced stability.

Don’t miss this opportunity to translate current research into practical, evidence-based interventions that enhance your patients’ stability and performance.

References

1. Kawabata, M., & Shima, N. (2023). Interaction of breathing pattern and posture on abdominal muscle activation and intra-abdominal pressure in healthy individuals: A comparative cross-sectional study. Scientific Reports, 13(1), 1-9. https://doi.org/10.1038/s41598-023-37629-5
2. Li, Y., Zhao, Q., Zhang, X., E, Y., & Su, Y. (2025). The impact of core training combined with breathing exercises on individuals with chronic non-specific low back pain. Frontiers in Public Health, 13, 1518612. https://doi.org/10.3389/fpubh.2025.1518612
3. Murray SA, Driscoll M. Finite element investigation of the intrinsic stiffness contribution of intra-abdominal pressure in a transient spine and trunk model. Comput Biol Med. 2025 Sep;196(Pt A):110549. doi: 10.1016/j.compbiomed.2025.110549. Epub 2025 Jul 3. PMID: 40614524. https://pubmed.ncbi.nlm.nih.gov/40614524/
4. Sembera, M., Busch, A., Kobesova, A. et al.The effect of abdominal bracing on respiration during a lifting task: a cross-sectional study. BMC Sports Sci Med Rehabil 15, 112 (2023). https://doi.org/10.1186/s13102-023-00729-w
5. Seo, H., Jeong, G., & Chun, B. (2024). Impact of Diaphragm-Strengthening Core Training on Postural Stability in High-Intensity Squats. Life, 14(12), 1612. https://doi.org/10.3390/life14121612

Dearest Gentle Readers,

It has come to this author’s most refined attention that a most curious scandal has fluttered through the drawing rooms - or rather, the online salons - of the pelvic health world. The whispers suggest that the reputable purveyor Intimate Rose has, perhaps, been reappropriating patients from their dear therapist partners by embarking upon a bold new venture: the offering of telehealth services.

One can scarcely imagine a more titillating topic among those who prize propriety and pelvic alignment in equal measure. And thus, in the spirit of intellectual inquiry, I present to you an ethical analysis of this latest society stir: Intimate Rose versus Pelvic Floor Therapists.

The tale begins, as many modern dramas do, on that most notorious of forums, Facebook. A well-respected instructor from the esteemed Herman & Wallace Institute, shared an innocent observation in a popular support group. Having ordered a pelvic wand for a patient, they received an automated invitation for that very patient to engage in virtual pelvic floor services.

Some found the offer thoughtful, even gallant - particularly in cases where patient-provider gender mismatch posed a barrier. Yet others clutched their pearls, aghast at what they perceived as a potential overreach. Within moments, the comments swelled to a chorus exceeding fifty voices - some indignant, some indifferent, and a few serenely supportive.

It was, as they say, a scandal with excellent posture.

According to Dr. Nancy Kirsch’s tome, Ethics in Physical Therapy (2024), the first step in any ethical inquiry is to identify the realm, whether individual, institutional, or societal.

In this case, dear readers, we find traces of all three. The individual therapist wrestles with feelings of betrayal or relief. Society at large may applaud increased access to care. Yet the heart of the controversy lies within the organizational realm, a perceived discord between Intimate Rose’s business decisions and the expectations of the Pelvic Health Community.

And oh, how quickly those expectations can sour when business and benevolence entwine too tightly.

Our therapists, like the heroes and heroines of any great moral tale, passed through all five ethical stages:

• Moral Sensitivity - the uneasy flutter of “something feels off.”
• Moral Judgment - the pondering of right versus wrong.
• Moral Motivation - the desire to do something about it.
• Moral Courage - the bravery to actually say something.
• Moral Potency - the strength to act and endure the fallout.

And indeed, act they did some commented publicly, others whispered privately, and a few renounced Intimate Rose altogether. There were letters, posts, and even podcasts. One might call it a veritable Regency Riot - via Wi-Fi.

Is this a case of right versus wrong, or merely a duel between two virtues?

While some would label it misconduct, others, including your humble author, see instead a true ethical dilemma: a choice between two acceptable, yet conflicting courses of action.

After all, dear reader, there is honor in both sides:

• Intimate Rose seeks to extend access to care.
• Therapists seek to protect their patient relationships.

A moral quandary worthy of the finest London drawing rooms.

Lady Whistledown, ever thorough, has examined the ten criteria of ethical clarity. A sampling follows:

1. Context & Character – For a decade, Intimate Rose has graced our community with generosity: free starter kits, global donations, educational outreach, and over $2 million in support of pelvic health causes. Their affiliate program offers modest rewards for both patients and therapists, while free YouTube resources, blogs, and training sessions abound. Truly, their consistent kindness and commitment to patient care hardly bespeak the manners of a villainous schemer.
2. The Players – On one side, Intimate Rose; on the other, pelvic health providers (some insurance-based, some cash-based). Those in private practice perhaps felt their clients might be wooed away. Yet, survey results revealed none of Intimate Rose’s telehealth patients were taken from other therapists.
3. Consequences – Might the company lose favor among providers? Might patients feel conflicted? Certainly. But evidence shows telehealth outcomes rival in-person care (Razak Ozdincler et al., 2025; Lin et al., 2025).
4. Laws & Obligations – As long as state telehealth regulations are observed, no impropriety exists. Transparency, after all, was maintained through pre-launch communications.
5. Professional Guidance – The APTA and AOTA themselves embrace telehealth as a means to widen access.
6. Legal Test – The only real trespass may be slander; those hasty tongues wagging falsehoods (NYC Bar Association, 2025).
7. The Stench Test – Does it smell off? To some, yes. Betrayal has a distinct bouquet. Yet virtue ethics (beneficence, non-maleficence, justice, autonomy, veracity, fidelity) all appear intact (Kirsch, 2024).
8. Front-Page Test – “Company Expands Access to Pelvic Care” inspires far less uproar than “Company Steals Patients.” Scandal, it seems, is in the phrasing.
9. Mom Test – One’s mother might simply say, “If you’re as good as you claim, my dear, your patients shall stay.”
10. Professional Test – Many seasoned mentors would call this not theft, but savvy business strategy. After all, other beloved practitioners in our field have followed the same “educate, nurture, offer” model to great acclaim.

Cultivating an audience before offering products is, in truth, a well-established business practice. So why the uproar among pelvic health providers? Perhaps it is the struggle to embrace an abundance mindset over one of scarcity. Similar scenarios elsewhere drew little ire, yet here, it seems, the matter strikes far too close to home.

This author, ever impartial, concludes that we face not malice, but misunderstanding. A dilemma indeed - where both sides act in good faith yet find themselves at odds.

Three approaches offer resolution:

• Rules-Based: No rule was broken; thus, no penalty applies.
• Ends-Based: The greater good, increasing patient access, outweighs commercial discomfort. Pelvic health providers no longer using Intimate Rose due to a misunderstanding is harmful to the company. However, Intimate Rose offering telehealth services to patients who do not have access to a local in person therapist, are home bound, or prefer telehealth due to fear or history of trauma is definitely a larger provider of “good.”
• Care-Based: Healing the relationship through communication and transparency serves all parties best.

No one, dear reader, is automatically swept into telehealth services. A customer who purchases a tool may merely receive a polite missive or text noting the existence of such offerings, or an invitation to learn more. These post-purchase courtesies may, upon request, be removed for those using a provider’s code. Patients may yet glimpse the occasional update or newsletter, but any suspicion of client re-appropriation may now be, quite elegantly, laid to rest.

Harmony, it seems, can be restored with a touch of dialogue and decorum.

Let this serve, dear readers, as a reminder that in matters of both ethics and enterprise, the path to virtue lies not in outrage, but in understanding.

When next you feel that unmistakable whiff of impropriety, pause before unsheathing your quill (or opening your comment thread). Reflect, inquire, and consult your moral compass - for therein lies the difference between righteous indignation and mere gossip.

After all, preserving one’s reputation and one’s reason is the finest posture of all.

P.S. Should this tantalizing ethical quandary have piqued your curiosity, one may further indulge one’s moral refinement by attending Ethical Concerns for Pelvic Health Professionals scheduled for November 23, 2025 where we will learn how to journey through the landscape of moral quandaries together.

References:

• Kirsch, N. R. (2024). Professional issues and ethics in physical therapy: A case-based approach (2nd ed.). McGraw Hill. 
• Lin, K. Y., Chen, C. Y., Wu, P. C., Huang, M. H., Ou, Y. C., Kao, Y. L., & Lin, K. H. (2025). The feasibility and effects of a telehealth-delivered physical therapy program for postmenopausal women with urinary incontinence: A pilot mixed-methods study. Maturitas, 197, 108376. https://doi.org/10.1016/j.maturitas.2025.108376

As a new pelvic health physical therapist, you’re quickly discovering how interconnected the body’s systems truly are. Pain, bowel and bladder function, sexual health, and emotional well-being are all influenced by factors that extend beyond the musculoskeletal system. One emerging area that deserves attention is nutrition - a key player in inflammation, gut health, and even pelvic floor muscle function.

Integrating nutrition awareness into your practice doesn’t mean stepping outside your professional scope. It means understanding how diet affects the systems you already treat and collaborating effectively with nutrition professionals to optimize patient outcomes.

Why Nutrition Belongs in Pelvic Rehab
The gut and pelvic organs share complex neural and biochemical communication pathways. When the gut is inflamed or imbalanced, this “viscerosomatic crosstalk” can alter pelvic floor tone, coordination, and reflex activity, potentially amplifying pain via musculoskeletal pathways (1). Gut microbiota also influences the production of short-chain fatty acids and other byproducts that affect intestinal permeability, immune signaling, and systemic inflammation, which are key mechanisms in central sensitization and pelvic pain (2).

Certain foods may act as direct irritants to sensitive pelvic tissues, like the bladder or vulvar mucosa, triggering burning, urgency, or pain flares. In addition, food sensitivities or intolerances (especially non-IgE–mediated types) can increase inflammation or disrupt digestion in ways that influence pelvic symptoms (3). Understanding these connections helps you appreciate why some patients experience symptom changes after dietary shifts, even if formal nutrition counseling is provided by a functional nutrition provider or other nutrition professional.

While research is still developing, clinical studies are strengthening the nutrition–pelvic pain link. A 2023 study found that individuals with both IBS and endometriosis who followed a low-FODMAP diet experienced significant reductions in pain and improvements in quality of life (4). These results support what many clinicians observe in practice: thoughtful dietary modification can complement pelvic floor therapy and reduce symptom burden.

Practical Ways to Integrate Nutrition Awareness
As a new clinician, you don’t need to “prescribe” diets, but you can begin building awareness, gathering relevant information, and partnering with nutrition professionals.

1. Ask About Diet and GI Symptoms
   Include food-related questions in your intake:

• “Have you noticed any foods that make your symptoms better or worse?”
• “Do you experience bloating, urgency, or pain after meals?”
• “Have you ever tried dietary changes to help with your symptoms?”

Even these simple questions open the door for meaningful discussion and collaborative problem-solving.

2. Recognize Patterns and Refer Appropriately
   If a patient reports consistent food-related flares, unexplained weight loss, GI bleeding, or restrictive eating behaviors, refer to a physician or nutrition professional specializing in gastrointestinal or pelvic health. Working as a team ensures patients get safe, targeted guidance.

3. Use Low-Risk Dietary Experiments
   Under supervision or as part of a multidisciplinary plan, patients can trial small, low-risk adjustments such as reducing bladder irritants (caffeine, alcohol, acidic foods) or following a structured elimination/reintroduction process guided by a dietitian or functional nutritionist. The key is tracking outcomes systematically using food/symptom diaries.

4. Reinforce Foundational Nutrition Principles
   Encourage balanced, anti-inflammatory dietary patterns: vegetables, fruits, lean proteins, fiber (if tolerated), and healthy fats. These broad principles align with general wellness recommendations and support tissue healing, hormonal regulation, and immune balance.

Building Your Competence as a New PT
Early-career clinicians often feel pressure to “know everything.” When it comes to nutrition, your role is not to diagnose or prescribe, but to:

• Recognize when food may be contributing to symptoms.
• Collaborate with nutrition professionals and physicians to ensure comprehensive care.
• Educate patients on body awareness, symptom tracking, and realistic expectations.

Courses like Nutrition Perspectives for Pelvic Rehab, scheduled next on December 6-7, 2025, by Megan Pribyl, PT, CMPT, offer an excellent foundation. This course introduces the science of nutrition’s impact on pelvic health and provides practical frameworks for integrating it into clinical reasoning without overstepping scope of practice.

For new pelvic rehab therapists, integrating nutrition awareness offers a powerful way to enhance patient care. Understanding the links between diet, gut health, inflammation, and pelvic pain helps you view each patient through a truly whole-body lens.

By asking informed questions, observing patterns, and collaborating across disciplines, you can empower patients to take an active role in their healing. When nutrition meets pelvic rehab, we move closer to comprehensive, compassionate, and evidence-informed pelvic health care.

References:

1. Zhou Q, Verne GN. Molecular Mechanisms and Pathways in Visceral Pain. Cells. 2025 Jul 25;14(15):1146. doi: 10.3390/cells14151146. PMID: 40801578; PMCID: PMC12345894.
2. Palma, G. D., Reed, D. E., & Bercik, P. (2023). Diet–microbial cross–talk underlying increased visceral perception. Gut Microbes, 15(1), 2166780. https://doi.org/10.1080/19490976.2023.2166780
3. Ren, H., Cao, B., Xu, Q., Zhao, R., Li, H., & Wei, B. (2025). Role of microbiota in pain: From bench to bedside. IMetaOmics, 2(1), e58. https://doi.org/10.1002/imo2.58
4. Varney JE, So D, Gibson PR, Rhys-Jones D, Lee YSJ, Fisher J, Moore JS, Ratner R, Morrison M, Burgell RE, Muir JG. Clinical Trial: Effect of a 28-Day Low FODMAP Diet on Gastrointestinal Symptoms Associated With Endometriosis (EndoFOD)-A Randomised, Controlled Crossover Feeding Study. Aliment Pharmacol Ther. 2025 Jun;61(12):1889-1903. doi: 10.1111/apt.70161. Epub 2025 May 4. PMID: 40319391; PMCID: PMC12107219.

Since I started working with patients with osteoporosis or osteopenia almost 20 years ago, I've noticed an interesting phenomenon. Initially, most patients I saw were in their late 70s and 80s. But within the last 10 to 15 years, the age of my patient population has decreased. I begin receiving referrals for people in their 50s and 60s with osteopenia or osteoporosis after getting their first DEXA scan. Many were traumatized by the diagnosis. They were women who exercised regularly, ate healthily, and took responsibility for a positive lifestyle. It was almost as if they were experiencing PTSD. They were shocked, nervous, and questioning why it happened to them.

One of my first priorities in their care plan was to help calm or down-regulate their sympathetic nervous system. They were in a fight or flight state, and the cortisol running through their bodies was not kind to their bones. I educated them that the DEXA scan only measures bone density and not quality. Quality has come to the forefront as an important component of the lattice-like structures of our bones, yet we still don't have a good way to measure it. I wanted them to understand that the DEXA scan, although it is the gold standard, is only one piece of the puzzle. I used to say, “Let’s pretend your T score is exactly the same as another individual, but that individual is a couch potato who smokes, eats junk food, and basically follows an unhealthy lifestyle. Do you really think your risk of fracture is identical? I wanted them to feel that their actions had had a positive influence on their health, even with the diagnosis. And I truly believe that it does.

Following the evaluation, they started in the Decompression position, also known as hook-lying, and based on the work of Sara Meeks. We explored belly breathing, intercostal breathing, and found the neutral spine position. They were invited to completely relax, allowing the surface of the mat to support them. Not only did this help calm their sympathetic nervous system by activating their “rest and digest” parasympathetic nervous system, but it also placed them in a gravity-eliminated position. Sitting is compressive to the vertebral bodies and discs. Supine positioning allows the anterior aspect of the vertebral bodies (where most spinal compression fractures occur) to decompress. Thus, the name “Decompression position.”

This is the part of physical therapy where it sometimes feels we are doing more mental than physical therapy. But it is an important step. Educating patients is one of the greatest gifts that we can offer in rehabilitation. It not only helps them understand the diagnosis, it also empowers them. Many people with osteoporosis or osteopenia assume their only option is medication. While we certainly do not recommend one option over another, we do educate them that there are multiple ways to manage their disease. A few include site-specific exercises, body mechanics, stress management, and encouraging an educated discussion with their medical provider on the pros and cons of osteoporosis medications. These are steps they can take to feel they have control back in their lives.

From there, we gradually increase their challenges in terms of exercise, balance, and help them return safely to the life they deserve.

Osteoporosis Management: An Introductory Course for Healthcare Professionals provides tools to help your patients move forward with their chronic disease. We hope you'll join us on November 8th for this one-day seminar.

References:

1. Jia-Sheng Ng¹, Kok-Yong Chin. Potential mechanisms linking psychological stress to bone health. Int J Med Sci. 2021 Jan.

AUTHOR BIO
Deb Gulbrandson, PT, DPT, Balance and Falls Professional (Geriatrics Academy of the APTA)

Dr. Deb Gulbrandson has been a physical therapist for over 48 years, with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to businesses and industries. She owned a private practice for 27 years in the Chicago area, specializing in orthopedics and Pilates. She and her husband, Gil, a former certified orthotist, “semi-retired” to Evergreen. They teach Osteoporosis management to physical therapists around the country. Deb also works for Mt Evans Homecare and Hospice and sees private patients for physical therapy as well as Pilates clients in her home studio. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country-currently 46 out of 63.

Deb is a graduate of Indiana University with a BS in Physical Therapy and a former NCAA athlete, where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to be able to combine her skills as a PT and Pilates instructor. In 2011, she received her Doctorate in Physical Therapy from Evidence in Motion.

Dr. Gulbrandson frequently presents community talks on topics related to Osteoporosis and safe ways to develop Core Strength. She is a certified Pilates Instructor through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist using the Meeks Method, and has her CEEAA (Certified Exercise Expert for the Aging Adult) through the Geriatric Section of the APTA.

Cancer treatment, even when curative, often leaves a cascade of physiological consequences on the pelvic region. Pelvic rehabilitation clinicians are uniquely positioned to help survivors reclaim function, reduce symptoms, and improve quality of life.

Why Rehabilitation Matters in Oncology - Especially for Pelvic Practitioners
Before jumping into the how, it’s important to acknowledge the why. Pelvic morbidity following gynecologic cancers such as cervical, endometrial, vulvar, and ovarian malignancies is strikingly prevalent. Many survivors experience urinary symptoms, fecal dysfunction, dyspareunia, vaginal stenosis, and pelvic floor muscle hypertonicity. Studies have shown that lower urinary tract dysfunction can affect up to 70–85% of patients after cervical cancer surgery, and as many as two-thirds report sexual dysfunction (1). The causes of these complications are multifactorial and can stem from surgical disruption, radiation-induced fibrosis and vascular changes, chemotherapy side effects, nerve injury, hormonal alterations, and scar tissue formation. These effects are often cumulative and synergistic, making each patient’s recovery trajectory unique.

Moreover, the prognosis is non-linear; impairments may not appear until months or even years after treatment as fibrosis and tissue stiffening continue to evolve. Encouragingly, research demonstrates that when rehabilitation interventions are applied early and consistently, patients can achieve significant and lasting improvements - some maintained even a year post-treatment (2). Given these realities, pelvic rehabilitation is an essential component of comprehensive survivorship care.

Rehabilitation After Gynecologic & Bladder Cancer - What the Evidence Says
One of the most well-studied areas in oncologic pelvic rehabilitation focuses on gynecologic cancer survivors experiencing dyspareunia during intercourse. A mixed-methods study of 31 women who participated in a 12-week multimodal pelvic physical therapy program - combining education, manual therapy, and pelvic floor muscle exercises - demonstrated significant improvements from baseline to one year in pain, sexual function, urinary symptoms, psychological wellbeing, and body image (2).

Importantly, the benefits achieved at the end of treatment were maintained 12 months later, suggesting long-term durability of outcomes. Qualitative interviews from the same group further revealed that participants perceived meaningful reductions in pain, improved sexual comfort, and enhanced urinary control (2).

A growing body of systematic reviews and recent clinical trials supports the superiority of multimodal pelvic floor interventions that combine pelvic floor muscle training, education, and adjunct therapies over single-modality approaches. These integrated programs consistently demonstrate broader improvements in bladder, bowel, sexual, and general pelvic floor function compared to education or passive interventions alone (3). A 2024 umbrella review echoed these findings, highlighting that multimodal therapy can alleviate incontinence and sexual dysfunction while improving pelvic floor muscle performance, though higher-quality studies are still needed. Manual therapy techniques, including scar mobilization, myofascial release, and neural mobility, are also frequently incorporated. Particularly in areas affected by surgery or radiation, to counteract tissue stiffening, fibrosis, and adhesions that can limit recovery (4).

While the literature on bladder cancer rehabilitation remains more limited, emerging research indicates promising results. A 2024 review on rehabilitation following orthotopic neobladder (ONB) reconstruction identified urinary incontinence as a frequent complication and underscored pelvic floor muscle training as a key component of post-operative management (5). The same review emphasized the need to standardize pelvic floor rehabilitation protocols to reduce practitioner variability and improve outcomes across care settings.

More broadly, evidence from cancer survivor cohorts demonstrates that non-invasive pelvic floor rehabilitation (PFR), including manual therapy, neuromuscular re-education, and targeted education, can effectively reduce self-reported pain, improve voiding and defecation coordination, and address pelvic dysfunction across diverse cancer types (4). In addition, case reports have described comprehensive, individualized physical therapy programs after pelvic radiotherapy that successfully integrate internal and external techniques, dilator use, and adherence support to restore function and comfort (6).

Although the evidence base for bladder cancer–specific rehabilitation is still developing, the principles established in gynecologic oncology, such as progressive pelvic floor training, manual and soft-tissue interventions, and individualized patient education, are highly translatable. These approaches can be adapted to the unique anatomical and surgical circumstances of bladder cancer survivors, including those with urinary diversions or neobladders, ensuring a comprehensive and compassionate path toward recovery and quality-of-life restoration.

A Glimpse into Emerging Trends & Gaps
The field of oncologic pelvic rehabilitation is rapidly evolving, with new technologies and research directions poised to expand access, precision, and personalization of care. One promising development is the rise of e-rehabilitation programs for cancer survivors. A 2025 proof-of-concept study evaluated an online pelvic health e-rehabilitation platform that combined educational modules with virtual exercise coaching for gynecologic cancer survivors experiencing urogenital impairments. The study found the intervention to be both feasible and acceptable, suggesting that digital delivery could improve continuity of care and extend access to underserved or geographically remote populations (7).

Parallel to this, advances in digital prediction modeling are offering new possibilities for individualized rehabilitation planning. Recent multimodal deep learning models—such as MultiSurv—can integrate imaging, histopathology, and clinical data to predict recurrence and survival outcomes in bladder cancer. These predictive tools may one day assist clinicians in stratifying rehabilitation risk, identifying high-need patients earlier, and tailoring intervention intensity accordingly (8).

Similarly, breakthroughs in artificial intelligence–driven imaging are improving structural visualization of the pelvic floor. Semi-supervised deep learning models for MRI segmentation are becoming increasingly accurate, offering potential for enhanced mapping of pelvic anatomy, fibrosis, and treatment-related changes that could inform individualized rehabilitation strategies (8).

Despite these innovations, substantial gaps remain at the intersection of oncology and rehabilitation. There is still a lack of large-scale randomized controlled trials examining pelvic floor rehabilitation in bladder cancer survivors, limited long-term follow-up data, and no universally standardized rehabilitation protocols across cancer types. Moreover, the field would benefit from stronger evidence integrating internal manual therapy, neural modulation, and multimodal therapeutic approaches into oncology-specific rehabilitation frameworks. Bridging these gaps will be critical to optimizing recovery trajectories and ensuring that all cancer survivors have access to evidence-based pelvic health care.

Learn More in Our Upcoming Course
If you are a pelvic rehabilitation clinician seeking to deepen your expertise in managing cancer-associated pelvic dysfunction join us in the upcoming Oncology of the Pelvic Floor Level 2B course scheduled for November 1–2, 2025. This intermediate level course covers gynecologic and bladder cancers and includes risk factors, diagnostic pathways, and prognostic considerations. Participants will explore the sequelae of medical cancer treatments and gain insight into how surgery, chemotherapy, and radiation impact pelvic structures, tissue health, neural integrity, and overall quality of life.

Oncology of the Pelvic Floor Level 2B presents evidence-based rehabilitation strategies, nutritional considerations, and practical home program options that patients can implement between sessions. Clinicians will receive evaluation and treatment interventions that can be immediately integrated into practice, bridging the gap between research and real-world application.

Reference:

1. Li, X., Liu, L., He, J., Yan, J., & Wang, Y. (2023). Analysis of the effectiveness of the application of pelvic floor rehabilitation exercise and the factors influencing its self-efficacy in postoperative patients with cervical cancer. Frontiers in Oncology, 13, 1118794. https://doi.org/10.3389/fonc.2023.1118794
2. Cyr, P., Dostie, R., Camden, C., Dumoulin, C., Bessette, P., Pina, A., Gotlieb, W. H., Lapointe-Milot, K., Mayrand, H., & Morin, M. (2022). Improvements following multimodal pelvic floor physical therapy in gynecological cancer survivors suffering from pain during sexual intercourse: Results from a one-year follow-up mixed-method study. PLOS ONE, 17(1), e0262844. https://doi.org/10.1371/journal.pone.0262844
3. Cyr, MP., Jones, T., Brennen, R. et al.Effectiveness of Pelvic Floor Muscle and Education-Based Therapies on Bladder, Bowel, Vaginal, Sexual, Psychological Function, Quality of Life, and Pelvic Floor Muscle Function in Females Treated for Gynecological Cancer: A Systematic Review. Curr Oncol Rep 26, 1293–1320 (2024). https://doi.org/10.1007/s11912-024-01586-7
4. Kone AM, Roldan SP, Velez V, Roldan CJ. Non-Invasive Pelvic Floor Rehabilitation in Cancer Population. J Exp Pathol. 2024; 5(1): 14-20. https://www.scientificarchives.com/article/non-invasive-pelvic-floor-rehabilitation-in-cancer-population
5. Xu M, Chen S, Liu X, Luo Y, Wang D, Lu H, Jiang M, Chen X. Best evidence for rehabilitation management of urinary incontinence in patients with bladder cancer following orthotopic neobladder reconstruction. Asia Pac J Oncol Nurs. 2024 Dec 26; 12: 100647. doi: 10.1016/j.apjon.2024.100647. PMID: 39896758; PMCID: PMC11782885. https://pmc.ncbi.nlm.nih.gov/articles/PMC11782885/
6. Coughenour, E., Alkhameys, F., & Sharma, N. K. (2024). Rehabilitation of pelvic floor dysfunction after radiation therapy for a rare gynecological cancer: A case report. Gynecologic Oncology Reports, 56, 101534. https://doi.org/10.1016/j.gore.2024.101534
7. Bernard S, Perreault K, Pepin D, Gauthier LR, Roy-Richard C, Lamontagne MÈ, Dalzell MA, Mcneely ML. A pelvic health eRehabilitation program to address urogenital impairments after breast and gynecologic cancer: A proof-of-concept study protocol. Digit Health. 2025 Sep 24; 11: 20552076251382088. doi: 10.1177/20552076251382088. PMID: 41018515; PMCID: PMC12461042. https://pubmed.ncbi.nlm.nih.gov/41018515/
8. Wahab, N., Alzaid, E., Lv, J., Shephard, A., & Raza, S. E. (2025). ModalSurv: A Multimodal Deep Survival Framework for Prostate and Bladder Cancer. ArXiv. https://arxiv.org/abs/2509.05037

You may be reading this thinking, “I don’t treat Intersex patients in my practice. I’ve never even met anyone who is Intersex. What’s the point of learning about Intersex variations?” However, statistically speaking, you most likely have met someone who is Intersex, and you might even have a few patients right now who are Intersex (but you just don’t know it)!

In fact, 1.7% of the population is Intersex. This is about the same percentage of folks who are redheads. So, if you’ve ever seen someone walking down the street or treated someone in your clinic as a patient who has red hair, you’ve probably also seen and treated someone who was Intersex.

Someone who is Intersex may have variations in their hormones, chromosomes, internal reproductive anatomy, and/or external/genital anatomy. Intersex variations can be found in utero during pregnancy, at birth, during adolescence if someone has not undergone puberty by the typical age, during examinations in adulthood while screening for other health issues, and during adulthood if someone is struggling with conception. Some folks even go their entire lives without knowing they are Intersex, and it’s actually found on a post-mortem exam!

Currently, there are over 40 known Intersex variations. And even within an Intersex variation, variations can exist. No two people are exactly the same. We all have differences, which is why every patient deserves individualized care, examinations, and treatments.

Historically, healthcare providers and the medical world have caused great harm and trauma to many in the Intersex community through non-consensual, non-medically necessary examinations, medications, and surgical procedures. As healthcare providers, we need to practice from a trauma-informed lens and understand this historical trauma in order to provide better Intersex-affirming care to our patients and to help educate our colleagues so that they also can provide better affirming care to their patients.

We need to tailor our interventions to each person’s specific goals, needs, wishes, and anatomical differences.

Want to learn more about how to do this?
Come Intersex Patients: Rehab and Inclusive Care on November 8th! In my course, you will learn how to become an Intersex-affirming provider and a better healthcare ally to the Intersex community! Come learn with me today!

Resources

1. (2020, May 18). FAQ: Intersex, Gender, and LGBTQIA+. https://interactadvocates.org/faq/intersex-lgbtqia/.
2. (2021, January 26). FAQ: What is Intersex? https://interactadvocates.org/faq/.
3. (2023). QGuides Resource Guide Intersex. https://qlife.org.au.
4. National LGBTQIA+ Health Education Center. (2020). Affirming Primary Care for Intersex People 2020. https://www.lgbtqiahealtheducation.org/wp-content/uploads/2020/08/Affirming-Primary-Care-for-Intersex-People-2020.pdf.
5. Fenway Health. (2020, October 26). Improving Health Care for Intersex People. https://fenwayhealth.org/improving-health-care-for-intersex-people/.
6. Human Rights Watch. (2017, July 25). US: Harmful Surgery on Intersex Children Medically Unnecessary Operations Risk Lifelong Suffering. https://www.hrw.org/news/2017/07/25/us-harmful-surgery-intersex-children.

AUTHOR BIO
Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI

Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI graduated from Rutgers School of Biomedical & Health Sciences with her Doctor of Physical Therapy degree. She is a Pelvic Health Physical Therapist, a Certified Lymphedema Therapist, a Pregnancy & Postpartum Corrective Exercise Specialist, an LSVT BIG Parkinson’s Disease Certified Therapist, and an APTA Credentialed Clinical Instructor. She is also a trained childbirth and postpartum doula. Molly is a member of the APTA Academy of Pelvic Health Physical Therapy and is also a Teaching Assistant with the Herman & Wallace Pelvic Rehabilitation Institute.

Molly is passionate about providing accessible healthcare to pelvic health patients of all age ranges, all gender identities, all sexualities, all body variations, and all ability levels

Pelvic health rehabilitation has grown tremendously over the decades, expanding from a publicly viewed mentality of “just Kegels” to a comprehensive, whole-body, and whole-life approach. As rehabilitation providers, we now treat the complex interplay of muscles, fascia, organs, and the nervous system that influences bladder, bowel, and sexual health. But one area that is still underrepresented in many rehabilitation settings is pessary care.;

Pessary fitting has historically been performed by gynecologists and urogynecologists, but in more recent years, especially since the APTA released a position statement in favor of pelvic health physical therapists being able to fit pessaries in 2022, pessary care has entered the rehab scope of practice. Adding pessary fitting, management, and follow-up into a pelvic rehab practice can provide immense benefits for patients, providers, and the healthcare system at large.

Pelvic organ prolapse (POP) is incredibly common, affecting nearly half of people who have given birth. As pelvic health providers, we are not surprised to hear many patients are left with only two extremes: surgery or “wait and see.” We know that pelvic floor therapy can help POP, with things like lifestyle changes, bowel/bladder habit changes, support garments, pressure management, and exercise, but what about our patients who need more?

Pessaries provide a non-surgical, reversible, and evidence-based option that can dramatically improve symptoms of prolapse and stress incontinence. Pelvic rehab providers have been happy to provide traditional therapy options, but now we’re able to offer the additional option of pessary care if we have the right training and permissions from our licensing and state boards. Pelvic health rehabilitation providers already assess pelvic floor function, educate patients on anatomy, and provide individualized exercise programs. Integrating pessary fitting for appropriate patients is a natural progression or addition of this care.

Most of our patients are seeking pelvic therapy because they want to get back to the activities that matter. They come in with goals like running after their kids, practicing yoga without leakage, enjoying intimacy, or simply walking without pressure or heaviness. A pessary can act like a structural support “orthotic” for the pelvic floor, allowing therapy exercises to be more effective, reducing discomfort, and helping patients meet their functional goals faster. The amazing part about pessaries is that they can be used as short-term solutions, like for a run, or an all-day solution, like with a patient who stands for a 12-hour shift.

Why don’t pelvic rehabilitation providers just wait and refer to the “experts” for pessary fittings? Appointments with urogynecologists or surgeons can require long wait times, travel to urban centers, or may not even exist in rural areas. There is a possibility of higher expenses if a person goes to a larger facility and has a high deductible. In other countries (like Australia, Canada, France, and Germany, to name a few), rehab providers are the primary pessary fitters! And even in the US, there are many therapists who have been fitting pessaries for years, usually under the training and guidance of gynecologists or urogynecologists.

When rehabilitation providers offer pessary care, this expands access to conservative treatment for all patients, but especially those with less access to pessary care due to financial, scheduling, or access issues. For patients who feel dismissed in or apprehensive of traditional medical settings, the supportive, education-focused, trauma-informed environment of pelvic rehab can also reduce anxiety and improve outcomes.

Patients often see their pelvic rehab providers weekly, developing strong trust and rapport. This relationship may make a patient more open to learning about pessaries, asking questions, and following up regularly for fit checks and care. Integrating pessary education and management strengthens that continuum of care, reducing the drop-off that can occur when patients are bounced between multiple providers. Be mindful that fitting pessaries is an art and comes with a need to have a medical provider looped into the patient’s plan of care. Medical providers can help manage any potential skin issues, discharge issues, or infection. There will also be times when a rehabilitation provider does not have the skill set to meet the needs of a patient, and the patient needs to be referred to a more skilled or advanced provider.

For therapists, adding pessary care is not just about tools; it is also an opportunity for professional growth. Pessary fitting requires advanced clinical reasoning, commitment to whole-patient solutions, and adaptability to evolving best practices. From a business standpoint, it allows a clinic to differentiate itself, attract new referrals, and provide a comprehensive service that keeps patients within its continuum of care longer.

Current research shows that pessaries are safe, cost-effective, and highly acceptable to patients. Professional organizations (such as the APTA Academy of Pelvic Health and AOTA) recognize the need for interdisciplinary, conservative options in managing POP and incontinence. By adopting pessary care, rehab providers position themselves at the forefront of evidence-based pelvic health practice.

Ultimately, pelvic rehab is about giving patients the knowledge and tools to take ownership of their health. Implementing pessary care provides one more option, whether used as a long-term solution, a bridge to surgery, or a way to stay active and comfortable during postpartum recovery, high-impact activity, or menopause.

Adding pessary fitting to our skill set is not about replacing what we already do as pelvic rehab providers. Fitting pessaries can enhance our provider toolkit, help us collaborate with other providers, and meet patients where they are. When used alongside education, exercise, and behavioral strategies, pessaries can be life-changing. By implementing pessary care, pelvic rehab providers honor the true spirit of our profession: addressing the whole person, restoring function, and empowering patients with choices beyond the “surgery or nothing” dichotomy.

Take the Next Step: Learn Pessary Care in Practice
If you’re ready to expand your clinical toolkit and bring the benefits of pessary care to your patients, join us for Pessaries and Pelvic Rehab: Introduction to Pessary Fitting, Care, and Management.

This two-day, in-person continuing education course is designed for experienced pelvic rehab providers who want to integrate pessary fitting into their practice. With a blend of pre-course lectures and hands-on lab instruction, you’ll gain the advanced assessment skills, fitting techniques, and clinical reasoning tools to confidently and safely implement pessary care.

Upcoming Course Dates & Locations:

• Chicago, IL | November 8–9, 2025
• Tacoma, WA | January 31–February 1, 2026
• Houston, TX | September 12-13, 2026

This course features pre-course anatomy and POP modules, lab-based POP and vaginal dimension assessments, supervised pessary fitting practice, and a pessary fitting kit included with registration. Give your patients more options, strengthen your scope of care, and be part of the growing movement to integrate pessary care into pelvic rehabilitation.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

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

She strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, she opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Mental health, physical health, and pelvic health are all intricately connected through the nervous system. In my clinical experience, one of the most consistent challenges I have seen patients face is feeling overwhelmed, not just physically, but emotionally. Many of these patients carry invisible burdens of trauma, stress, and anxiety that may show up as pain, tension, fatigue, and even digestive and pelvic health issues. These patients often present with complex pelvic pain symptoms, which may be magnified, adding to their emotional distress.

A recent case involved a young postpartum woman who had delivered a 10 lb. 7 oz baby and was experiencing significant symptoms of symphysis pubis separation. While the physical discomfort was considerable, what deeply impacted her was the emotional toll — a profound sense of disconnection from and lack of control over her body.

Through a comprehensive, integrative approach that included body mechanics education, breathwork, acupressure, and nervous system self-regulation tools, she learned to reconnect with her body in an empowering way. This program not only addressed biomechanical issues but also helped soothe her nervous system, enabling her to meet herself with compassion and care.

Over the course of her care, she progressed from a place of pain and overwhelm to one of resilience and autonomy. This case illustrates how integrative therapies can play a pivotal role in both physical healing and emotional restoration during the postpartum period.

As an evidence-based, integrative, and trauma-informed approach, Acupressure, which is rooted in Traditional Chinese Medicine, has shown great promise. The use of Acupressure for anxiety is a common practice 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 anxiety¹. Yintang (EX-HN 3), an acupoint located between the eyebrows, is known to have a mentally stabilizing effect in Traditional Chinese Medicine². A growing number of studies have also found that acupressure is effective in relieving the symptoms of depression³, Emerging research shows that Acupressure taps into the neural networks across multiple systems, aiding in emotional regulation and healing.

The Nervous System and Its Link to Mental Health
The nervous system acts as the body’s communication network. When it’s dysregulated, often due to stress, trauma, or illness, it can trigger a wide range of mental and physical symptoms, such as:

• Anxiety and panic
• Muscle tension
• Sleep disruption
• Pelvic dysfunction
• Chronic pain

In patients who are dysregulated, we may see a sympathetic overdrive that activates their “fight or flight” response. True healing often requires guiding the body out of the survival mode and back into a calm, regulated state, and this is where integrative holistic tools like Acupressure can become a key therapeutic bridge.

Integrating Acupressure into Pelvic Health and Mental Wellness
The pelvic floor is highly responsive to stress, often tightening in response to anxiety, fear, or unresolved trauma. This can result in pelvic pain, urinary dysfunctions, dyspareunia, constipation, and a whole range of pelvic health dysfunctions.

These symptoms are not just physical; they often reflect underlying nervous system dysregulation. That’s why incorporating acupressure into pelvic health care can be a game-changer for many patients. Acupressure can assist with:

• Calming hyperactive pelvic nerves
• Improving circulation and mobility in the pelvic region
• Releasing stored muscular tension and trauma
• Supporting emotional grounding and resilience

Especially during or after pregnancy, childbirth, surgery, or emotional trauma, Acupressure offers a safe, compassionate way to help patients reconnect with their bodies and move toward healing.

How Acupressure Supports Mental Health & Healing
Acupressure involves applying gentle, intentional pressure to specific acupoints located along the body’s energy meridians. These points correspond with key organs and systems—including the nervous system, digestive system, and reproductive system- and can have profound effects on both physical and emotional health.

Clinical Benefits of Acupressure Include:

• Vagus nerve regulation to reduce stress and anxiety
• Easing muscle tension and chronic pain
• Supporting emotional regulation and trauma release
• Promoting deep relaxation
• Improving sleep

By integrating acupressure into pelvic health and physical therapy, we can support whole-person healing—restoring not just movement and function, but also a sense of safety, stability, and emotional balance.

Acupressure Points for Anxiety, Pain & Pelvic Health
Here are a few commonly used acupoints that support both mental and physical wellness:

• Yintang (EX-HN 3) – Located between the eyebrows
  Mentally stabilizing effect, calming point
• LI 4 (Large Intestine 4) – Located between the thumb and index finger
  Relieves general tension, headaches, and body pain
• 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
  Strengthens core energy and helps with fatigue and abdominal tension
• GV20 (Governing Vessel) – Top of the head
  ; Promotes calm and emotional clarity

These points can be gently stimulated during therapy or taught as part of a home program, offering patients the tools for emotional self-regulation.

A recent study by Yang et al (2021) cited several key Acupressure points that can help with Anxiety & fatigue (Heart 7, Spleen 6), chemotherapy-induced nausea, vomiting, and anxiety in women with breast cancer ( Pericardium 6), primary dysmenorrhea (Liver 3), and anxiety & pain in cancer patients (Large Intestine 4, Heart 7). Several studies also found Acupressure to be effective for cancer pain⁴ and labor pain management⁵.

As a holistic pelvic health practitioner who is psychologically informed with an Integrative physical therapy clinical practice, I recognize the deep-rooted mind-body connections and the need to address the “whole” person. Whether our patients are healing from surgery, managing chronic pain, or navigating anxiety and pelvic dysfunction, their nervous system is always central to their well-being.

To learn more about Acupressure, please join us for the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for Oct 11^th& 12^th. This course will introduce course participants to the basics of Traditional Chinese Medicine (TCM), Acupuncture & Acupressure. Of the twelve major Meridians or energy channels, this course will focus on the Bladder, Kidney, Stomach, and Spleen meridians. In addition, there are other important Meridian points that stimulate the nervous system and can be used for self-regulation to manage Anxiety, pain, and a host of other symptoms. The course also offers two potent Acupressure home exercise programs and wellness programs.

This course also introduces Yin yoga as a powerful holistic practice with Acupressure and offers an evidence-based perspective on how Yin poses within each meridian can channelize energy through neurodynamic pathways with powerful integrative applications to facilitate healing in multiple dimensions.

References

1. 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
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Author Bio
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University New York, with a Doctor of Physical Therapy degree. Rachna has since been working in outpatient hospital and private practice settings with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer County, New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner, and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. Her clinical practice has focused on an Integrative physical therapy approach blending traditional physical therapy methods with holistic practices that address the whole person - physically, mentally, emotionally, and spiritually. She specializes in working with pelvic health patients who have bowel and bladder issues with high pelvic pain, which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and the Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole, focusing on the physical, emotional, and energy body.