Recently, I had a patient present to my practice with unretractable vaginal pain that was causing her quite a bit of suffering. Peyton (name changed) had been referred by a local osteopathic physician. For around a year, she had increasing severe vaginal pain. There was no history of assault, trauma, fall, or injury around the time of onset of symptoms. However, she had a kidney infection that caused back pain in the month prior to her pain onset.

Peyton is home schooled, but she was unable to attend outings that required longer sitting, such as field trips or church. She also was having some urinary retention with start and stop stream and resultant urinary frequency. Peyton’s mother said the pain was distressing to Peyton and would cause her to cry. She had an unremarkable medical history. However, under further questioning, we discovered she did have a history of bed wetting later than usual (until age 7) and she had persistent leg pain. With standing longer than 15 minutes, her legs would hurt and feel weak, which prevented her from performing sports or being physically active. She also had experienced some achy low back sensations since the kidney infection. Peyton had been screened by urology, her primary care, an osteopath, as well as a vulvar pains specialist who diagnosed her with nerve pain, but said there is no good viable treatment.

Objective findings revealed normal range of motion in her spine with the exception of limited forward flexion (feeling of back tightness at end range). Hip screening was negative for FABERS, labral screening or capsular pain patterns. General dural tension screening was positive for increased lower extremity and sensation of back tightness with slump c sit. Neural tension test was positive bilaterally for sciatic, R genitofemoral, L Iliohypogastric and Ilioinguinal nerves, and bilateral femoral nerves. Patient had a mild, barely perceptible lumbar scoliosis, and development of bilateral lower extremities and feet was symmetric and normal.

Because of the child’s age, we did not perform internal vaginal exam or treatment. This required treating the nerves that supply the vaginal area. All treatments were done with the patient’s mother present with both consent of the child and the mother.

For treatment, we started with the three inguinal nerves (Ilioinguinal, Iliohypogastric and genitofemoral) because of their relationship with the kidney (symptoms came on after kidney infection) as well as the correlation with the patient’s most limiting symptoms (genital pain). We cleared the fascia along the lumbar nerve roots, the lateral trunk fascia, the psoas, the inguinal region, the entrapments along the kidney and psoas, the inguinal rings and canal, and worked on neural rhythm (these techniques can be learned at the Pelvic Nerve Manual Assessment and Treatment class that I will be teaching later this month).

Over the next weeks, we used similar treatments for the sciatic nerve, femoral nerve, pudendal, and coccygeal nerves. We noted that the patient had an area of restricted tissue along her coccyx that was adhered, and her symptoms had some correlation with tethered cord. We did lots of soft tissue work along the coccyx and working along the coccyx roots, including some internal rectal work. We also did fascial and visceral work in the bladder region, as well as in the lumbar and sacro-coccygeal region.

Peyton’s referring physician and mother were notified of findings and possible tethered cord symptoms (leg weakness and pain, bladder symptoms, delayed nocturnal continence). The patient’s family felt she was getting better and was not interested in any kind of surgical intervention, and her physician also felt that with our progress, he was not interested in exploring that referral, unless the family was interested.

After just 4 treatments Peyton was no longer having any vaginal symptoms and was emptying the bladder normally. After 8 treatments Peyton was reporting no more lumbar pain or lower extremity symptoms, and follow up treatments were reduced to once a month. The patient was given a home program of neural flossing in a small yoga program we recorded on her mother’s phone. We had her mother work on the small area that remained adhered along patient’s tailbone. The area is much smaller, but it reproduces some pelvic pain for the patient, so we are carefully and slowly working along this area because of some of the global neural sx it produces.

The patient’s mother reports she is more active, no longer complaining of leg or vaginal pain. The patient has less generalized anxiety and she is able to void fully. When the pt grows in height, there is a return in some symptoms, likely due to increased neural tension. So, we have the family on standby and when the patient grows, they come back in for 2 visits, which is usually enough to get the patient back to her new baseline.

My 6 year old girl (going on 13) asks “Alexa” to play the Descendants II soundtrack over and over again. So the song, “Space Between,” was lingering in my head while reading the most recent articles on pudendal neuralgia, particularly when pudendal entrapment is to blame. After all, entrapment, by medical standards, describes a peripheral nerve basically being caught in between two surrounding anatomical structures.

Ploteau et al., (2016) presented 2 case studies highlighting the warning signs when pudendal nerve entrapment does not follow the Nantes criteria. A brief summary of those 5 criteria follows:

• Pain in the region of the pudendal nerve innervation from anus to penis or clitoris.
• Pain most predominant while sitting.
• The patient does not wake at night from the pain.
• No sensory impairment can be objectively identified.
• Diagnostic pudendal nerve block relieves the pain.

The case studies of a 31 and a 68 year old female revealed endometrial stromal sarcoma and adenoid cystic carcinoma in the ischiorectal fossa, with night pain was noted in both patients, as well as no pain with sitting or defecation, respectively. Clinicians must always be mindful to resolve red flags in patients.

In 2016, Florian-Rodriguez, et al., studied cadavers to determine the nerves associated with the sacrospinous ligament, focusing on the inferior gluteal nerve. Fourteen cadavers were observed, noting the distance from various nerves to the sacrospinous ligament (from a pelvic approach) and to the ischial spine (from a gluteal approach). The S3 nerve was closest to the sacrospinous ligament, and the pudendal nerve was the closest to the ischial spine. In 85% of subjects, 1 to 3 branches from S3/S4 nerves pierced or ran anterior to the sacrotuberous ligament and pierced the inferior part of the gluteus maximus muscle. The authors concluded the inferior gluteal nerve was less likely to be the source of postoperative gluteal pain after sacrospinous ligament fixation; however, as the pudendal nerve branches from S2-4, it was more likely to be implicated in postoperative gluteal pain.

A study by Ploteau et al. (2017) explored the anatomical position of the pudendal nerve in people with pudendal neuralgia. In 100 patients who met the Nantes criteria, 145 pudendal nerves were surgically decompressed via a transgluteal approach. At least one segment of the pudendal nerve was compressed in 95 of the patients, either in the infrapiriform foramen, ischial spine, or Alcock’s canal. In 74% of patients, nerve entrapment was between the sacrospinous ligament and the sacrotuberous ligament. Anatomical variants were found in 13% of patients, often with a transligamentous course of the nerve.

When the pudendal nerve is caught in the narrow space between ligaments in the pelvis, diagnosing the source of pain is paramount. Research supports a gluteal approach in releasing the entrapped nerve. Post-surgical care falls into the hands of pelvic floor therapists, so taking “Pudendal Neuralgia and Nerve Entrapment: Evaluation and Treatment” may be something to consider in order to provide optimal care.

Ploteau, S, Cardaillac, C, Perrouin-Verbe, MA, Riant, T, Labat, JJ. (2016). Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician. 19(3):E449-54
Florian-Rodriguez, ME, Hare, A, Chin, K, Phelan, JN, Ripperda, CM, Corton, MM. (2016). Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study. American Journal of Obstetrics and Gynecology. 215(5):646.e1-646.e6. doi: 10.1016/j.ajog.2016.06.025
Ploteau, S, Perrouin-Verbe, MA, Labat, JJ, Riant, T, Levesque, A, Robert, R. (2017). Anatomical Variants of the Pudendal Nerve Observed during a Transgluteal Surgical Approach in a Population of Patients with Pudendal Neuralgia. Pain Physician. 20(1):E137-E143

Neurophysiology is a dynamic and highly complex system of neurological connections and interactions that allow for bodily performance. When all of those connections are working correctly, our bodies can function at optimal levels. When there is a break or injury to those connections, dysfunction results but amazingly in some circumstances, our bodies have work arounds to allow for certain functions to continue working.

If we take the sexual neural control system of the male, for instance, a perfect example of this can be described. Many men were injured fighting in World War II. During their time in battle, many experienced spinal cord injuries. Some of these injuries were severe resulting in complete spinal cord damage at level of injury. A physician, Herbert Talbot, in 1949, documented his examination of 200 men with paraplegia. Two thirds of the men were surprisingly able to achieve erections and some were able to experience vaginal penetration and orgasm. Much of their basic functionality had been lost however amazingly there was preservation of erectile function.

The reason these men with paraplegia were able to maintain erectile or orgasm functionality is due to the physiological function in the sacral spinal cord. A reflex arc is present in this region. The definition of a reflex arc is a nerve pathway that has a reflexive action involving sensory input from a peripheral somatic or autonomic nerve synapsing to a relay neuron or interneuron in the sacral cord segment then synapsing to a motor nerve for output to the muscular region. These messages do not need to travel up the spinal cord to the brain in order to be activated. Instead they work within a ‘loop’ at the sacral spinal cord level. In the case of spinal cord injury, erectile function as well as other functions controlled by reflex arcs, can be preserved.

For women, the same is true. In order for a female to have engorgement of the clitoris or orgasm, the sacral spinal reflex arc needs to be intact. If a woman experiences a spinal cord injury above the sacral region, the ability to have a reflexive orgasm within the sacral spinal reflex arc will remain.

The sacral reflex arc also plays an important role in activation of the pelvic floor muscles during the sexual response cycle. During genital stimulation in both the male and female, the bulbospongiosus or bulbocavernosus begins to activate in a reflexive pattern to hinder the outflow of blood from the region which facilitates erectile tissue of the penis and clitoris to become erect. This can then be followed by rhythmic reflexive contractions of the pelvic floor musculature during orgasm.

To learn more about the implications that neurologic disorders can have on the sexual system, please join us for Neurologic Conditions and Pelvic Floor Rehab, coming to Grand Rapids, MI in September.

Goldstein, I. (2000). Male sexual circuitry. Scientific American, 283(2), 70-75.
Sipski, M. L. (2001). Sexual response in women with spinal cord injury: neurologic pathways and recommendations for the use of electrical stimulation. The journal of spinal cord medicine, 24(3), 155-158.
Wald, A. (2012). Neuromuscular Physiology of the Pelvic Floor. In Physiology of the Gastrointestinal Tract (Fifth Edition)(pp. 1023-1040).

In the dim and distant past, before I specialised in pelvic rehab, I worked in sports medicine and orthopaedics. Like all good therapists, I was taught to screen for cauda equina issues – I would ask a blanket question ‘Any problems with your bladder or bowel?’ whilst silently praying ‘Please say no so we don’t have to talk about it…’ Fast forward twenty years and now, of course, it is pretty much all I talk about!

But what about the crossover between sports medicine and pelvic health? The issues around continence and prolapse in athletes is finally starting to get the attention it deserves – we know female athletes, even elite nulliparous athletes, have pelvic floor dysfunction, particularly stress incontinence. We are also starting to recognise the issues postnatal athletes face in returning to their previous level of sporting participation. We have seen the changing terminology around the Female Athlete Triad, as it morphed to the Female Athlete Tetrad and eventually to RED S (Relative Energy Deficiency Syndrome) and an overdue acknowledgement by the IOC that these issues affected male athletes too. All of these issues are extensively covered in my Athlete & The Pelvic Floor’ course, which is taking place twice in 2018.

But what about pelvic pain in athletes?

How can we ensure that pelvic floor muscle dysfunction is on the radar for a differential diagnosis, or perhaps a concomitant factor, when it comes to athletes presenting with hip, pelvis or groin pain? Gluteal injuries, proximal hamstring injuries, and pelvic floor disorders have been reported in the literature among runners: with some suggestions that hip, pelvis, and/or groin injuries occur in 3.3% to 11.5% of long distance runners.

In Podschun’s 2013 paper ‘Differential diagnosis of deep gluteal pain in a female runner with pelvic involvement: a case report’, the author explored the case of a 45-year-old female distance runner who was referred to physical therapy for proximal hamstring pain that had been present for several months. This pain limited her ability to tolerate sitting and caused her to cease running. Examination of the patient's lumbar spine, pelvis, and lower extremity led to the initial differential diagnosis of hamstring syndrome and ischiogluteal bursitis. The patient's primary symptoms improved during the initial four visits, which focused on education, pain management, trunk stabilization and gluteus maximus strengthening, however pelvic pain persisted. Further examination led to a secondary diagnosis of pelvic floor hypertonic disorder. Interventions to address the pelvic floor led to resolution of symptoms and return to running.

‘This case suggests the interdependence of lumbopelvic and lower extremity kinematics in complaints of hamstring, posterior thigh and pelvic floor disorders. This case highlights the importance of a thorough examination as well as the need to consider a regional interdependence of the pelvic floor and lower quarter when treating individuals with proximal hamstring pain.’ (Podschun 2013)

Many athletes who present with proximal hamstring tendinopathy or recurrent hamstring strains, display poor ability to control their pelvic position throughout the performance of functional movements for their sport: along with a graded eccentric programme, Sherry & Best concluded ‘…A rehabilitation program consisting of progressive agility and trunk stabilization exercises is more effective than a program emphasizing isolated hamstring stretching and strengthening in promoting return to sports and preventing injury recurrence in athletes suffering an acute hamstring strain’

If you are interested in learning more about how pelvic floor dysfunction affects both male and female athletes, including broadening your differential diagnosis skills and expanding your external treatment strategy toolbox, then consider coming along to my course ‘The Athlete and the Pelvic Floor’ in Chicago this June or Columbus, OH in October.

The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S), Mountjoy et al 2014: http://bjsm.bmj.com/content/48/7/491
‘DIFFERENTIAL DIAGNOSIS OF DEEP GLUTEAL PAIN IN A FEMALE RUNNER WITH PELVIC INVOLVEMENT: A CASE REPORT’ Podschun A et al Int J Sports Phys Ther. 2013 Aug; 8(4): 462–471. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812833/
‘A comparison of 2 rehabilitation programs in the treatment of acute hamstring strains’ Sherry MA, Best TM J Orthop Sports Phys Ther. 2004 Mar;34(3):116-25. https://www.ncbi.nlm.nih.gov/pubmed/15089024

Angie Mueller PT, DPT is the instructor of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care, a new course on the hypopressive technique and abdominal massage for pelvic health. Join Dr. Mueller on July 27-29 in Princeton, NJ to learn more!

One of the first things I do as a pelvic PT when helping a woman recover from pelvic or core dysfunction, is center her uterus. I believe the uterus is the center of a women- biomechanically, physiologically, and energetically. I have seen that when the uterus is out of position, everything else in the pelvis and core is largely impacted and functions less efficiently. This includes muscular, gastrointentinal, liver, bowel and bladder, hormonal and sexual function.

The uterus is supported by several important ligaments, which extend from the uterus out to the pelvic bones, as well as to the organs surrounding it- bladder, bowel and intestines. So if this magnificent central organ is out of her “center”- leaning forwards or backwards, or tipped to on side or the other- this can lead to a myofascial imbalance in the pelvis and cause symptoms of pelvic floor dysfunction, pain, and hormonal imbalances.

In treating thousands of women with pelvic dysfunction, I have observed that a uterus which is leaning too far forward (anteflexed) is often associated with urinary incontinence, issues with bladder urgency and frequency, and bladder prolapse (cystocele). A uterus that is tipped backwards is often associated with constipation, hemorrhoids and bowel prolapse (rectocele). A uterus that is leaning left or right is often associated with hip dysfunction, sacroiliac joint dysfunction and lumbo-pelvic alignment issues. This leads to and hip and/or knee and/or back pain due to asymmetrical pulling of the internal abdomino-pelvic fascia, especially the uterosacral and cardinal ligaments, which affects pelvic and sacral bone alignment, and then knee and ankle tracking. So centering the uterus will balance the internal pelvic and abdominal fascia, and can significantly improves cases of back pain, hip pain, knee or ankle pain.

Ensuring our organs are in their best position for receiving blood, lymph, nerve and hormonal support is critical to their health and function! If any organ in the body, especially the uterus, is not in its optimal position to receive blood, nerve, lymphatic and hormonal circulation, its function will be impacted. Therefore a mal-positioned uterus can also lead to problems with the menstrual cycle, painful periods, and fertility. When assisting any woman through a rehabilitative process, I have found it critical to appreciate how her uterine position contributes to and impacts her overall pelvic and core health- from a musculoskeletal, biomechanical and physiological perspective.

I have found that the best pelvic therapy outcomes result from use of both passive and active techniques to center the uterus. The first step is passive positioning of the uterus, which is most efficiently accomplished through abdominal massage. Abdominal self massage should be done daily. Abdominal massage will help to release any myofascial and ligamentous restrictions that are leading to a mal-positioned uterus. Abdominal massage also greatly improves blood flow and lymphatic circulation to the gut and pelvic organs leading to improved digestion and organ detoxification. Once her uterus is centered by the massage, it is important to immediately implement an active technique that will keep the uterus centered. This active uterine positioning technique must trigger the appropriate posture and breath that will keep her uterus centered with movement and throughout the activities of the day.

The second step to positioning her uterus is active activation of abdomino-pelvic musculature and key fascial chains that elevate and center the pelvic organs. This is accomplished through one of the latest core neuro-reeducation techniques- Low Pressure Fitness®. The Low Pressure Fitness methodology involves a seamless progression of postures and poses that cause a reduction in pressure in the abdomen and trigger an automatic response from the core muscles- abdominals, pelvic floor, multifidus, diaphragm. Low Pressure Fitness uses a breathing technique known as Hypopressive Breathing to reduce intra-abdominal pressure and optimize organ position. The term Hypopressive means “low pressure”. Traditional exercise, core training, sports, and most of our everyday activities are Hyperpressive – they increase the pressure in the abdomen. When the pressure in the abdomen is not appropriately managed, pressure increases, and this causes the spine to compress and the organs (especially the uterus) to move downward and away from their optimal “centered” position. But when the hypopressive breath is triggered, the pressure in the abdomen is reduced, the spine decompresses, the core musculature is gently strengthened, all of the organs lift, and the uterus is centered.

When the uterus is centered, magic happens… the fascial tension in the pelvis balances out; the resting tone of the abdominal and pelvic muscles improve and become easier to strengthen; the blood flow and lymphatic circulation in the pelvis is improved and sexual function and fertility is enhanced; hormones are better regulated and monthly cycles regulate; bowel and bladder function is optimized; the waistline reduces; pain in the back, abdomen and hips is reduced and posture improves. When all of these wonderful things occur, it is directly associated with improved energy, mood, creativity and self confidence. So remember, centering the uterus, through both active and passive techniques, is key when treating any woman. Self abdominal massage followed up by Low Pressure Fitness® are the most powerful techniques I have found to center the uterus and resolve pelvic and core dysfunction in women of all ages and lifestyles.

Dr. Nicole Cozean was just awarded the IC/BPS Physical Therapist of the Year by the IC Network, one of the largest patient advocacy groups for interstitial cystitis! Today she shares her treatment approach for this complex dysfunction. Join Dr. Cozean in San Diego on April 28-29, 2018 to learn everything there is to know about interstitial cystitis.

Interstitial cystitis (IC) is a chronic pelvic pain condition characterized by pelvic pain and urinary urgency/frequency. IC is frequently accompanied by other symptoms¹, including painful intercourse, low back or hip pain, nocturia, and suprapubic tenderness.

While pelvic floor physical therapy is the most proven treatment for interstitial cystitis, most patients require a multi-disciplinary approach for optimal results. The majority are forced to develop this holistic approach on their own, but one of the most valuable things a physical therapist can provide is assistance in creating their own unique treatment plan. The American Urological Association has released treatment guidelines for interstitial cystitis, and potential treatments fall into several different categories. It is important to note that most treatments aren’t effective for the majority of patients, so a trial-and-error approach is needed to find the right balance for each patient. Tracking symptoms with a weekly symptom log can be a powerful tool to optimize the individual treatment plan.

Summary of the AUA Guidelines for IC – Download Here

Oral Medications

Oral medications are primarily used to reduce pain.Anti-depressants can dampen the nervous system, decreasing the severity of pain reported. Anti-histamines have also been shown to be effective in reducing the pain and symptoms of interstitial cystitis, perhaps because of their ability to reduce inflammation and break the cycle of dysfunction-inflammation-pain (the DIP cycle). Some patients require opioid painkillers for adequate pain control.

Urinary tract analgesics can provide temporary pain relief for some patients, but cannot be taken consistently because they thicken the urine and strain the kidneys. Some patients find success using these medications (Azo, Pyridium, Uribel) during severe pain flares.

The only FDA-approved oral treatment for interstitial cystitis is Pentosan Polysulfate (PPS, Elmiron®). This is commonly prescribed to patients after an IC diagnosis, but has been shown to be effective in only 28-32% of patients. It also requires a long time (often 6-9 months) to build up in the system and take effect, and many patients stop taking the drug before they could see effect because of side effects (including hair loss) or cost. Unfortunately, many patients lose more than a year after their initial diagnosis waiting to see if Elmiron will work for them, when it is unlikely to provide complete relief.

Antibiotics should never be prescribed for IC in the absence of a confirmed infection.

Bladder and Medical Procedures

Bladder instillations deliver numbing medication directly to the bladder through a catheter and can provide temporary pain relief for some patients. If these are effective, they typically are repeated at least weekly as symptoms return. Some patients don’t tolerate the catheterization well, finding the procedure causes more pain than it prevents. Typical bladder instillations consist of Lidocaine, Heparin, or a combination of the two.

Another route of treatment works by artificially stimulating the nerves the innervate the bladder and pelvic floor.Percutaneous tibial nerve stimulation (PTNS) directs electrical impulses from the ankle up through the pelvic floor. This is an outpatient procedure typically performed weekly for a course of 12 weeks. A more permanent option is implanting a device under the skin of the buttock to target the sacral or pudendal nerve root directly.With this procedure, the patient is given a ‘trial run’ with an external device to see how it performs. If significant improvements are noted, the device can be permanently implanted.

Many patients see marked improvement in their symptoms with a home care program. Deep breathing or meditation can calm the nervous system and reduce the amplifying effect of an upregulated nervous system. A stretching regimen targeting the inner thighs, glutes, abdomen, and pelvic floor can relax muscles and reduce nerve irritation in the region. Self-massage can find and eliminate the trigger points that are causing symptoms. Home tools like a foam roller can address external trigger points, while patients can be taught internal self-release with the help of a tool like the PelviWand or another tool.

Elimination Diet

One of the most common misunderstandings about IC centers on the ‘IC Diet.’ In fact, there’s no such thing. While nearly 90% of IC patients report that diet influences their symptoms in some way, the scope and severity of dietary triggers varies greatly between patients. There are a few common culprits - coffee, tea, citrus fruits, artificial sweeteners, tomatoes, cranberry juice - but no guarantee that a patient will be sensitive to all (or any) of these. Many patients read about an ‘IC Diet’ online after receiving their diagnosis, and are convinced that they need to cut out a huge portion of their diet.

Instead, they should be doing an elimination diet focused on identifying their trigger foods.With this approach, they eliminate most of those common culprits and see how it affects their symptoms.If they notice an improvement, they can gradually add foods back into their diet, one at a time, until they see symptoms increase again. This allows patients to identify their specific trigger foods.

Our advice for IC patients is simple - avoid your trigger foods and eat healthy. It doesn’t have to be any more restrictive than that.

There are also several supplements that have shown benefit for patients, either in clinical trials or anecdotally. Prelief (calcium glycerophospate) is an antacid that may reduce the consequences of eating a trigger food. L-Arginine is a semi-essential amino acid that facilitates blood flow and vasodilation; in clinical trials it was shown to be effective for nearly 50% of patients in reducing pain and urinary symptoms. Aloe Vera pills are used by many patients, and thought to help replenish the bladder’s protective layer. Finally, a combination of supplements known as Cystoprotek is also a common supplement taken by IC patients, combining anti-inflammatory flavonoids with molecules that may reinforce the bladder lining.

Complementary and Alternative Medicine

Acupuncture has been shown to provide relief for pelvic pain patients², with 73% of men with chronic prostatitis (either identical or closely related to IC) reporting improvement. These men received two treatments weekly for six weeks, focusing around the sacral nerve. Women with pelvic pain and painful intercourse have also reported improvements in pain with 10 sessions of acupuncture³.

Cognitive-Behavioral Therapy (CBT) has been shown to help reduce pain in conditions as diverse as cancer, low back pain, and pelvic pain. In pelvic pain, ten one-hour sessions of CBT was shown to provide significant benefit for nearly half of patients⁴. Supportive psychotherapy was also shown to have benefits for pelvic pain patients.

A multi-disciplinary approach provides the best results for patients. Physical therapists, who see our patients regularly, can be a great resource in suggesting additional treatment options. The American Urological Association IC Guidelines can be an important resource in guiding patients to other options and developing their unique treatment plan.

Information and Resources

For additional patient resources available for download, feel free to visit The IC Solution page.. In our upcoming course for clinicians treating interstitial cystitis (April 28-29, 2018 in San Diego), we’ll focus on the most important physical therapy techniques for IC, home stretching and self-care programs, and information to guide patients in creating a holistic treatment plan.

1. Cozean, N. "Pelvic Floor Physical Therapy in the Treatment of a Patient with Interstitial Cystitis, Dyspareunia, and Low Back Pain: A Case Report". Journal of Women's Health Physical Therapy. 2017
2. Chen R, Nickel JC. "Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome"Urology. 2003 Jun;61(6):1156-9; discussion 1159.
3. Schlaeger, J, et al. "Acupuncture for the Treatment of Vulvodynia: A Randomized Wait‐List Controlled Pilot Study". Journal of Sexual Medicine. 30 January 2015. https://doi.org/10.1111/jsm.12830
4. Masheb, et al. "A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy". PAIN® Volume 141, Issues 1–2, January 2009, Pages 31-40

There has been a bit of buzz on the various news outlets and social media feeds about the “new organ” the interstitium. On March 27th an article appeared in Scientific Reports, an online peer-reviewed journal from the publishers of Nature. This work was presented by a team of researchers that utilized a new in vivo laser endomicroscopy technique that demonstrated this tissue is a matrix of collagen bundles and elastic fibers surrounded by fluid rather than the tightly packed layers of connective tissue that was previously observed on fixed slides . This submucosal layer was observed in the entire gastrointestinal tract, the urinary bladder, bronchus, dermis, bronchus and peri-arterial soft tissue and fascia. The authors state, “In sum, we describe the anatomy and histology of a previously unrecognized, though widespread, macroscopic, fluid-filled space within and between tissues, a novel expansion and specification of the concept of the human interstitium” ^{Benias et al., 2018}.

The only thing ‘new’ is the way that this group of scientists observed the tissue that until now has primarily been studied ex vivo. I find it rather humorous to note that it is mainstream news that histologists in the 21st century just realized that there is a difference in the architecture of living versus dead tissue. They noted a significant change in the appearance of tissue slides that were chemically fixed in the traditional manner when compared to studies of in vivo structures as well as fresh frozen samples. The researchers noted this tissue in the dermis as well as urinary system, gastrointestinal system and respiratory system. This further supports one of my favorite talking points presented in the visceral mobilization courses “fascia is fascia is fascia is fascia.”

As an instructor that presents entire courses around the importance of the fascial system within all structures of the body including the dermis, epimysium, all organs, and the adventitia of vessels, I am thrilled to see this layer of the fascial system receive recognition and garner the attention it deserves. However, to refer to the interstitium as a new undiscovered organ is to ignore the work of the International Fascia Research Congress as well as many other notable scientists. These researchers see the fascial system as the dynamic mesenchymal tissue that unites every cell in the body and allows for fluid and tissue movement.

French hand surgeon Dr. Jean-Claude Guimrberteau has documented this tissue utilizing microendoscopy on living subjects for the past 20 years. Dr Guimberteau created a brilliant DVD called Strolling Under the Skin, you can view an excerpt available on YouTube. Following the success of several videos, he went on to co-author the book Architecture of Human Living Fascia: The extracellular matrix and cells revealed through endoscopy.

Another brilliant researcher is Orthopedic Surgeon Dr. Carla Stecco. Her paper The Fascia: the forgotten structure is an excellent review of the three-dimensional continuity of the myofascia. Following multiple publications, she also authored the book The Functional Atlas of the Human Fascial System. Her work is limited to the myofascial layer and does not include the visceral fascia although she notes its presence in her published works. For those that would like to know more about this tissue, I highly recommend both of these authors. If you wish to explore how a physical therapist can utilize this information in clinical practice, join me for one of my courses on fascial manipulation. The fascial based treatment for pelvic dysfunction series includes:

• Mobilization of the Myofascial Layer: Pelvis and Lower Extremity
• Mobilization of Visceral Fascia: The Gastrointestinal System
• Mobilization of Visceral Fascia: The Urinary System
• Mobilization of the Visceral Fascia: The Reproductive System of Men and Women

Benias, P. C., Wells, R. G., Sackey-Aboagye, B., Klavan, H., Reidy, J., Buonocore, D., ... & Theise, N. D. (2018). Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Scientific Reports, 8(1), 4947. https://:doi.org/10.1038/s41598-018-23062-6, 2018.

Stecco, C., Macchi, V., Porzionato, A., Duparc, F., & De Caro, R. (2011). The fascia: the forgotten structure. Italian journal of anatomy and embryology, 116(3), 127.

The Institute has welcomed occupational therapists since our founding in 2006. In addition, three OTs: Richard Sabel, MA, MPH, OTR, GCFP, Erica Vitek, MOT, OTR, BCB-PMD, PRPC, and Tiffany Ellsworth Lee MA, OTR, BCB-PMD all teach courses as members of our faculty. (Erica Vitek is also one of several OTs who holds certification as a Pelvic Rehabilitation Practitioner through H&W).

Recently, the Institute was contacted by an Occupational Therapist who has attended many of our courses, regarding a challenge she was experiencing obtaining CEUs in her state (Oregon) for courses on Pelvic Rehab and Biofeedback. In light of this, the Institute has been discussing with some of the occupational therapists on our faculty, as well as representatives of the BCIA and Marquette University, and how to spread awareness about and recognition of OT’s roles in pelvic rehab. Below, we’ve asked faculty member Erica to share a bit more about her journey and the role of the pelvic rehab occupational therapist.

As an OT student, I had a professor who brought in practicing clinicians to discuss their unique roles out in the field. Pelvic health happened to be one of the topics of the day. I was completely intrigued by the clinician, who had such passion about the role of OT in pelvic health. It became clear that helping people with impaired basic bodily functions was imperative to fulfilling life roles and participation; it was OT. I knew from that moment that I wanted to help people deal with these challenging, private issues.

In my journey, I did not immediately start out in pelvic health, but instead in an acute care hospital that had a women’s health program with a strong interest in pelvic health. A very experienced OT and her team of 2 additional OTs were doing great work in that department already. The window of opportunity opened for me to mentor with that group and I eventually was able to begin to get my own referrals and develop a robust hospital-based outpatient practice. At that time, ALL of my experience had been with OTs doing this work and I was naïve to the fact that outside of my world, most of the clinicians doing this type of work were physical therapists (PT). I asked to join a highly trained and skilled group within my health system of all women’s health PTs. Overtime, I was able to demonstrate my level of competency within the group of PTs and contribute valuable things to our organization. Herman and Wallace Rehabilitation Institute was instrumental in my quest to demonstrate competency as they allowed OTs a clear pathway for enrollment in their coursework and application for the Pelvic Rehabilitation Practitioner Certification examination. I can be proud to have those credentials to my name.

My challenges in the area of pelvic health practice have thankfully been minimal, nearly nonexistent, and it has come to my awareness in recent weeks that this is not the case for OTs around the country trying to develop themselves as pelvic health practitioners. My original OT mentors reassured me with the AOTA’s published document titled Occupational Therapy Practice Framework: Domain & Process, detailed a clear place in the role of pelvic health. This document has gone through 3 revisions over the course of its first publication in 2002. The 2nd edition was published in 2008 and the 3rd edition in 2014. I’d like to cite a few important areas of the document that I find to be helpful in an OT’s quest to demonstrate our role in pelvic health rehabilitation.

I’d first like to quote the definition occupational therapy according to the 3rd edition, “occupational therapy is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy practitioners use their knowledge of the transactional relationship among the person, his or her engagement in valuable occupations, and the context to design occupation-based intervention plans that facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and social interaction) needed for successful participation. Occupational therapy practitioners are concerned with the end result of participation and thus enable engagement through adaptations and modifications to the environment or objects within the environment when needed. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non-disability-related needs. These services include acquisition and preservation of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. “

As we look closer at the framework and the definition of OT, there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as “…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.” The clearest examples of the OT’s role in pelvic health occupations within this section include: 1) ADL section: toileting and hygiene (continence needs, intentional control of bowel movements and urination) and sexual activity. 2) IADLs section: sleep participation (sustaining sleep without disruption, performing nighttime care of toileting needs). 3) Achieving full participation in work, play, leisure, and social activities, requires one to be able to maintain continence in a socially acceptable manner in which they can feel confident and comfortable to fulfill their roles and duties.

Client factors as defined in this document are “Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations. Client factors include values, beliefs, and spirituality; body functions; and body structures.” Client factors are further identified as affecting the performance skills and participation of the clients we work with. OT’s role per definition is to “facilitate change and growth in client factors”. In order to fully enhance our client’s performance skills/participation related to change and growth in client factors, OT’s have to examine the whole person, including pelvic health impairments, which have a negative influence on performance. Within client factors, the document defines body structures as, “Anatomical parts of the body, such as organs, limbs, and their components that support body function.” Within this category, one can refer to multiple items named that relate to the care that OTs provide in pelvic health rehabilitation, including but not limited to, structures related to the digestive, metabolic, and endocrine systems and structures related to the genitourinary and reproductive systems.

Since the first email from this individual in Oregon, we have been reached by several other OTs asking about similar challenges and questions about scope of practice. Because of our commitment to honoring the AOTA’s Practice Framework, and because we believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions, the Institute is working with members of our faculty and professional network to advocate for recognition of OTs in pelvic rehab and resolve confusion about scope of practice. For those interested in further resources, please check out:

• Pelvic Floor Biofeedback
• The Women’s Health 4 OT Facebook Group
• The OTs for Pelvic Health Facebook Group
• Occupation Therapy in Postpartum Care Facebook Group
• Womens Health Occupational Therapy Australia Facebook Group

American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68, S1-S48.

Using sEMG biofeedback to get real-time results

Tiffany Lee, MA, OTR, BCB-PMD and Jane Kaufman, PT, BCB-PMD are internationally board-certified clinicians in the treatment of pelvic floor muscle dysfunction through the Biofeedback Certification International Alliance. Combined, they have over fifty years of treatment experience using sEMG biofeedback. Their new course, “Biofeedback for Pelvic Floor Muscle Dysfunction”, will provide the nuts and bolts of this powerful tool so that clinicians can return to the clinic after this course with another component to their toolbox of treatment strategies.

As a clinician treating patients with pelvic floor muscle dysfunction, have you gone away from a treatment session and asked yourself ‘what else can I do for this patient?’. Have you considered adding surface EMG, often referred to as biofeedback, to your treatment plan, but aren’t sure how to go about it correctly or effectively? Perhaps you think you can’t use the sensor because the patient has pain. Maybe you think biofeedback only helps with up-training or strengthening.

So exactly what is biofeedback? Why should I consider this modality? Biofeedback provides a non-invasive opportunity for patients to see muscle function visualized on a computer screen in a way that allows for immediate feedback, simple representation of muscle function, and allows the patient and the clinician the opportunity to alter the physiological process of the muscle through basic learning strategies and skilled cues. Many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation is what helps patients really hone in on body awareness and connect all the dots. Here are a few comments that our patients have made; “I can now pay attention to my muscle while at work thanks to the visual of my muscle when sitting and standing”; “I needed to see my muscle to fully understand how to release the tension in it “; “I totally get what I need to do now that I have a clear picture of what you want”; “Seeing is believing”.

A 2017 study by Moretti, E., et al. is a great article that helps support the concept that measuring the pelvic floor electrical activity through a standard vaginal sensor is not always an option. For many patients, use of surface electrodes with peri-anal electrodes will provide the same reading and offer a more comfortable alternative for those patients who cannot use an internal sensor. This allows the clinician more opportunities to use this treatment modality with ease and assurance that the patient can learn from the visual representation of the muscle without fear of penetration from a sensor, and get great results!

In another study by Aysun Ozlu MD, et al. the authors conclude that biofeedback assisted pelvic floor muscle training, in addition to a home exercise program, improves stress urinary incontinence rates more than home exercise program alone.

Herman & Wallace is offering a course for clinicians in Alexandria, Virginia this June that will answer all of your questions and concerns about this fabulous treatment tool: biofeedback! This course enables the clinician to learn and practice this valuable tool and gain knowledge about the benefits of this modality, so that treatment can begin immediately with ample opportunity for patient’s positive feedback and awareness of muscle function. Participants will experience being a biofeedback practitioner and patient (using a self-inserted vaginal or rectal sensor). Participants will be administering biofeedback assessments, analyzing and interpreting sEMG signals, conducting treatment sessions, and role-playing patient instruction/education for each diagnosis presented during the many hands-on lab experiences. Biofeedback is a powerful tool that can benefit your patient population, and add to your skill-set.

Moretti, E., Galvao de moura Filho, A., Correia de Almedia, J., Araaujo, C., Lemos, C. “Electromyographic assessment of women’s pelvic floor: What is the best place for a superficial sensor?” Neurology and Urodynamics; 2017; 9999:1-7.;
Aysun Ozlu MD, Neemettin Yildiz MD, Ozer Oztekin MD, “Comparison of the efficacy of perineal and intravaginal biofeedback assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence”

Advancing Understanding of Nutrition’s Role in…..Well….Everything

Gratitude filled my heart after being able to take part in the pre-conference course sponsored by the APTA Orthopedic Section’s Pain Management Special Interest Group this past February. For two days, participants heard from leaders in the field of progressive pain management with integrative topics including neuroscience, cognitive behavioral therapy, motivational interviewing, sleep, yoga, and mindfulness to name a few. It’s exciting to witness and participate in the evolution of integrative thinking in physical therapy. When it was my turn to deliver the presentation, I had prepared about nutrition and pain, I could hardly contain my passion. While so much of our pain-related focus is placed on the brain, I realized acutely the stone yet unturned is the involvement of the enteric nervous system (aka the gut) on pain and….well…everything.

Much appreciation is due to those on the forefront of pain sciences for their research, their insight, their tireless work to fill our tool boxes with pain education concepts. Neuroscience has made tremendous leaps and bounds as has corresponding digital media to help explain pain to our patients. One such brilliant 5-minute tool can be found on the Live Active YouTube channel.

What I love about this video is how intelligently (and artistically!) it puts into accessible language some incredibly complex processes. It even mentions lifestyle and nutrition as playing a role in what is commonly referred to as a maladaptive central nervous system.

"Maladaptive central nervous system"

Ok. I’ll admit, I struggle with the implications of this term. However, what doesn’t sit right with me is the concept of chronic or persistent pain being entirely in the brain as though the brain is a static entity. We know the brain to be plastic but often do not identify just how this is so.

What about the role of our second brain…. the one with 200-600 million neurons that live in that middle part of our body (right next to / inside our pelvis)? Termed the enteric nervous system, this second brain both stores and produces neurotransmitters^{Turna, et.al., 2016}, serves as the scaffolding of interplay between the ENS, SNS, and CNS. This ENS is home to the interface of “bugs, gut, and glial” which are “not only in anatomical proximity, but also influence and regulate each other…interconnected for mutual homeostasis.”^{Lerner, et.al., 2017} In fact, part of this process then directly impacts the brain. “Healthy brain function and modulation are dependent upon the microbiota’s [gut bugs] activity of the vagus nerve.”^{Turna, et.al., 2016}. Further, “by direct routes or indirectly, through the gut mucosal system and its local immune system, microbial factors, cytokines, and gut hormones find their ways to the brain, thus impacting cognition, emotion, mood, stress resilience, recovery, appetite, metabolic balance, interoception and PAIN.”^{Lerner, et.al., 2017}

So, by process of logic, it requires little convincing to conclude that the food we eat or fail to eat directly impacts the health or dysfunction of this magnificently orchestrated system. One that directly and profoundly impacts our brain, our body, our being. And it’s a concept that our patients, our clients, ourselves, know in our gut to be true.

And it’s thanks to all the hard work of those who have come before us that we can share in the advancing understanding for the benefit of thousands who need your help, expertise and guidance. Please join me for Nutrition Perspectives for the Pelvic Rehab Therapist. The next course will be in Springfield, MO on June 23-24, 2018. Vital and clarifying information awaits you!

Live Active. (2013, Jan) Understanding Pain in less than 5 minutes, and what to do about it! https://www.youtube.com/watch?v=C_3phB93rvI Retrieved March 28, 2018.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Turna, J., Grosman Kaplan, K., Anglin, R., & Van Ameringen, M. (2016). "What's Bugging the Gut in Ocd?" a Review of the Gut Microbiome in Obsessive-Compulsive Disorder. Depress Anxiety, 33(3), 171-178. doi:10.1002/da.22454