Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI joins the Herman & Wallace faculty with her new course on Restorative Yoga for Physical Therapists, which is launching in remote format this June 6-7, 2020. Kate brings over 15 years of teaching movement experience to her physical therapy practice with specialities in Pilates and yoga with a focus on alignment and embodiment. Kate’s pilates background was unusual as it followed a multi-lineage price apprenticeship model that included study of complementary movement methodologies such as the Franklin Method, Feldenkrais and Gyrotonics®. Building on her Pilates teaching experience, Kate began an in depth study of yoga, training with renown teachers of the vinyasa and Iyengar traditions. She held a private practice teaching movement prior to transitioning into physical therapy and relocating to Seattle.

Yoga is a common term in our current society. We can find it in a variety of settings from dedicated studios, gyms, inside corporations, online, on Zoom, at home, and on retreat. The basic structure of a typical yoga class is a number of flowing or non flowing postures, some requiring balance, some requiring going upside down, and many requiring significant mobility to achieve a certain shape. At the end of these classes is a pose called savasana, corpse pose (or sometimes translated for comfort as final resting pose). In this pose, which is often a treat for students after working through class, students lie on the ground, eyes closed, possibly supported by props, and rest. It is perhaps the only other time in the day when that person is instructed to lie on the floor in between sleep cycles.

Savasana is one of many restorative yoga postures. In the work created and popularized by Judith Hanson Lasater, PT, PhD¹, restorative yoga has taken a turn away from the active physical postures, breath manipulations and meditations that are commonplace in how we think of yoga. She has focused on rest and the need for rest in our current climate of productivity, poor self-care, and difficulty managing stress and pain.

In a dedicated restorative yoga class (not a fusion of exercise then rest, or stretch then rest… which are really lovely and have their own benefits), a student comes to class, gathers a number of props, and is instructed through 3 to 5 postures, all held for long durations to complete an hour or longer class. Consider what it would look like to do 3 things over one hour with the intent of resting. It is quite counter-culture. Students have various experiences to this type of practice, but overtime many begin to feel the need for rest (or restorative practice) in a similar way that one feels thirsty or hungry.

We know the benefits of rest: being able to access the ventral vagal aspect of the parasympathetic nervous system is what Dr. Stephen Porges² suggests supports health, growth and restoration. There is impact on the ventral vagal complex in the brainstem that regulates the heart, the muscles of the face and head, as well as the tone of the airway. To heal, we need access this pathway. To manage stress, we need to access this pathway. To be able to choose our actions rather than be reactionary, we need to access this pathway. Restorative yoga is an accessible method that may be a new tool in a patient’s tool box to help manage their nervous systems.

1. Relax and Renew: Restful Yoga for Stressful Times by Judith Hanson Lasater PT, PhD
2. Polyvagal Theory by Stephen W Porges PhD

Herman & Wallace is excited to announce an upcoming course on pelvic rehab for the gender diverse patient, written and instructed by Dr. Laura Meihofer, DPT, ATC. As Dr. Meihofer indicated in a recent blog, "[t]he number of individuals who identify as transgender is growing each year. The Williams Institute estimated in 2016 that 0.6% of the U.S. population or roughly 1.4 million people identified as transgender (Flores, 2016)... With the rise of individuals who identify as transgender, gender non-binary and intersex, healthcare professionals have equally seen an influx of patients who require care throughout their discovery and transition."

The new course from Dr. Meihofer is called "Gender Diversity and Pelvic Health: Comprehensive Care for Transgender Men and Women", and it will be debuting on May 29-31, 2020 in Livingston, NJ.

Dr. Meihofer was kind enough to share some thoughts about the new course, her practice, and herself with The Pelvic Rehab Report. Thank you, Laura!

Tell us about yourself, Laura!
My name is Laura Meihofer and I’ve been a physical therapist for 7 years. I work at Mayo Clinic and I see patients throughout the gender spectrum who most commonly struggle with pelvic floor dysfunctions relating to overactive muscles such as: chronic and acute pelvic pain, urinary frequency/urgency/incontinence/hesitancy, constipation, pain with intercourse, low back and hip pain.

What can you tell us about your new course, "Gender Diversity and Pelvic Health"?

Currently there are roughly 1.25 million transgender identified individuals in the United States and this number is growing. This course will help to dispel the idea of “other” when treating this demographic and demonstrate how much sameness there is when treating pelvic floor dysfunction.

These skills will greatly benefit any practice as this population is so underserved, they are looking for allies that are not just nice but competent. When you are able to successfully treat gender diverse patients, they spread the word about the great care they received and you now have a strong referral base. Taking this course opens up a whole new referral base of amazing people.

This course will not only feature videos from thought leaders in the field but will also highlight testimonials from patients and caregivers who have undergone their own gender transitions.

What essential skills does your course add to a practitioner’s toolkit?
I think the most important technique that attendees will learn will be how to assess a trans women and trans man after they have undergoing genital reconstruction surgery. Attendees will gain competence in the care of the gender diverse patient at any stage during their gender transition.

What was your inspiration to create this course for trans-identified patients?
Working at a major medical institution, I found that it was difficult finding providers in a patient’s area that were competent in care of a transgender patient. As I talked more and more with various physical therapists I realized they were thirsty for knowledge on how to serve these individuals. So I created the course!

What prepared you to create this course?
The most important thing I have done for this course is treat hundreds of patients who are trans identified throughout their gender journey. This allowed me to not only see all the medical interventions they went through but also to hear their personal journey of transition. These experiences expanded my empathy for what they go through and inspired me to search within myself on how I can be better for them. This desire to improve opened a creative well inside of me from which this course grew.

Discuss the effect conditions covered in your course have on a patient’s quality of life, your experience treating patients with this condition, and how their quality of life has increase after successful treatment.
Individuals who identify as transgender suffer from pelvic floor dysfunction just like our cis gender folks. There is no current data to capture the prevalence of pelvic floor issues in this specific population to date, however there is research to support the overall lack of care these individuals receive. Based on the results from the U.S. Transgender Survey which surveyed 28,000 respondents, the numbers in the health care field were staggering.

33% of respondents had at LEAST one negative experience with a health care provider in the last year due to being transgender. Negative experiences were qualified as verbal harassment, refusal of treatment or having to teach the health care provider about transgender people to receive appropriate care. 23% of respondents did not see a doctor when they needed to due to fear of being mistreated as a transgender person.

This course aims has two primary aims:
1) Educate providers on the unique concerns that transgender individuals experience related to hormone replacement and surgical techniques.
2) Equip attendees to provide competent care for this demographic

Join Dr. Meihofer for Gender Diversity and Pelvic Health this May 29-31, 2020 in Livingston, NJ!

Earlier this year, Herman & Wallace sponsored the first ever pelvic rehab course for physios in Nairobi, Kenya in partnership with The Jackson Clinics Foundation. After returning from that course, Kathy Golic, PT spent months writing a new course, adapting information from Pelvic Floor Level 1, Level 2A, and the Pregnancy and Postpartum series. This October, Kathy (along with co-instructors Casie Danenhauer and Sherine Aubert) returned to teach her follow-up course that expanded on the first module, introducing lectures and labs tailored to the community of pelvic physios in Kenya. This dispatch comes from instructor Kathy Golic, PT, who sent in this article shortly after returning from the course. Huge thanks to Kathy and her colleagues Sherine Aubert and Casie Danenhauer for doing this important work!

It has been a week now, and as I type looking out on the windy rainy day, it is hard to believe that I was so recently in a warm, sheltered classroom sequestered from the hustle and bustle of Nairobi. A place which has captured my heart. Really it is the people, especially my new “sisters” who I spent so much time with during this last two-week course module. Once again, I experienced chill bumps every day from witnessing the growth, the stories, the wisdom and the compassion of these bright, motivated, committed physiotherapists who came back for the 2nd module in our series to help them become experts in the field of Pelvic Health. This module covered topics of Pregnancy, Postpartum care, Prolapse, Colorectal Conditions including fecal incontinence and constipation, and Coccydynia. We had a terrific printed course manual for this 2nd in the series, thanks to the partnership of Herman and Wallace and Jackson Clinics Foundation. With my wonderful and resourceful, skilled colleagues from LA, Casie Danenhaur, and Sherine Aubert, we included comprehensive lectures, lively demonstrations, hands on creative experiential learning opportunities, and awesome supervised lab training sessions. We also had a lot of case study discussions, and live case studies where we assisted the students, who are practicing physiotherapists, in conducting thorough assessments and clinical reasoning processes to treat and make plans to further the progress of their patients.

All of this in itself was incredibly rewarding. But there was more. The power of sacrifice we witnessed. The power of solidarity and true generosity. Most of these women continued to have to work after class even while in this two-week module; in class from 8-4, but then going on their way, some of them through heavy Nairobi traffic, to treat patients in their offices, or to work hospital shifts. One student heading out after a Wed. afternoon class told me that she was going to work from 7- midnight, then would sleep until 4am, then back to work until 7 am, before returning to class at 8 am. She also had to miss one class to participate in her mentorship for her ortho advanced diploma, so had to make up a test with us the next day. (she aced the test!) Now for the generosity. I will share just 1 of many stories. One of the physios asked a patient of hers whom she felt she could use some help with, if she would mind traveling to the KMTC classroom where we were teaching so the other students could learn, while we the visiting instructors, would help guide in her assessment and care. This woman agreed, and got up at 3:30 am, traveled by bus for 3 hours to come for her treatment. She willingly shared her story, and it was tough to hear. She worked as a vegetable vendor carrying produce on her back, lifting it, and sitting on a stone for hours each day. She, a mother of 5 grown children with an unemployed husband. Her physio and the class did quite well in their assessment and with treatment and suggestions. She seemed pleased. Then as she prepared to leave, some of the physio students “passed the hat” and collected 7,000 kshillings (about $70.00) and presented this humble lady with the money so that she could afford transportation home. It is my understanding that most Kenyans spend 50% of their income on food, so sharing with this patient was a true sacrifice. But for these ladies, there was no question about it. This is how they live and how they work. They are themselves so grateful for the knowledge, skills and experience that they are getting through this program, and they will pay it backwards and forwards. My colleagues this time and last time, are also indebted to them for all they have taught us. It is truly an honor and privilege to be part of this great program, and I too am thankful for all the team players in this venture.

Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has just joined the Herman & Wallace faculty and co-authored the new course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.
Aparna was kind enough to introduce herself to us here on The Pelvic Rehab Report.

Thank you for your time Aparna! To start, tell us a little bit about yourself.
My name is Aparna. I’ve been a physical therapist for 22 years. About 16 years ago I switched focus from orthopedics to treating pregnancy and postpartum patients and that’s where my initial interest in pelvic care started. In 2006 following my pregnancy and birth of my daughter, my interest in pelvic care grew with my special interest becoming pelvic pain.

I teach and mentor the pelvic health therapists within the fairly large hospital system that I work at and collaborate with our spine center team and our sports team.

What can you tell us about this new breathing course that is not mentioned in the “course description” and “objectives” that are posted online?
Physical therapy has evolved and continues to evolve as we speak. Regional inter dependence, wherein the different systems interplay, and one structure influences another, is fascinating. No longer is the body considered and treated as independent fragmented pieces. The ‘core’ with the contribution of the Diaphragm and the pelvic floor is so much more than just the Transverse Abdominis and the Multifidus working together. Fascial restrictions of the lower abdomen and the pelvis can influence how the low back feels, thoracic stiffness can influence the interplay between the various abdominal muscles by way on their insertion into the lower ribs, musculo- skeletal pain and postural deviations can stem from incorrect breathing patterns etc.

Normal breathing rate is about 10 times every minute. Breathing incorrectly reinforces wrong movement patterns tens of thousand times a day with negative consequences on the musculoskeletal system.

This course offers an in depth look at the diaphragm from the perspective of both orthopedic and pelvic therapists and attempts to tie in the diaphragm to the thoracic spine, the ribs, the pelvic floor, the core, posture and finally the athlete.

What essential skills does the breath course add to a practitioner’s toolkit?
The practitioner will walk away with the ability to view the patient as a “whole”. It offers a different perspective on neck and back pain, posture/ alignment along with the ability to assess for and connect breathing and the diaphragm to stability/ the core, continence issues and the Autonomic Nervous System.

As therapists we already do a great job of addressing strength issues, assessing and correcting posture, mobilizing etc. You can add to your treatment options by learning how the diaphragm works in concert with other muscles (especially the abdominals) and systems, identifying breathing pattern dysfunctions and postures, and movement patterns which may be linked to breathing pattern dysfunctions. This understanding is beneficial for both orthopedic and pelvic patients.

What inspired you to create this course? What void does this new offering fill?
I have used breathing and evaluation of the diaphragm as a part of pelvic care for several years now. As the mentor for the pelvic program at my hospital, and as a part of the spine team and sports team, I work with pelvic therapists, orthopedic therapists, manual certified therapists, and sports certified therapists. Through my interactions I have come to realize that although many of the therapists are aware that the Diaphragm and breathing are important, they are unsure of how to assess for dysfunctions and address those dysfunctions. I initially started conducting classes within the hospital system. At the same time Leeann who is a sports certified therapist and holds a manual therapy certificate and I started collaborating on our patients. Using a combination of her knowledge and effective manual techniques with my pelvic care and breathing techniques we realized that along with my pelvic patients; our back and neck patients, and her sports patients were all benefitting from this combined approach. We realized along the way that we had information worth sharing with our colleagues that would benefit them in treating their patients, and started classes within the hospital system and that is how this class was born!

What was your process like creating this course?
As a trained pelvic therapist, I have incorporated and used breath and the diaphragm in my treatment for over a decade. Leeann and I have created this course using a combination of our clinical experiences, our education in our respective chosen paths of patient care, and most importantly using recent and relevant research articles from journals to guide us extensively in creating this course.

Breathing and the Diaphragm: Pelvic and Orthopedic Therapists is a new course being offered next March 27-29, 2020 in Sterling Heights, MI, and again on December 11-13, 2020 in Princeton, NJ. It is created and taught by Aparna Rajagopal, PT, MHS and Leeann Taptich, PT, DPT. Come learn how the diaphragm and breathing can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi component system that works together.

As more and more patients seek care for pelvic floor dysfunction, the need for more qualified practitioners is becoming apparent. Many patients prefer to see a clinician who they identify with, which is why it is important for practitioners of all genders to learn to treat pelvic floor dysfunction. Because much of the public's awareness of pelvic rehab comes out of women's health, the vast majority of pelvic health practitioners are women.

There is currently a shortage of male pelvic health practitioners. To help us understand why it is so important to fix that, we reached out to several male clinicians who have attended the Male Pelvic Floor: Function, Dysfunction, and Treatment course to ask them about the need for more men in the field. Here are some answers to the question:

“Why is it important to have male providers available to treat male patients in the field of pelvic health?”

Grant Headley of Bridgetown Physical Therapy of Portland, Oregon (www.bridgetownpt.com)
While as PT’s we all approach our patients with interest in helping them as individuals, some of our patients feel more comfortable sharing certain details with a provider of the same gender. Many of the hang-ups some men have about receiving care from a female provider are related to an older generation, to certain traditional or religious cultural beliefs, or to certain beliefs about propriety related to receiving care.

As acknowledged in our coursework, generally men have cultural barriers that traditionally do not permit sharing of vulnerability or weakness, especially in the sexual domain. Here are a few unsolicited statements I feel encapsulate what my own male patients have told me: Some heterosexual men feel more comfortable sharing the details of their dysfunction with a man because they find it difficult to admit vulnerability in the presence of a female. Some men prefer not to relay the clinically pertinent details of dysfunctional sexual encounters with a female because they do not wish to make the female practitioner uncomfortable. Many men feel that they can relay more detail about the mechanics of the sexual dysfunction or signs of improvement to a male provider. Some men have told me that they felt their sexual dysfunction was minimized or that they have been treated with patronizing language by a female pelvic PT in the past. Unfortunately, these patients attribute this negative experience to the PT being female, and they are not comfortable having a second opinion with a female.

Although we strive to present as open-minded and neutral to our patients, they may have an affinity for a male provider. This could foster a more constructive clinical partnership towards working on their goals if they perceive fewer communication barriers. I can offer my own experience as a past patient suffering with pelvic floor dysfunction; I was so desperate for help and I felt so grateful that there was a physical therapist in my city at all that was willing to help me. I did not care that she was female and that I had to receive treatment at a women's health clinic for new mothers in the University Hospital. Many female therapists reading this article have likely transferred lifesaving PT care to scores of men. This organization of H&W that does so much good for a sensitive aspect of men's care is dominated by women- this needs to be acknowledged as a net positive but also appreciated that much of the education and application of care is an adaptation from what has worked for women in the past. Many men will be so grateful to receive care and get better. Some men unfortunately will have barriers to receiving care and for those patients, we can seek out and encourage our male colleagues to get involved in pelvic rehab so we can all provide more access to care.

Lance Frank of Flex Physical Therapy in Atlanta (www.flexptatl.com)
Personally, as a male provider in pelvic health, I find that the men I treat are much more comfortable and at ease discussing topics like erections (or lack thereof) and sexual dysfunction, as well as incontinence, or pelvic pain. In a female dominated sub-specialty of physical therapy, sometimes as a male it can be intimidating and even embarrassing for some men to discuss these topics at all, let alone with a female; so having the option to speak and be treated by another male who may better understand the changes, anatomy, and problems they’re experiencing may feel a bit less daunting. Our culture has made male masculinity fragile and I think some populations of men who need pelvic floor rehab may feel embarrassed to be treated by a female clinician if their perception of being seen by a female is emasculating. Ultimately, I think there needs to be more men in this field because there needs to be better visibility of male pelvic health providers in general, as well as better representation of men acknowledging that male pelvic floor disorders exist and are willing and able to treat them.

Eddie Gordon of Flow Rehab in Seattle (www.flowrehab.com)
There are far fewer male physiotherapists treating men with pelvic floor dysfunctions, but I am hopeful this will change for the better. Lack of access to male pelvic physios is a relative barrier to care because some men are more comfortable seeing a male pelvic provider the same way most women would prefer seeing a female pelvic physio. In general, men do not typically seek treatment as frequently or early enough the way most women do. If male pelvic physios are not available, then men may more likely delay treatment, which could potentially worsen their problem. Ironically, when it comes to men with pelvic floor dysfunctions, men are underrepresented, but I am hopeful that more male PT’s will be joining the movement to educate the male population.

Milan Patel of Comprehensive Therapy Services in San Diego (comprehensivetherapy.com)
I believe it's important to have male providers in the pelvic health field for many reasons, one being the opportunity for connection. I think we connect best with reflections of ourselves and for men seeking out a pelvic health provider that can be hard to find. In my experience, pelvic physical therapy works best when your patient can be open and honest, and establishing a strong connection between therapist and patient is the first step. Another reason is that people should have options for the provider they want. In San Diego I am the only male pelvic physical therapy provider which means most men seeking pelvic floor therapy have no choice but to see a female. If you switched the genders in the last sentence you could see how that is problematic. Many women prefer to have their pelvic PT be a female, I just think guys should get the same choice.

Steven Lavender of The Physical Therapy Practice NYC in New York (thephysicaltherapypractice.nyc)
In my experience as a gay male practitioner practicing pelvic floor physio on only men:

Gay male patients usually prefer a gay provider because they feel like they don’t have to explain lifestyle issues and choices, they may be unused to being touched by women, and maybe misogynistic.

Some straight men have told me that they think a male practitioner would know more about their pelvic issues than a woman. Some men don’t think women are strong enough nor have long enough fingers to get to the places they need to be. Some straight men report they might be attracted to a female therapist and get an erection or feel embarrassed about appearing unmanly with their particular pelvic condition.

For some men being touched by a woman is a religious issue so many males of the Jewish and Muslim faiths prefer to see a male practitioner.

Some men could not care less who sees them as long as they get better.

One woman called me for advice or for an appointment from some distance because they "figured a gay man in New York City just might know more about my ass and ass pain than any local jack-assed doctor in my neck of the woods." True story.

If you are interested in learning to treat male patients, the Male Pelvic Floor: Function, Dysfunction, and Treatment course is a great place to start! The course is taking place twice more in 2019, this September 13-15, 2019 in Pasadena, CA, and again in Fort Myers, FL on October 19-21, 2019. We are already booked four times in 2020 as well, so be sure to check out the full course schedule for all available dates.

The number of individuals who identify as transgender is growing each year. The Williams Institute estimated in 2016 that 0.6% of the U.S. population or roughly 1.4 million people identified as transgender (Flores, 2016). This was a 50% increase from a 2011 survey which estimated only 0.3% or 700,000 people identified as transgender (Gates, 2011). Though these numbers are growing each year, due to increased visibility and social acceptance, it is presumed that these numbers are underreported due to inadequate survey methods, stigma/fear associated with “coming out” and deficient definitions of the multitude of options for gender identity (Flores, 2016).

With the rise of individuals who identify as transgender, gender non-binary and intersex, healthcare professionals have equally seen an influx of patients who require care throughout their discovery and transition. Though medical intervention for these individuals is not new, the first documented surgery was in 1922 to Dora Richter, it has often been segmented and lacking in evidence-based treatment strategies (“Dora Richter,”2019). In 1979 The World Professional Association for Transgender Health (WPATH) was founded and published their first version of the Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People (“WPATH,” 2019). Currently, WPATH is on their seventh version of the SOC which is opening doors for the treatment of this population.

Though organizations such as WPATH have attempted to standardized care, the patient experience and reception of quality care are significantly lacking. In 2015 the National Center for Transgender Equality performed a groundbreaking survey of 27,215 respondents with the aim to “understand the lives and experiences of transgender people in the United States and the disparities that many transgender people face” (“About,”n.d., para. 1). This survey revealed that 33% of individuals who saw a health care provider had at least one negative experience related to being transgender (National Center for Transgender Equality, 2015). Negative experiences included; being refused treatment, verbal harassment, physically or sexually assault, and teaching the provider about transgender people in order to get appropriate care (National Center for Transgender Equality, 2015). Alternatively, 23% of respondents did not see a doctor when they needed to because of fear of being mistreated as a transgender person (National Center for Transgender Equality, 2015). Though these statistics are staggering and affronting there is hope for a better future.

Research for the care of these patients, specifically related to pelvic floor physical therapy, is on the rise. In the Annals of Plastic Surgery, an article was published with the purpose to capture incidence and severity of pelvic floor dysfunction pre-surgery, monitor any progression of symptoms with standardized outcome measures and highlight the role of physical therapy in the treatment of patients undergoing vaginoplasty (Manrique, et al., 2019). While in the Journal of Obstetrics & Gynecology a retrospective case series similarly focused on physical therapy pre and post-operatively highlighting dilator selection and success, pelvic floor dysfunction including bowel and bladder as well as reported abuse history (Jiang, Gallagher, Burchill, Berli, & Dugi, 2019). Through articles such as these clinicians can expect an uptick in calls questioning if they treat these patients. This begs the question of, "How can you best prepare?"

The answer is simple, attend continuing education. It is where you can not only learn evidence-based evaluation and treatment but also connect with other providers and mentors that care for these patients. In 2020 Herman & Wallace will be offering a continuing education course that serves this exact purpose. Keep your eyes on next years offerings, as spaces will surely fill quickly.

About. (n.d.). Retrieved May 15, 2019, from http://www.ustranssurvey.org/about
Dora Richter. (2019, May 09). Retrieved May 15, 2019, from https://en.wikipedia.org/wiki/Dora_Richter
Jiang, D. D., Gallagher, S., Burchill, L., Berli, J., & Dugi, D. (2019). Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstetrics & Gynecology,133(5), 1003-1011. doi:10.1097/aog.0000000000003236
Manrique, O. J., Adabi, K., Huang, T. C., Jorge-Martinez, J., Meihofer, L. E., Brassard, P., & Galan, R. (2019). Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes. Annals of Plastic Surgery,82(6), 661-666. doi:10.1097/sap.0000000000001680
National Center for Transgender Equality. (2015). Annual report of the U.S. Transgender Survey. Retrieved May 15, 2019, from https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
Wpath. (n.d.). Standards of Care version 7. Retrieved May 15, 2019, from https://www.wpath.org/publications/soc

This post was written by the teaching team of Nancy Cullinane, PT, MSH, Kathy Golic, PT, and Terri Lannigan DPT, who took their talents to Nairobi, Kenya to teach a modified version of Herman & Wallace's Pelvic Floor Level 1 course.

At the end of week 1 of Kenyan Pelvic Floor Level 1, we are pleased to report that 35 physiotherapists are embracing pelvic health physical therapy. Our students are primarily from the Nairobi area, however a handful have traveled from rural areas. The majority of them have some aspect of women's health in their job duties, however, only two have previously performed internal pelvic floor muscle techniques. On the first day of class, we spent significant introductory time discussing course objectives, students' clinical experience, Kenyan healthcare delivery, and what they hoped to gain from us. One student described teaching herself skills she is using in her clinical practice from watching YouTube videos. Another student commented, "the only tool I have to treat my patients is the kegel exercise and it isn't working for many of my patients. I know I'm missing something and I hope to find it here." The concept of internal pelvic floor muscle evaluation and treatment is new in Kenya and this is the first presentation of this coursework. There was significant anxiety surrounding internal pelvic muscle examination lab in the course. Several participants were not aware what "internal examination" meant in the course description when they registered. One student did not return on day two because of it. Nonetheless, as soon as the first internal assessment lab was completed, the pace picked up considerably.

These pioneering physiotherapists have developed new skills this past week for treating overactive bladder, mixed urinary incontinence, overactive pelvic floor muscles, prolapse, and diastasis recti. We have delved into discussion regarding sexual trauma and how cultural differences here in Kenya will impact the students' potential strategies in initiating conversations with their patients. Nine of our students are employed at Kenyatta National Hospital, the largest public hospital in Nairobi. Several are employed in private hospitals, who serve those citizens who pay to receive care in their respective systems. Many of our students are under-employed and some see patients privately in their homes, often for cash.

We have additional Herman & Wallace Pelvic Floor Level 1 curriculum planned for week two, but we will also present the additional curriculum we have written specifically for these Kenyan physiotherapists. We will dedicate ample time toward connecting these motivated students with global mentoring resources, but we will also lay groundwork in helping them to set up a support network for pelvic health PT with each other.

We are honored and grateful to Herman & Wallace for donating Pelvic Floor Level 1 curriculum and to The Jackson Clinics Foundation for its history in changing physical therapy delivery in Kenya, including the financing of travel for this course. We are also thankful to Kenya Medical Training College for covering the cost of instructor lodging. At the half way mark of level 1, we feel we have already received so much more than we have given. We are especially grateful to the 35 course participants who will be changing the face of women's health physical therapy in Kenya from here on. Improving the quality of life for women improves the quality of life for families, and has an overall positive impact on the community.

The photography from this course is the creation of Marielle Selig, who acted as both technical support and official photographer for the Kenya Pelvic Floor Level 1 course. More of her work will be posted at https://mariselig.pixieset.com/.

This post is a follow-up to the February 20th post written by Nancy Cullinane, "Pelvic Floor One is Heading to Kenya" 

By the time folks are reading this, Nancy Cullinane, PT, MHS, WCS, Terri Lannigan, PT, DPT, OCS, and I will likely be in a warm, crowded classroom in Nairobi, Kenya helping 30+ “physios” navigate the world of misbehaving bladders, detailed anatomy description, and their first internal lab experiences. No doubt it will be both challenging and extremely rewarding. We are so grateful to the Herman & Wallace Pelvic Rehab Institute for sharing their curriculum in partnership with the Jackson Clinics Foundation to allow us to offer their valuable curriculum in order to affect positive health care changes.

I personally am humbled and honored to get to play a small but key role in the development of foundational knowledge and skills for these women PT’s who will no doubt change the lives of countless Kenyan women, and, consequently, their families.

My adventure truly began when I offered to write lectures on the topics of Fistula and FGM/C (female genital mutilation/cutting) and I began the process of crash course learning about these topics. The quest has taken me on a deep dive into professional journals, NGO websites, surgical procedure videos and insightful interviews with some of the pioneers working for years including “in the field” to help women in Africa and in countries where these issues are prevalent.

Before I began my research on the topic of fistula, I pretty much thought of a fistula as a hole between two structures in the body where it doesn’t belong, and narrowly thought of in terms of anal fistulas, acknowledging how lucky we are that there are skilled colorectal surgeons who can fix them. But after more research, my world view changed. (Operative word here being “world”).

A fistula is an abnormal or surgically made passage between a hollow or tubular organ and the body surface, or between two hollow or tubular organs. For our purposes here today, I am referring to an abnormal hole or passage between the vagina and the bladder, or rectum, or both. When the fistula forms, urine and/or stool passes through the vagina. The results are that the woman becomes incontinent and cannot control the leakage because the vagina is not designed to control these types of body fluids.

According to the Worldwide Fistula Fund, there are ~ 2 million women and girls suffering from fistulas. Estimates range from 30 to 100 thousand new cases developing each year; 3-5 cases/1000 pregnancies in low-income countries. A woman may suffer for 1-9 years before seeking treatment. For women who develop fistula in their first pregnancy, 70% end up with no living children. 

Vesicovaginal fistulas (VVF) can involve the bladder, ureters, urethra, and a small or large portion of the vaginal wall. Women with VVF will complain of constant urine leakage throughout the day and night, and because the bladder never fills enough to trigger the urge to void, they may stop using the toilet altogether. During the exam there may be pooling of urine in the vagina.

Rectovaginal Fistula is less common, and accounts for ~ 10% of the cases. Women with RVF complain of fecal incontinence and may report presence of stool in the vagina. These women often will also have VVF.

In Kenya, most fistulas are obstetric fistulas, which occur as a result of prolonged obstetric labor (POL). These are also called gynecologic, genital, or pelvic fistulas. Traumatic fistulas account for 17-24 % of the cases and are caused by rape, sexual or other trauma, and sometimes even from FGM/C. The other type of fistula by cause is iatrogenic, meaning unintentionally caused by a health care provider during procedures such as during a C-section, hysterectomy, or other pelvic surgery. Most fistulas seen in the US are of this type.

Prolonged Obstructed Labor most often occurs when the infant’s head descends into the pelvis, but cannot pass though because of cephalo-pelvic disproportion (mismatch between fetus head and mother’s pelvis) thus creating sustained pressure on the tissues separating the tissues of the vagina and bladder or rectum, (or both) leading to a lack of blood flow and ultimately to necrosis of the tissue, and the development of the fistula. Those who develop this type of fistula spend an average of 3.8 days in labor (start of uterine contractions), some up to a week. In these cases, family members or traditional birth attendants may not recognize this is occurring, and even if they do, they may not have the instrumentation, the facilities or the skills necessary to handle the situation with an instrumental delivery or a C-section. And many of these women are in remote locations without transportation to appropriate facilities or lack the money to pay for procedures.

There are many adverse events and medical consequences that can result as a result of untreated obstetrical fistulas including the death of the baby in 90% of the cases. Physical effects besides the incontinence previously mentioned can include lower extremity nerve damage, which can be disabling for these women, along with a host of other physical and systemic health issues. The social isolation, ostracization by community, divorce, and loss of employment can lead to depression, premature lifespan, and sometimes suicide.

The good news is there are several great organizations making a difference.

In most cases, surgery is needed to repair the fistula. Sometimes, however, if the fistula is identified very early, it may be treated by placing a catheter into the bladder and allowing the tissues to heal and close on their own, and this is more viable in high-income countries after iatrogenic fistulas, but unfortunately, most women in the low-income countries have to wait for months or years before they receive any medical care.

There is an 80-90% cure rate depending on the severity, but according to the Worldwide Fistula Fund, 90% are left untreated, as the treatment capacity is only around 15,000 per year for the 100,00 new patients requiring it. Prevention is vital.

Despite successful repair of vesicovaginal fistulas, research shows that 15-35% of women report post-op incontinence at the time of discharge from the hospital, and that 45-100% of women may become incontinent in the years following their repair. Studies suggest that scar tissue-fibrosis of the abdominal wall and pelvis, and vaginal stenosis are strongly associated with post-operative incontinence.

According to research by Castille, Y-J et al in Int. J Gynecology Obstet 2014, there can be improved outcome of surgery both in terms of successful closure of vesicovaginal fistula and reduced risk of persistent urinary incontinence if women are taught a correct pelvic floor muscle contraction and advised to practice PFM exercise. Other studies have shown a positive effect from pre and post op PT in both post op urinary incontinence and PFM strength and endurance with a reduction of incontinence in more than 70% of treated patients, with improvements maintained at the 1year follow up. SO, THIS IS ONE REASON WE ARE SO EXCITED TO BE GOING TO KENYA!

I inquired about the use of dilators via email communication with surgeon Rachel Pope , MD MPH who has done extensive work in Malawi with women who have suffered from fistula, including the use of dilators, and her response was: “in women who have had obstetric fistula the dilators seem only marginally helpful after standard fistula repairs. The key is to have a good vaginal reconstructive surgery where skin flaps that still maintain their blood supply replace the area in the vagina previously covered by scar tissue. The dilators work exceedingly well when there is healthy tissue in place, and I think the overall outcomes are better for women in those scenarios compared to the cement-like scar we often see in women with fistulas.”

In the US, there are specialist surgeons who provide surgical repairs. While genitourinary fistulas can occur because of obstructed labor and operative deliveries in high income countries, they can also occur in a variety of pelvic surgeries, post pelvic radiation, as well as in cases of cancer, infections, with stones, and as well etiology includes instrumentations such as D&Cs, catheters, endoscopic trauma, and pessaries, and as well in cases of foreign bodies, accidental trauma, and for congenital reasons. As pelvic therapists it is important to know your patients’ surgical and medical history and to pay special attention to the patient’s history regarding their incontinence description and onset and be mindful during exam to notice possible pooling of urine in the vagina. Though rare in terms of occurrence, we should be aware of the possibility and may play a role in referring the patient to a physician who can do further diagnostic testing

In conclusion, I want to thank UK physiotherapist Gill Brook MCSP (DSA) CSP MSC, president of the IOPTWH who shared with me by interview her knowledge of fistula and experiences with the Addis Ababa Fistula Hospital in Ethiopia, which she has been visiting for 10 years, as well as Seattle’s Dr. Julie LaCombe MD FACOG who has performed fistula surgeries in Uganda and Bangladesh and met with me personally to share about obstetrical trauma and fistula surgery and management.

Nancy, Terri and I will look forward to sharing photos and more about our journey and experiences, upon our return. In the meantime, check out the Campaign to End Fistula and join the campaign.

How does a male sports and orthopedic physical therapist come to teach about pelvic health and wellness? I was fortunate enough to spend ten years in the NHL as the physical therapist and athletic trainer for the Florida Panthers. Ice hockey is one of the sports that has the highest incidence of groin strains among other pelvic related pathologies.¹ As a clinician that was responsible for taking care of the world’s best hockey players, I was challenged to understand the interconnected relationships between the lumbopelvic-hip complex very quickly.

In the early years of my career development and the treatment of mostly males with pelvic pathologies, I leaned heavily on pelvic health professionals to help me understand an area of the body I received little training on in school and even less in my clinical care as a sports and orthopedic manual physical therapist. After years of treating hip and pelvic pathologies on my players I became more comfortable in this enigmatic area of the body. A good friend of mine was on faculty with Herman & Wallace and we frequently would communicate and compare notes. She was treating an increasing number of “sports hernias” (now termed athletic pubalgia or core muscle injury) and was relying on me to help her understand this injury and how to treat it. In turn, she helped me understand what went on in the pelvic health profession and what those therapists were trained to treat and how they went about it.

This collaboration eventually led to me joining Herman & Wallace and offering a sports and orthopedic perspective to pelvic floor consideration. I have attended Herman & Wallace’s Pelvic Floor courses to fully understand the training that a pelvic health therapist undergoes. Admittedly, I do not perform internal work because I have found a niche helping clinicians such as myself who understand that the pelvic floor is a key variable in human movement and we need to understand it at a much higher level than what we are exposed to in school, but don’t have the career trajectory of becoming an internal practitioner of the pelvic floor.

I have designed the Athletes and Pelvic Rehabilitation course to reach both the sports and orthopedic clinician as well as the pelvic health practitioner who might be a veteran of pelvic floor education and treatment. Both groups will leave this course with additional tools for their clinical tool box in the realms of manual therapy and exercise.² Here are some of the objectives for the course:

1. Provide clinicians that do not perform internal work a better and more complete understanding of how the pelvic floor integrates into human movement, particularly higher-level activities such as running, lifting and all types of sporting movements.
2. Provide both the experienced and pelvic floor early learner with a comprehensive paradigm of exercise theory, development and progressions as well as how to provide non-internal manual therapy to influence the performance of the pelvic floor.
3. Provide strategies for clinicians to determine when your patient would be better served with a referral to a pelvic health practitioner and what the current evidence is to support your decision.
4. Create innovative and engaging therapeutic exercise programs (home exercise programs too!) for your patients directed at the pelvis with specific attention to upright and functional positioning.

What do people who have attended courses with Dr. Dischiavi have to say? Janna wrote the following email to Herman & Wallace about Steve's Course:

"Good morning. I wanted to make sure that you knew what a fantastic clinician you have to join your team in Steve Dischiavi. I am a practicing OB and orthopedic therapist and felt this course was fantastic! Usually the main goal is to come away with a couple of clinical "pearls." I felt as though I came away with a full days worth of "pearls." I really liked that the course was not totally pelvic floor based, however was totally relevant to the women's health population, but it will also apply to the majority of my current patient population as well. Thank you for the opportunity to learn from Steve!"

1. Orchard JW. Men at higher risk of groin injuries in elite team sports: a systematic review. Br J Sports Med. 2015;49(12):798-802.
2. Tuttle L. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 2016;40(1):15-19.

In the spring of 2019, myself and two lab assistants will have the privilege of teaching PF1 to Kenyan physical therapists through the Kenya Medical Training College (KMTC) in Nairobi, Kenya. The program at KMTC started six years ago by Washington DC-based physical therapist Richard Jackson, and The Jackson Clinics Foundation (Teachandtreat.org), with a focus on orthopedic manual therapy. A neuro rehab program ensued two years later, and the aim for this women’s health program is to build a three level course series similar to the way it is taught in the United States. The goal of all of these programs is to transition them to Kenyan faculty within six years, which has recently occurred in the orthopedic component. Herman & Wallace Pelvic Rehab Institute has graciously agreed to donate curriculum content to the women’s health course component.

Teaching assistant Terri Lannigan, PT, DPT, OCS, who has taught the lumbopelvic girdle course in the orthopedic program, and also practices women’s health physical therapy in the US, began laying the groundwork for this program with her students and in the Nairobi community last December. “Not only is there a tremendous need, but there is a lot of excitement from a group of students currently taking courses in the program, that women’s health education is coming to KMTC!”

Over the past month, I have been editing the Pelvic Floor 1 course to tailor it to our Kenyan physical therapist audience. The overwhelming majority of Kenyan PT’s do not have access to biofeedback or electric stim, so those sections will be omitted. As there are no documentation or coding requirements in the Kenyan health system, those sections of curriculum will also be edited out. Many of Terri’s PT students complained of significant underemployment, so we will keep the marketing component in our lectures, in hopes to promote expansion of women’s health PT to a larger segment of the Kenyan population.

Meanwhile, teaching assistant Kathy Golic, PT of Overlake Hospital Medical Center’s Pelvic Health Program in Bellevue, WA has headed up the data collection for a lecture on managing fistula and obstetric trauma. Kathy has accumulated data from many sources and conferred with several PTs currently involved in both clinical education as well as direct patient care in multiple African nations, to help us to create relevant, meaningful and culturally appropriate curriculum for this section of the PF1 course.

Pelvic Floor Level 1 will be offered between March 25 – April 6, 2019 at Kenya Medical Training College. We will post photos and additional information of our class and our experiences. We are grateful to Herman and Wallace and The Jackson Clinics Foundation for allowing us to be involved in this exciting endeavor.