Childhood Obesity, Pregnancy and the Pelvic PT

Jenni Gabelsberg  DPT, MSc, MTC

This blog was written by H&W faculty member Jenni Gabelsberg DPT, MSc, MTC, WCS, BCB-PMD. You can catch Jenni teaching Care of the Postpartum Patient later this month in Oakland, CA.

Physical Therapists specializing in Women’s Health are in a unique position to help guide and inspire women during their perinatal years, affecting both the health of the woman, as well as the long-term health of any unborn children.

In a recent study published in The Journal of Perinatal and Neonatal Nursing, early onset childhood obesity was determined to be one of the leading pediatric health concerns in the US. Women in their peripartum years need to be educated on what the risk factors for childhood obesity are, and how their personal health decisions can affect their children even before they are conceived. These risk factors are stated as being: maternal obesity at time of conception; excessive weight gain during pregnancy; smoking before, during, and/or after pregnancy; and bottle-feeding the infant after birth.

If a child is born of an obese mother, it has been shown that by four years of age, 24% of children were already obese (and only 9% of children born to mothers of normal weight during first trimester of pregnancy). If a mother gained more than the recommended amount of weight during her pregnancy, it has been shown that there is a 6 times increased risk of that child being overweight or obese by preschool. According to the WHO, an obese mom who gains more than the WHO recommended 11-20 pounds during pregnancy has a 48% increased risk of having an overweight or obese child by age 7. Children who are exposed to smoke in utero were both higher risk of being obese in childhood, and also being of shorter stature. And finally, infants who were fed by bottle were shown to have three times greater risk of rapid weight gain compared to those breast-fed in the first three years of life.

These risk factors not only affect the infant’s birth weight, but can also influence their weight as toddlers and preschool ages. According to the WHO, “Childhood obesity is one of the most serious public health challenges of the 21st century. “ The prevalence of childhood obesity globally is increasing at a rapid rate and has serious implications into adulthood. If children begin life as overweight or obese, they are much more likely to remain obese into adulthood, and also more likely to develop lifelong chronic conditions such as diabetes and heart disease.

More information about childhood and adult obesity can be obtained by watching the HBO series “Weight of the Nation”, which has interviews of many researchers who are focusing their studies on the secondary complications of obesity and how we can fight them. As physical therapists treat women during their childbearing years, it is critical that we use that time to educate women on the long term impact of their health choices and inspire them to make positive changes that will impact both their health and their children’s health for the long term.

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Catastrophizing, Depression, and Pain in Male Chronic Pelvic Pain

A recent article titled "Pain, Catastrophizing, and Depression in Chronic Prostatitis/Chronic Pelvic Pain Syndrome" describes the variations in patient symptom report and perception of the condition. The article describes the evidence-based links between chronic pelvic pain and anxiety, depression, and stress, and highlights the important role that coping mechanisms have in reported pain and quality of life levels. One of the ways in which a provider can assist in patient perception of health or lack thereof is to provide current information about the condition, instruct the patient in pathways for healing, and provide specific care that aims to alleviate concurrent neuromusculoskeletal dysfunction.

Most pelvic rehabilitation providers will have graduated from training without being informed about chronic pelvic pain syndromes. And as most pelvic rehabilitation providers receive their pelvic health knowledge from continuing education courses, unless a therapist has attended coursework specifically about male patients, the awareness of male pelvic dysfunctions remains low. If you are interested in learning about male pelvic health issues, the Institute introduces participants to male pelvic health in the Level 2A series course. The practitioner who would like more information about male patients can attend the Male Pelvic Floor Function, Dysfunction, and Treatment course that is offered in Torrance, CA at the end of this month.

The authors in this study point out that chronic pelvic pain is not a disease, but rather is a symptom complex. Despite the persistent attempts to identify a specific pathogen as the cause of prostatitis-like pain, this article states that "…no postulated molecular mechanism explains the symptoms…" As with any other chronic pain condition, research in pain sciences tells us that behavioral tendencies such as catastrophizing is not associated with improved health. The authors utilized a psychotherapy model in developing a cognitive-behavioral symptom management approach and found significant reductions in CPP symptoms. The relevance of this information for our patient population includes having the ability to screen our patients for depression, to recognize tendencies to catastrophize, and to implement useful strategies for our patient.

What does your facility currently use as a depression screening tool? Having this information at hand when communicating with a referring provider is very helpful. Explaining the biology of the vicious cycle of emotional stress and pain responses can help a patient understand why following up on a referral to a psychologist or counselor may be helpful towards his health. Identifying catastrophizing as the patient who is hypervigilent about symptoms, ruminates about his condition, expresses an attitude of helplessness, or magnifies the threat of the perceived pain can aid in identification of the patient who needs more than a few stretches, a TENS unit, or manual therapy.

A new course offered this year by the Institute will provide excellent foundational background information as well as practical patient care techniques about emotional and psychological principles that influence chronic pain. This course, Integrating Meditation and Neuropsych Principles to Maximize Physical Therapy Interventions, is instructed by Nari Clemons, a physical therapist who excels in pelvic rehabilitation, and Shawn Sidhu, a psychiatrist with a special interest in mind body medicine. The course is offered only one time this year, in September in Illinois, so sign up early!

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Movement and the Pelvic Patient

Tracy M. Spitznagle

This blog was written by H&W instructor, Tracy Spitznagle,PT, DPT, MHS, who instructs the Movement Systems Approach course with Herman & Wallace. You can catch Tracy in the next offering of her course, April 12-13 in Houston, TX.

Should pelvic health practitioners be concerned about movement? Based on personal conversations this month, I would argue an emphatic “yes!”

The first part of 2014 has been exciting for me for understanding movement impairment education. Recently, I attended the Washington University Program in Physical Therapy MSI retreat, where discussion focused on movement and the hip. It was an amazingly cool dialog! The retreat was hosted by Dr. Shirley Sahrmann and guest speaker Dr. Donald Neumann. After the retreat, the University had a visiting lectureship and I had the pleasure of having a breakfast meeting with guest speaker Dr Chris Powers. It has been a movement system educational smorgasbord.

Consider this: the physiological system for which physical therapists are responsible is the movement system. Pain in the pelvic region is commonly associated with myofascial pain, but why did the neural muscular system develop the problem pain to touch? I believe the therapist needs to consider how the neuro-muscular components of the lumbopelvic region could be foremost in the cause of the pain.

At this retreat, I had great reaffirmation of my ideas related to movement. According to Chris Powers, “Increased hip adduction with medial rotation is the most common movement impairment during cutting, jumping and running in women with ACL injuries, there is a huge body of research to support this.”

However, the female athlete is not the only one who moves improperly and develops pain and tissue injuries. Women of all ages are more likely to adduct and medially rotate their hip, simply the habit of leg crossing when sitting re-enforces this issue. This movement impairment can be partially explained by the shape of the female pelvis and the architecture of the muscles. Believe it or not, my favorite muscle, (Don Neumann’s, too) the obturator Internus, is implicated in the movement impairment of the female with an ACL injury as well as the female with pain with intercourse.

Don Neumann PT PhD agrees; according to Dr Neumann, “it is logical to consider that the obturator Internus is more susceptible to strain due to the 130 degree turn it takes out of the pelvis.”

Thus, I believe it is logical to test for hip lateral rotation weakness as well as excessive movement in to adduction and medical rotation as a common movement habit of women, and especially women with pain located deep in the pelvis over the region of the obturator internus.

Motion analysis based on the methods developed by Chris Powers requires a lot of expensive equipment to analyze movement and only those who can run, jump and cut benefit from his information. On the other hand, movement testing of simple tasks that you already know how to do (i.e. bending, standing on one leg, and reaching up overhead) are inexpensive tools to evaluate movement. The hardest part is learning what to look for. Once you recognize kinesiological-based movement impairments you can provide corrective activities at a very low overhead!

The Movement course I teach for Herman and Wallace provides the opportunity to learn a basic movement exam that can be used for women of all ages. The course provides an overview of the anatomy of the hip, spine and SIJ and how impairment movement of these regions relate to common pelvic pain conditions you may be treating. This course provides a means for you to specifically educate your patient on how to move with less pain!

Want more from Tracy? Check her out in Houston in April!

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Pelvic Belts and Gluteal Muscles

Does wearing a pelvic belt affect the activation of the gluteus maximus and gluteus medius muscles in healthy males? Recent research asked this question, and the results, although difficult to extrapolate to other patient populations, are interesting. Surface electromyography (sEMG) amplitude was measured in 20 male patients during 6 exercises, and the amplitude during the exercise was compared to a maximum voluntary contraction. The findings demonstrated that muscle activation increased in the gluteus maximus when a pelvic belt was worn. Activation in the gluteus medius was unchanged for all exercise except during the clam exercise when the gluteus medius was noted to be more active.

Mean age in the study was 23 years, and all participants reported a lack of disease or injury. All were able to complete the exercises without pain. The 6 exercises that were instructed by an experienced physical therapist included hip clam, side lying hip abduction, single limb squat, single limb deadlift, frontal planar lunge, and frontal planar hop. Each exercise was performed 3 times, the order of exercise was randomized, and the dominant limb was used.

The authors bring up interesting points and hypotheses in relation to the sEMG findings. In a patient who presents with lumbar pain and delayed gluteus maximus activation, can a pelvic belt be utilized to improve muscle activation and therefore pelvic stability? Is adding a belt such as the COMPRESSOR belt used in this study valuable for allowing a patient to optimally complete dynamic activities, or does the belt inhibit gluteus medius activity by providing support that the muscles are supposed to provide? Most research invites us to consider the clinical implications of an intervention or a strategy, and the rehabilitation provider must assess the value of the strategy for that particular patient.

For practitioners who are interested in fine-tuning skills in lumbopelvic and hip assessment, Tracy Spitznagle, instructor in the Physical Therapy program at Washington University, will teach the Movement System Approach to Musculoskeletal Pelvic Pain: Lumbar, Hip, and SI Joint in April in Houston, TX. In this 2-day continuing education course, participants will learn to recognize movement impairment syndromes, perform movement tests, and develop a corrective exercise program based on a specific movement examination.

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Postpartum Exercise: Keepin it Real(istic)

Postpartum mothers are often juggling intense schedules: infant feeding, mealtimes for other family members, work both in and outside of the home, and there is scarce time for self-care. Throw in the typical postpartum fatigue, potential for postpartum depression, adjustment to parenting or adding another child to a family, risk for weight retention, and the ability of a new mom to resume or begin exercises can be beyond daunting. An additional complication arises when a woman has been on bed rest, as she has lost muscle mass and cardiorespiratory function and endurance. How can we best set up a new mother for success?


Research published in the journal Clinical Sciences reports that regardless of exercise intensity, women receiving postpartum intervention experience health benefits. If a woman is unable to reduce the weight gain that occurs in pregnancy, by 6 months postpartum she will have increased risk factors for developing chronic disease, according to the authors. In the study, 20 women were instructed in nutrition advice and low intensity (30% heart rate reserve (HRR)) and another 20 women women were instructed in nutrition advice and moderate intensity(70% HRR) exercise. A group of controls (n = 20) was included and matched for BMI, age and parity.

The exercise program included supervised walking for 45 minutes, 3-4 times per week for 16 weeks. In order to achieve the target heart rate, some women walked with or without a stroller, or with a double stroller with added weight. The participants attended a supervised exercise session at least one time per week, and the first session was limited to 25 minutes, including a 5 minute warm-up and 5 minute cool down. Sessions were increased by 5 minutes per week up to a 45 minute limit. Pedometers were administered, home exercise logs were used to record distance when not in the clinic. and food intake diaries were completed. Each woman met with a nutritionist to be given a program that met her caloric needs and allowed for weight loss as appropriate. Women were screened for chronic disease at 7-8 weeks postpartum and again at 23-25 weeks postpartum.

Regardless of exercise intensity, both intervention groups lost body mass, had decreases in plasma low-density lipoprotein, and had reduced glucose and adiponectin concentrations, all positive changes for reducing chronic disease risk. As hypothesized, the control group did not experience the same positive changes. Here's the bad news: hanging on to increased BMI and low activity levels in the postpartum period can lead to lack of health. The good news: low-intensity walking programs and nutrition advice can improve risk factors for chronic disease. Many women may think they have to exercise at moderate intensity, 5-7 days per week, and while there may be additional fitness benefits from increased exercise intensity, our first goal for patients can be overall health versus fitness.

How do we get new moms into exercise? Make it reasonable, fun, social! Hold postpartum fitness classes at your clinic or at a local center. Teach the women who are in your care about wellness principles, or offer a community lecture. If you want to learn more about postpartum fitness classes, the topic is discussed in the Care of the Postpartum Patient and in Postpartum Special Topics. The next Postpartum class happens in early April, so check out the website for details!

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Pediatric Patients and the Pelvic Rehab Therapist

In 2011, H&W was thrilled to add a new course to our list of offerings. Pediatric Incontinence and Pelvic Floor Dysfunction was a much-needed addition to our pelvic floor courses. Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served, which can cause undo stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Dawn Sandalcidi, the author of this course, and Robin Lund, her co-instructor, sat down with Pelvic Rehab Report to talk more about this course and their work with children.

PRR: Dawn, you developed this course many years ago. What initially inspired you to write this course?

Dawn Sandalcidi

When I set out to create this course, there were no courses offered in pediatrics for pelvic health. There was also nobody doing any pediatric courses when I began this quest.

PRR: How has this course evolved over the years?

My first class had only eight people that attended. I was shocked to see that half of the class were pediatric physical therapists looking to help their patients. At that point in time I realized I needed to rewrite the class to accommodate those learning the pelvic floor information for the first time

PRR: Robin, you will be joining Dawn as a co-instructor of this course in 2014. What pearls of wisdom have you picked up in your clinical practice that you'd like to pass onto course participants?

Robin Lund

The only population I work with is pediatrics, usually up to 18 years of age, but sometimes up to mid 20's. Children coming to me for treatment of pelvic floor dysfunction are usually between the ages of 5 and 14 years old, but sometimes I treat children slightly younger or older than this. I am specialized in the treatment of torticollis also, so I work with babies a lot. What i've learned is:

1.) Most incontinence symptoms I see are caused or worsened by constipation and most of the time parents don't know their children are constipated because they are "going" every day. If you don't hit constipation management hard in your treatment plan, you will rarely be 100% successful.

2.) Another thing I have learned is that pediatricians and pediatric gastroenterologists often just treat the symptoms and are not always aggressive enough in their management of constipation. I educate my parents on constipation and its effect on bladder and bowel dysfunction and he;p them become good advocates for their child so they can get more action from their doctor.

3.) Work extra hard to earn your pediatric patient's trust and friendship. You will soon become their favorite person and they will want to please you and will work harder on their home program.

PRR: What can you tell us about this course that isn't covered in the description and objectives?

Dawn: It will change your life and the lives of your patients. Pediatrics is a career changing specialty that you will fall in love with!

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

Dawn: Most of us see patients who are adults who also have children with bowel and bladder issues. The pediatric patient suffers most. Not only is a problem for the child but it's also a problem for his/her entire family. We know, based on the literature, that children suffer significantly with psychological disorders related to bowel and bladder issues. The change you see in the child and the family when their discharge from therapy is remarkable!

If you'd like to learn more from Dawn and Robin, we will be offering the Pediatric course twice in 2014. The first offering will be in Nashua, NH in April. The second event will take place in Greenvile, SC in August.

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Getting Men to Pelvic Rehab

In a study conducted in Western Sydney, Australia, researchers aimed to discover the barriers and enablers to attending preoperative pelvic floor muscle training for men scheduled for a radical prostatectomy. Semi-structured interviews were completed with referral sources (urological cancer surgeons, nurses, and general practitioners pelvic rehabilitation providers (physical therapists and continence nurses and male patients having surgery at a public and a private hospital.

Key factors that encouraged men to attend pelvic muscle training included having a referral from a provider that was for a specific therapist or center. Barriers to attending rehabilitation included potential cost of private pelvic floor muscle training, and lack of awareness about pelvic muscle rehab among both providers and patients. The providers were often not aware of public sector providers of pelvic muscle training, and patients were unaware of potential benefits of rehabilitation.

While the numbers of referrers (11 providers (14 and patients (13) do not represent a large population, the recorded and transcribed interview allowed the subjects to express themselves without constraint. Some of the providers described the challenge of patients getting lost between the general practitioner and the specialists, the physiotherapists stated that formal training for male pelvic rehab was lacking and that providers were in the habit of referring for women, rather than men, and that the physiotherapist had not made an attempt to market services for male rehabilitation.

Physicians also noted that they refer to pelvic floor rehabilitation because the current and emerging literature is so positive regarding preoperative pelvic muscle training. The patients who were given a specific referral (especially when convenient regarding location and making an appointment) were more likely to schedule rehabilitation.

From this research, we can ask some questions of our current practices. Is a therapist at your facility trained to treat male urinary incontinence? Are the providers and the community aware of your pelvic rehabilitation program? Are the providers aware of the research promoting preoperative physiotherapy for urinary incontinence post-prostatectomy? If you are interested in knowing more about this patient population, the Male Pelvic Floor Function, Dysfunction, and Treatment course takes place at the end of the month in California. In the course we discuss prostatectomies and post-operative recovery, male pelvic pain, and male sexual health.

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The Value of Dialog Regarding Birth Experience

Postpartum depression is a very real, frequently occurring phenomenon that has potentially serious adverse effects on the mother, the child, and on the family as a whole. Serious consequences can include, according to McCoy et al, marital disruption, child neglect or abuse, and suicide. While there are many factors including hormonal shifts that can influence a woman in the postpartum period, strong predictive risk factors can include age less than 25, readmission to the hospital, inability to breastfeed, and lower self-reported health of the mother. A rehabilitation professional is uniquely poised to monitor a postpartum woman over an episode of care and can screen for changes in mood, behavior, or identify risk factors.

Screening for postpartum depression is often completed clinically utilizing the Edinburgh Postnatal Depression Scale. There is a shortened version, the EPDS-3, that asks about self-blame, states of anxiety, and feeling scared, and the shortened version has been documented to have excellent sensitivity. Postpartum psychosis and postpartum post-traumatic stress disorder can also negatively impact a woman's health and a provider needs to be alert for concerning symptoms.

Satisfaction with birth experience has been found to be a risk factor for developing postpartum depression. While we cannot affect a mother's birth experience after the fact, we can offer witness to her feelings, thoughts, and concerns, and we can offer support as rehabilitation professionals. What better way to learn about a patient's challenges and current sense of health than to allow a woman to share her experiences about pregnancy, labor and delivery. Inquiring in an open, non-judgmental manner about a patient's history can provide space for a patient to describe her experiences, perceptions, joys, and concerns. Having a working knowledge of the risk factors allows for therapeutic conversations and referrals in the clinical setting.

In the postpartum course, we discuss the above issues as well as how to observe, listen to, and assess a woman who may need referral for postpartum mental health screening. We also discuss the recent research shedding light on issues of depression in new fathers. The next opportunity to take Care of the Postpartum Patient is in Oakland, CA at the end of March. A great resource page on the website is the "Depression During and After Pregnancy Fact Sheet" that can be printed out and shared with patients. Other links and information is also located on the website that can be accessed by clicking here.

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The Importance of Early Intervention in Hip Labral Tears: Who’s at Risk and Why Physical Therapy is Important

Ginger Garner

This blog was written by H&W course instructor Ginger Garner PT, MPT, ATC, PYT, who will be teaching her brand-new course, Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management, in Akron, OH this June.

Hip labral injury is now recognized as a “major cause of hip dysfunction and a primary precursor to hip osteoarthritis.” Although acetabular labral tears were first identified in 1957, attention has only been directed toward the acetabulum in the last 10-15 years.

Populations at highest risk for hip labral injury include women, expectant mothers, women who have had vaginal hysterectomies, and young and middle-aged athletes. Women suffer from hip labral injuries more frequently than men, putting women at highest risk for premature aging in the hip and osteoarthritis.

Adding to insult to injury is the average time between injury and diagnosis is typically 2.5 years, significantly reducing long-term outcomes for joint preservation. Pelvic girdle pain, lumbopelvic pain, and extra-articular hip injury are also common comorbidities that accompany hip labral tears, making differential diagnosis essential to successful management.

Hunt et al (2007) cites that “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.” This statement underscores the vital importance of a collaborative, interdisciplinary partnership in medicine. Early intervention in hip joint preservation requires teamwork on the part of all health care specialties involved in a patient’s care. Physical therapists are a critical part of that team.

Structural disorders of the hip are not the only culprit for hip labral injury, and as a result, development of a unique skill set for hip labral injury assessment that includes soft tissue and structural integrity evaluation is required. This positions physical therapists as perhaps one of the most ideal clinicians to differentially diagnosis hip impairment due to their expertise in both structural and soft tissue assessment.

It cannot be overemphasized that missing a hip labral diagnosis can mean a devastating long-term prognosis for a patient. What’s more is diagnosis is elusive, making it even more important for physical therapists and related providers to establish parameters for early intervention through critical evaluation of the hip. Hunt et al (2007) state diagnosis requires “a high index of suspicion, special attention to subtle patterns of presentation, and timely consideration for imaging studies.” A 10-12 week trial of physical therapy is recognized in the literature as the standard for initial conservative management and should address not only the primary pathology but the sequela that complicates hip labral management, such as pelvic, spine and lower-extremity abnormalities.

If you would like more from Ginger on this topic, the new Hip Labrum Injury courseemphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. Ginger's courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. Ginger will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip. Registration is available here.

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Valsalva and the Pelvic Floor

Within the evaluation process for pelvic muscle health, a woman is often asked to "bear down" so that the examiner can assess muscle coordination. This maneuver is also utilized during assessment for prolapse or pelvic organ descent. Clinically, the patient's ability to perform a lengthening or bearing down is quite varied, depending upon many factors such as levator plate resting position, strength and coordination, childbearing status, and comfort with the maneuver. What are the implications of not being able to bear down? An interesting study published in 2007 concluded that women, when asked to perform a Valsalva maneuver (a forced expiration against a closed glottis), frequently co-contracted the levator ani muscles.

Participants included 50 nulliparous women between 36-38 weeks gestation and they were assessed with translabial 3D/4D ultrasound following emptying of the bladder. In almost half of the subjects, a pelvic floor muscle contraction was noted during the attempted Valsalva. Patients were provided with visual biofeedback to train the levator muscles to avoid a concurrent contraction, and despite the training, 11 of the 50 women were still unable to avoid a co-activation. (Keep in mind that for purposes of assessment, the prolapse would be best imaged or viewed if the levator muscles were not tightening.) For this reason, the study concludes that levator muscle co-activation is a significant confounder of pelvic organ descent. While a contraction of the pelvic floor muscles may be a positive, protective action when thoracic pressure is increased, a woman's degree of prolapse or pelvic organ descent may appear diminished during an examination. The authors of the study conclude that a clinician may have a false-negative finding for prolapse in the presence of strong, intact pubovisceral muscles.

This research highlights the value of being able to coordinate pelvic muscle activity with the trunk and with breathing. What is also very interesting is that the 50 women studied were all in late third trimester of pregnancy when assessed. Does the population studied have carry-over to non-pregnant women, or women who have never been pregnant? Does the co-contraction exist at the same rates for nulliparous, non-pregnant women? How will the lack of coordination for bearing down during increased trunk pressure affect labor and delivery? Is there a role for pelvic rehabilitation providers in assisting women who have difficulty coordinating the muscles of the trunk and pelvis prior to delivery? To the last question, I would answer "yes" when considering the women who have been referred to pelvic rehabilitation prior to labor and delivery. Having the opportunity to lengthen a tight, shortened pelvic floor, strengthen, alleviate pain in tissues from prior scars or from tension, and to improve confidence about the body's ability to perform the function of bearing down for childbirth can be a very positive preparation for a woman's childbirth experience.

For all the other research ideas that this article generates, we can see that many unanswered questions remain. Even when the research points us in valuable directions, having the skills to assess the patient to find out what is needed in her particular case is critical. For further refining of pelvic muscle assessment techniques, including skills for assessing and treating prolapse and pelvic organ descent, the Pelvic Floor Level 2B continuing education course offers lectures and labs. PF2B is next offered in early March in Oregon, and later this year in Illinois, North Carolina, and Missouri.

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