Treating patients who have chronic pelvic pain is challenging for many reasons. The nature of chronic pain in any body site often means that the patient has a multifactorial presentation that requires a team approach to interventions. And because the pelvis also contains the termination of several body systems such as the urologic, reproductive, and gastrointestinal, there exists potential for addressing a musculoskeletal issue that is masking a medical issue which requires intervention by a medical provider. The phrase "When you have a hammer, everything looks like a nail" can be applied to patient care for any discipline. When a patient presents with chronic pelvic pain, pelvic rehabilitation therapists can usually find tender pelvic muscles to treat. Is the pelvic muscle tenderness from guarding due to visceral pain or infection?

In a 2013 article in the journal General Practitioner, Dr Croton describes red flag symptoms in acute pelvic pain. These include pregnancy, pelvic or testicular masses, and vaginal bleeding and/or pain in postmenopausal women. During the history taking, patients can be asked about menstrual patterns, possibility of pregnancy, and sexual history. Further medical evaluation may include a pregnancy test, ultrasound, laparoscopy, and urine tests to rule out infection. While the above is not an exhaustive list, it reminds the pelvic rehabilitation provider to always keep in mind the potential for medical evaluation and intervention. Once a patient has been deemed to have "only chronic pelvic pain," a new, equally challenging list emerges: is the pain generated by an articular issue, myofascial dysfunction, neuropathy, psychological stress, or postural pattern? Is the pain local, such as in the pubis symphysis or in the sacroiliac joint ligaments, or are the symptoms referred from a nearby structure, such as the abdominal wall or the thoracolumbar junction? And what are the best methods to examine in a systematic way the various theories about the origins of a patient's pain?

Peter Philip has created a course to provide answers to the above questions. He combines skills in both orthopedics and manual therapy, and pulls from an extensive knowledge about pelvic pain and differential diagnosis which was the research topic of his Doctor of Science degree. Peter's course provides clearly instructed techniques in anatomical palpation, spinal and joint assessment, and he also instructs in how the nervous system and cognition can impact a patient's perception of pain. The course will be offered at the end of this month in Seattle- don't miss this chance to refine skills in differential diagnosis for chronic pelvic pain!

Concepts in "core" strengthening have been discussed ubiquitously, and clearly there is value in being accurate with a clinical treatment strategy, both for reasons of avoiding worsening of a dysfunctional movement or condition, and for engaging the patient in an appropriate rehabilitation activity. Because each patient presents with a unique clinical challenge, we do not (and may never) have reliable clinical protocols for trunk and pelvic rehabilitation. Rather, reliance upon excellent clinical reasoning skills combined with examination and evaluation, then intervention skills will remain paramount in providing valuable therapeutic approaches.

Even (and especially) for the therapist who is not interested in learning how to assess the pelvic floor muscles internally for purposes of diagnosis and treatment, how can an "external" approach to patient care be optimized to understand how the pelvic floor plays a role in core rehabilitation, and when does the patient need to be examined by a therapist who can provide internal examination and treatment if deemed necessary? There are many valuable continuing education pathways to address these questions, including courses offered by the Herman & Wallace Institute that instruct in concepts focusing on neuromotor coordination and learning based in clinical research.

One article that helps us understand how the trunk can be affected by the pelvic floor was completed in 2002 by Critchley and describes how, in the quadruped position, activation of the pelvic floor muscles increased thickness in the transversus abdominis muscles. Subjects were instructed in a low abdominal hallowing maneuver while the transversus abdominis, obliquus internus, and obliquus externus muscle thickness was measured by ultrasound. While no significant changes were noted in obliques muscle thickness, transversus abdominis average measures increases from 49.71% to 65.81% when pelvic floor muscle contraction was added to the abdominal hollowing. Clinical research such as this helps us to understand how verbal cues and concurrent muscle activation may affect exercise prescription.

A collection of clinical research concepts such as the article by Critchley is valuable in connecting points of function and dysfunction for patients with trunk and pelvic conditions- a large part of many clinicians' caseloads. The Pelvic Floor Pelvic Girdle continuing education course instructs in foundational research concepts that tie together the orthopedic connections to the pelvic floor including lumbopelvic stability and mobility therapeutic exercises. Common conditions such as coccyx pain and other pelvic floor dysfunctions are instructed along with pelvic floor screening, use of surface EMG biofeedback, and risk factors for pelvic dysfunction. If you would like to pull together concepts in lumbopelvic stability with your current internal pelvic muscle skills, OR if you would like to attend this course to learn external approaches, you can sign up for the class that takes place in late September in Atlanta.

Lumbopelvic pain is a common diagnosis in pregnancy that can be challenging for both the patient and the provider. A recent study assessed the effectiveness of 10 weeks of Hatha yoga in women between 12-32 weeks of gestation. 60 pregnant women ages 14-40 were divided into two groups, with the intervention group being guided in yoga exercises, and the control group instructed in postural activities. Nine pregnant women in the yoga group and six women in the control group were lost to withdrawal, obstetric complications, or refusal to participate. Excluded were women with twin pregnancies, medical restrictions, women using analgesics or those participating in physical therapy. Outcomes included a Visual Analog Scale (VAS) to measure pain intensity, and tests of lumbar and posterior pelvic pain. Lumbar provocation tests used in the study included trunk flexion and circumduction, paraspinal muscle palpation, and pelvic tests included the posterior pelvic pain provocation test.

Yoga intervention included weekly one hour sessions including 34 poses. The sessions focused on, in this order, breathing and joint warm-ups (10 minutes), poses and breathing exercises (40 minutes), and meditation and relaxation (10 minutes.) Pain intensity was assessed at the beginning and end of each session. Control group participants were instructed in typical postural changes during pregnancy as well as suggested postural support for various positions.

Results of the research include lower pain scores in the yoga group, with the authors concluding that yoga is an effective intervention for women who have pelvic girdle pain in pregnancy. A final VAS score of no pain, or "0" was reported in 71% of the yoga group and in 21% of the control group. The women in this study also reported emotional benefits of tranquility, lowered stress, "an easy mind," mental balance, and increased sense of closeness to the baby. While the lumbar provocation tests improved in both groups in response to intervention, pelvic girdle provocation tests remained positive in both groups at conclusion of the study even in those who had lowered pain scores.

This brings up interesting questions about the nature of the causative factors for the patient's pain. Also of interest is that in the control, or "postural orientation" group, lumbar provocation tests were improved even when reports of pain were not noted. You can discuss this research and more at the upcoming Yoga for Pelvic Pain course taking place in California in March with Dustienne Miller, yoga therapist and physical therapist.

Throughout the Guidelines on Chronic Pelvic Pain created by the European Association of Urology, the recognition of anxiety and depression as a concomitant symptom of chronic pelvic pain is made. Various types of pelvic dysfunctions have been demonstrated to have an association with anxiety and depression, including urethral pain, chronic pelvic pain, anorectal disorders, and sexual dysfunction. While a first line of medical treatment for patients who complain of neuropathic pain type, according to the Guidelines, is the prescribing of antidepressants, there are other interventions identified in the literature for alleviating anxiety and stress related to chronic pain. One of the studied interventions for pain, anxiety, and stress is yoga.

In a systematic review and meta-analysis for yoga and low back pain (which is also a common comorbidity of pelvic pain) yoga was found to have "…strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness…" and the study concludes that yoga can be recommended for patients who have chronic low back pain. In this review of ten randomized controlled trials including 967 subjects with chronic low back pain, no serious adverse events were reported. A report in the journal Alternative Medicine Review states that yoga, which may be considered an adjunct therapy for stress and anxiety, is supported by good compliance among patient populations and a lack of drug interactions. The same study states that better research is needed before strongly recommending yoga for the specific purposes of reducing anxiety and stress. The current research is plagued with common statistical challenges: lack of a control group, variations in studied physiological markers, lack of validated scales, and heterogenous study populations.

For the pelvic rehabilitation provider, having a working knowledge of common yoga terminology and postures can assist in modification or adaptation of a patient's current routine. In addition, learning to apply yoga concepts and postures such as breathing, trunk and pelvic coordination, soft tissue lengthening within a patient's comfort can add to a pelvic rehab provider's toolbox. There is room for you to join Dustienne Miller, physical therapist and yoga instructor, in California at the Yoga for Pelvic Pain course. Contact the Pelvic Rehabilitation Institute if you have any questions about this continuing education course.

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy C. Sanderson, PT, OCS, PPRC.

Describe your clinical practice.:

I am a co-owner of a private physical therapy practice in the Spokane, Washington area. We currently have 3 clinics and staff 14 providers overall. I have been an Orthopaedic Certified Specialist since 1996, and our clinic is primarily an orthopedic setting. We do, however, provide several specialties, including Pelvic Rehab, Vestibular Program, and Video Gait Analysis for athletes.

How did you get involved in the pelvic rehabilitation field?

I have been practicing since 1993 and began a Women’s Health program in 1994 at a previous place of employment. When I had interviewed for the position of a staff physical therapist for this clinic, I was asked if I would be interested in starting any new programs for the company. The manager had recommended that I develop a Women’s Health program. Truthfully, I had not heard of Women’s Health in the early 90’s, but I really wanted the job, so I said “absolutely!” I figured that I was a woman and I knew some things about health, so how hard could it be. Countless hours of continuing education and several years of marketing to the local physicians and community, we have now built our Pelvic Rehab program up to 3 physical therapists providing treatment to all of our clinics in the Spokane, Washington area.

What patient population do you find the most rewarding in treating and why?

I have enjoyed the patients who are experiencing sexual pain disorders for the past 15 years and have found this to be the most rewarding. Several times, I have been contacted after the birth of children to be told how grateful the couple has been to achieve such a life experience. Most recently, I received an email from a patient whom I had not seen in 3 years because she wanted to let me know that she and her husband were finally able to achieve intercourse after several years of counseling and my help with physical therapy. It is extremely gratifying to know that we can make a difference in peoples’ lives.

What motivated you to earn PRPC?

I have been practicing for greater than 20 years, including treating patients with all types of pelvic conditions, and after so many years, I wanted to challenge myself to see if truly what I was doing as a practitioner was effective, appropriate, and up to date. I decided that reviewing my education, seeking further education, and testing would be an effective way to do so. I felt that as I was preparing for this exam, I was able to realize that my treatment techniques are effective and appropriate. I am extremely grateful to the Herman & Wallace Pelvic Rehabilitation Institute for providing such great instructors to teach these skills.

Learn more about Amy C. Sanderson, PT, OCS, PPRC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

A recent on-line survey queried fourty-four Obstetrician-Gynecologists (OB-GYNs) in British Columbia to learn more about the needs of physicians who treat women who have endometriosis and chronic pelvic pain (CPP). Physicians reported that women who present with endometroisis or chronic pelvic pain usually require more visits than other patients, for reasons including medical and pain management, lack of a clear diagnosis, and lack of improvement in condition. Evaluation techniques utilized by the physicians often included laparoscopy and ultrasound, and despite these practices, the OB-GYNS reported challenges in making a diagnosis or successfully treating their patients with CPP. In fact, survey results indicated that 5% of the respondents were able to diagnose a patient for a cause of pelvic pain in > 70% of patients. Most of the physicians reported that less than half of the women treated had a good response to interventions. Although the highest rate of referral for these providers was to another OB-GYN specializing in pelvic pain, nearly 60% of the time a referral to physical therapy was reported.

Although some of the narrative comments encountered in this survey were positive, including one physician's report of having "…good success with physiotherapy…", more often the providers expressed frustration and annoyance when faced with not only the challenges of diagnosis and treatment, but also the poor compensation and the longer visits required for counseling and teaching of patients. In addition to wanting more clear guidelines on diagnosis and management of female CPP, physicians expressed interest in having group educational sessions for patients, and more resources such as educational brochures on self-management for patients.

How can pelvic rehabilitation providers fill in this knowledge gap? I recall asking a referring provider if he was pleased with his patients' rehabilitation outcomes, and he expressed such a relief that I was taking the "dregs of the practice." He meant nothing disparaging about the patients themselves, he explained, just that when these patients walked in the door he felt a sinking feeling because he did not know what to do for them. Now, he reported, these same patients were returning from a pelvic rehabilitation referral and excitedly reporting on progress they had made. So many physicians and other referring providers still do not understand the scope of the patient populations that we can treat in pelvic rehabilitation. We can provide a necessary bridge between the challenge of diagnosing and medically treating chronic pelvic pain and the rehabilitation approach that addresses the chronic pain issues. Differential diagnosis of chronic pelvic pain from a rehabilitation standpoint is a skill set that every therapist must continually improve upon. If you are interested in learning more about these skills, sign up for faculty member Peter Philip's continuing education course Differential Diagnostics of Chronic Pelvic Pain next month in Connecticut.

Herman & Wallace Pelvic Rehabilitation Institute would like to express thanks to the following therapists who participated in the development of our new certification, the Pelvic Rehabilitation Provider Certification, or PRPC. There were many stages of development in the rigorous process required to create a certification. Expertise was needed to provide input about examination content, format, and scope. Item writers were needed to create the 450 items needed for our test bank. Teams of reviewers volunteered time to revise items prior to the first exam offering, and raters spent many hours in team web conferences following the exam so that a cut score could be created.

Each of the following therapists contributed in some way to this process, and we are grateful for their time and expertise. (If I have forgotten to list anyone, let me know- we want to give credit where credit is due!) The PRPC is the only certification available that recognizes pelvic rehabilitation providers treating men and women across the lifespan. Congratulations to the first group of PRPC!

Dustienne Miller

Allison Ariail

Peter Philip

Karen Vande Vegte

Elizabeth Hampton

Lila Abbate

Holly Tanner

Nari Clemons

Heather Rader

Deanna Dreier

Joyce Steele

Michelle Lyons

Susannah Haarmann

Christine Cabelka

Brandi Kirk

Sagira Vora

Teri Elliott-Burke

Holly Herman

Pamela Downey

Genne DeHenau-McDonald

Tina Tyndall

Rachel Kilgore

Tina Allen

Kristina VanNiel

Megan Kranenburg

Rachel Brandt

As therapists are increasingly immersed in understanding of mechanisms of chronic pain and central nervous system phenomena, a question persists: what should we do with the peripheral tissues? As is usual in discussions that can take an either/or approach, the answer may lie somewhere in the middle. A recent article discussing myofascial trigger points (TrP) discusses the hypotheses surrounding this phenomena as a peripheral versus central mechanism. In a very well-cited summary of the issue, the authors come to some very helpful conclusions that you may find useful in your clinical practice.

If a trigger point, by definition, is a hyperirritable spot in a taut band of skeletal muscle that may or not have referred pain, what then, is driving the soft tissue dysfunction? Some authors argue that the peripheral nervous system is at fault, while others point to the central nervous system as the driver. Peripherally, nociceptive input may sensitize dorsal horn neurons. Centrally, patients who have chronic pain will have larger areas of pain, described as being a result of higher central neural plasticity. This is a controversial topic, and the authors are quick to point out that experimental evidence is "sparse." While there is support in the literature for peripheral trigger points creating central sensitization, the article states that "…preliminary evidence suggests that central sensitization can also promote TrP activity."

While this study does an excellent job describing various clinical and experimental research, hypotheses, and strength of evidence to support the hypotheses, the summary points are that trigger points may be both a central and peripheral phenomena, and that chronicity of the condition may drive the focus of rehabilitation efforts. Specifically, the authors state that when a patient presents with peripheral sensitization, treatment should be directed towards inactivation of the trigger point, mobilizing joints and nerves, and functional activity. Patients who present with persistent pain may require more attention directed to the central system utilizing a multidisciplinary approach such as medications, medical and physical therapy management, and psychological therapy. Fear, anxiety, and the neuroscience approach to pain should be addressed.

These issues are discussed throughout many the Institute's courses, but if you hope to get an earful about connective tissue and chronic pain research AND add tools to your toolbox, Institute faculty member Ramona Horton offers Myofascial Release for Pelvic Dysfunction. Join Ramona in June in Ohio, the last chance to take the course in 2014!

How the concepts of stigma and taboos affect bowel function is the focus of a recent article by Chelvanayagam, a lecturer in mental health in England. The author establishes that previously taboo subjects are becoming less hidden in the media, such as sexual function or urinary incontinence, but that in the UK, bowel function is still considered taboo. When people are not given language and social permission to discuss health concerns, conditions go underreported or unrecognized and under treated.

The author points out that patients with bowel dysfunction such as irritable bowel disease, fecal incontinence, and stomas feel stigmatized and are hesitant to discuss concerns with heath care providers or loved ones. The social implications of bowel disorders can lead to socially isolating behaviors including difficulty going out to eat, participating in physical activities, or taking sick leave from work.

Because pelvic rehabilitation providers discuss intimate issues including bowel function with patients, communication skills are very important in order to allow the patient to feel comfortable about the topic. Both verbal and non-verbal techniques will be observed and responded to by the patient. Various stigma-reducing strategies are described in the article. At the interpersonal level, cognitive-behavioral and empowerment strategies are recommended, and at the community level, education and advocacy are listed. Each of these strategies are ones that the pelvic rehabilitation provider is capable of providing.

If you have been wanting to learn more about bowel dysfunction and pelvic rehabilitation, the Institute added to our offeringsa bowel course that is next offered in June in Minneapolis, and November in Los Angeles area.

As I looked through this post by an accomplished yoga instructor on the "Top 10 Yoga Postures for Strength," I tried to look at the words and images through the eyes of our typical patients. The chosen postures made the list as they contained foundational "alignment and strength needed to master many more advanced postures." While this may be true for some, I can easily imagine the trouble that most of my patients would find by attempting to cruise through the demonstrated techniques. With jump backs, headstands, handstands, and one arm side planks, there is little caution made about hyper extensibility, about "gripping" postures as Diane Lee explains so well, or about compensatory patterns that can cause strain or injury.

The yoga instructor is not to be blamed- any magazine, blog post, or website that sells fitness or wellness attempts to package information to the public in attractive and efficient methods. An impressively toned, graceful, and high-level yoga practitioner is perfect for such a marketing goal. Unfortunately, any person reading an instructor's guide to finding your physical strength does not have said instructor giving the required feedback about joint position, compensations, and necessary modifications or starting postures.

Patients everywhere espouse the benefits of a yoga practice, and we all have likely met someone whose life was drastically changed for the better after finding yoga. Can yoga also be the cause of an injury? I recall entering a new yoga class at a gym (where the instructor had created a "guru" type following) and I was horrified at the instructor's lack of restraint in guiding a room of 70 or more students through very advanced poses that they were simply expected to push themselves through. The students wore their suffering like a badge, telling each other to "stick it out" as they would keep getting stronger. The instructor then approached me and, without knowing anything about me or my body, twisted me aggressively into a posture that I quickly unraveled as soon as she moved away. As if students cannot find enough ways to push the body outside of a comfort zone, having an instructor violate basic safety principles (was I returning to yoga after a spinal surgery?) adds to the potential for injury.

In a systematic review of adverse events associated with yoga, Cramer, Krucoff & Dobos describe musculoskeletal injuries such as fractures, ligament tears, joint injuries, disc annular tears, and several cases related to breathing techniques. Headstands were a common method for acquiring a yoga-related injury. The authors suggest that for patients who have physical or mental ailments, yoga can be adapted to a patient's "…needs and abilities and performed under the guidance of an experienced and medically trained yoga teacher."

While yoga does not need to be discouraged, we may need to consider the patient's abilities and challenges, and be familiar with our community resources prior to suggesting that a patient begin yoga. If you are more interested in advancing your own practice and in learning how to apply yoga principles and postures to your patient populations, the Institute has several means to accomplish this. For patients who have pelvic pain, Dustienne Miller will teach Yoga for Pelvic Pain in March, where you can learn how to tailor specific yoga techniques for specific patient presentations and conditions. You can also check out Ginger Garner's live and on-line yoga courses by clicking here (scroll down to Yoga as Medicine).