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Oct 16, 2014


Avulsion fractures refer to a forcible separation, or tearing away of bone due to a sudden and powerful contraction of muscle. This injury is most common in adolescents, with the as yet developing growth plates being a likely location of avulsion. A systematic review of the literature published in 2011 describes the pathology of pelvic avulsion fractures as "highly prevalent" among adolescent athletes. Additionally, patients who have mature skeletons and who have a history of prior surgical interventions to the bones are also at risk for pelvic avulsion fractures.


Avulsion fractures appear to occur most commonly during the eccentric phase of muscle activity during sporting activities. Pre-existing pain in hip or pelvis may be present, but is not a reliable predictive sign of subsequent fracture. Included in this review article were 48 case reports and case series of which 88% related to physical activity and the remaining 12% related to previous surgical procedures. Within the cases related to physical activity, the mean age of fracture in subjects was 16.8, with 84% being male. Activities in which subjects were involved involved included soccer, gymnastics, and running sports. In the cases related to surgery, mean age of fracture was 56.4, and 100% were female. All of the surgery-related cases presented in the literature were treated with conservative measures. Conservative care described included a period of bed rest for 3 days progressing to walking with crutches until the patient was able to walk without significant pain.


Symptoms reported by patients who have suffered an avulsion fracture of the pelvis may include reporting a popping sensation, local pain, and difficulty walking. Having had a bone harvest from the iliac crest may also predispose a patient to a subsequent avulsion fracture. The authors state that surgery may be considered when there is greater than 2 centimeters of displacement of the avulsion or if the ischial tuberosity is involved.


Oct 15, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Jamie Besante DPT, PRPC


Vicki Lukert

What patient population do you find most rewarding in treating and why?

I find my generation and my younger clients the most rewarding because I have seen myself in them and they are so brave. They knew something wasn’t right with their bodies and they stood up and asked for help and solutions. I have seen many clients with years of dysfunction, pain and suffering and to be able to prevent this in my younger clients means so much. I always say I sleep so easy at night because I feel that I have done my best to help as many people as I can that day.

How did you get involved in the pelvic rehabilitation field?

While earning my entry-level doctorate in physical therapy, we had a brief lecture on “Women’s Health” physical therapy that resonated with me as a young women who suffered from pelvic dysfunction. I asked to complete one of my student affiliations in Women’s Health and I fell in love with the field, treating both men and women.

Oct 10, 2014

pregnant yoga

Do women who participate in yoga during pregnancy feel more optimistic, more powerful, and more well? Yes! This is the reply from a study involving 21 women who enrolled in a yoga class for six weeks. While twelve of the women had previously practiced yoga, none were currently practicing. The format of the class involved the following components: checking in (sharing the prior week's experiences), centering (visualization and breathing exercises), warm-up (neck rolls, shoulder exercises, and side stretches), yoga flow (yoga standing positions such as sun salutation), standing postures (balance, wall positions), mat work (seated postures and hip exercises), Savasana (modified to left side lying), and meditation.


Outcomes tools utilized in this study included the Life Orientation Test-Revised for measuring optimism, the Power as Knowing Participation in Change Tool version II for measuring sense of power, the Short-Form 12 Version 2.0, and the Well-being Picture Scale. Participants in the study were also given a journal to document time spent practicing yoga, and how they felt after practicing yoga, both physically and emotionally. The authors conclude that yoga as a self-care practice can be used to promote self-care and well-being in women who are pregnant.


Why are feelings of power, well-being, and optimism valuable for women who are pregnant? The authors discuss the literature which has suggested higher levels of adaptive coping in women with high-risk pregnancies, and the concept that optimism is associated with physical health. Previous studies about using yoga during pregnancy have proposed benefits to the mother both during her pregnancy as well as during labor and delivery. The authors of the study also describe power within the perspective of Rogers' science of unitary human beings, with sharing of interesting philosophical concepts such as resonancy, integrality, and diversity of the human-environmental field.


Oct 09, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Vicki Lukert PT, PRPC


Vicki Lukert

Describe your clinical practice:

I work at the University of Florida Health Rehab Centers at Magnolia Parke and Medical Plaza, an outpatient clinic which is part of the large teaching hospital in Gainesville, FL. I head up the Pelvic Health team which consists of seven therapists. We treat pelvic and abdominal conditions in females, males and children. It is very exciting to be a part of such an enthusiastic, knowledgeable and creative team. Due to the fact we are a teaching hospital we get to see some of the most complex patients imaginable which come from all over.


How did you get involved in the pelvic rehabilitation field?

Oct 09, 2014

Earlier this year, the Food and Drug Administration issued a warning about serious side effects of laxatives if not used according to the label or when used in the presence of certain comorbities. Sodium phosphate laxatives, according to the label, are to be taken as a single daily dose, and for no more than three days. In addition to the warning to contact a physician if the patient has kidney disease, cardiac conditions, or dehydration, the FDA advises patients to ask their physician before taking the drug with age older than 55, or when taking certain medications. These medications include: diuretics, angiotensin-converting (ACE) inhibitors, angiotensin receptor blockers (ARBs), and nonsteroidal anti-inflammatory drugs (NSAIDs).


Laxatives are grouped into different classes and have varied effects on a person's gastrointestinal system. The following is adapted from the Mayo Clinic's website and describes the main types of laxatives.


Laxative Type
Brand Example

Oral osmotics Draw water into the colon to improve passage of stool Miralax
Oral bulk formers Absorb water to form soft, bulky stool Metamucil
Oral stool softeners Add moisture to stool Surfak
Oral stimulants Trigger rhythmic contractions of intestinal wall Senekot
Rectal stimulants Trigger rhythmic contractions of intestinal wall Dulcolax

Because laxatives can interact with medications, asking about medication lists (including supplements and herbals) is important for pelvic rehabilitation providers. Even the teas available at the grocery store that are marketed to help with digestion and specifically, constipation, may work well and may interact with a patient's medications. If you are interested in learning more about laxatives, constipation, and promotion of bowel health with rehabilitation techniques, sign up for the Bowel Pathology and Function continuing education course. This course, written by faculty member Lila Abbate, has been well-received and aims to further the knowledge of therapists who are treating patients with bowel dysfunction. The next course is coming up next month in California!

Oct 07, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Kim Krueger, MPT, BCB-PMD, PRPC


Kim Krueger

Describe your clinical practice:

I work at Courage Kenny Rehabilitation Institute in Stillwater, MN. It is an out-patient clinic specializing in treating clients with neurological and general orthopedic conditions. My pelvic rehabilitation practice includes both women and men with referrals from several Ob-Gyn groups, Urologists and general practice physicians. Our facility also has a large, warm water pool in which I spend the other half my day treating clients primarily with chronic pain and orthopedic conditions. I have a very interesting mix of clientele and am never bored!


How did you get involved in the pelvic rehabilitation field?

Oct 06, 2014


What are the spontaneous mental images that women who have chronic pelvic pain report, and how might the positive or negative mental images relate to chronic pelvic pain? These questions are the focus of research published by authors from the UK in the journal Pain Medicine. Mental images are distinguished in this study from thoughts, or thinking in words, as mental images are "cognitions with sensory-perceptual qualities." These qualities are often visual, and may also be related to smell, touch, taste, and hearing. Ten women were interviewed, 8 of whom had a diagnosis of endometriosis or adenomyosis. The researchers explained that they wanted to learn more about the women's thoughts when in pain, and asked about any images that popped into their heads when in pain. Researchers asked other questions about images related to specific categories, while attempting to avoid offering any leading words during their interview. The patients' most significant mental image (chose by the patient) was then explored for content, triggers, related emotion, meaningfulness, activity impairment, and related behavioral changes.


Other data collected included the Brief Pain Inventory short form, the Pain Catastrophizing Scale, the Spontaneous Use of Imagery Scale, the Hospital Anxiety and Depression Score, and the Mini-International Neuropsychiatric Interview. The range of pain duration in the subjects was 3-20 years, with a mean age of 36.2. While every one of the ten women reported that pain was a trigger, other triggers for a negative mental image included movement, social gatherings, exercise, babies, anxiety, sex, sleep, talking about pain, and reminders of surgery or menstruation- in other words, common daily activities or experiences. The content of the most significant mental images included being raped, having "malicious demons" playing around the pelvis, bright lights in an operating room, being terrorized, feeling sad, helpless, anxious, angry, panicky, guilty, disgusted, horrified, and revulsed. The associated meanings were usually also quite negative in nature. The women reported active avoidance of the triggers when able, limiting activities such as social outings or physical activity. Positive or "coping" images were also reported, with images such as putting the pain into a box, mentally "rubbing pain" medication on the body, or imagining a loved one.


What does this information have to do with pelvic rehabilitation? This study utilized a cognitive-behavioral (CBT) framework, and aspects of CBT are tools that rehabilitation professionals utilize in daily practice. Simply put, a cognitive-behavioral approach addresses how a person's thoughts and feelings affect behavior. In rehabilitation, research studies have described how CBT is utilized in the physical therapy setting, and how therapists can be trained to use skills in CBT to help patients . We can engage patients in conversations about what negative images may be impacting movement, and what positive images may be utilized as healthy coping strategies. For more information about the mind and patient education, join us at Carolyn McManus's continuing education course Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain which takes place next month in Seattle.

Oct 03, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Kristi Ayars, PT, DPT, PRPC.


Kristi Ayars

Who/what inspired you to become involved in pelvic rehabilitation?

I knew it could be done, so after moving from Washington back home to California in late 2003, when a patient came in with a chief complaint of leakage I asked around and found out nobody here was doing pelvic physical therapy. I jumped right in. I took the Level 1 class and every other pelvic floor class that came along for the first 5 years while seeing an ever-increasing number of people needing pelvic floor therapy. Then, I had to restrain myself to only one or two classes a year. Now, almost 11 years later, just having done a huge literature update and after passing the PRPC I have a renewed sense of awe that there is so much to offer people based on evidence.


What patient population do you find most rewarding in treating and why?

Oct 03, 2014

Dorsal Sacral Ligament

Several researchers have contributed to foundational literature in trunk control including Richardson, Snijders, and Hull. One study of interest completed by these authors and other colleagues assessed sacroiliac joint stability with contraction of the transversus abdominis muscles compared to contraction of all the lateral trunk muscles.


In this experiment, 13 healthy subjects without a history of low back pain participated in the tests. Eight men and five women with a mean age of 26 and who were able to complete the required muscle activations participated in the study. The subjects were positioned in prone, and electromyographic recordings as well as ultrasound imaging were used to verify the muscle activation patterns. To measure sacroiliac joint stiffness or laxity, Doppler imaging of vibrations was utilized. The theory of using vibration to measure joint stiffness includes that a transfer of vibration across a joint is best when the joint is more stiff, according to the authors.


The results of the study include a decrease in laxity (or an increase in stiffness) in the sacroiliac joint when either muscle patterns were used, however, when the transversus only was activated, laxity was decreased more than during a more global contraction.


Oct 02, 2014


The Herman & Wallace Pelvic Rehabilitation Institute is excited to offer continuing education courses this year in mindfulness and in meditation, which are not necessarily one in the same. However, each has a relationship with the other, and may be combined into lovely practices. More importantly, you may be wondering, "How does mindfulness fit into pelvic rehab?" Mindfulness or meditation has been applied to many pain diagnoses, and even to pelvic rehab conditions such as bowel or bladder dysfunction, and pelvic pain. (For some interesting reading about mindfulness and meditation, check out the National Center for Complementary and Alternative Medicine's website by clicking here.


In this Canadian study, 14 women participated in four sessions of mindfulness and cognitive behavioral therapy tailored to women with provoked vulvodynia (PVD). The sessions were spaced 2 weeks apart, and each session was 2 hours in length. The program included education in PVD and in pain neurophysiology, cognitive behavioral skills ("identifying problematic thoughts"), progressive muscle relaxation (contract-relax), and mindfulness exercises. The mindfulness exercises included eating meditation, mindfulness of breath, body scan and mindfulness of thoughts. The goal of this particular research article was to describe the women's thoughts about participation in the study activities. The authors report on six major themes from the study:

1)Feeling more normal and part of a community in the group setting
2)Positive psychological outcomes
3)Impact of relationship (supportive versus unsupportive partner)
4)Feeling of gratitude for group facilitators
5)Concern about barriers to continuing their mindfulness practice
6)Feelings of self-efficacy in being able to exert control over their pain


One of the major themes expressed by the participants in this study is that of feeling more "normal" through finding out that other women have the same symptoms and knowing that there are a myriad of symptoms associated with vestibulodynia. By participating in the study, women reported having improvements in self-esteem and feeling more optimistic about their challenges with physical activities such as sexual relationships. Carloyn McManus, who has degrees in both physical therapy and psychology, shares her expertise in our new course: Mindfulness-based Biopsychosocial Approach to the Treatment of Chronic Pain. The next opportunity to take this mindfulness continuing education course, and learn skills that you can immediately apply in mindfulness is this November in Seattle.

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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Oct 24, 2014 - Oct 26, 2014
Location: Marathon Physical Therapy

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College

Pelvic Floor Level 2B - St. Louis, MO
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic

Pelvic Floor Level 3 - Derby, CT
Dec 12, 2014 - Dec 14, 2014
Location: Griffin Hospital

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performace Center

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center

Pelvic Floor Level 3 - Fairfield, CA
Mar 13, 2015 - Mar 15, 2015
Location: NorthBay HealthCare