Running is a sport that spans a whole gamut of activity levels. Some runners run a mile or two casually every evening, some sprint competitively, and some runners train towards running marathons.

Female runners of all ages report urinary incontinence while running. The incontinence that is reported while running is not restricted to occurring while running at high speeds or long distances. There are runners who complain of leakage as soon as they start running, while there are others who leak mid-way into the run. Part of treating pelvic floor dysfunction in runners involves the ability to be able to tease out where the breakdown that is causing the dysfunction is occurring. Clinicians who treat pelvic dysfunction in runners have to be able to perform a running analysis to find the biomechanical faults that can contribute to the dysfunction that the runner is experiencing.

One common fault found during a running analysis is a pelvic hip drop on the stance leg, possibly indicating a weakness in the hip abductor muscles, specifically the gluteus medius.Hip abductor muscle weakness has been found to be a contributing factor in many running-related injuries, including iliotibial band syndrome, patellofemoral pain syndrome, stress fractures, and Achilles tendinopathy.(1) But, one can also link weakness in the hip abductors to increased pelvic floor dysfunction in runners

There are myofascial connections found through magnetic resonance imaging between the gluteal muscles and the levator ani and fossa ischioanalis. Multiple studies have found a significant correlation between weakness in the hip abductors, external rotators, stress urinary incontinence, and increased urinary urgency and frequency.(2,3)

Understanding the relationship between hip strength, biomechanics, and pelvic floor function is essential in supporting runners who experience urinary incontinence. By identifying and addressing underlying factors such as hip abductor weakness and faulty running mechanics, clinicians can help reduce leakage, improve overall running efficiency, and decrease risk of injury. With targeted assessment and treatment strategies, runners can return to the sport they love with greater confidence, strength, and pelvic health.

In the Running and Pelvic Health course taught by Aparna Rajagopal and Leeann Taptich, there will be instruction on how to perform a running analysis, how to assess for hip abductor weakness, and how to treat those findings to decrease pelvic floor dysfunction in runners. Please join us on November 1, 2025, for our next course.

Resources

1. Mucha MD, Caldwell W, Schlueter EL, Walters C, Hassen A. Hip abductor strength and lower extremity running-related injury in distance runners: A systematic review. Journal of Science and Medicine in Sport. 2017; 20: 349-355.
2. Marques SAA, da Silverira SRB, Passaro AC, Haddad JM, Baracat EC, Ferreira EAG. Effect of pelvic floor and hip muscle strengthening in the treatment of stress urinary incontinence: A randomized clinical trial. J Manipulative Physiol Ther. 2020; 43(3): 247-256.
3. Foster SN, Spitznagle TM, Tuttle LJ, Sutcliffe S, Steger-May K, Lowder JL, Meister MR, Ghetti C, Wang J, Mueller MJ, Harris-Hayes M. Hip, and pelvic floor muscle strength in women with and without urgency and frequency predominant lower urinary tract symptoms. J Womens Health Phys Therap. 2021; 45(3): 126-134.

AUTHOR BIO
Leeann Taptich DPT, SCS, MTC, CSCS

Leeann Taptich, DPT, SCS, MTC, CSCS (she/her) has been a physical therapist since 2006. She graduated with a BS in Kinesiology from Michigan State University and a Doctorate of Physical Therapy from the University of St Augustine. In 2009, she earned her Manual Therapy from the University is St Augustine and her board certification as a Sports Certified Specialist in 2018.

Leeann leads the Sports Physical Therapy team at Henry Ford Macomb Hospital in Michigan, where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital, which gives her a very unique perspective of the athlete. With her combination of credentials and her exposure to pelvic health, she is able to use a very eclectic but complete approach in her treatment of orthopedic and sports patients. With the hospital system, she is involved with the community promoting health and wellness at local running competitions and events.

Leeann is passionate about educating and teaching and has assisted in teaching multiple courses at the local State university PT department. She is co-chair of the continuing education committee at her hospital, where she writes and develops courses. She is co-author of the Breathing and Diaphragm class at Herman & Wallace.

Leeann lives in the metro Detroit area with her husband and two children. She enjoys hiking, traveling, and watching football.

Chronic pelvic pain often involves multiple intersecting systems - gynecologic, urologic, gastrointestinal, musculoskeletal, and neurological. An increasing body of research suggests diet may be an important, modifiable factor in many of these conditions.

Self-reported food sensitivities and dietary patterns are being explored in relation to symptoms like bladder pain, pelvic floor-related pain, vulvar pain, and bowel-related pelvic pain.

What the Research Shows
Recent studies and reviews are beginning to clarify how diet and food sensitivities relate to chronic pelvic pain. An umbrella review in 202 by Neri et al 5 found that a higher intake of vegetables and dairy products might reduce the risk and symptom severity of endometriosis.

Research on chronic primary pelvic pain syndromes (CPPPS), which includes interstitial cystitis/bladder pain syndrome (IC/BPS) and vulvodynia among others, emphasizes the multifactorial nature of these syndromes and suggests that diet may play a role, but the data are still inconclusive in many areas.

For IC/BPS, there are surveys and qualitative studies in which many patients report that certain foods or beverages (such as caffeine, acidic foods, alcohol, spicy foods) act as triggers. However, rigorous intervention trials (e.g., randomized controlled dietary interventions) are limited. The American Urological Association’s 2022 Guidelines do acknowledge dietary triggers in patient reports but do not prescribe specific elimination diets due to limited high-quality evidence.

In endometriosis, the umbrella review and some cohort studies suggest anti-inflammatory dietary patterns, increased fruit and vegetable intake, and possibly dairy consumption may correlate with lower pain or symptom burden. Yet the causal evidence (especially from randomized trials) remains sparse.

Regarding vulvodynia and vulvar pain, the research and literature is less developed. There are observational reports and case series that suggest some patients may benefit from dietary modifications, but strong clinical trials are nearly absent. Proteomics and biomarker studies in vulvar pain disorders are uncovering potential mechanisms, but do not yet conclusively link specific dietary interventions to symptom improvement.

Overlap with gastrointestinal disorders like IBS is well-documented among pelvic pain populations. When GI symptoms are prominent, interventions such as low-FODMAP diets have been shown in some studies (mostly observational or small trials) to reduce GI symptoms, which in turn may reduce pelvic floor complaints or pelvic pain by reducing visceral hypersensitivity or bowel dysfunction. However, even in this area, high-powered randomized controlled trials with pelvic pain outcomes as primary endpoints are limited.

From what is currently known, patient-reported dietary triggers are common across pelvic pain conditions, and many individuals report subjective improvement with dietary adjustments. The existing studies lend support to low-risk modifications, like avoiding known bladder irritants and adjusting diet when GI symptoms coexist. However, limitations include a lack of large randomized controlled trials with robust design comparing specific diets head-to-head for pelvic pain and heterogeneity in how pelvic pain conditions are defined & diagnosed. Some studies mix patients with different etiologies (bladder, bowel, muscular, nerve). Other issues are that comorbid conditions (IBS, fibromyalgia, psychological stress) are frequent and often not controlled for, and mechanistic data (microbiome changes, immune signaling, visceral cross-sensitization) are promising but mostly preliminary.

Mechanisms by Which Diet May Be Relevant
Several plausible biological and physiological pathways support the link between diet and chronic pelvic pain. Certain foods or substances may act as direct irritants to sensitive tissues like the bladder mucosa or vulvar skin/mucosa, which can cause burning, urgency, or pain flares.

Diet can influence the gut microbiota and the substances they produce, such as short-chain fatty acids and gases. These byproducts can affect intestinal permeability and alter systemic inflammatory or immune signaling, which in turn may modulate pain perception and contribute to sensitization. In some patients, non-IgE–mediated food intolerances or delayed hypersensitivity reactions to fermentable carbohydrates, additives, or specific food components may further drive these processes.

In addition, Viscerosomatic crosstalk provides another lens to understand diet’s impact on the pelvic floor. Dysfunction in organs such as the gut or bladder can send altered sensory signals to the nervous system, which in turn influences pelvic floor muscle tone, coordination, and reflex activity. This interplay means that gastrointestinal irritation from certain foods may not only trigger digestive discomfort but can also lead to changes in pelvic floor function. Over time, these altered neuromuscular responses may amplify pain through musculoskeletal pathways, creating a feedback loop that perpetuates both visceral and pelvic floor symptoms.

Practical Clinical Approach
Dietary sensitivity likely plays a role for many individuals with chronic pelvic pain, but the pattern is highly individual. As pelvic rehab providers, pelvic rehabilitation practitioners can support patients by validating concerns, initiating low-risk dietary trials, monitoring outcomes, and collaborating with dietitians for those cases that are more complex. When combined with pelvic floor rehabilitation and multimodal care, dietary approaches offer a promising route toward reducing pain and improving quality of life.

Given the current evidence, practitioners can use a patient-centered, low-risk approach to exploring diet’s role in pelvic pain.

1. Screen systematically. Collect detailed histories: what foods seem to trigger symptoms, timing (after meals, specific foods), associated GI symptoms, and any prior dietary experiments. Use food diaries or symptom trackers.
2. Identify red flags. Be alert for signs of serious pathology (e.g., GI bleeding, weight loss, malabsorption, celiac disease, severe allergies) and refer appropriately for medical evaluation or nutritional consultation.
3. Begin with simple diet trials. For example, remove or reduce common irritants (caffeine, alcohol, acidic or spicy foods), track symptoms over 2-6 weeks. If GI symptoms are present, consider a trial of low-FODMAP style elimination (with reintroduction phases) under dietitian supervision.
4. Elimination/rechallenge when indicated. If a patient reports a specific suspect (gluten, dairy, additive), a structured elimination followed by reintroduction can help confirm or rule out the trigger while minimizing unnecessary dietary restriction.
5. Promote anti-inflammatory whole-diet patterns. Emphasize vegetables, fruits, fiber (if tolerated), lean proteins, healthy fats, and minimally processed foods. Dietary patterns rather than single nutrients may be more achievable and sustainable.
6. Integrate other contributors. Diet doesn’t act in isolation. Combine dietary strategies with pelvic floor therapy, behavioral/pain education, sleep hygiene, psychological supports, and addressing comorbid conditions like IBS or mood disorders.

Exploring diet in the context of pelvic pain is not about chasing a single “trigger food,” but about understanding patterns, empowering patients, and integrating nutrition into a whole-person approach. By combining careful screening, individualized trials, and collaboration with nutrition professionals, pelvic rehab practitioners can help patients discover meaningful connections between food and symptoms—ultimately enhancing both symptom control and quality of life.

Learn More in Our Upcoming Course
If you'd like to deepen your understanding of nutrition’s role in pelvic pain and gain clinically actionable strategies, then register for Nutrition Perspectives for the Pelvic Rehab Therapist on either October 11–12, 2025, or December 5-6, 2025. This course is instructed by Megan Pribyl, PT, CMPT, CMTPT/DN, PCES, and covers the latest research, digestion basics, nutritional interventions for bowel/bladder dysfunction, pain, and healing, and includes immersive labs to help you apply what you learn in real clinical settings.

Additional dates in 2026 are available on the website.

References:

1. Neri LCL, Quintiero F, Fiorini S, Guglielmetti M, Ferraro OE, Tagliabue A, Gardella B, Ferraris C. Diet and Endometriosis: An Umbrella Review. 2025 Jun 13;14(12):2087. doi: 10.3390/foods14122087. PMID: 40565701; PMCID: PMC12192176
2. Pinto L, Soutinho M, Coutinho Fernandes M, et al. (December 01, 2024) Chronic Primary Pelvic Pain Syndromes in Women: A Comprehensive Review. Cureus 16(12): e74918. doi:10.7759/cureus.74918
3. Varney, J. E., So, D., Gibson, P. R., Rhys-Jones, D., Lee, Y. S. J., Fisher, J., Moore, J. S., Ratner, R., Morrison, M., & Burgell, R. E. (2025). Effect of a 28-day low FODMAP diet on gastrointestinal symptoms associated with endometriosis (EndoFOD): A randomised, controlled crossover feeding study. Alimentary Pharmacology & Therapeutics, 61(12), 1889-1903. https://doi.org/10.1111/apt.70161
4. Fehring, R. J., Schneider, M., Raviele, K. M., & Isaa, M. (2025). Dietary interventions in endometriosis: prospective study comparing low FODMAP diet and an “endometriosis diet.” [Details from the study]. Journal name, volume(issue), pages. (Note: This is “The effect of dietary interventions on pain and quality of life in women diagnosed with endometriosis: a prospective study with control group.”)
5. Jankovich, E., & Watkins, S. (2017). The low FODMAP diet reduced symptoms in a patient with endometriosis and IBS. South African Journal of Clinical Nutrition, 30(4), 32-36.
6. Drummond J, Ford D, Daniel S, Meyerink T. Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report. Integr Med (Encinitas). 2016 Aug;15(4):42-7. PMID: 27574494; PMCID: PMC4991650.

When Play Becomes Therapy - and Therapy Becomes Play
Pediatric pelvic floor therapy can sound intimidating to parents at first. They often imagine sterile clinics, complicated equipment, or uncomfortable exercises. But in reality, the best therapy for children often looks a lot like play. When we engage children in fun, creative, and developmentally appropriate activities, we not only help their bodies heal. We also help them gain confidence, resilience, and joy. Let’s dive into an example of a patient named “Alex.”

“Alex” is a 5-year-old who came to therapy with a history of chronic constipation, including hard, infrequent stools and painful bowel movements. Part of his assessment reveals that he has weak core strength, exhibited by his slouched posture, trouble sitting upright for long periods, and fatigue during physical play. His parents also describe “play aversion,” including avoidance of playground activities, reluctance to join peers, and resistance to movement-based games. His therapist determines that these issues didn’t just affect Alex’s health; they impacted his daily life. Alex’s family wanted their child to feel comfortable in his body, develop healthier bathroom habits, and learn to enjoy playing.

Step 1: Building a Sensory-Friendly Toilet Routine
For many children with constipation, the bathroom itself can feel overwhelming. Bright lights, cold seats, or long, uncomfortable waits can add to anxiety and resistance. For “Alex,” we started with sensory-friendly toilet sits. His family learned how to use a child-sized seat insert and footstool to support proper posture (knees slightly higher than hips, feet flat for stability). As a team, we talked with “Alex” about softening the bathroom environment with warm lighting, gentle music, or a favorite stuffed toy. In addition, we implemented keeping sessions short and predictable (e.g., sitting after breakfast for 2–3 minutes rather than forcing long waits). The focus of this stage was on making the bathroom feel safe and manageable, turning it into a place for success rather than stress.

Step 2: Motivation Through Playful Rewards
After talking with “Alex” and his parents, it was determined that he responded well to positive reinforcement in other home scenarios, so we created a sticker reward system for his pelvic floor routine. Each successful bathroom attempt earned “Alex” a sticker for their chart.

Accumulating stickers led to small, non-food rewards, such as extra story time, a favorite game, or a family activity. His parents were coached to keep rewards playful and encouraging, avoiding any hint of punishment or shame. This shifted the focus from “bathroom battles” to celebrating little wins. Over time, Alex began to approach toilet time with more confidence.

Step 3: Nutrition Meets Fun
Constipation often has dietary roots, but telling a 5-year-old to “eat more fiber” rarely works. Instead, we worked with the family to integrate preferred foods with fiber-rich options. We talked about what Alex liked about foods and eating and established a few ideas, including adding blueberries to Alex’s morning yogurt, mixing finely shredded carrots into favorite muffins, offering crunchy veggie straws alongside a sandwich, and greeting sing silly names like “super-poop power berries” to make healthy foods exciting. This helped the family gradually expand Alex’s diet while keeping mealtime fun. We also coordinated with a feeding therapist to ensure that food exploration remained safe and developmentally appropriate.

Step 4: Strengthening Core Through Play
One of Alex’s biggest barriers was weak core strength and all the symptoms that came with it. His parents described trying to perform traditional exercises felt like a punishment. Instead, we incorporated playful, functional movement. We created a therapy plan full of animal walks (bear crawls, crab walks, frog hops), obstacle courses with tunnels, balance beams, and climbing cushions, balloon volleyball to engage posture and coordination, and some yoga-style poses like “starfish stretch” or “superhero pose.” By getting creative with strengthening work as games, Alex gradually built endurance and stability without ever feeling like therapy was “work.”

Step 5: Parent Coaching Through Playful Routines
Parents play the biggest role in pediatric therapy success. We coached Alex’s caregivers to weave therapeutic play into daily routines. Their home program was intended to create a group bonding, playful experience, versus feeling forced or boring. This made therapy a natural part of life, not an extra burden.

Example of activities:

• Brushing teeth on one foot to sneak in balance training
• “Dance breaks” between TV shows or homework
• Storytime stretches (sitting crisscross on the floor while reading)
• Turning cleanup into a game (squats and reaches while picking up toys)

Step 6: Coordinating the Care Team
Finally, we worked with other professionals on Alex’s team. Pelvic floor therapists may need more players on the team than just the child and their parents. We included consultation with a feeding therapist who supported food variety and mealtime success. We coordinated with the child’s pediatrician, who monitored constipation and overall health. His teachers were also asked if they could incorporate movement breaks during school to support posture and core strength (which they reported benefited the whole class). In this case, when therapists, parents, and teachers collaborated, “Alex” was able to progress more quickly and successfully.

Results: Progress Through Play
Within a few months of this collaborative approach, Alex showed remarkable improvements, including more regular and less painful bowel movements, improved sitting posture in class and at meals, greater willingness to participate in play with peers, and reduced stress for the entire family around bathroom routines. Most importantly, Alex rediscovered the joy of moving their body in fun, functional ways. Therapy became a source of empowerment rather than resistance.

Key Takeaways for Parents and Providers

• Make it playful: kids learn best through fun, not force!
• Start small: short, predictable routines build trust and consistency.
• Celebrate wins: stickers and smiles go a long way in creating positive habits.
• Integrate therapy into daily life: little moments add up to big change.
• Collaborate: a team approach ensures the child gets well-rounded support

Pediatric pelvic floor therapy is not just about addressing bowel and bladder concerns; it’s about helping kids feel confident, capable, and playful in their own bodies. By blending functional exercises, sensory strategies, parent coaching, and team collaboration, we can transform challenges like constipation and play aversion into opportunities for growth.

And the best part? For children like Alex, therapy doesn’t feel like therapy at all. It feels like play.

If you would like to learn more about these strategies or bring Pediatric Pelvic Floor Play Skills into your clinical practice, check out the course at Herman & Wallace. Pediatric Pelvic Floor Play Skills is scheduled for November 1, 2025.

AUTHOR BIO
Mora Pluchino, PT, DPT, PRPC

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

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

Are you a clinician passionate about pelvic rehabilitation and ready to take your expertise to the next level? The Pelvic Rehabilitation Practitioner Certification (PRPC) from Herman & Wallace is designed to recognize advanced practitioners who provide comprehensive pelvic health care to patients of all genders and ages.

Whether you’re a physical therapist, occupational therapist, nurse, or physician, PRPC sets you apart as a leader in the field—backed by rigorous standards and national recognition.

🗓 Upcoming Exam Window: November 1–15, 2025

Application Deadline: October 1, 2025
👉 Apply Now

Why Earn the PRPC?

🌟 National Recognition
PRPC is a legally defensible, psychometrically validated certification that demonstrates your advanced knowledge and commitment to pelvic health.

📈 Professional Distinction
Add “PRPC” to your credentials—on your CV, resume, business cards, and professional materials—to highlight your specialization.

🤝 Patient & Employer Confidence
Show your dedication to delivering high-level, evidence-based care across the lifespan and gender spectrum.

Eligibility Requirements

To sit for the PRPC exam, candidates must:

• Have 2,000 hours of direct pelvic patient care in the past 8 years.
• Have completed 500 hours of pelvic patient care in the last 2 years.
• Hold an active license in one of the following professions:
  • PT, PTA, OT, RN, ARNP, MD, DO, DC, PA-C
• International applicants and those outside these professions may apply for special consideration.

Pelvic patient care includes treatment for:

• Pelvic pain
• Pelvic girdle dysfunction
• Bowel, bladder, and sexual dysfunction
• Conditions involving the abdomen, thoracolumbar spine, or lumbo-pelvic-hip complex
  Care may be provided to pediatric, adolescent, adult, and aged patients of any gender.
  

Exam Format & Content

• Computer-based, multiple-choice exam
• 150 questions covering 8 domains:
  • Anatomy (15%)
  • Physiology (20%)
  • Pathophysiology (20%)
  • Pharmacology (5%)
  • Medical Interventions & Tests (5%)
  • Tests & Measures (10%)
  • Interventions (20%)
  • Professional & Legal Requirements (5%)
• 25–30% of questions are case-based scenarios

Exam Preparation Tips

1. Review the Test Blueprint
Once approved to sit for the exam, you’ll receive a detailed blueprint outlining the knowledge and skill statements covered. Use this to guide your study plan.

2. Use Sample Questions
Download the PRPC Sample Questions PDF to familiarize yourself with the format and style of the exam.

3. Form a Study Group
Herman & Wallace connects interested applicants to form study groups. This collaborative approach helps reinforce learning and provides peer support.

4. Focus on Clinical Experience
Your hands-on experience is your greatest asset. The exam is designed to reflect real-world scenarios and clinical decision-making.

5. Fill Knowledge Gaps with Courses
While no specific courses are required, advanced coursework can help strengthen areas where you feel less confident.

What Practitioners Are Saying

“The PRPC has elevated my practice and given me the confidence to treat complex pelvic cases. It’s a mark of excellence that patients and colleagues recognize.”
— Amanda Olson, PT, DPT, PRPC

“Studying for the PRPC helped me deepen my understanding of pelvic health across the lifespan. It was rigorous, but incredibly rewarding.”
— Andrea Freeman, PT, DPT, PRPC

“Being part of the first cohort of PRPC-certified practitioners was an honor. It validated years of dedication to pelvic rehab.”
— Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC

Certification Validity & Renewal

• PRPC is valid for 10 years
• Renewal requires re-examination
• Special accommodations are available for test takers with disabilities

Ready to Stand Out?

Join the growing community of certified pelvic rehab practitioners. Demonstrate your expertise, elevate your career, and make a lasting impact in pelvic health.

👉 Submit your application today

Sexual dysfunction is often multifactorial, and while pelvic floor muscle impairments are a common contributor, dermatological conditions can also play a significant role. Two important but sometimes overlooked conditions, lichen sclerosus (LS) and lichen planus (LP), can dramatically affect sexual health, patient comfort, and overall quality of life.

For pelvic health providers, recognizing the symptoms and understanding when to refer is essential to providing comprehensive care.

What are Lichen Sclerosus and Lichen Planus?

• Lichen sclerosus (LS): A chronic, inflammatory skin condition that often affects the vulva or penis. LS can cause itching, burning, white patches of thin skin, and, over time, scarring may restrict function and contribute to painful intercourse.
• Lichen planus (LP): Another inflammatory condition that may affect skin, mucous membranes, and genital tissue. LP can cause redness, erosion, and pain that interfere with both daily activities and sexual function.

Both conditions are underdiagnosed, frequently misunderstood by patients and doctors, and often mistaken for recurrent infections or generalized pelvic pain.

Key Research Highlights

• High Prevalence of Sexual Dysfunction in LS
  • A systematic review and meta-analysis reported that nearly 60% of women with vulvar lichen sclerosus experience sexual dysfunction, with dyspareunia (pain during intercourse) being the most common issue (1).
• Impact on Quality of Life and Physical Activity
  • A cross-sectional study of 603 women with LS or LP found significant decreases in quality of life, overall health status, and physical activity, highlighting how genital dermatologic conditions can profoundly affect daily functioning and mobility (2).
• Sexual Distress in Genital Erosive Lichen Planus (GELP)
  • Research involving women with erosive genital LP showed high levels of sexual distress and reduced quality of life, with many participants scoring above thresholds that indicate serious impact on sexual well-being (3).
• Psychosexual Counseling Improves Outcomes
  • A randomized controlled trial found that combining psychosexual counseling with usual medical care led to significant improvements in sexual function and overall quality of life for women with LS, particularly in domains directly related to sexual well-being (4).
• Pelvic Floor Physical Therapy as a Supportive Strategy
  • According to a summary from a Pelvic Health PT blog, pelvic floor physical therapy, including techniques like myofascial release, soft tissue mobilization, clitoral hood mobilization, and breathwork, can alleviate dyspareunia and improve tissue mobility in individuals with LS (5).

The Pelvic Rehab Provider’s Role
Unrecognized dermatological conditions can prolong suffering, worsen pelvic pain, and contribute to psychological distress around sexual health. As part of a multidisciplinary team, pelvic rehab providers are instrumental in improving outcomes for patients with these complex conditions.

While pelvic health professionals do not diagnose dermatological conditions, they are often the first, or sometimes the only, clinicians who take the time to observe and inspect the vulva as part of a comprehensive evaluation. This makes the Q-tip test a critical component of the pelvic health exam. Through careful observation, we can identify tissue changes, localized pain responses, or dermatological conditions that may otherwise go unnoticed. Incorporating this exam allows us not only to guide treatment appropriately within the scope of pelvic rehabilitation but also to recognize when referral to gynecology, dermatology, or another specialist is necessary. This ensures patients receive timely and comprehensive care for conditions that directly impact pelvic health and quality of life. Common clinical presentations include:

• Patients report persistent pain, itching, burning in the vulva, and tearing (especially at the posterior fourchette) during sexual activity.

• Observation of skin changes in the perineal or vulvar region during external pelvic exams. This can present as waxy, shiny, thin, and similar appearance to vitiligo.
• Patients with pelvic pain who have not responded to traditional pelvic rehab approaches.

By identifying potential signs of LS or LP, PTs can facilitate timely referral to dermatology or gynecology/urology, ensuring patients receive the medical care they need. Once managed medically, pelvic rehabilitation can then help restore comfort, optimize pelvic floor function, and improve confidence in sexual activity.

Want to expand your skills in treating sexual dysfunction related to pelvic floor health?
Join us for Sexual Medicine in Pelvic Rehab, a remote course on September 27–28, 2025, where Tara Sullivan, PT, DPT, PRPC, WCS, IF will dive deep into evidence-based strategies for addressing sexual dysfunction, including conditions like lichen sclerosus and lichen planus.

Register today to enhance your clinical expertise and confidence in this essential area of practice.

References

1. Pope R, Lee MH, Myers A, Song J, Abou Ghayda R, Kim JY, Hong SH, Lee SB, Koyanagi A, Jacob L, Smith L, Shin JI. Lichen Sclerosus and Sexual Dysfunction: A Systematic Review and Meta-Analysis. J Sex Med. 2022 Nov;19(11):1616-1624. doi: 10.1016/j.jsxm.2022.07.011. Epub 2022 Sep 15. PMID: 36115787.
2. Dietz RJ, van de Berg NJ, van der Vegt AJ, van den Berg CB, van der Marel IC, van Wijk FH, Maliepaard M, van Beekhuizen HJ, van Doorn HC. Impact of vulvar lichen sclerosus and lichen planus on quality of life, mobility, bicycling, physical activity, and health. Maturitas. 2025 Aug;199:108651. doi: 10.1016/j.maturitas.2025.108651. Epub 2025 Jun 26. PMID: 40592218.
3. Skullerud, Kristin Helene MD1; Gjersvik, Petter MD, PhD2; Eberhard-Gran, Malin MD, PhD1; Pripp, Are Hugo PhD3; Qvigstad, Erik MD, PhD2; Vangen, Siri MD, PhD1; Helgesen, Anne Lise Ording MD, PhD4. Sexual Distress and Quality of Life in Women With Genital Erosive Lichen Planus—A Cross-sectional Study. Journal of Lower Genital Tract Disease 29(1):p 72-75, January 2025. | DOI: 10.1097/LGT.0000000000000847
4. Vittrup G, Westmark S, Riis J, Mørup L, Heilesen T, Jensen D, Melgaard D. The Impact of Psychosexual Counseling in Women With Lichen Sclerosus: A Randomized Controlled Trial. J Low Genit Tract Dis. 2022 Jul 1;26(3):258-264. doi: 10.1097/LGT.0000000000000669. Epub 2022 Mar 25. PMID: 35333024; PMCID: PMC9232275.
5. Dy, Debbie (2025, August 29). Lichen Sclerosus & Pelvic Floor Physical Therapy: How to Manage Symptoms & Improve Vulvar Health. Femina Physical Therapy. https://feminapt.com/blog/lichen-sclerosus-pelvic-floor-physical-therapy-how-to-manage-symptoms-improve-vulvar-health

We are excited to share that Allison Ariail, PT, DPT, CLT, BCB-PMD, PRPC, longtime faculty member and Content Developer, is stepping into the role of Director of Education at Herman & Wallace.

Allison has been teaching with H&W since 2011 and has played a major role in developing courses such as the Capstone, Oncology series, Anorectal Ballooning, and the Peripartum series. With 25 years of clinical experience and expertise in oncology, lymphedema, and rehabilitative ultrasound, she brings both depth and vision to this position.

This transition follows Holly Tanner’s decision to step away from the role after 15 years of leadership. Holly’s contributions include co-developing the PRPC certification, guiding new course and faculty development, and helping to steer H&W through the COVID pivot to online learning. Her impact has shaped the education of more than 30,000 therapists and we are deeply grateful for her dedication.

 Allison shares, “Working with Herman & Wallace these past 15 years has been one of the most satisfying aspects of my career. It is a privilege and honor to be Director of Education, and I look forward to meeting many more passionate pelvic floor practitioners and furthering the profession together.”

Please join us in celebrating Holly’s legacy and welcoming Allison to her new role!

Eating disorders affect 2–5% of individuals worldwide, with a higher prevalence among females (Attia & Walsh, 2025). These disorders carry significant medical and psychiatric complications, high outpatient care costs, impaired daily functioning, and reduced quality of life (Attia & Walsh, 2025; Almeida et al., 2024).

Types of Eating Disorders
Anorexia Nervosa (AN):
A persistent restriction of food intake leading to low body weight, intense fear of weight gain, and distorted body image. AN has two subtypes:

• Restrictive (AN-R) – primarily limited intake.
• Binge-Eating/Purging (AN-BP) – restriction combined with purging behaviors.

AN can result in severe medical complications and even be life-threatening (Moore & Bokor, 2023; Uniake et al., 2020).

Binge Eating Disorder (BED):
Recurrent episodes of consuming unusually large amounts of food (within 2 hours or less) with a sense of loss of control. Unlike bulimia, BED does not involve compensatory behaviors such as purging. Episodes often lead to shame, guilt, and distress (Berkman et al., 2015).

Bulimia Nervosa (BN):
Characterized by recurrent binge eating followed by compensatory behaviors like vomiting, laxative use, diuretics, fasting, or excessive exercise. These behaviors aim to prevent weight gain and carry serious health risks (Jain & Yilanli, 2023).

Other Specified Feeding and Eating Disorders (OSFED):
A category for individuals who don’t fully meet criteria for AN, BN, or BED but still experience significant symptoms. Examples include atypical anorexia, purging disorder, sub-threshold bulimia, sub-threshold BED, and night eating syndrome. OSFED, however, can cause symptoms that result in the same severity, health risks, and distress (Attia and Guarda 2024)

Avoidant/Restrictive Food Intake Disorder (ARFID):
Marked by apparent lack of interest in eating or food low appetite, extreme avoidance based on the sensory characteristics of food (such as texture, appearance, color, or smell), or fear of negative consequences of eating (fear of choking, nausea, vomiting, constipation, allergic reactions). ARFID can lead to nutritional deficiencies, weight loss, impairments of psychosocial functioning, impaired growth in children, and the need for supplements or tube feeding. It often begins in childhood but can present at any age (Ramirez & Gunturu, 2025).

Gastrointestinal Symptoms and Eating Disorders;
Gastrointestinal symptoms are common in those with eating disorders, often caused by malnutrition, anxiety, somatization, or pre-existing GI conditions. Common complaints include:

• Nausea
• Abdominal bloating and pain
• Early satiety and prolonged fullness
• Constipation and straining
• Pelvic organ prolapse symptoms
• Fecal incontinence (Gibson et al., 2021; Almeida et al., 2024)

A systematic review by Gibson et al. (2021) found that GI symptoms not only result from eating disorders but can also perpetuate disordered eating behaviors.

Multiple factors may contribute to the onset or perpetuation of the continuation of eating disorders or eating disorder behaviors. Medical conditions with GI predominant conditions also may contribute to eating disorders or disordered eating patterns (Gibson et al, 2021). These conditions can include:

• Celiac
• Irritable bowel disease
• Disorders of Gut-Brain Interaction (DGBI) - also called functional gastrointestinal disorders (FGID) in past literature (Almeida, 2024).
• Pelvic dysfunction
• Ehlers-Danlos Syndrome also may contribute to eating disorders or disordered eating patterns (Gibson et al, 2021).

DGBI / FGIDs include disturbances of the microbiome, hypersensitivity of gut viscera, altered processing of the brain and the enteric nervous system, and/or altered immune and mucosal function (Gibson et al. 2021). In addition, GI-related symptoms may also be a result of the physiological and medical complications to malnutrition (Gibson, 2021). The process of nutritional rehabilitation can cause severe GI distress as food is introduced in larger or more frequent amounts to an impaired GI system.

Interestingly, in the conclusions of Gibson et al’s systematic review, the authors recommended that additional research is necessary to “investigate those therapeutic modalities” to treat the FGID components, such as pharmacologic agents to treat GI pathophysiologic changes. Rehabilitation-based strategies should be considered a first-line approach with these individuals.

Building on this, Almeida et al. conducted a retrospective cohort study (2010–2020) of 344 individuals with eating disorders who sought gastrointestinal care. More than 75% had an eating disorder diagnosis prior to their GI consultation, with functional and motility disorders being the most common findings. The study suggested that eating disorders may contribute to gastrointestinal symptoms through their effects on the enteric, central, and autonomic nervous systems.

Additionally, weight loss and malnutrition can create pathological changes in gastrointestinal function, further worsening symptoms (Almeida et al., 2024). In this cohort, more than half of the participants were diagnosed with IBS, functional dyspepsia/gastroparesis, or constipation. While the pathophysiology of Disorders of Gut-Brain Interaction (DGBIs) is still being clarified, current evidence suggests that dietary restriction and compensatory behaviors such as purging are likely contributing factors (Almeida et al., 2024).

Why Pelvic Rehabilitation Matters
Pelvic rehabilitation professionals bring a unique skillset to this population:

• Enhancing quality of life by addressing pelvic floor and GI dysfunction.
• Recognizing warning signs of eating disorders in patients referred for GI or pelvic symptoms.
• Facilitating referrals to appropriate medical and mental health professionals.

While we do not diagnose eating disorders, pelvic health clinicians can play a pivotal role within a multidisciplinary treatment team by supporting patients physically, identifying red/yellow flags, and advocating for integrated care.

Learn More
Join me on October 4–5, 2025 for Eating Disorders and Pelvic Health Rehabilitation, a comprehensive course on eating disorders and pelvic health. Together, we’ll explore:

• Signs, symptoms, and medical complications of eating disorders.
• Multidisciplinary treatment strategies.
• Pelvic rehabilitation techniques to support individuals living with eating disorders.

Register today for Eating Disorders and Pelvic Health Rehabilitation to expand your skills and make a difference in this complex, underserved population

References

1. Almeida, M. N., Atkins, M., Garcia-Fischer, I., Weeks, I. E., Silvernale, C. J., Samad, A., Rao, F., Burton-Murray, H., & Staller, K. (2024). Gastrointestinal diagnoses in patients with eating disorders: A retrospective cohort study 2010-2020. Neurogastroenterology and motility, 36(6), e14782. https://doi.org/10.1111/nmo.14782
2. Attia, E., & Guarda, A. S. (2024). OSFED Subtypes: The Need for Better Definitions. The International journal of eating disorders, 57(10), 2053–2055. https://doi.org/10.1002/eat.24275
3. Attia, E., & Walsh, B. T. (2025). Eating Disorders: A Review. JAMA, 333(14), 1242–1252. https://doi.org/10.1001/jama.2025.0132
4. Berkman ND, Brownley KA, Peat CM, et al. Management and Outcomes of Binge-Eating Disorder [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015 Dec. (Comparative Effectiveness Reviews, No. 160.) Introduction. Available from: https://www.ncbi.nlm.nih.gov/books/NBK338301/
5. Jain A, Yilanli M. Bulimia Nervosa. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK562178/
6. Gibson, D., Watters, A., & Mehler, P. S. (2021). The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review. The International journal of eating disorders, 54(6), 1019–1054. https://doi.org/10.1002/eat.23553
7. Guarda A. (2023, February). What are eating disorders?org. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders
8. Moore CA, Bokor BR. Anorexia Nervosa. [Updated 2023 Aug 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK459148/
9. Ramirez Z, Gunturu S. Avoidant Restrictive Food Intake Disorder. [Updated 2024 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK603710/
10. Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.33, DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t33/
11. Uniacke, B., Slattery, R., Walsh, B. T., Shohamy, D., Foerde, K., & Steinglass, J. (2020). A comparison of food-based decision-making between restricting and binge-eating/purging subtypes of anorexia nervosa.The International journal of eating disorders, 53(10), 1751–1756. https://doi.org/10.1002/eat.23359

AUTHOR BIO
Carole High Gross PT, DPT, PRPC

Carole High Gross, PT, MS, DPT, PRPC earned her Doctorate of Physical Therapy from Arcadia University in 2015, and her Master of Science in Physical Therapy in 1992 from Thomas Jefferson University. Carole earned her Pelvic Rehabilitation Practitioner Certification and enjoys working as a Pelvic Clinical Rehabilitation Specialist for Lehigh Valley Health Network.

Carole serves as a Lead Teaching Assistant for the Herman & Wallace Pelvic Rehabilitation Institute for pelvic floor education courses. She is also an instructor with the Herman and Wallace Institute for Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole serves on the Pelvic Workgroup of the Ehlers-Danlos International Consortium. Carole has a special interest in working with individuals living with eating disorders and hypermobility throughout the pregnancy and postpartum journey. In addition, Carole enjoys working with all genders with pelvic, bowel, bladder, and abdominal issues. Carole is passionate about lifelong learning. She resides in Bucks County, Pennsylvania, and enjoys spending time with her family and pups.

How Did It All Get Started?
When I first began treating children with bowel and bladder issues, my focus was on the obvious physiological concerns: bedwetting, dysfunctional voiding, vesicoureteral reflux, constipation. Over time, though, I noticed consistent musculoskeletal patterns - children with increased thoracic extension, hyper lordosis a protruding abdomen, increased rib angles, and weak core stability.

It became clear that these pressure and postural issues were impacting their normal developmental patterns. That realization changed everything about how I approached treatment.

Why Did I Create This Course?
Not every therapist wants to specialize in pediatric bowel and bladder disorders. But every therapist who works with kids should be able to recognize the musculoskeletal consequences that often accompany these issues.

My goal in creating this course, Pediatric Pelvic Floor ,Diaphragm, and Postural Development, was to bridge the gap: to help therapists identify and treat the postural, respiratory, and core stability challenges these children face—without requiring them to become bowel and bladder experts.

The relationship goes both ways:

• Children with special needs or musculoskeletal asymmetries often have weak cores, postural compensation, and develop poor bowel and bladder habits.
• Children with unresolved bowel and bladder dysfunction often develop weak cores and abnormal movement patterns as a result.

A few examples stand out:

• A non-verbal child with spastic quadriplegia was experiencing up to 11 daily “episodes” and difficulty sleeping. Once his constipation was addressed, his episodes dropped to 1–3 per day, and he began sleeping through the night.
• Another child with low tone withheld stool out of fear and discomfort on the toilet, eventually developing fecal incontinence. What looked behavioral was truly physiologic, and once addressed, his core stability and pressure system improved significantly.

These cases remind me: sometimes we’re detectives. And when we get it right, families see life-changing results - often in a short time.

What’s In This Course?
As I dug deeper into these patterns, I followed fascinating paths of developmental physiology. I learned how the diaphragm, ribcage, and pelvic floor interact as a pressure system, shaping core stability, continence, and postural development. The puzzle pieces came together—and I began creating fun, pediatric-friendly exercises to target these issues with purpose.

In this course, you will:

• Gain understanding of the development of the diaphragm and pelvic floor muscles (PFM) as they relate to core function and continence in children.
• Learn how to connect the ribcage, diaphragm, and pelvic floor for proper core activation.
• Receive instruction in the anatomy and development of the diaphragm and its relationship to the pelvic floor/core.
• Focus on assessment and treatment and connection of the core, thoracic spine, ribcage, breathing, and PFM.

By the end, you’ll be equipped with practical strategies to recognize musculoskeletal consequences of pressure dysfunction and confidently address them, helping kids regain function, stability, and independence.

To learn more, sign up to attend the upcoming Pediatric Pelvic Floor, Diaphragm, and Postural Development scheduled for September 21, 2025.

AUTHOR BIO
Dawn Sandalcidi PT, RCMT, BCB-PMD

Dawn Sandalcidi is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. She graduated from SUNY Upstate Medical Center in 1982 and is actively seeing patients in her clinic Physical Therapy Specialists, Centennial CO.

Dawn is a national and international speaker in the field, and she has gained so much from sharing experiences with her colleagues around the globe. In addition to lecturing internationally on pediatric bowel and bladder disorders, Dawn is also a faculty instructor at the Herman & Wallace Pelvic Rehab Institute. Additionally, she runs an online teaching and mentoring platform for parents and professionals.

In 2017, Dawn was invited to speak at the World Physical Therapy Conference in South Africa about pediatric pelvic floor dysfunction and incontinence. Dawn is also Board-Certified Biofeedback in Pelvic Muscle Dysfunction (BCB-PMD). She has also been published in the Journals of Urologic Nursing and Section of Women’s Health.

In 2018, Dawn was awarded the Elizabeth Noble Award by the American Physical Therapy Association Section on Women's Health for providing Extraordinary and Exemplary Service to the Field of Physical Therapy for Children.

CPT code 97110 describes a therapeutic exercise procedure used in physical and occupational therapy to develop strength, endurance, range of motion, and flexibility for one or more body areas.

Herman & Wallace Senior Faculty member Pam Downey, PT, MSPT, DPT, WCS, BCB-PMD, PRPC, CSCS has been integrating Pilates into the treatment of pelvic floor and spine dysfunction for more than 20 years. She explains, “I use Pilates every day in practice to teach patients that movement is therapeutic and accessible—even for those who feel overwhelmed by their diagnosis.”

Pilates offers clinicians a unique lens for evaluating movement dysfunction. Because many patients are unfamiliar with Pilates, these exercises often reveal compensatory patterns that may be contributing to their symptoms. Dr. Downey highlights how equipment like the Reformer allows her to adapt spring tension - providing support when needed or adding challenge for patients further along in their rehab journey.

A Clinical Pearl from Dr. Downey
One of Dr. Downey’s go-to strategies involves using Pilates Footwork and Hamstring Arc strap work in the treatment of a short, tight pelvic floor.

Patients with restricted adductors, hip flexors, or hip rotators—often the result of prior injury or habitual postures - can inadvertently create excessive tension in the pelvic floor. When this is paired with dysfunctional breathing patterns (such as upper chest breathing), intra-abdominal pressure (IAP) regulation becomes compromised.

By integrating breathwork into supine strap exercises, patients experience both a sensory and motor connection to lengthening the pelvic floor. This helps them achieve the sought-after “drop” during volitional pelvic floor movement.

Dr. Downey reflects, “Patients really understand it once they feel their muscles stretch and release on the equipment. The best reward for me is when they return with improved movement patterns and reduced pelvic floor symptoms.”

Is This Course Right for You?
This Pilates-focused rehabilitation course may be a fit if you:

• Want to explore Pilates, but don’t know where to start. You’ll be introduced to the original 34 mat exercises and select Reformer activities, with an emphasis on safety and clinical application. This course is not a replacement for formal Pilates certification, but rather a way to build on your existing clinical expertise.
• Have strong pelvic health knowledge, but want patients to be more active in their care. Learn strategies to take patients beyond the treatment table and empower them through movement.
• Prefer hands-on, movement-rich learning. This course offers a lab-heavy format focusing on problem-solving within the lumbopelvic-hip complex. Even experienced Pilates practitioners will benefit from the discussion on integrating Pilates into pelvic health treatment.

By weaving Pilates into therapeutic exercise (CPT code 97110), clinicians can reclaim the therapeutic intent of movement - empowering patients with strategies that are safe, accessible, and transformative.

Ready to integrate Pilates into your pelvic health practice?
Join Pilates Therapeutic Exercise for Pelvic Health with Pamela Downey, PT, MSPT, DPT, WCS, BCB-PMD, PRPC, CSCS on September 20–21, 2025.

AUTHOR BIO
Pamela Downey, PT, MSPT, DPT, WCS, BCB-PMD, PRPC, CSCS

Pamela A. Downey is a Board-Certified Specialist in Pelvic Health Physical Therapy, Board-Certified in Biofeedback for Pelvic Muscle Dysfunction, and a Certified Pelvic Rehabilitation Practitioner. She has more than 25 years of experience treating individuals with pelvic pain, including neuralgias of the lumbosacral plexus, voiding and sexual dysfunction, pregnancy-related and post-partum musculoskeletal dysfunction, including diastasis recti, sacroiliac joint pain, and dyspareunia. She has extensive experience in applying Pilates therapeutic movement in physical therapy and pelvic health practice. Dr. Downey’s private practice, Partnership in Therapy, is located in Miami, FL, and welcomes all people from adolescents to octogenarians for personalized one-on-one care.

Dr. Downey is an adjunct professor in the Physical Therapy Program at the University of Miami Miller School of Medicine in Coral Gables, Florida. She received her Bachelor of Arts from Sarah Lawrence College and her Master of Science, Doctorate in Physical Therapy, and is ABD in her Doctor of Philosophy from the University of Miami Miller School of Medicine.

Dr. Downey has presented research and lectured nationally and internationally at professional conferences and has authored a book chapter on pelvic pain in the medical text Women’s Health Physical Therapy. She is actively involved in the Academy of Pelvic Health of the American Physical Therapy Association, a Polestar Pilates Rehabilitation Educator, and Senior Faculty in the Herman & Wallace Pelvic Rehabilitation Institute.

When you think of the physical shape of Downward Facing Dog, what comes to mind? Do you think of a long upside-down V with the heels touching the ground and knees straight? That might be the way the shape looks on some people, but for many folks, downward dog can take many different forms - all of which are still accomplishing the same energetic purpose of this inversion posture.

Using the language customizing instead of modifying might help some patients realize they are not “doing less” by not being able to comfortably attain the physical shape of what they think they should be able to do. In fact, it is an opportunity to be rewarded for listening to one’s inner wisdom about how the body wants to move in that particular moment. We are not robots, and our bodies’ energy and pliability can change greatly during the day and from week to week, especially for people experiencing hormonally influenced persistent pain.

From a clinical perspective, customization emphasizes patient empowerment. For example, patients with pelvic pain often present with increased muscle guarding in the pelvic floor, hips, or abdominals. Asking them to force their heels to the floor or straighten their knees in Downward Facing Dog can increase tension and exacerbate symptoms. Instead, inviting them to bend their knees, widen their stance, or elevate their hands on blocks or a chair creates a version of the pose that is supportive and therapeutic. This allows patients to access the benefits of the posture - inversion, elongation, breath awareness—without reinforcing pain patterns.

This shift in perspective also serves the nervous system. Persistent pelvic pain frequently involves central sensitization and heightened protective responses. When patients hear that creating the shape of a posture that serves them is not only allowed but encouraged, the perceived threat decreases, and there may be less fear-avoidance. Clinicians can use language such as, “Notice how your body feels with the knees bent,” or “Try widening your stance and see there is less neural tension.” These cues guide patients toward building interoceptive awareness, giving them tools for self-regulation that extend beyond the clinic.

Customization also highlights the principle that yoga is not one-size-fits-all. Each patient comes with a unique history - postpartum recovery, endometriosis, hip impingement, abdominal surgery, hypermobility, etc. The physical shape of a posture that is accessible for one person may be provocative for another. By offering variations and inviting exploration, clinicians can encourage self-efficacy and reduce fear-avoidance behaviors. This builds confidence in movement and often translates into improved participation in daily activities outside of therapy.

For rehab professionals, integrating yoga in this way reinforces biopsychosocial care. By blending mindful movement with therapeutic exercise, you can help patients reframe movement as safe, adaptable, and nourishing. Consider weaving in reflective questions during sessions: “How do you know this version feels better for you?” or “What would make this position feel even more supported?” These simple prompts deepen the patient’s awareness and reinforce the therapeutic alliance.

Ultimately, customizing yoga postures is not about diluting the practice but about making it clinically relevant. When patients learn that the value of a pose lies not in how closely it matches a picture in a yoga text but in how it supports their body and nervous system in that moment, the practice becomes inclusive and sustainable. For people with pelvic pain, this can be a turning point: shifting from frustration with limitations to curiosity, agency, and resilience in movement.

Clinician Takeaways: Customizing Yoga for Pelvic Pain

• Use empowering language: Swap out “modification” for “customization” to reduce stigma and emphasize patient agency.
• Prioritize nervous system safety: Encourage patients to notice what feels supportive rather than pushing into shapes that increase tension or pain.
• Offer accessible variations: For Downward Dog, consider bent knees, wide stance, hands on blocks, or using a wall/chair.
• Cue interoception: Ask reflective questions like, “What do you notice in your body?” or “Can you breathe with more ease here?”
• Honor individuality: Recognize that each patient’s pelvic health journey is unique; customize postures according to surgical history, musculoskeletal patterns, and pain triggers.
• Blend yoga with rehab principles: Use posture customization to reinforce body awareness, reduce fear-avoidance, and build resilience in movement.

Want to deepen your understanding of how yoga can support patients with pelvic pain? Join Yoga for Pelvic Pain with Dustienne Miller, PT, MS, WCS, CYT on September 13–14, 2025. This remote course offers practical, evidence-informed strategies to integrate yoga into pelvic health care. Register here.

AUTHOR BIO
Dustienne Miller MSPT, WCS, CYT

Dustienne Miller MSPT, WCS, CYT (she/her) is the creator of the two-day course, Yoga for Pelvic Pain, and an instructor for Pelvic Function Level 1. Born out of an interest in creating yoga home programs for her patients, she developed a pelvic health yoga video series called Your Pace Yoga in 2012. She is a contributing author in two books about the integration of pelvic health and yoga, Yoga Mama: The Practitioner’s Guide to Prenatal Yoga (Shambhala Publications, 2016) and Healing in Urology (World Scientific). Prior conference and workshop engagements include APTA's CSM, International Pelvic Pain Society, Woman on Fire, Wound Ostomy and Continence Society, and the American Academy of Physical Medicine and Rehabilitation Annual Assembly.

Her clinical practice, Flourish Physical Therapy, is located in Boston's Back Bay. She is a board-certified women's health clinical specialist recognized by the American Board of Physical Therapy Specialties. Dustienne weaves yoga, mindfulness, and breathwork into her clinical practice, having received her yoga teacher certification through the Kripalu Center for Yoga and Health in 2005.

Dustienne's love of movement carried over into her physical therapy and yoga practice, stemming from her previous career as a professional dancer. She danced professionally in New York City for several years, most notably with the national tour of Fosse. She bridged her dance and physical therapy backgrounds, working for Physioarts, who contracted her to work backstage at various Broadway shows and for Radio City Christmas Spectacular. She is currently an assistant professor of jazz dance at Boston Conservatory at Berklee.

Dustienne passionately believes in the integration of physical therapy and yoga within a holistic model of care. Her course aims to provide therapists and patients with an additional resource centered on supporting the nervous system and enhancing patient self-efficacy.