Our Pelvic Rehab Report blogger sat down with Dr. Heather Howard, the instructor of our Sexual Health Clinical Toolkit course, to talk about her course, her practice, and the experience and knowledge she brings to the field of pelvic rehab. Here's what Heather had to say:

What inspired you to create this course?

This course was inspired by my gratitude to the physical therapists who helped me through my own debilitating pelvic pain crisis. The support I received, coupled with the lack of sexuality research and resources for the sexual effects of my condition, led me to become a sexologist and mind-body health facilitator. My mission as a sexologist is to improve sexual health care for all people. In my clinical practice, I help people meet their sexual goals by providing relevant education and skills training. I can help even more people by sharing my tools, resources, and clinical perspective with women's health care providers.

What resources and research were used when writing this course?

In over a decade of collaborating with women's health PTs as a client, researcher, clinician and educator, I have learned the extent to which patients are looking to their PTs for sexual advice, and how PTs are providing sexuality education and counseling on a daily basis. I have also learned about the challenges new and experienced PTs face in providing sexual solutions and what training they would most appreciate in this area. Many of those challenges were revealed in the natural course of my collaboration, and I decided to gain a thorough understanding by conducting a mini-study which consisted of asking co-investigating PTs in my dissertation research about what tools and training they would find helpful in supporting their clients with the sexual challenges they face. There were 12 PTs in the 9 co-investigating PT and medical practices for my dissertation, and I created a list of requested tools and training from those interviews. I have covered most of those requests in this course. I also conducted extensive literature reviews for both my dissertation on integrating sexual response in interventions for pelvic pain, and for a published article on sexual adjustment counseling for women with chronic pelvic pain. The literature establishes what is needed, such as what most of us see in clinical practice: that patients with CPP report more sexual problems than patients with any other type of chronic pain; that a multimodal, multidisciplinary approach is to optimal for treating pelvic pain; that pain management and psychotherapy do not necessarily lead to improved sexual function for people with pelvic pain; and what elements of are needed in sexuality education to implement change. I will address the elements contained in this course later in this interview, which were determined based on the literature and my own interviews with women's health PTs. While research describes what this large population is missing in terms of sexuality adjustment support, it offers few practical solutions for the problem. Clinical protocols and educational resources for sexual rehabilitation for people with chronic health conditions are not well defined or researched yet, so I have built my own educational and clinical approach based on well-established sexuality counseling and embodiment techniques. The sexuality information I teach is based on the research and methodologies of experienced sexuality researchers and counselors that date back to Alfred Kinsey, William Masters and Virginia Johnson, Helen Sanger Kaplan, Jack Annon, and William Hartman and Marilyn Fithian. The experiential mind-body health approaches that I utilize borrow from the traditions of Voice Dialogue, Body Dialogue, Mindfulness, and Somatic Experiencing, all of which are taught in Somatic Psychology programs. I hope to conduct more clinical research soon to add to the literature.

What can you tell us about this continuing education course that is not mentioned in the "course description" and "objectives" that are posted online?

This course provides attendees with a personalized clinical toolkit, which consists of a framework for sexual health management, as well as practical sexual solutions for patients. Attendees improve their ability to conduct sexual health assessments and suggest innovative and relevant sexual solutions and resources. We also discuss approaches to facilitate patient embodiment, which is an important component for pain management and sexual satisfaction. Even the most experienced providers gain new approaches and a deeper understanding of the problems they see every day.

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

Sexual health is a vast topic and the majority of the courses out there focus on teaching sexuality information. The problem is that information alone is rarely sufficient for health care providers to integrate what they have learned in a course into their clinical practices. Research has shown that the elements of sexuality education that are needed for effective implementation are as follows:

1. Sexuality information (aimed at improving knowledge and resources)

2. Sexuality attitudes self-assessment (aimed at helping providers become more comfortable with a broad spectrum of sexual attitudes and behaviors, and more aware of their personal biases and "blind spots," so that they can provide a safer space for sexual discussions)

3. Sexuality counseling practice and supervision (aimed at improving professional confidence and appropriate practical solutions)

I am most concerned about optimizing clinical implementation, so I offer some of all 3 elements in this course, with an emphasis on #3. This course complements other available courses in sexuality information (such as the upcoming H&W ISSWSH course on sexual medicine), sexuality attitudes assessment (such as the H&W Sexual Spectrum Education course coming soon), and sexuality counseling (AASECT conferences).

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

Patients look to their women's health care providers for sexual advice, and most providers offer excellent support and advice with little formal training in the area of human sexuality. Patients benefit from a methodical approach to care, and a sound methodology is never more important than with a topic as sensitive as sexuality. My more than 1500 class hours of training in human sexuality have helped me see sexuality problems from a broad perspective and re-framing client problems is often as important as the specific rehabilitation solutions we offer. As a result, many providers who take this course see sexuality through a new lens, which can have benefits on a professional and personal level. They also become familiar with the variety of tools and solutions available to help their patients, many of which they integrate into their own practices.

Don't miss the chance to learn more from Heather! The next offering of this course is in San Diego, CA on June 22-23 - Register today!

Pelvic rehabilitation providers tend to have personalities that inspire patients to share intimate concerns and issues. One issue that we can play a part in bringing to light is that of medication usage for male sexual performance. Viagra, or the generic version, sildenafil, is a drug that improves blood flow to the penis. It is also one of the the most counterfeited drugs in the world, according to this report. The issue has been in the media for several reasons in recent weeks, with counterfeit manufacturing as one of the concerns.

The United States Food and Drug Administration recently issued a warning about a recall for an over-the-counter male sexual enhancement supplement, "Lighthening Rod," because the supplement contained an undeclared amount of the medication sildenafil. What's the harm? Drugs.com lists 34 major drug reactions for sildenafil, including blood pressure changes (hypotension) or other cardiac effects when taken with nitroglycerines. A national study completed in Australia reports that erectile dysfunction may be a clinically relevant predictive tool for cardiovascular risk, and it may be that men are not sharing information about their sexual function with providers due to embarrassment. In fact, in a news report about a presentation at the American Urologic Association, research presented found that only 25% of men with erectile dysfunction seek treatment.In what has been described as an unprecedented move, Viagra has now made the drug available for purchase on its website, issuing a warning about acquiring the drug without a prescription or ordering a counterfeit drug. While this approach may help to avoid black market purchases of the medication, it also may allow men who don't feel comfortable filling prescriptions for the drug to purchase it in the privacy of their own home.

In terms of our role in helping men avoid the pitfalls of the diagnosis of erectile dysfunction as well as the potential harm from medication available without a prescription, we can start by asking more questions. A good question to start with is "Are there any other supplements or medications that are not on your medication list?" or "Are there any medications or supplements that you purchase from the internet or from a local store?" We can also be sure to include questions about sexual function and health on patient intake forms, and include such verbal questions in our history taking. Because the patient may not feel comfortable on a first visit discussing intimate issues such as erectile dysfunction, in our education of the patient we can provide anatomy and physiology lessons related to sexual function. For any patient who admits to purchasing sexual enhancement drugs that have questionable contents, the patient should be referred to his medical provider to discuss the issue immediately, and the patient can be instructed in the potential adverse effects and in the need to discontinue such medications.

Many pelvic rehabilitation providers are more comfortable discussing sexual health with female patients than with male patients. This topic may be an excellent place to start when it comes to ensuring that our male patients have a place where they can feel safe discussing such sensitive issues, and where they can receive the most current information about their issues. To learn more about erectile dysfunction in general, you can visit sites such as Medline where interactive educational modules can be found.

While the co-existence of fecal incontinence (FI) and constipation is well-recognized in the pediatric and geriatric population, the authors of this article suggest that the relationship is under-appreciated in the adult population. Samuel Nurko, MD, and Mark Scott, PhD, describe the association between pediatric functional fecal incontinence and constipation, stool retention, and incomplete evacuation. In adults, they point out, constipation may also be related to pelvic floor dysfunction and denervation. The negative impact on quality of life creates the need for these issues to be addressed more readily, both in adults and in children.

The study mentioned above cites a prevalence of fecal incontinence in school-aged children of 1-4%. The majority of the research cited in the article report that this incontinence is related to underlying constipation. Factors that may contribute to childhood holding of stool or to rectal dysfunction include constipation early in childhood, painful bowel function, "coercive toilet training practices and social stressors", fecal impaction, and treatments involving anal manipulation. It has been surprising to me how many adult patients describe psychologically stressful childhood associations with bowel function.Fortunately, the psychological stress, low self-esteem, and decreased quality of life that is associated with childhood bowel dysfunction improves with successful treatment of the condition. Childhood behavioral issues including bullying, disruptive behavior, and social withdrawal also are noted to improve following improvement in fecal issues, suggesting that the terrible social impact of fecal incontinence may be to blame for some of the behavioral issues.

In relation to the adult population, the authors state that while the coexistence of constipation and FI may not be known, constipation has been shown to be an independent risk factor for FI and incomplete emptying is associated with fecal incontinence.In the patient who has poor emptying of the bowels, overflow can occur, and this type of leakage is then associated with constipation. It follows, then, that treatment of the constipation should improve the fecal leakage. Three mechanisms are described regarding the pathophysiology of incontinence caused by constipation: overflow due to fecal impaction; post-defecation leakage caused by rectal stool retention from a rectal evacuatory disorder; and general pelvic floor weakness or denervation. Certainly, neurological or other disease conditions can cause bowel dysfunction, yet this article focuses on "functional" constipation not caused by such diseases.

Clinically, patients who present with fecal leakage can have a difficult time understanding the relationship between constipation and fecal incontinence. Educating the patient about bowel health and function are critical in "selling" the self-management strategies that will form the foundation of the patient's recovery. If you are interested in learning more about bowel health and function, come to the 2A course that instructs the participant in common colorectal conditions, constipation, and fecal incontinence. If you have already taken the course, check out the Institute's new course on bowel dysfunction that includes a lab for anorectal balloon re-training.

Last weekend, Pelvic Rehab Report guest-blogger, Erica Vitek MOT, OTR, BCB-PMD, attended H&W's Pediatric Incontience and Pelvic Floor Dysfunction course in Madison, WI. This course was developed and is instructed by Dawn Sandalcidi. Erica had this to say about her experience in the course:

The most recent Herman & Wallace course I attended was Pediatric Incontinence course taught by Dawn Sandalcidi. I had been patiently waiting for this course to come to the Midwest/Wisconsin area and when it did I signed up immediately.

I have been treating women's and men's health patients for just over 8 years. Since I took the level 1 pelvic floor course with Herman and Wallace, I have been so impressed with the layout and organization of the material. The take-away information from each course allowed me to return to the clinic on Monday and begin treating patients in new and different ways. I've found that the ideas presented can be immediately implemented and improve the quality of life of all the individuals in need of such specialized treatment. As an occupational therapist coming into the field of pelvic floor disorders, I needed the additional depth and focus on pelvic structure and anatomy since this was not a main focus of my underlying educational degree and I can not say enough about how much their coursework prepared me.

Prior to last weekend's course, I had always treated pelvic floor dysfunction in adults but would get the occasional phone call from a parent looking for help with a child who had bowel or bladder issues. The parents sounded so desperate to find help and I struggled to locate someone in my immediate area that could help them. Since generalized pediatric evaluation and treatment is not something with which I have experience, I was not sure if this course would be able to provide me with all the things I would need to get going. If anything, I thought, this course might help me to better understand my adult patients and even get some additional ideas to help them. The pediatric course exceeded all of my expectations! Dawn packed the two days with all the diagnoses for which pediatric patients would be referred, reseached based data with up-to-date terminology, endless practical ideas for behavioral modification specific to children, medical testing interpretation, the psychological considerations, start-to-finish clinic video evaluations of pediatric pateints, and an affordable start-up list of things to purchase to get going right away. Dawn put a passion in me to widen my base of referrals to include pediatrics and give children and parents with these problems somewhere to turn. Changing a child's life in this way could mean all the difference.

In the April Physical Therapy Journal, authors ask the question: does the relationship between the patient and the physical therapist impact patient outcome? This relationship, or therapeutic alliance, was measured through use of the Working Alliance Inventory at the second treatment session. The 182 patients included in the reporting were all diagnosed with chronic low back pain, and they completed outcomes before and after 8 weeks of treatment including the Patient-Specific Functional Scale, the Global Perceived Effect Scale, the visual analog scale, and the Roland-Morris Disability Questionnaire. The patients were divided among 7 experienced physical therapists.

The authors conclude that "Higher levels of therapeutic alliance...were associated with greater improvements in perceived effect of treatment, function, and reductions in pain and disability." Considering that this alliance was measured at the second visit, it clearly does not take a patient long to decide if there is a positive alliance formed. So how do we create that alliance? One of the reported limitations of the study is the lack of knowledge about the therapists' behaviors or interpersonal skills, therefore a correlation between such skills and patient's perceived alliance cannot be made. Another research article appearing in the same journal may offer some clues towards this issue.

An article titled "Measuring Verbal Communication in Initial Physical Therapy Encounters" suggests that clinical communication is critical in providing the patient with a positive experience. How can that be measured? 27 patient initial evaluations completed among 9 physical therapists were observed, audio recorded, and categorized using the Medical Communications Behavior System, a tool created to measure information-providing interactions. The results of the categorizations included that the therapists spoke for nearly 50% of the time compared to the patient's 33%. Emotional content was rarely included. Experienced clinicians were found to give more advice or suggestions, to utilize less restatement, and were also noted to be more likely to talk concurrently or interrupt the patient.

Documented negative therapist behaviors included being interrupted in the clinic, giving disapproval, or using jargon. These types of interactions or behaviors may be easily limited with setting standards for limiting interruptions (only in emergencies), or by being certain that each treatment room is stocked with similar equipment, that sort of thing. Avoiding disapproving statements or use of jargon requires that the therapist "listen" to him or herself, avoid falling into verbal habits, and make an effort to consciously choose language that is patient-centered and positive. The authors point out that basic clinical communication requires listening without interruption and making effort to hear what the patient is truly saying or is trying to say.

In our efforts to provide information in our clinic setting, where it seems there is never quite enough time to complete patient and clinician paperwork/documentation, share home program information and complete clinical interventions, it is easy to understand why the above tasks may be challenging. Both research articles are groundbreaking in that when evaluating some of the factors that are related to the patient/therapist relationship and communication, our profession is beginning to make connections among variables that appear to be less tangible. It is this information that can help explain why some patients are more adherent, why some respond better to particular interventions, or to a particular person. For our part, when outside of the research community, we can make efforts to attend to patient rapport, relationships, and communication, and look for more guidance on how to measure these variables and provide the optimal experience for our patients.

In January, H&W faculty member Elizabeth Hampton PT, WCS, BCB-PMD presented at the APTA’s Combined Sections Meeting in San Diego, CA in a presentation sponsored by the Orthopedic Section. The presentation was called “Core Rehab without ‘Going There’: Evidence Supporting Direct and Indirect Evaluation and Treatment of PFM Dysfunction.”

In her talk, Elizabeth discussed contributing factors to pelvic health and continence, including muscular, fascial, neural, biomechanical and motor control factors. She also noted a pilot study done by HW’s own Stacy Futterman, PT, MPT, WCS, BCB-PMD, which prompted a wonderful discussion about the role hip labral tears and femoral acetabular impingement has on the pelvic floor.

Elizabeth was gracious enough to share details about her presentation with Pelvic Rehab Report. Below is what she had to say about this topic.

EH: In this talk, I focused on pelvic health and continence being a distinct specialty within orthopedic manual therapy. Considering the interrelationship between musculoskeletal, urinary, colorectal and sexual function, I believe an integrative understanding of all systems is required for autonomous, direct-access physical therapists as we look towards Vision 2020. Indeed, IFOMT’s definition of orthopedic manual therapy correlates directly to the women’s health physical therapist.

In my talk, I proposed that a comprehensive pelvic health and orthopedic manual therapy evaluation is required for the evaluation and treatment of pelvic pain and pelvic health conditions. I noted (and the audience agreed) that the reality is that not all PTs will have a comprehensive pelvic health knowledge base. Key items for a pelvic pain exam have not been standardized for physical therapists that do not have training in direct pelvic health and continence evaluation and treatment methods. Barriers to clinician evaluation of pelvic floor function and dysfunction can include education, apprehension, aversion, risk management concerns and knowing how and when to include pelvic health questions during client history- taking.

One example of a lack of comprehensive pelvic health knowledge base is the therapist who instructs on pelvic floor contractions - without prior assessment by the therapist - during a clinician- designed core rehabilitation program. Without evaluation, the competence of pelvic floor muscle contraction is in question. Cueing a muscle contraction without assessment, therefore, is not a skilled intervention in and of itself.

This prompted a discussion of whether a direct pelvic floor evaluation is indicated with all clients needing core rehabilitation. We also discussed external (i.e. indirect) assessment via the Ischiorectal fossa or client’s hand on their sacrum/ischii as options for a general screening. Further research is needed to determine when direct (internal) or indirect (external) evaluation methods of PFM contraction/relaxation are appropriate.

I encouraged all clinicians to attend the minimum of a Level One Pelvic Floor course through Herman & Wallace or the APTA. Regardless of the long term clinical interest of each PT in pursuing pelvic rehab as a focus, a Level One PF course would enable each clinician to perform a fundamental history, effective bowel and bladder screening and an understanding of the anatomy of the pelvic ring, even if they chose not to perform direct PFM assessment and treatment in the clinic.

I observe that the attitude of ‘us’ vs. ‘them’ still persists between clinicians who do have women’s health PT skillset and those who do not. This attitude has the potential to impair clinical collaboration and the inclusion of PTs of other specialties into the study of pelvic health, continence and women’s health physical therapy. Our profession would be well-served to focus on meeting the needs of the clients through a comprehensive orthopedic/ biomechanical/ urogyn/ colorectal knowledge base, rather than by separating client treatment according to clinician toolbox (i.e. women’s health vs. orthopedic.)

The Description of Specialty Practice for the Women’s Clinical Specialty includes a highly-detailed orthopedic skillset. Likewise, women’s health physical therapy is a highly-specialized field within orthopedic manual therapy. Both toolboxes are required for comprehensive evaluation and treatment of clients with women’s health, pelvic health and continence dysfunction.

Among the patients who we serve, the diagnosis of orthotopic neobladder, or "neobladder" can leave the pelvic rehab therapist wondering about the procedure itself as well as the best course of therapy. Understanding the anatomy and physiology of the surgical diversion, the risks and benefits, and the common urinary dysfunctions can assist in development of the plan of care.The neobladder surgery is one option for patients who must have the bladder removed, often in the event of bladder cancer. As the 4th most common cancer in the United States, theNational Cancer Instituteestimates that there will be over 72,000 new cases of bladder cancer in the US in 2013. Other reasons a patient may be a candidate for a neobladder surgery include a neurogenic bladder that risks renal function, radiation injury to the bladder, severe urinary incontinence, and pelvic pain syndromes.

The surgery involves creating a pouch for storage of urine from a portion of the small intestine. For a brief and helpful video of how this surgery is completed, click here. Early complications of the surgery include rupture of the new bladder reservoir and bacterial peritoneal infection. This is a medical emergency and would be treated with antibiotics and surgical revision. Late complications can include urinary obstruction. More commonly, patients who are referred for pelvic rehabilitation may experiencedysfunctions including urinary incontinence and retention. While the latter tends to be an issue in the immediate post-surgical period, incontinence is more prevalent in later recovery. A Medscape article about urinary diversions and neobladder can be accessed here.

An article reviewing 1000 cases of neobladder surgery over 25 years reports complications including hydronephrosis, incisional hernia, ileus or small bowel obstruction, urinary tract infection, B12 deficiency, and occasional obstruction and even death. The authors conclude that patient age and comorbidities contribute to the challenge of avoiding such complications, and that patients are best managed in a surgical center where many of the operations are completed. In another article describing the urinary function outcomes in 49 women who were treated with a neobladder diversion, daytime incontinence was reported in 43%, nightime incontinence in 55%, and hypercontinence in 31%. Hypercontinence refers to difficulty emptying the neobladder. Aweb postingon a site for survivors of bladder cancer describes a technique that women can use to aid in emptying the pouch.

A review of websites and journal articles describing postoperative interventions typically lists "Kegel exercises" as one part of training. Further research will assist in providing recommendations for treatment, yet at this time, patients will be able to benefit from standard therapy approaches for urinary dysfunction. Behavioral training can help the new pouch stretch to some extent, the patient may need to learn to relax the pelvic floor while using low level abdominal pressure to empty the bladder, and information about proper hydration will also be beneficial. Because the lining of the neobladder is mucosal, it sloughs off bits of tissue that appear in the urine as a normal part of postoperative voiding. This fact increases the importance of maintaining a hydrated level of fluid in the body to help pass these bits of tissue and avoid blockage. Keep in mind that many patients who present with a neobladder may have experienced other medical treatments for cancer or other disease processes or illnesses, and the effects of these other medical interventions can affect speed of recovery.

A patient who was recently referred to me for continence training following a neobladder surgery progressed to 75% improvement of stress incontinence over a period of 6- 8 weeks, with a further recovery with home program to near 90% recovery. His examination included pelvic muscle strength, coordination, and endurance assessment via the rectal canal, and his treatment plan included a progressive exercise program based on the findings of the exam. Each patient who presents to our facilities will have a varied history, and a thorough subjective exam will guide the pelvic rehab provider in determining the appropriate examination approach. There are patient resources available on the internet that also inform the rehab therapist. For example, the Bladder Cancer Advocacy Network provides this handout "for patients from patients" that highlights suggestions and common questions. If you are working in or near a large hospital system, finding out who performs these surgeries may offer an opportunity for marketing if you are not yet seeing these patients. If you are in a more rural location, you may find that a patient living in your community can complete follow-up in your clinic while attending medical appointments with the surgeon as needed.

Pelvic Floor Muscles: To Strengthen or Not to Strengthen?

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images.

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles.

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted.

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels."

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images. 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."  If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted. 

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels." 

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

In April of this year, H&W is thrilled to be offering a brand new course on Bowel Pathology and Function. Our Pelvic Rehab Report blogger interviewed the instructor Lila Abbate, PT, DPT, MS, OCS about her new course.

1. What can you tell us about this continuing education course that is not mentioned in the "course description" and "objectives" that are posted online?

This course goes into detail about laxative weaning, how and when to use over-the-counter products and some supplements, food that are helpful to aid in bowel function. The course looks at different concomitant past medical histories such IBS, the neurogenic bowel with a SCI patient, MS and fibromyalgia and the progression of their bowel issues and how PTs can assist these patients. The course discusses evidence-based treatment vs. anecdotal and clinical experiences.

2. What inspired you to create this course?

I felt that there was a need for a course like this. So many patients have very complicated bowel issues and there is so much more to think about regarding a complicated bowel patient. As a pelvic PTs, I realized that I needed to understand more of the general knowledge of the gut and how physicians approach the problem, how so many over-the-counter products can be destructive to normal bowel function and the dysfunction bowel patients that most patients get in to and cannot get out of and how we are able to help them.

3. Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

As all H&W courses have an emphasis on the manual orthopedic approach, we screen and treat both vaginal and rectal pelvic floor muscles in this course, evaluate and treat for diastasis recti in both the male and female population and we discuss the use of biofeedback for the complicated patients. We also complete rectal ballooning as part of the lab.

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

If you have bowel patients that have been difficult to take through the course of care, or if you took PF2A a while ago and need a refresher on bowel pathology, or if have a deeper interest in bowel dysfunction, this course will give you the additional knowledge that you are looking for.

5. How has this knowledge and skill set benefited you in your own practice?

My practice specializes in pelvic pain and bowel dysfunction. Bowel dysfunction is such an underserved population within pelvic floor dysfunction population. In the US alone in 2004, a primary complaint of constipation was responsible for 6.3 million patient visits to medical care centers, resulting in total (direct and indirect) costs of $1.7 billion, which we can surmise 8 years later, has almost doubled and these patients need care.

6. What resources and research were used when writing this course?

Evidenced-based research is the primary guide used to present most information. However, clinical expertise and anecdotal information cannot be ignored due to the fact that we have such low peer-reviewed articles presented on this topic. Information gathered from medical conferences will also be presented.

This course will be offered April 13-14 at Stony Brook University in New York. Don't miss this excellent opportunity - Register today!