The following post comes to us from Herman & Wallace faculty member Tina Allen, PT, BCB-PMD who teaches many courses with the institute. Tina's new course, Manual Therapy Techniques for the Pelvic Rehab Therapist, will be debuting this October in San Diego, CA.

As a physical therapist who has been treating pelvic floor dysfunction for 20 years, the patient who still impacts me the most happens to be the second patient I ever treated. The patient was a 22 year old woman who, before she even was referred to me for pelvic pain, had already seen 14 medical providers and experienced 10 procedures including a hysterectomy. She had been told by more than half of her providers that this pain was “in her head”, that “she needed counseling”, and that there was no reason for her pain. With 4 years of clinical experience at the time, I felt discouraged and wondered how I was going to help her. Then I remembered that no one else could look at her muscles and biomechanics like a PT could.

I started out by educating her about the muscles “down there”, observed how she moved with her daily tasks and then I completed her seemingly first ever muscular evaluation of the perineum. After 6 sessions of down training, muscle reeducation, manual therapy, strengthening of her hip and teaching her how to self mobilize the tissues of the perineum, she reported a pain level of 3/10- the lowest her pain level had been since she was 13 years old! Of course, she asked why it took so long for her to be referred to PT.

While this felt like an extreme story to me at the time, I now know that this is still the reality for many of the clients that we work with as pelvic floor PT’s. This experience set up the aspiration for me to have medical residents in my clinic with me to teach them what PT can do for patients and so that the residents can better evaluate their patients. As pointed out in research in the Journal of Graduate Medical Education, residents in obstetrics and gynecology do not feel adequately prepared to manage the care of women who have chronic pelvic pain^{Witzeman & Kopfman, 2014}. Specifically, residents reported negative attitudes towards patients with pelvic pain, and feelings of not having enough time to address their patients’ needs. When asked about how they preferred to learn more about care of patients with pelvic pain, the residents were interested in one-on-one clinical teaching as well as use of diagnostic algorithms. At this point in time I have medical residents with me at least 2 days per month. It’s a start!

So, what does a typical day look like with a 1st year OB/GYN resident in your clinic?

First, I always do my best to let my clients know in advance that a physician will be with me that day. The patient can always decline but most patients are accommodating. I have found that most of our patients want to advocate for themselves and others by having that physician with us in our session to teach them about how PT has helped them.

I spend the first 30 minutes when the resident arrives by bringing out the pelvic floor muscle model and explaining the function of all the muscles and how those muscles impact function. I also describe how this function is impacted by fascia, the muscles of the trunk, biomechanics and mind/body connections. Then we start seeing patients. After I have reviewed the patient’s current status, we begin our session. The patient is asked to give the resident their history and medical history. It’s been wonderful to watch my patients teach the residents and to hear the patients be able to explain their condition including procedures and functional restrictions.

The residents will then be instructed to palpate and learn about restricted tissues, observe how the patient uses their pelvic floor muscles, core, trunk and legs with their daily tasks. The residents have the opportunity to observe how we progress the patient’s self care in therapy.

While the session may start with the resident feeling frustrated that they are not able to be seeing their own patients or preparing for their tests, it usually ends with the resident asking when they can come back to the clinic to learn more about what we do and how we can help patients.

I urge all of us to reach out and invite physicians, PA’s, ARNP’s, midwives, naturopaths and nurses into our clinics to learn. With a little advanced planning we can get patients the help they need as soon as possible.

Witzeman, K. A., & Kopfman, J. E. (2014). Obstetrics-Gynecology Resident Attitudes and Perceptions About Chronic Pelvic Pain: A Targeted Needs Assessment to Aid Curriculum Development. Journal of graduate medical education, 6(1), 39-43.

Herman & Wallace faculty member Eric Dinkins, PT, MS, OCS, Cert. MT, MCTA teaches the Manual Therapy for the Lumbo-Pelvic-Hip Complex: Mobilization with Movement and Laser-Guided Feedback for Core Stabilization course for Herman & Wallace. He is one of only 13 practitioners in America credentialed to teach the Mulligan Concept of Manual Therapy, and is a published author. Join him in Arlington, VA on August 20-21, 2016 to learn new joint mobilization, evaluation, and treatment skills.

Much research has been published regarding evaluation and diagnosis of the Sacroiliac Joint (SIJ). Low back pain and pelvic girdle pain is a common complaint with patients in all clinic settings. Laslett (Manual Therapy 2005) gave our profession valuable insight into categorizing a cluster of tests to try to ensure Physical Therapists and Chiropractors know if the SI joint is a pain source of our patients. We now also have several articles reaffirming the validity of the Active Straight Leg Raise (ASLR) and Stork testing for SIJ dysfunction (Manual Therapy 2008; JBMR 2012; PT 2007). However, after talking with clinicians who attend my Mobilization with Movement classes, as well as many colleagues in the outpatient orthopedic setting, there is a definitive lack of understanding how to use this information to translate over to successful treatment. This is understandable considering there have been several articles published regarding the poor validity and consistency between clinicians regarding palpation skills and bony landmarks in the lumbar spine and pelvis (ex: Manual Therapy 2012). But perhaps the fault is not in the clinician proficiency, but rather in the nature that we are attempting to diagnose an SIJ dysfunction?

If you were to consult with experts in body kinematics, gait analysis, and biomechanics regarding the true movement of the SIJ, there will be many different answers depending on the action that they were describing. Particularly when it comes to dysfunction. Disagreements abound when describing conditions such as “upslips”, “inflares”, etc and virtually all back their arguments with clinical anecdotal success rates. These arguments often leave clinicians with inconsistencies in treatment and increased failures.

This blog is meant to be a persuasive argument for using function-improving or pain- eliminating techniques for diagnosis and treatment of SIJ dysfunction. The logic of this approach is often misunderstood. But if applied correctly, satisfies most theory surrounding the SIJ, and provides immediate feedback for knowing how to resolve the condition and what you are treating.

We have pain provocative testing that is most commonly used in attempting to diagnose a SIJ dysfunction. However, after interpreting these tests, the clinician is still left without a true diagnosis as to the nature of what is happening at this joint to cause pain or dysfunction. This is likened to the "painful shoulder" or "low back pain" prescription we see. The error rates, even in the cluster, still leaves room for inaccurate assessment and therefore potential misguided treatment. Lumbar facet, musculature, hip capsule imbalance, are just some examples that can produce false positives on the typical SIJ tests that are used in clinic. Therefore, it is necessary to understand that pain provocative testing ONLY tells us that pain is coming from that structure that is being tested. And NOT that it is “THE” source of the dysfunction.

Now consider using function-improving or pain-eliminating techniques for your evaluation. The ALSR test, as an example, function improving special test. Compression applied to various aspects of the pelvis or supporting musculature yield a positive finding if the SLR is now easier if the force is applied. Combing this information with the faulty kinetic testing of the Stork and/or leg pull test to determine the involved side yield an immediate feedback for both the clinician and the patient as to what forces are needed to correct the dysfunction that is limiting the functional activity and restore normal motion. Treatment would then be applied by creating a force on the innominate, sacrum, or both and would then be maintained throughout the movement and can be considered a form of active exercise (manual assisted active exercise). If retesting of the affected motion yields a sustained improvement, the accurate diagnosis has now been made. And surely this diagnosis would be upheld if the patient returned at a later date to demonstrate no regression occurred.

If the force applied to the pelvis was directed toward posterior rotation at the innominate and/or an anterior rotation at the sacrum, and the affected motion cleared without pain or limited motion, it would be confirmed that these forces were necessary to correct the dysfunction on the involved side regardless of the "ambiguous diagnosis' including the potential of a previously held thought of an anterior rotation of the pelvis (making the argument of what actually happened at the pelvis mute). This may have been achieved through altering inputs viewed as a potential "threat" by the system, or mechanics stresses, etc. Regardless, if manual correction of this condition was applied and the dysfunction was correction through re-creating this without pain, one would conclude that this dysfunction was the primary eitiology of the symptoms. If the symptoms returned or the functional test was not normalized, an easy conclusion would then be that despite manual correction eliminating pain during the activity, this correction was not addressing the source of the dysfunction. And therefore the clinician should consider treatment elsewhere.

In essence, the body is capable of directing what it needs in order to return to a normal functioning homeostasis…without the application of pain. Now this pain-eliminating testing becomes your assessment, treatment and potentially your home exercise program!

To conclude, it is my suggestion to all manual based physiotherapists and chiropractors to strongly consider pain-eliminating techniques for both evaluation and treatment in their practice.
Did I mention yet that your patient already voted for that….?

Laslett, M, et al. "Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests" Manual Therapy 10 (2005) 207-218
M. de Groot, et al. "The active straight leg raising test (ASLR) in pregnant women: Differences in muscle activity and force between patients and health subjects" Manual Therapy 13 (2008) 68-74
Hungerford, B, et al. "Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion with the Stork Test on the Support Side" Phys Ther. 2007 Jul;87(7):879-87.
O'Surrivan PB, Beales DJ. "Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework" Man Ther. 2007 May;12(2):86-97.
Arab AM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. "Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint" Man Ther. 2009 Apr;14(2):213-21. doi: 10.1016/j.math.2008.02.004. Epub 2008 Mar 25.

Herman & Wallace Pelvic Rehabilitation Institute faculty member, Ginger Garner PT, L/ATC, PYT, will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more. Read below as Ginger shares why the voice is a linking science.

The Voice as a Linking Science for Clinical and Business Efficacy

Your voice can be the key to your success. Forbes magazine’s #3 habit in an article, Five Habits of Highly Effective Communicators, is “Find your own voice.” London’s think tank Tomorrow’s Company declares in a recent report on efficacy in business leadership, “Having a voice really matters for employees today.” The director of the Involvement and Participation Association (IPA) and vice-chair of the London-based MadLeod Review on employee engagement says, “Voice is extremely important because there are many changing business concepts and one of the essential ones is trust. Our voice is one of the things we really need to change old management paradigms and build trust in an organization.”

If you are an instructor, teacher, educator, therapist, or all four, having a voice is synonymous with having a job. You can’t do your job without a voice. And yet, we don’t spend much time thinking about vocal physiology, much less how to maintain and even improve it.

The most powerful change agent or therapeutic modality you have - is your voice. Yet, the voice is often overlooked as a therapeutic tool. Think of how important it is for someone giving a TED talk to have good vocal quality, for example. Now consider how important it is for others, like you, who may have to speak for hours on end each day. The vocal folds must be cared for just like we attend to the mind and body during postural yoga practice or movement therapy.

What were the other findings of the report?

• Voice is the foundation of sustainable business success. It increases employee engagement, enables effective decision-making and drives innovation.
• Finding your voice involves both cultural and structural pursuit. First, we need to be culturally competent and sensitive. Only then can we provide the right process through which our voice can be heard.

The power of the voice cannot be ignored, particularly for those who have allergies, respiratory issues, or struggle to make a powerful impact or to establish themselves as an effective team member or thought leader. Oftentimes, the voice is the single variable that holds us back from making the success we are seeking in our work. US News World and Report states,

“Whether you are an aspiring leader or in a support role, developing your communication skills can impact your success. First, let’s take a look at the complexities of communication. It's more than the words you use. It's how and when you choose to share information. It's your body language and the tone and quality of your voice.”

Psychology Today and National Public Radio have recently reported on the relationship between vocal quality and job success and effectiveness. Both agree that speech rate, tone of voice, facial expression, and diction have a great deal of power to make or break effective communication. If tone doesn’t match facial expression, for example, neural dissonance occurs, which erodes trust, increase skepticism, and cooperation.¹ In fact, warm vocal tone is a sign of transformational leadership, which generates “more satisfaction, commitment, and cooperation between team members”.² Changing pitch increases therapeutic potential and improves the chances of your being understood by colleagues, especially when diction is congruent with emotion.¹ Additionally, training mindfulness during public speaking can improve prefrontal cortex activity, which allows for improved social awareness, mood-regulation, decision-making, and empathy.⁴ Vocal awareness and training can slow your pace of speaking, which is shown to deepen others’ respect for you and simultaneously calm anxiety, traits which are bridge-building and healing for all relationships, business and personal.

About MISTY

MISTY is a not-for-profit organization and event dedicated to teaching others about therapeutic yoga.
Ginger’s workshop, “Vocal Liberation,” will introduce techniques for developing and preserving the voice, including projection, quality, longevity, and therapeutic impact through fusion of nada yoga and ENT physiology, which Ginger has developed over her career in public speaking and vocal performance. Want to learn about therapeutic yoga at MISTY? There’s still time to join Ginger and a host of other talented speakers and therapists. Learn more and register at http://www.homyogaevents.com.

Use of affective prosody by young and older adults. Dupuis K, Pichora-Fuller MK. Psychol Aging. 2010 Mar;25(1):16-29.
Leadership = Communication? The Relations of Leaders' Communication Styles with Leadership Styles, Knowledge Sharing and Leadership Outcomes. de Vries RE, Bakker-Pieper A, Oostenveld W. J Bus Psychol. 2010 Sep;25(3):367-380.
Short-term meditation training improves attention and self-regulation. Tang YY, Ma Y, Wang J, Fan Y, Feng S, Lu Q, Yu Q, Sui D, Rothbart MK, Fan M, Posner MI. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17152-6.

Faculty member, Ginger Garner PT, L/ATC, PYT will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more.

Yoga is, unarguably, a popular contemplative science, enjoying 36.7 million practitioners in the US alone, up from 20.4 million in 2012.1 A 16 billion dollar industry, yoga is one of the most widely utilized methods of complementary and integrative medicine in America today. In 2008, the editor of Yoga Journal declared “yoga as medicine” as the next great wave. That was right in the middle of the Great Recession, when the last thing on the collective healthcare industry’s mind was yoga.

What happened during the same time frame as the interest in yoga surged?

Our expanded knowledge of hip anatomy, physiology, and pathophysiology exploded onto the medical scene, providing more information than ever about how to address, preserve, and otherwise attend to the hip joint. Prior to this new age of research, the hip was relegated to a joint worthy of no more than a tendonitis, bursitis, or osteoarthritis diagnosis. A person was simply a hip replacement candidate or not. There was no other option once a hip joint had prematurely degenerated. Now, that has all changed, thanks to technological advances in diagnostic testing and investigation.

Yet, the worlds of hip preservation and rehabilitation and yoga have yet to join hands. Many of my patients and colleagues have suffered from unnecessary hip injuries, from labral tears, all types of impingement, and compounding secondary diagnoses such as torn hamstrings, sports hernias, gluteal tendinopathy, to pelvic pain, all due to yoga practice. Some suffered injuries in yoga class during a single traumatic injury, and some injuries were drawn out over years of accumulated microinjury to capsuloligamentous, bony, or cartilaginous structures.

Hip labral injuries (HLI) have vastly increased over the last 10 years, perhaps making HLI the newest orthopaedic diagnosis of the 21st century. This discovery also makes surgical and conservative management of HLI uncharted territory. Conservative therapy includes nonsurgical and post-surgical rehabilitation, and since the average time from injury to diagnosis is 2.5 years, there are many people with hip, pelvic, back, or sacroiliac joint pain that have undiagnosed hip labral tears.

I should make myself quite clear, however. I am not out to demonize yoga or fear-monger the practice of yoga or how it may wreck a person’s body (to use recently controversial language).

My purpose is two-fold: To clarify 1) “what” and “how” yoga can be a safe, effective form or physical therapy and rehabilitation for the hip and pelvis, as well as to 2) underscore the areas where yoga posture practice should be evolved to prevent injury.

To that end, I have written and will be presenting a new 4-hour workshop entitled, Hip Preservation: Yoga Reconsidered, at the Montreal International Symposium on Therapeutic Yoga (MISTY) this weekend in Canada. The lecture is relevant for yoga teachers, yoga enthusiasts, yoga therapists, and health care professionals who are interested in learning how to prevent hip injury in yoga practice.

The workshop will introduce identification of imbalances that could contribute to HLI, as well as understand the common mistakes made in yoga practice that could increase HLI or hip impingement. Understanding the pain patterns that surround HLI are also critical to safe and therapeutic yoga practice and will be discussed. Discussion of structure, function, ability and “dis”ability of the hip, including their major substrates, will help identify the “red flags” in yoga practice, identifying high risk populations and those who need postural modification(s) and/or outside referral to physical therapy.

I am looking forward to instructing a high energy, action-packed hands-on learning session at MISTY on March 19-20, along with my presenting a 2-hour lecture on maximizing public speaking impact through Vocal Liberation: The Voice as Therapy.

• The Voice as a Linking Science for Clinical and Business Efficacy
• Hip Preservation: Yoga Reconsidered
• Ginger’s lecture overview - Montreal International Symposium for Therapeutic Yoga

Want to learn more?
Bring Ginger’s 16 hour continuing education course, Differential Diagnosis for Hip Labral Injuries to your facility in 2017 through Herman & Wallace Pelvic Rehabilitation Institute.

Yoga in America 2016 Survey. Yoga Alliance and Yoga Journal. January 2016.

Faculty member Lila Bartkowski- Abbate PT, DPT, MS, OCS, WCS, PRPC teaches the Bowel Pathology, Function, Dysfunction and the Pelvic Floor course for Herman & Wallace. Join her in Tampa on April 2-3, or one of the other two events currently open for registration.

Constipation, an often under reported health issue, afflicts about 30% of Americans. ¹ The diagnosis of chronic constipation may seem like a simple concept, however the etiology of chronic constipation presents itself in many different forms. Dyssynergic defecation is one of many factors that can lead to a presentation of chronic constipation in a patient. Dyssynergic defecation or “paradoxical contraction” occurs when the muscles of the abdominals, puborectalis sling, and external anal sphincter function inappropriately while attempting a bowel movement. ² The lack of coordination of these muscles results in a contraction versus a lengthening of the pelvic floor muscles with baring down. Dyssynergic defecation is different than a structural issue such as a rectocele or hemorrhoids causing the inability to pass stool effectively or constipation due to slow colon transit time or pathological disease. Making the diagnosis of dyssynergic defecation by symptoms alone is often not reliable secondary to overlap of similar symptoms with chronic constipation due to factors such as a structural issue, irritable bowel syndrome (IBS), or irritable bowel disease (IBD). The diagnosis of dyssynergic defecation can be difficult and is often made through physiologic testing such as balloon expulsion testing or MRI with defecography. ² However, physical therapists can often manually feel that a paradoxical contraction is happening when asking a patient to bare down on evaluation.

Patients with dyssynergic defecation may present to pelvic floor physical therapy with complaints of: ¹ ²

1. Abdominal symptoms such as bloating, pain, and cramping
2. Poor response to laxatives and fiber supplementation that does not fully resolve their issue
3. Have had testing for anatomical or neurological abnormalities with no significant findings
4. Complaints of concomitant pelvic pain due to over activity of the pelvic floor muscles

Physical Therapists specializing in pelvic floor rehab can be a valuable part of the medical team with treating these patients. Biofeedback training by physical therapists has been shown to decrease anorectal related constipation symptoms and abdominal symptoms in patients with dyssynergic defecation. In a sample of 77 patients with dyssynergic defecation, physical therapists provided biofeedback training for 6-8 weeks that included manual and verbal feedback, surface EMG, exercises using a rectal catheter, rectal ballooning to improve rectal sensory abnormalities, ultrasound, pelvic floor and abdominal massage, electrical stimulation if needed, and core strengthening and stretching to improve the patients’ maladaptive habits while attempting to pass a bowel movement. Significant decreases were seen on all three domains (abdominal, rectal, and stool) on the PAC-SYM (Patient Assessment of Constipation) questionnaire post biofeedback training. ² It is noteworthy that 74% of these patients presented to the clinic with complaints of abdominal symptoms such as bloating, pain, discomfort, and cramping.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab secondary to overlapping symptoms of different causes of chronic constipation. Physical therapists are able to provide these patients with conservative treatment that can effectively improve or eliminate their problem, recognize dyssynergic defecation as a possible differential diagnosis, and refer to the appropriate medical professional for further testing. Recognizing and treating dyssynergic defecation is something physical therapists will learn how to become effective at in the upcoming Herman and Wallace Course: Bowel Pathology, Function, Dysfunction & the Pelvic Floor April 2-3 in Tampa, FL and October 8-9 in Fairfield, CA.

1. Sahin M, Dogan I, Cengiz M et al. (2015). The impact of anorectal biofeedback therapy on quality of life of patients with dyssynergic defecation. Turk J Gastroenterol. 26(2):140-144

2. Baker J, Eswaran S, Saad R, et al. (2015). Abdominal symptoms are common and benefit from biofeedback therapy in patients with dyssynergic defecation. Clin Transl Gastroenterol. 30(6)e105. doi: 10.1038/ctg.2015.3

The following comes to us from Carolyn McManus, PT, MS, MA, our resident expert in the power of mindfulness and it's applications to rehabilitation. Carolyn was recently featured in a video from the Journal of the American Medical Association for her contributions to a newly published research article. Join Carolyn at her course, Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain on May 14th and 15th in California's Bay Area!

Neuroimaging studies show that cortical and sub-cortical brain regions associated with cognitive and emotional processing connect directly with descending pain modulating circuits arising in the brainstem. As diminished nociceptive inhibition by descending pain modulation is a likely contributing factor to the persistence of pain, these cortical and sub-cortical connections to relevant brainstem regions provide a means by which maladaptive cognitive and emotional processing can contribute to the persistence of pain¹. It is possible that strategies to help patients self-regulate cognitions and emotions could promote pain reduction through restoring the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

To be mindful is to rest the mind in the present moment with stability and acceptance and without additional cognitive or emotional elaboration. Mindful body awareness is a central component. Training in mindful awareness has been shown to improve attention regulation, emotional processing and body awareness and contribute to reduced pain intensity, catastrophizing, depression and anxiety^2,3,4,5. Training in mindfulness has also been shown to modulate brain activity in areas associated with body awareness and pain processing^6,7. It is possible that the adaptive modulation of cortical and sub-cortical areas engaged with mindful cognitive, emotional and physical self-regulation could contribute to reducing pain through improving the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

One of my patients reflected the clinical benefits of mindfulness training when he said, “I needed to learn how to not freak out when my exercises or daily activities increased my pain. Focusing my mind on the present moment was enormously helpful. I would tell myself, “Breathe. Just be here. Calm down.” By breathing and relaxing I could take control of how I was reacting and I immediately saw a difference. My pain did not increase out of control.”

I am thrilled to be sharing my 30+ year experience in mindfulness and patient care in my upcoming course through Herman and Wallace.

1. Ossipov M, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8(2):143-151.
2. Holzel BK, Lazar SW, Guard T, et al. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Science. 2011;6: 537–559.
3. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013 Feb;14(2):230-42.
4. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013 Aug 26;8(8):e71834.
5. Schutze , Slater H, O’Sullivan P, et al. Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Front Psychol. 2014 Aug 4;5:839.
6. Zeidan F, Martucci KT, Kraft RA, et al. Brain mechanisms supporting modulation of pain by mindfulness meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
7. Nakata H, Sakamoto K, Kakigi R. Meditation reduces pain-related activity in the anterior cingulated cortex, insula, secondary somatosensory cortex and thalamus. Front psychol. 2014;5:1489.

Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC is a published researcher and practitioner who has worked in the realms of brain injury, lymphedema, and oncology. Now she's leading the charge to encourage rehabilitation practitioners to utilize ultrasound diagnostic imaging with their patients, and you can learn these techniques in her Rehabilitative Ultrasound Imaging - Women's Health and Orthopedic Topics course taking place May 1 - 3 in Dayton, OH. We've partnered with SonoSite to make the best ultrasound equipment available for participants in this course.

Most of us are treating patients who have back pain of some nature, and we know the importance of the local stabilizing muscles including the transverse abdominis, the lumbar multifidus, and the pelvic floor muscles. These muscles work together to provide tension and create a corset of stability throughout the trunk. A common goal is to rehabilitate these muscles in order to restore motor control and strength, but the muscle depth can make them difficult to assess and palpate.

I recently read a study that is looking at the development of a test to identify lumbar multifidus function. Herbert et al. found promising results when looking at this “multifidus lift test” for inter-rater reliability and concurrent validity to identify dysfunction in the multifidus. They compared the results of this test with real-time ultrasound imaging of the lumbar multifidus. Inter-rater reliability was excellent and free from errors of bias and prevalence. Concurrent validity was demonstrated through its relationship with the reference standard results at L4-L5, but not so much for L5-S1. This preliminary research supports the reliability and validity of the multifidus lift test to assess lumbar multifidus function at some spinal levels. If this test could be further validated for other spinal levels it would be very beneficial for therapists who are using a specific stabilization program to treat patients.

Until this test is further developed and validated how can therapists know for sure that their patient is truly activating their multifidus? Ultrasound imaging is the answer! Ultrasound imaging gives therapists real-time feedback for whether a patient is able to correctly activate a muscle or not. It is also a wonderful biofeedback tool for patients who are trying to rehabilitate these muscles. Getting your hands on an ultrasound machine can be tough, but therapists who work in a hospital system may have an easier time than you'd think. I have worked with many therapists to help them get access to ultrasound units through “hand me down” units from imaging or labor and delivery departments. I also have helped private practice therapists set up a working relationship with a physician who has an ultrasound in their office. Thinking outside of the box can allow clinicians to gain access to ultrasound units without having to spend a lot of money. Join me in Dayton Ohio this May to hear more about how ultrasound imaging can improve your practice and allow you to incorporate a specific stabilization program into your toolbox.

Herbert JJ, Koppenhaver SL, Teyhen DS, Walker BF, Fritz JM. The evaluation of lumbar multifidus muscle function via palpation: reliability and validity of a new clinical test. Spine J. 2015; 15(6): 1196-202.

The following post comes to us from Herman & Wallace faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison authored "Use of transabdominal ultrasound imaging in retraining the pelvic-floor muscles of a woman postpartum" and is a leading expert in the use of ultrasound imaging for pelvic rehab. She is the author and instructor of the Rehabilitative Ultrasound Imaging: Women’s Health and Orthopedic Topics offered with Herman & Wallace.

In the pelvic floor series we learn how to perform examinations for cystoceles and rectoceles. It can be more difficult for therapists to examine and quantify the degree of uterine descent. In the last few years translabial ultrasound imaging has also been used to identify what is happening in the anterior compartment upon Valsalva and pelvic floor contraction, including the uterus. This is helpful when trying to determine the degree of uterine prolapse. Degree of pelvic organ descent visible on by ultrasound has been shown to have a near-linear relationship with measures on the POPQ.

Clinically we see that some patients with severe prolapses have few symptoms, while other patients with smaller prolapses will have more severe complaints of symptoms. This can be puzzling to the clinician who is trying to treat prolapse patients. Shek and Dietz performed a study to set cutoff measures of uterine descent that will predict symptoms of prolapse. Translabial ultrasound imaging was performed on 538 women with 263 women reporting prolapse symptoms. Seventy-five percent of the women presented with grade two or greater prolapse on the POPQ, with most of being cystoceles or rectoceles. The women with more complaints of symptoms of prolapse were more likely to have uterine prolapse. There was a strong association between degree of uterine descent and symptoms of prolapse. They determined that an optimal cutoff to predict symptoms of prolapse due to uterine descent is a cervix descending to 15 mm above the pubic symphysis.

This study intrigues me and makes me wonder how much we are focusing on cystoceles and rectoceles and not looking at uterine prolapses. Using translabial ultrasound imaging is a nice tool to allow the clinician to see what is going on with all of the pelvic organs. With one Valsalva maneuver you are able to assess a lot of information including support of the pelvic organs. It also gives the clinician another way to quantify the degree of prolapse. Ultrasound imaging is a wonderful tool that clinicians can use for assessment as well as a biofeedback tool. If you are interested in learning how to perform this type of assessment, I will be teaching Rehabilitative Ultrasound Imaging: Women’s Health and Orthopedic Topics May 1-3 in Dayton, OH.

Shek KL, Dietz HP. What is abnormal uterine descent on translabial ultrasound? Int. Urogynecol J. 2015; 26(12)1783-7.

Today we are honored to present our featured Certified Pelvic Rehabilitation Practitioner Jessica Dorrington, PT, MPT, OCS, PRPC, CMPT, CSCS! Jessica was kind enough to answer a few questions about her role in pelvic rehab.

Describe your clinical practice:
Our clinic practice is an outpatient orthopedic private practice. We are committed to making individual results accessible through compassionate therapeutic care. Our practice spans treating men, women and children through a realm of urologic, gynecologic, obstetric, and colorectal conditions- as well as orthopedic conditions.

How did you get involved in the pelvic rehabilitation field?
Initially, I was an outpatient orthopedic physical therapist. Within the first few months of my career, the clinic I was working at needed someone to just “teach Kegel exercises”. When I realized the impact that you could have on someone’s life, I was immediately drawn to the pelvic rehabilitation field. I saw getting someone even 75 percent improvement was a whole different success than getting a shoulder patient 75 percent better that could now throw their ball to their dog. It was restoring relationships, saving marriages, and giving women the freedom to go do things they could not do before.

What/who inspired you to become involved in pelvic rehabilitation?
My patients inspire me every day. I initially started treating incontinence patients and then gradually added chronic pain patients to my case load. Each patient that achieved such success with pelvic rehabilitation inspired me to wanting to learn more and reach out to more patient’s in need of physical therapy. This led me into treating men and children with pelvic rehabilitation issues. My favorite story that initially started me on my career path was a 95 year old women who came to me for low back pain. I asked her if she had any incontinence. After 4 visits, she removed a pessary (that she had for the past 55 years-since the birth of her last child) and was painfree and fully continent!

What patient population do you find most rewarding in treating and why?
My favorite patients are those that have seen every specialist and have complex histories. Being able to really listen to their story and give them answers in a health care setting that has not found a solution to their condition is such a wonderful experience. Our professional affords us such a great opportunity to really get to know these patients, dive deep into their history and put the puzzle pieces together for them in a way most professions do not have time for in our current medical model.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
As I have grown as a practitioner over the years, the biggest message I have is to really listen to each story. Even a simple SI joint dysfunction patient or a seemingly straight forward stress incontinence patient can have subjective and objective information that really points to the root of the issue. We can really serve these patients the best and premier care if we are up to date on our dermatologic, hormonal influences, musculoskeletal system, and are strong orthopedic clinicians.

What has been your favorite Herman & Wallace Course and why?
Michelle Lyons Athlete and the Pelvic Floor course was wonderful. Michelle is a gifted facilitator of education, has so many pearls of valuable resources and tidbits. She also does a wonderful job combining the orthopedic and pelvic floor world together.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Holly has been truly inspirational to me as she is so passionate about her career and passionate about our profession. Her education on hormones really helps me to sort out for patients when I feel there is a hormonal influence.

What do you find is the most useful resource for your practice?
A pelvic model and Adrian Louw’s Explanation of Pain/Neuroscience education has been such a great resource. For most pelvic pain patient’s there is some sort of sensitive nervous system overlie and the way he educates patients has been lifechanging. The other strong resource has been motivational interviewing education. This allows to really guide these patients in a way that assesses their readiness and motivation for change. The other resource is using the rehabilitative ultrasound imaging. Jackie Whittaker has been such a wonderful mentor to me and this resource has revolutionized the way that I treat diastasis patients, local stabilization, and men and pediatric populations.

What motivated you to earn PRPC?
I am doing more speaking engagements to other medical providers and am doing a lot of mentorship. Being in these roles, I feel having credentials to back the clinical experience is really valuable.

What makes you the most proud to have earned PRPC?
I took the exam without studying, largely because I wanted to see if my skills and knowledge was antiquated (being I have been doing pelvic floor therapy x 14 years). I found the test to be really fun and challenging in an exciting way. The case studies were true examples of the complex patients we treat and so I enjoyed the process.

What advice would you give to physical therapists interested in earning PRPC?
My advice would be to really do some great critical reasoning around your current patients. We learn best by our patients and doing a practice of critically thinking and differential diagnosis around your current patients will give a platform for this. I recalled treating several patients during the examination and could picture very similar patient presentations. The other piece I would recommend is reviewing your anatomy and pharmacology.

What is in store for you in the future?
I am continually blessed to be able to lead a wonderful team of therapists at our outpatient private practice. We are launching a labor and delivery program and post-partum evaluations. Educating the medical community at large has been a focus of mine and I would like to continue to do so to get the word out about pelvic floor PT. I have been asked to speak at the United Nations next Spring and will be presenting about Pelvic Floor in relation to Motherhood Maternity. Mentorship to pelvic floor therapists and students also continues to be a focus.

What role do you see pelvic health playing in general well-being?
I strongly feel pelvic health therapists could play a role in every orthopedic patient’s care. We have so many tools to really evaluate patients from a full body spectrum and have the ability to address any lumbopelvic condition with true depth. Having this vital information about their bodies can really empower all individuals to return to what they love to do in an active healthy lifestyle!

“Please stress the need to examine men…For some reason, most female PT`s shy away from a male’s private parts totally. It would be great if females were taught that it's important to go there…And treat us as equals in this arena.”

This is an excerpt from a recent email we received at Herman & Wallace headquarters, and it highlights a common theme, that of patient access to care. While there are many factors driving patient access to pelvic health, availability of therapists trained in various conditions is certainly one major issue. By the time any patient is referred to pelvic rehabilitation, they have already overcome the challenge of many providers not being aware that there is help for pelvic health issues, and insurance or payment hurdles that can also cause a patient to delay or avoid recommended treatment. Many physical therapy programs have done an outstanding job in developing and marketing women’s health programs, with men’s health programs addressing post-prostatectomy care or male pelvic pain coming along almost as an afterthought.

So what is really limiting the care of men who wish to overcome urinary, pain, or sexual dysfunction? For many locations around the country, there simply is not enough awareness of the scope of pelvic rehab, the nearest pelvic rehab provider may be far away geographically (or have a months-long waiting list), or the clinic may limit pelvic healthcare to women. If the clinic chooses to only provide care to women, what are we being discriminating about? The word “discriminate” has at least two rather distinct definitions, one that is more negative, and meaning that we are acting in an unjust or prejudicial manner, and another that simply means we are recognizing a difference between patient groups. If we choose to discriminate against treating men in a pelvic health setting, it’s easy to understand that if a therapist has never been instructed in how to examine a male patient, it may be prudent to avoid such evaluation until training is completed. We can find examples of this situation in other aspects of clinical care: if I have never taken proper training in evaluation of the vestibular system, for example (a condition that historically has not always been comprehensively instructed in school), then it’s in my best interest (and that of the patient) to only provide such care once I have taken appropriate training.

If our care of male pelvic health conditions is due to lack of specific training, what is our professional responsibility for acquiring training in conditions such as post-prostatectomy urinary incontinence, male genital pain, or erectile dysfunction? If we are to serve the pelvic health populations well, our training should progress to include lifespan issues for all ages and all genders. If we actively choose to avoid treating a population or condition, is that fair to the community seeking care? The ethics of choosing not to treat patients of a particular gender or condition are interesting to consider, but are not the scope of this post. On the other hand, the business side of being able to market to and welcome male patients in our clinics is very positive, and of course, all of our patients tend to be grateful for what we offer.

If you are interested in learning more about male pelvic healthcare, the Institute has several courses that can help you do so. These courses include an introduction to men at the Pelvic Floor Level 2A course, the Male Pelvic Floor: Function, Dysfunction and Treatment course (3 days dedicated to evaluation and treatment of urinary, sexual, and pain dysfunction), the Post-Prostatectomy course, as well as several manual therapy courses such as our myofascial courses. It is understandable that pelvic health for men may be less familiar territory for many of us based on our graduate training and experiences. If fear or discomfort is holding us back, at least attending a training course can help provide strategies and tools for gaining more comfort in treating men. We are at an exciting time in the pelvic health field when treating men is gaining more ground. If you are not already, join this exciting movement by signing up for one of the many classes available to you!