Since I started working with patients with osteoporosis or osteopenia almost 20 years ago, I've noticed an interesting phenomenon. Initially, most patients I saw were in their late 70s and 80s. But within the last 10 to 15 years, the age of my patient population has decreased. I begin receiving referrals for people in their 50s and 60s with osteopenia or osteoporosis after getting their first DEXA scan. Many were traumatized by the diagnosis. They were women who exercised regularly, ate healthily, and took responsibility for a positive lifestyle. It was almost as if they were experiencing PTSD. They were shocked, nervous, and questioning why it happened to them.

One of my first priorities in their care plan was to help calm or down-regulate their sympathetic nervous system. They were in a fight or flight state, and the cortisol running through their bodies was not kind to their bones. I educated them that the DEXA scan only measures bone density and not quality. Quality has come to the forefront as an important component of the lattice-like structures of our bones, yet we still don't have a good way to measure it. I wanted them to understand that the DEXA scan, although it is the gold standard, is only one piece of the puzzle. I used to say, “Let’s pretend your T score is exactly the same as another individual, but that individual is a couch potato who smokes, eats junk food, and basically follows an unhealthy lifestyle. Do you really think your risk of fracture is identical? I wanted them to feel that their actions had had a positive influence on their health, even with the diagnosis. And I truly believe that it does.

Following the evaluation, they started in the Decompression position, also known as hook-lying, and based on the work of Sara Meeks. We explored belly breathing, intercostal breathing, and found the neutral spine position. They were invited to completely relax, allowing the surface of the mat to support them. Not only did this help calm their sympathetic nervous system by activating their “rest and digest” parasympathetic nervous system, but it also placed them in a gravity-eliminated position. Sitting is compressive to the vertebral bodies and discs. Supine positioning allows the anterior aspect of the vertebral bodies (where most spinal compression fractures occur) to decompress. Thus, the name “Decompression position.”

This is the part of physical therapy where it sometimes feels we are doing more mental than physical therapy. But it is an important step. Educating patients is one of the greatest gifts that we can offer in rehabilitation. It not only helps them understand the diagnosis, it also empowers them. Many people with osteoporosis or osteopenia assume their only option is medication. While we certainly do not recommend one option over another, we do educate them that there are multiple ways to manage their disease. A few include site-specific exercises, body mechanics, stress management, and encouraging an educated discussion with their medical provider on the pros and cons of osteoporosis medications. These are steps they can take to feel they have control back in their lives.

From there, we gradually increase their challenges in terms of exercise, balance, and help them return safely to the life they deserve.

Osteoporosis Management: An Introductory Course for Healthcare Professionals provides tools to help your patients move forward with their chronic disease. We hope you'll join us on November 8th for this one-day seminar.

References:

1. Jia-Sheng Ng¹, Kok-Yong Chin. Potential mechanisms linking psychological stress to bone health. Int J Med Sci. 2021 Jan.

AUTHOR BIO
Deb Gulbrandson, PT, DPT, Balance and Falls Professional (Geriatrics Academy of the APTA)

Dr. Deb Gulbrandson has been a physical therapist for over 48 years, with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to businesses and industries. She owned a private practice for 27 years in the Chicago area, specializing in orthopedics and Pilates. She and her husband, Gil, a former certified orthotist, “semi-retired” to Evergreen. They teach Osteoporosis management to physical therapists around the country. Deb also works for Mt Evans Homecare and Hospice and sees private patients for physical therapy as well as Pilates clients in her home studio. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country-currently 46 out of 63.

Deb is a graduate of Indiana University with a BS in Physical Therapy and a former NCAA athlete, where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to be able to combine her skills as a PT and Pilates instructor. In 2011, she received her Doctorate in Physical Therapy from Evidence in Motion.

Dr. Gulbrandson frequently presents community talks on topics related to Osteoporosis and safe ways to develop Core Strength. She is a certified Pilates Instructor through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist using the Meeks Method, and has her CEEAA (Certified Exercise Expert for the Aging Adult) through the Geriatric Section of the APTA.

Cancer treatment, even when curative, often leaves a cascade of physiological consequences on the pelvic region. Pelvic rehabilitation clinicians are uniquely positioned to help survivors reclaim function, reduce symptoms, and improve quality of life.

Why Rehabilitation Matters in Oncology - Especially for Pelvic Practitioners
Before jumping into the how, it’s important to acknowledge the why. Pelvic morbidity following gynecologic cancers such as cervical, endometrial, vulvar, and ovarian malignancies is strikingly prevalent. Many survivors experience urinary symptoms, fecal dysfunction, dyspareunia, vaginal stenosis, and pelvic floor muscle hypertonicity. Studies have shown that lower urinary tract dysfunction can affect up to 70–85% of patients after cervical cancer surgery, and as many as two-thirds report sexual dysfunction (1). The causes of these complications are multifactorial and can stem from surgical disruption, radiation-induced fibrosis and vascular changes, chemotherapy side effects, nerve injury, hormonal alterations, and scar tissue formation. These effects are often cumulative and synergistic, making each patient’s recovery trajectory unique.

Moreover, the prognosis is non-linear; impairments may not appear until months or even years after treatment as fibrosis and tissue stiffening continue to evolve. Encouragingly, research demonstrates that when rehabilitation interventions are applied early and consistently, patients can achieve significant and lasting improvements - some maintained even a year post-treatment (2). Given these realities, pelvic rehabilitation is an essential component of comprehensive survivorship care.

Rehabilitation After Gynecologic & Bladder Cancer - What the Evidence Says
One of the most well-studied areas in oncologic pelvic rehabilitation focuses on gynecologic cancer survivors experiencing dyspareunia during intercourse. A mixed-methods study of 31 women who participated in a 12-week multimodal pelvic physical therapy program - combining education, manual therapy, and pelvic floor muscle exercises - demonstrated significant improvements from baseline to one year in pain, sexual function, urinary symptoms, psychological wellbeing, and body image (2).

Importantly, the benefits achieved at the end of treatment were maintained 12 months later, suggesting long-term durability of outcomes. Qualitative interviews from the same group further revealed that participants perceived meaningful reductions in pain, improved sexual comfort, and enhanced urinary control (2).

A growing body of systematic reviews and recent clinical trials supports the superiority of multimodal pelvic floor interventions that combine pelvic floor muscle training, education, and adjunct therapies over single-modality approaches. These integrated programs consistently demonstrate broader improvements in bladder, bowel, sexual, and general pelvic floor function compared to education or passive interventions alone (3). A 2024 umbrella review echoed these findings, highlighting that multimodal therapy can alleviate incontinence and sexual dysfunction while improving pelvic floor muscle performance, though higher-quality studies are still needed. Manual therapy techniques, including scar mobilization, myofascial release, and neural mobility, are also frequently incorporated. Particularly in areas affected by surgery or radiation, to counteract tissue stiffening, fibrosis, and adhesions that can limit recovery (4).

While the literature on bladder cancer rehabilitation remains more limited, emerging research indicates promising results. A 2024 review on rehabilitation following orthotopic neobladder (ONB) reconstruction identified urinary incontinence as a frequent complication and underscored pelvic floor muscle training as a key component of post-operative management (5). The same review emphasized the need to standardize pelvic floor rehabilitation protocols to reduce practitioner variability and improve outcomes across care settings.

More broadly, evidence from cancer survivor cohorts demonstrates that non-invasive pelvic floor rehabilitation (PFR), including manual therapy, neuromuscular re-education, and targeted education, can effectively reduce self-reported pain, improve voiding and defecation coordination, and address pelvic dysfunction across diverse cancer types (4). In addition, case reports have described comprehensive, individualized physical therapy programs after pelvic radiotherapy that successfully integrate internal and external techniques, dilator use, and adherence support to restore function and comfort (6).

Although the evidence base for bladder cancer–specific rehabilitation is still developing, the principles established in gynecologic oncology, such as progressive pelvic floor training, manual and soft-tissue interventions, and individualized patient education, are highly translatable. These approaches can be adapted to the unique anatomical and surgical circumstances of bladder cancer survivors, including those with urinary diversions or neobladders, ensuring a comprehensive and compassionate path toward recovery and quality-of-life restoration.

A Glimpse into Emerging Trends & Gaps
The field of oncologic pelvic rehabilitation is rapidly evolving, with new technologies and research directions poised to expand access, precision, and personalization of care. One promising development is the rise of e-rehabilitation programs for cancer survivors. A 2025 proof-of-concept study evaluated an online pelvic health e-rehabilitation platform that combined educational modules with virtual exercise coaching for gynecologic cancer survivors experiencing urogenital impairments. The study found the intervention to be both feasible and acceptable, suggesting that digital delivery could improve continuity of care and extend access to underserved or geographically remote populations (7).

Parallel to this, advances in digital prediction modeling are offering new possibilities for individualized rehabilitation planning. Recent multimodal deep learning models—such as MultiSurv—can integrate imaging, histopathology, and clinical data to predict recurrence and survival outcomes in bladder cancer. These predictive tools may one day assist clinicians in stratifying rehabilitation risk, identifying high-need patients earlier, and tailoring intervention intensity accordingly (8).

Similarly, breakthroughs in artificial intelligence–driven imaging are improving structural visualization of the pelvic floor. Semi-supervised deep learning models for MRI segmentation are becoming increasingly accurate, offering potential for enhanced mapping of pelvic anatomy, fibrosis, and treatment-related changes that could inform individualized rehabilitation strategies (8).

Despite these innovations, substantial gaps remain at the intersection of oncology and rehabilitation. There is still a lack of large-scale randomized controlled trials examining pelvic floor rehabilitation in bladder cancer survivors, limited long-term follow-up data, and no universally standardized rehabilitation protocols across cancer types. Moreover, the field would benefit from stronger evidence integrating internal manual therapy, neural modulation, and multimodal therapeutic approaches into oncology-specific rehabilitation frameworks. Bridging these gaps will be critical to optimizing recovery trajectories and ensuring that all cancer survivors have access to evidence-based pelvic health care.

Learn More in Our Upcoming Course
If you are a pelvic rehabilitation clinician seeking to deepen your expertise in managing cancer-associated pelvic dysfunction join us in the upcoming Oncology of the Pelvic Floor Level 2B course scheduled for November 1–2, 2025. This intermediate level course covers gynecologic and bladder cancers and includes risk factors, diagnostic pathways, and prognostic considerations. Participants will explore the sequelae of medical cancer treatments and gain insight into how surgery, chemotherapy, and radiation impact pelvic structures, tissue health, neural integrity, and overall quality of life.

Oncology of the Pelvic Floor Level 2B presents evidence-based rehabilitation strategies, nutritional considerations, and practical home program options that patients can implement between sessions. Clinicians will receive evaluation and treatment interventions that can be immediately integrated into practice, bridging the gap between research and real-world application.

Reference:

1. Li, X., Liu, L., He, J., Yan, J., & Wang, Y. (2023). Analysis of the effectiveness of the application of pelvic floor rehabilitation exercise and the factors influencing its self-efficacy in postoperative patients with cervical cancer. Frontiers in Oncology, 13, 1118794. https://doi.org/10.3389/fonc.2023.1118794
2. Cyr, P., Dostie, R., Camden, C., Dumoulin, C., Bessette, P., Pina, A., Gotlieb, W. H., Lapointe-Milot, K., Mayrand, H., & Morin, M. (2022). Improvements following multimodal pelvic floor physical therapy in gynecological cancer survivors suffering from pain during sexual intercourse: Results from a one-year follow-up mixed-method study. PLOS ONE, 17(1), e0262844. https://doi.org/10.1371/journal.pone.0262844
3. Cyr, MP., Jones, T., Brennen, R. et al.Effectiveness of Pelvic Floor Muscle and Education-Based Therapies on Bladder, Bowel, Vaginal, Sexual, Psychological Function, Quality of Life, and Pelvic Floor Muscle Function in Females Treated for Gynecological Cancer: A Systematic Review. Curr Oncol Rep 26, 1293–1320 (2024). https://doi.org/10.1007/s11912-024-01586-7
4. Kone AM, Roldan SP, Velez V, Roldan CJ. Non-Invasive Pelvic Floor Rehabilitation in Cancer Population. J Exp Pathol. 2024; 5(1): 14-20. https://www.scientificarchives.com/article/non-invasive-pelvic-floor-rehabilitation-in-cancer-population
5. Xu M, Chen S, Liu X, Luo Y, Wang D, Lu H, Jiang M, Chen X. Best evidence for rehabilitation management of urinary incontinence in patients with bladder cancer following orthotopic neobladder reconstruction. Asia Pac J Oncol Nurs. 2024 Dec 26; 12: 100647. doi: 10.1016/j.apjon.2024.100647. PMID: 39896758; PMCID: PMC11782885. https://pmc.ncbi.nlm.nih.gov/articles/PMC11782885/
6. Coughenour, E., Alkhameys, F., & Sharma, N. K. (2024). Rehabilitation of pelvic floor dysfunction after radiation therapy for a rare gynecological cancer: A case report. Gynecologic Oncology Reports, 56, 101534. https://doi.org/10.1016/j.gore.2024.101534
7. Bernard S, Perreault K, Pepin D, Gauthier LR, Roy-Richard C, Lamontagne MÈ, Dalzell MA, Mcneely ML. A pelvic health eRehabilitation program to address urogenital impairments after breast and gynecologic cancer: A proof-of-concept study protocol. Digit Health. 2025 Sep 24; 11: 20552076251382088. doi: 10.1177/20552076251382088. PMID: 41018515; PMCID: PMC12461042. https://pubmed.ncbi.nlm.nih.gov/41018515/
8. Wahab, N., Alzaid, E., Lv, J., Shephard, A., & Raza, S. E. (2025). ModalSurv: A Multimodal Deep Survival Framework for Prostate and Bladder Cancer. ArXiv. https://arxiv.org/abs/2509.05037

You may be reading this thinking, “I don’t treat Intersex patients in my practice. I’ve never even met anyone who is Intersex. What’s the point of learning about Intersex variations?” However, statistically speaking, you most likely have met someone who is Intersex, and you might even have a few patients right now who are Intersex (but you just don’t know it)!

In fact, 1.7% of the population is Intersex. This is about the same percentage of folks who are redheads. So, if you’ve ever seen someone walking down the street or treated someone in your clinic as a patient who has red hair, you’ve probably also seen and treated someone who was Intersex.

Someone who is Intersex may have variations in their hormones, chromosomes, internal reproductive anatomy, and/or external/genital anatomy. Intersex variations can be found in utero during pregnancy, at birth, during adolescence if someone has not undergone puberty by the typical age, during examinations in adulthood while screening for other health issues, and during adulthood if someone is struggling with conception. Some folks even go their entire lives without knowing they are Intersex, and it’s actually found on a post-mortem exam!

Currently, there are over 40 known Intersex variations. And even within an Intersex variation, variations can exist. No two people are exactly the same. We all have differences, which is why every patient deserves individualized care, examinations, and treatments.

Historically, healthcare providers and the medical world have caused great harm and trauma to many in the Intersex community through non-consensual, non-medically necessary examinations, medications, and surgical procedures. As healthcare providers, we need to practice from a trauma-informed lens and understand this historical trauma in order to provide better Intersex-affirming care to our patients and to help educate our colleagues so that they also can provide better affirming care to their patients.

We need to tailor our interventions to each person’s specific goals, needs, wishes, and anatomical differences.

Want to learn more about how to do this?
Come Intersex Patients: Rehab and Inclusive Care on November 8th! In my course, you will learn how to become an Intersex-affirming provider and a better healthcare ally to the Intersex community! Come learn with me today!

Resources

1. (2020, May 18). FAQ: Intersex, Gender, and LGBTQIA+. https://interactadvocates.org/faq/intersex-lgbtqia/.
2. (2021, January 26). FAQ: What is Intersex? https://interactadvocates.org/faq/.
3. (2023). QGuides Resource Guide Intersex. https://qlife.org.au.
4. National LGBTQIA+ Health Education Center. (2020). Affirming Primary Care for Intersex People 2020. https://www.lgbtqiahealtheducation.org/wp-content/uploads/2020/08/Affirming-Primary-Care-for-Intersex-People-2020.pdf.
5. Fenway Health. (2020, October 26). Improving Health Care for Intersex People. https://fenwayhealth.org/improving-health-care-for-intersex-people/.
6. Human Rights Watch. (2017, July 25). US: Harmful Surgery on Intersex Children Medically Unnecessary Operations Risk Lifelong Suffering. https://www.hrw.org/news/2017/07/25/us-harmful-surgery-intersex-children.

AUTHOR BIO
Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI

Molly O’Brien-Horn, PT, DPT, CLT, PCES, CCI graduated from Rutgers School of Biomedical & Health Sciences with her Doctor of Physical Therapy degree. She is a Pelvic Health Physical Therapist, a Certified Lymphedema Therapist, a Pregnancy & Postpartum Corrective Exercise Specialist, an LSVT BIG Parkinson’s Disease Certified Therapist, and an APTA Credentialed Clinical Instructor. She is also a trained childbirth and postpartum doula. Molly is a member of the APTA Academy of Pelvic Health Physical Therapy and is also a Teaching Assistant with the Herman & Wallace Pelvic Rehabilitation Institute.

Molly is passionate about providing accessible healthcare to pelvic health patients of all age ranges, all gender identities, all sexualities, all body variations, and all ability levels

Pelvic health rehabilitation has grown tremendously over the decades, expanding from a publicly viewed mentality of “just Kegels” to a comprehensive, whole-body, and whole-life approach. As rehabilitation providers, we now treat the complex interplay of muscles, fascia, organs, and the nervous system that influences bladder, bowel, and sexual health. But one area that is still underrepresented in many rehabilitation settings is pessary care.;

Pessary fitting has historically been performed by gynecologists and urogynecologists, but in more recent years, especially since the APTA released a position statement in favor of pelvic health physical therapists being able to fit pessaries in 2022, pessary care has entered the rehab scope of practice. Adding pessary fitting, management, and follow-up into a pelvic rehab practice can provide immense benefits for patients, providers, and the healthcare system at large.

Pelvic organ prolapse (POP) is incredibly common, affecting nearly half of people who have given birth. As pelvic health providers, we are not surprised to hear many patients are left with only two extremes: surgery or “wait and see.” We know that pelvic floor therapy can help POP, with things like lifestyle changes, bowel/bladder habit changes, support garments, pressure management, and exercise, but what about our patients who need more?

Pessaries provide a non-surgical, reversible, and evidence-based option that can dramatically improve symptoms of prolapse and stress incontinence. Pelvic rehab providers have been happy to provide traditional therapy options, but now we’re able to offer the additional option of pessary care if we have the right training and permissions from our licensing and state boards. Pelvic health rehabilitation providers already assess pelvic floor function, educate patients on anatomy, and provide individualized exercise programs. Integrating pessary fitting for appropriate patients is a natural progression or addition of this care.

Most of our patients are seeking pelvic therapy because they want to get back to the activities that matter. They come in with goals like running after their kids, practicing yoga without leakage, enjoying intimacy, or simply walking without pressure or heaviness. A pessary can act like a structural support “orthotic” for the pelvic floor, allowing therapy exercises to be more effective, reducing discomfort, and helping patients meet their functional goals faster. The amazing part about pessaries is that they can be used as short-term solutions, like for a run, or an all-day solution, like with a patient who stands for a 12-hour shift.

Why don’t pelvic rehabilitation providers just wait and refer to the “experts” for pessary fittings? Appointments with urogynecologists or surgeons can require long wait times, travel to urban centers, or may not even exist in rural areas. There is a possibility of higher expenses if a person goes to a larger facility and has a high deductible. In other countries (like Australia, Canada, France, and Germany, to name a few), rehab providers are the primary pessary fitters! And even in the US, there are many therapists who have been fitting pessaries for years, usually under the training and guidance of gynecologists or urogynecologists.

When rehabilitation providers offer pessary care, this expands access to conservative treatment for all patients, but especially those with less access to pessary care due to financial, scheduling, or access issues. For patients who feel dismissed in or apprehensive of traditional medical settings, the supportive, education-focused, trauma-informed environment of pelvic rehab can also reduce anxiety and improve outcomes.

Patients often see their pelvic rehab providers weekly, developing strong trust and rapport. This relationship may make a patient more open to learning about pessaries, asking questions, and following up regularly for fit checks and care. Integrating pessary education and management strengthens that continuum of care, reducing the drop-off that can occur when patients are bounced between multiple providers. Be mindful that fitting pessaries is an art and comes with a need to have a medical provider looped into the patient’s plan of care. Medical providers can help manage any potential skin issues, discharge issues, or infection. There will also be times when a rehabilitation provider does not have the skill set to meet the needs of a patient, and the patient needs to be referred to a more skilled or advanced provider.

For therapists, adding pessary care is not just about tools; it is also an opportunity for professional growth. Pessary fitting requires advanced clinical reasoning, commitment to whole-patient solutions, and adaptability to evolving best practices. From a business standpoint, it allows a clinic to differentiate itself, attract new referrals, and provide a comprehensive service that keeps patients within its continuum of care longer.

Current research shows that pessaries are safe, cost-effective, and highly acceptable to patients. Professional organizations (such as the APTA Academy of Pelvic Health and AOTA) recognize the need for interdisciplinary, conservative options in managing POP and incontinence. By adopting pessary care, rehab providers position themselves at the forefront of evidence-based pelvic health practice.

Ultimately, pelvic rehab is about giving patients the knowledge and tools to take ownership of their health. Implementing pessary care provides one more option, whether used as a long-term solution, a bridge to surgery, or a way to stay active and comfortable during postpartum recovery, high-impact activity, or menopause.

Adding pessary fitting to our skill set is not about replacing what we already do as pelvic rehab providers. Fitting pessaries can enhance our provider toolkit, help us collaborate with other providers, and meet patients where they are. When used alongside education, exercise, and behavioral strategies, pessaries can be life-changing. By implementing pessary care, pelvic rehab providers honor the true spirit of our profession: addressing the whole person, restoring function, and empowering patients with choices beyond the “surgery or nothing” dichotomy.

Take the Next Step: Learn Pessary Care in Practice
If you’re ready to expand your clinical toolkit and bring the benefits of pessary care to your patients, join us for Pessaries and Pelvic Rehab: Introduction to Pessary Fitting, Care, and Management.

This two-day, in-person continuing education course is designed for experienced pelvic rehab providers who want to integrate pessary fitting into their practice. With a blend of pre-course lectures and hands-on lab instruction, you’ll gain the advanced assessment skills, fitting techniques, and clinical reasoning tools to confidently and safely implement pessary care.

Upcoming Course Dates & Locations:

• Chicago, IL | November 8–9, 2025
• Tacoma, WA | January 31–February 1, 2026
• Houston, TX | September 12-13, 2026

This course features pre-course anatomy and POP modules, lab-based POP and vaginal dimension assessments, supervised pessary fitting practice, and a pessary fitting kit included with registration. Give your patients more options, strengthen your scope of care, and be part of the growing movement to integrate pessary care into pelvic rehabilitation.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

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

She strives to help all of her 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, she opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Mental health, physical health, and pelvic health are all intricately connected through the nervous system. In my clinical experience, one of the most consistent challenges I have seen patients face is feeling overwhelmed, not just physically, but emotionally. Many of these patients carry invisible burdens of trauma, stress, and anxiety that may show up as pain, tension, fatigue, and even digestive and pelvic health issues. These patients often present with complex pelvic pain symptoms, which may be magnified, adding to their emotional distress.

A recent case involved a young postpartum woman who had delivered a 10 lb. 7 oz baby and was experiencing significant symptoms of symphysis pubis separation. While the physical discomfort was considerable, what deeply impacted her was the emotional toll — a profound sense of disconnection from and lack of control over her body.

Through a comprehensive, integrative approach that included body mechanics education, breathwork, acupressure, and nervous system self-regulation tools, she learned to reconnect with her body in an empowering way. This program not only addressed biomechanical issues but also helped soothe her nervous system, enabling her to meet herself with compassion and care.

Over the course of her care, she progressed from a place of pain and overwhelm to one of resilience and autonomy. This case illustrates how integrative therapies can play a pivotal role in both physical healing and emotional restoration during the postpartum period.

As an evidence-based, integrative, and trauma-informed approach, Acupressure, which is rooted in Traditional Chinese Medicine, has shown great promise. The use of Acupressure for anxiety is a common practice in integrative medicine. Acupoints such as Yin Tang (EX-HN3), Shenmen (HT7), Neiguan (P6), Hegu (LI4), Taichong (LV3), Jianjing (GB21), Zu San Li (ST36), and Sanyinjiao (SP6) are some of the most frequently used points to treat anxiety¹. Yintang (EX-HN 3), an acupoint located between the eyebrows, is known to have a mentally stabilizing effect in Traditional Chinese Medicine². A growing number of studies have also found that acupressure is effective in relieving the symptoms of depression³, Emerging research shows that Acupressure taps into the neural networks across multiple systems, aiding in emotional regulation and healing.

The Nervous System and Its Link to Mental Health
The nervous system acts as the body’s communication network. When it’s dysregulated, often due to stress, trauma, or illness, it can trigger a wide range of mental and physical symptoms, such as:

• Anxiety and panic
• Muscle tension
• Sleep disruption
• Pelvic dysfunction
• Chronic pain

In patients who are dysregulated, we may see a sympathetic overdrive that activates their “fight or flight” response. True healing often requires guiding the body out of the survival mode and back into a calm, regulated state, and this is where integrative holistic tools like Acupressure can become a key therapeutic bridge.

Integrating Acupressure into Pelvic Health and Mental Wellness
The pelvic floor is highly responsive to stress, often tightening in response to anxiety, fear, or unresolved trauma. This can result in pelvic pain, urinary dysfunctions, dyspareunia, constipation, and a whole range of pelvic health dysfunctions.

These symptoms are not just physical; they often reflect underlying nervous system dysregulation. That’s why incorporating acupressure into pelvic health care can be a game-changer for many patients. Acupressure can assist with:

• Calming hyperactive pelvic nerves
• Improving circulation and mobility in the pelvic region
• Releasing stored muscular tension and trauma
• Supporting emotional grounding and resilience

Especially during or after pregnancy, childbirth, surgery, or emotional trauma, Acupressure offers a safe, compassionate way to help patients reconnect with their bodies and move toward healing.

How Acupressure Supports Mental Health & Healing
Acupressure involves applying gentle, intentional pressure to specific acupoints located along the body’s energy meridians. These points correspond with key organs and systems—including the nervous system, digestive system, and reproductive system- and can have profound effects on both physical and emotional health.

Clinical Benefits of Acupressure Include:

• Vagus nerve regulation to reduce stress and anxiety
• Easing muscle tension and chronic pain
• Supporting emotional regulation and trauma release
• Promoting deep relaxation
• Improving sleep

By integrating acupressure into pelvic health and physical therapy, we can support whole-person healing—restoring not just movement and function, but also a sense of safety, stability, and emotional balance.

Acupressure Points for Anxiety, Pain & Pelvic Health
Here are a few commonly used acupoints that support both mental and physical wellness:

• Yintang (EX-HN 3) – Located between the eyebrows
  Mentally stabilizing effect, calming point
• LI 4 (Large Intestine 4) – Located between the thumb and index finger
  Relieves general tension, headaches, and body pain
• P 6 (Pericardium 6) – Inner forearm
  Calms the heart, reduces anxiety and nausea
• Sp 6 (Spleen 6) – Above the inner ankle
  Regulates reproductive health
• CV 6 (Conception Vessel) – Below the navel
  Strengthens core energy and helps with fatigue and abdominal tension
• GV20 (Governing Vessel) – Top of the head
  ; Promotes calm and emotional clarity

These points can be gently stimulated during therapy or taught as part of a home program, offering patients the tools for emotional self-regulation.

A recent study by Yang et al (2021) cited several key Acupressure points that can help with Anxiety & fatigue (Heart 7, Spleen 6), chemotherapy-induced nausea, vomiting, and anxiety in women with breast cancer ( Pericardium 6), primary dysmenorrhea (Liver 3), and anxiety & pain in cancer patients (Large Intestine 4, Heart 7). Several studies also found Acupressure to be effective for cancer pain⁴ and labor pain management⁵.

As a holistic pelvic health practitioner who is psychologically informed with an Integrative physical therapy clinical practice, I recognize the deep-rooted mind-body connections and the need to address the “whole” person. Whether our patients are healing from surgery, managing chronic pain, or navigating anxiety and pelvic dysfunction, their nervous system is always central to their well-being.

To learn more about Acupressure, please join us for the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for Oct 11^th& 12^th. This course will introduce course participants to the basics of Traditional Chinese Medicine (TCM), Acupuncture & Acupressure. Of the twelve major Meridians or energy channels, this course will focus on the Bladder, Kidney, Stomach, and Spleen meridians. In addition, there are other important Meridian points that stimulate the nervous system and can be used for self-regulation to manage Anxiety, pain, and a host of other symptoms. The course also offers two potent Acupressure home exercise programs and wellness programs.

This course also introduces Yin yoga as a powerful holistic practice with Acupressure and offers an evidence-based perspective on how Yin poses within each meridian can channelize energy through neurodynamic pathways with powerful integrative applications to facilitate healing in multiple dimensions.

References

1. Yang J, Do A, Mallory MJ, Wahner-Roedler DL, Chon TY, Bauer BA. Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic. Glob Adv Health Med. 2021; 10:21649561211058076. Published 2021 Dec 12. doi:10.1177/21649561211058076
2. Kwon CY, Lee B. Acupuncture or Acupressure on Yintang (EX-HN 3) for Anxiety: A Preliminary Review. Med Acupunct. 2018;30(2):73-79. doi:10.1089/acu.2017.1268
3. Li J, Zhang K, Zhao T, et al. Acupressure for depression: A systematic review and meta-analysis. Asian J Psychiatr. 2024; 92:103884. doi: 10.1016/j.ajp.2023.103884
4. He Y, Guo X, May BH, et al. Clinical Evidence for Association of Acupuncture and Acupressure with Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233
5. Chen Y, Xiang XY, Chin KHR, et al. Acupressure for labor pain management: a systematic review and meta-analysis of randomized controlled trials. Acupunct Med. 2021;39(4):243-252. doi:10.1177/0964528420946044
6. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521. doi:10.1089/acm.2018.0422
7. Alhusamiah B, Almomani J, Al Omari A, et al. The Effectiveness of P6 and Auricular Acupressure as a Complementary Therapy in Chemotherapy-Induced Nausea and Vomiting Among Patients With Cancer: Systematic Review. Integr Cancer Ther. 2024; 23:15347354241239110. doi:10.1177/15347354241239110
8. Go GY, Park H. Effects of Auricular Acupressure on Women with Irritable Bowel Syndrome. Gastroenterol Nurs. 2020;43(2): E24-E34. doi:10.1097/SGA.0000000000000332
9. Hasanin ME, Elsayed SH, Taha MM. Effect of Acupressure on Anxiety and Pain Levels in Primiparous Women During Normal Labor: A Randomized Controlled Trial. J Integr Complement Med. 2024;30(7):654-661. doi:10.1089/jicm.2023.0072
10. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256

Author Bio
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University New York, with a Doctor of Physical Therapy degree. Rachna has since been working in outpatient hospital and private practice settings with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer County, New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner, and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. Her clinical practice has focused on an Integrative physical therapy approach blending traditional physical therapy methods with holistic practices that address the whole person - physically, mentally, emotionally, and spiritually. She specializes in working with pelvic health patients who have bowel and bladder issues with high pelvic pain, which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and the Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole, focusing on the physical, emotional, and energy body.

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.
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