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Feb 27, 2015

Blog by Holly Tanner

A US study published in the International Society for Sexual Medicine last year reports on the available evidence linking cycling to female sexual dysfunction. In the article, some of the study results are summarized in the left column of the chart below. On the right side of the column, we can consider ideas about how to potentially address these issues.




Examples of Research Cited
Ideas for Addressing Potential for Harm
dropped handlebar position increases pressure on the perineum and can decrease genital sensation encourage cyclists to take breaks from dropped position, either by standing up or by moving out of drops temporarily
chronic trauma can cause clitoral injury encourage cyclists to wear appropriately padded clothing, to apply cooling to decrease inflammation, and to use quality shocks or move out of the saddle when going over rough roads/terrain when able
saddle loading differs between men and women women should consider specific fit for bike saddles
women have greater anterior pelvic tilt motion is pelvic motion on bike demonstrating adequate stability of pelvis or is there a lot of extra motion and rocking occurring?
lymphatics can be harmed from frequent infections and from groin compression patients should be instructed in positions of relief from compression and in self-lymphatic drainage
pressure in the perineal area is affected by saddle design, shape female cyclists with concerns about perineal health should work with a therapist or bike expert who is knowledgeable about a variety of products and fit issues
unilateral vulvar enlargement can occur from biomechanics factors therapists should evaluate vulvar area for size, swelling, and evidence of imbalances in the tissues from side to side, and evaluate bike fit and mechanics, encouraging women to create more symmetry of limb use
genital sensation is frequently affected in cyclists, indicating dysfunction in pudendal nerve therapists should evaluate female cyclists for sensory or motor loss, establishing a baseline for re-evaluation

Because women tend to be more comfortable in an upright position, the authors recommend that a recreational (more upright) versus a competitive (more aerodynamic and forward leaning) position may be helpful for women when appropriate. Although saddles with nose cut-outs and other adaptations such as gel padding in seats are discussed in the article, the authors caution against making any distinct recommendations due to the paucity of literature that is available. The paper concludes that more research is needed, and particularly for considering the varied populations of riders ranging from recreational to racing.


Feb 26, 2015

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in March!


Ginger Garner

Lots of you have reached out with questions about “best care” practices after hip surgery. There isn’t a whole lot in scientific literature written about rehab, and over many months of fielding questions on my closed HIP LABRAL PHYSIOTHERAPY FB page, I am finally ready to share what Best Care Practices after Hip Labral Surgery may look like.


Today is Post 1 of this series, which will follow me day-by-day, week-by-week, through the highs and lows of my recovery and rehabilitation. Here we go!


Feb 25, 2015

Blog by Holly Tanner

An important survey completed in Australia asked if prenatal pelvic floor function and dysfunction relates to postnatal pelvic floor dysfunction (PFD). Interestingly, the authors propose that "…damage to the pelvic floor is probably made before first pregnancy due to congenital intrinsic weakness of pelvic floor structures." Many of the patients involved in the study had dysfunction in more than one domain of pelvic health, with the authors recommending a comprehensive approach to the evaluation of pelvic floor dysfunction.


As part of the large study called the Screening for Pregnancy Endpoints study, or SCOPE, a prospective cohort study called Prevalence and Predictors of Pelvic floor dysfunction in Prenips, or 4P, was also completed. The 4P research (n = 858) contained 2 different studies including a questionnaire-based survey and a detailed clinical assessment. The survey utilized the Australian pelvic floor questionnaire which was administered at 15 weeks gestation and at 1 year postpartum. The Australian questionnaire scores items on domains of urinary dysfunction, fecal dysfunction, pelvic organ prolapse, and sexual dysfunction. When the participants answered the questionnaire the first time, all answers were directed to be answered for symptoms they experienced prior to being pregnant.


The results indicated that at 1 year postpartum, 90% of the women in this study reported pelvic floor dysfunction. Regarding the domains of bladder, bowel, prolapse and sexual symptoms, 71% of the participants reported symptoms from more than 1 of these domains, 31% from 2 domains, 24% from 3 sections of the survey, and 8% from all four sections. Other interesting statistics are as follows:


Feb 24, 2015

Blog by Holly Tanner

Results from a national survey of surgeons published in 2010 offers insights into the challenges that providers and patients face in addressing the complications caused by post-surgical adhesions. The survey included 55 multiple-choice questions, four open-ended questions, and four optional questions. The questions were posed to Dutch surgeons and trainees and included information about awareness of adhesions, use of anti-adhesive agents in surgery, informed consent, and benefits versus risks of adhesions. The survey also included items with "correct" answers containing data from evidence-based information about post-surgical adhesions including the following:

-postoperative adhesions are the cause of 70% of small-bowel obstructions-there is a 5% readmission rate after colorectal surgery related to postoperative adhesions

-there is approximately a 30% readmission rate following abdominal surgery due to adhesions

-adhesiolysis poses a 20% risk of accidental enterotomy

-a colonic total resection has highest rate of adhesion-related morbidity compared with partial small-bowel resection, appendectomy, or rectal resection

-being older than 60 is associated with less adhesions

Feb 23, 2015

Today the Pelvic Rehab Report caught up with instructors Bill Gallagher PT, CMT, CYT and Richard Sabel MA, MPH, OTR, GCFP to talk about their Integrative Techniques for Pelvic Floor & Core Function: Weaving Yoga, Tai Chi, Qigong, Feldenkrais and Conventional Therapies course being presented in Boston, MA this March 28 – 29. Check out their discussion of these awesome treatment techniques, including a free exercise regimen!


Bill Gallagher

Richard Sabel

Resurrecting the Dead Zone

When considering the board range of health issues that fall under the umbrella of pelvic dysfunction, we’ve observed that too many of our clients have PPA - poor pelvic awareness. Sure they’re cognizant of the pain, discomfort or distress associated with their particular issue, but in reality the pelvic region is, as Imgard Bartenieff described it, “the dead seven inches in most Americans’ bodies.” We’ve taken creative license here and call it “the dead zone.”


Feb 20, 2015

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Jaime Sepulveda, MD, PRPC.


Jaime Sepulveda

Describe your clinic practice:

I would describe my practice as female pelvic medicine and reconstructive surgery. I treat urinary and fecal incontinence, pelvic organ prolapse, bladder pain syndromes, recurrent urinary tract infections and dysfunctional disorders of the bowel and bladder.


How did you get involved in the pelvic rehabilitation field?

Feb 19, 2015

Prolapse Bladder

When considering rehabilitation of prolapse symptoms, therapists often implement an approach that addresses multiple factors related to pelvic health and function. Rehabilitation of prolapse symptoms may include bladder re-training, pelvic muscle strengthening, bowel health management, trunk and pelvic control strategies, avoidance of potential aggravating maneuvers such as bearing down, and education in management tools such as pessaries. As we have established in earlier posts in this 3-part series, each patient must be evaluated and treated with respect to her complaints and clinical findings. This post highlights a few of the many clinical research studies aimed at determining effectiveness of pelvic rehabilitation for prolapse symptoms.


In recent research, Hagen and colleagues completed a multi-center, randomized trial using parallel treatment groups to assess recovery from prolapse. Women with a stage I-III prolapse of any type confirmed by a physician using the POP-Q system and complaints of prolapse symptoms were the primary inclusion criteria. Women who had previously been treated by surgery for prolapse were excluded. The control group (n = 222) were given a prolapse lifestyle advice leaflet and no pelvic floor muscle training. The lifestyle advice included information about weight loss, constipation, avoidance of heavy lifting, coughing, and high-impact exercise. No information about pelvic floor muscle exercise was included.


The physiotherapy treatment group (n = 225) received up to 5 individualized sessions of pelvic floor muscle training over 16 weeks. The first appointments were scheduled closer together to allow for proper training in muscle education, with the latter appointments being spread further apart. Rehabilitation began with instruction in pelvic muscle anatomy and function. Exercises were instructed based on results of a pelvic muscle assessment, and exercises were progressed with a goal of up to 10, 10-second holds, and up to 50 quick contractions completed three times per day. Women were also instructed in a pre-contraction of the pelvic floor muscles prior to increases in intra-abdominal pressure. (Electromyography, electrical stimulation, or pressure biofeedback were not allowed among the interventions.)


Feb 18, 2015

This post was written by H&W founder and instructor Hollis Herman, DPT OCS WCS BCB-PMD IF AASECT PRPC, who authored and instructs the course, Sexual Medicine for Men and Women. She will be presenting this course this April in New Jersey!


Hollis Herman

This course is perfect to help you, the healthcare professional, feel comfortable and knowledgeable about all sorts of sexual issues. The course is fun, interesting and unlike any other you have taken.It has three parts.


Part 1: The first part is designed to help you get in touch with your attitudes, beliefs, values and biases regarding sexual function. There are questionnaires to fill out and bring with you to the course, movies to watch, and books to read. These questionnaires, movies, videos and books will bring up sexual subject matter, questions, images and ideas that may be controversial to you. You will be exposed to many variations in sexual activity and asked about your reactions, sexual development, upbringing, feelings and worries you may carry around.


Feb 17, 2015

Tai Chi

Tai chi is described in the National Center for Complementary and Integrative Health’s (NCCIH) introduction as a “moving meditation” that originated in China as a martial art. Slow, gentle movements are combined with awareness and breathing. To watch a demonstration of a short form of Tai Chi Chuan click here. The health benefits of Tai Chi have been studied for a variety of conditions, including research funded by the NCCIH. Examples of topics and populations studied in funded research include bone loss in menopause, cancer-related issues such as fatigue, depression, fibromyalgia symptoms, osteoarthritis, cardiovascular function, and other types of arthritis.


A systematic review published last year in Complementary Therapies in Medicine discussed the effects of Tai Chi on quality of life for patients with chronic conditions. Included in the review were 21 articles meeting the criteria of being a randomized, controlled trial, including adults with chronic conditions such as arthritis, asthma, cancer, COPD, diabetes, heart disease, or AIDS, with Tai Chi being the primary intervention that was assessed by an outcome measure. Of the seven studies evaluated for the musculoskeletal system, conditions studied related to post-menopausal osteoporosis, osteoarthritis, rheumatoid arthritis, or fibromyalgia. Quality of life questionnaires were completed by the patients using self-assessment forms.


Although the limitations in the study included poor recording of length of time of Tai Chi sessions, or lack of documentation of home program use of the exercise, Tai Chi was found to be a safe and simple approach that improved self-reported functions, both physiological and psychological. An additional benefit that is pointed out in this research is that Tai Chi requires no equipment or particular facility in which to practice.


Feb 13, 2015

Tarlov Cyst

Some of our patients will present with sacral or coccygeal pain, and the potential causes of this pain are numerous. One potential cause of sacrococcygeal pain is a Tarlov cyst, which occur when the nerve root sheaths are swollen and fill with cerebrospinal fluid. The condition can be very painful and can affect bowel, bladder, and sexual dysfunction due to the location of the nerves that may be compressed from the swelling. To learn more about the possible causes of Tarlov cyst formation, you can find a lot of information on the tarlovcystfoundation.org site. Symptoms might include low back and buttock pain, neurologic symptoms in the lower extremities, pain with sitting, and swelling over the sacral area. Pelvic dysfunction including bowel or bladder changes, rectal or vaginal pain, or painful intercourse can occur. The pain might worsen with forward flexion due to nerve tension, and pressure changes in cerebrospinal fluid can contribute to headaches or vision disturbances.


Unfortunately, most of our patients present with some or all of the above complaints, so how do we participate in the process of determining when the patient needs to return to a medical provider? In addition, these cysts might be discovered as an “incidental” finding on an imaging study, and the medical provider may complete further tests to determine if the cyst is causing the patient’s symptoms. The most important aspect of screening for dysfunction such as a Tarlov cyst, which can progress to significant neurologic impairment if symptomatic and eft untreated, is keeping track of our patient’s symptom progression and neurologic signs. Getting a baseline lower extremity neurologic screen for every patient with pelvic pain or dysfunction is an critical skill so that we can communicate any significant worsening or lack of progress to the medical provider. Such a lower extremity neurologic scan should include sensation testing, deep tendon reflexes, and signs such as Babinski and clonus tests.


Patients will also present to pelvic rehabilitation after having had a Tarlov cyst repair. Surgeries can include drainage of the cyst followed by use of a fibrin glue to occlude the cyst in hopes of preventing recurrence. The American Association of Neurological Surgeons points out on their website that surgery may not eliminate the patient’s symptoms, and care involving supervised pain management may be appropriate. From a rehabilitation standpoint, these patients may or may not be finding their way to a pelvic rehab practitioner. Is there a provider in your area who may be treating these patients and who is not aware that you have skills to offer? Interventions such as pain management strategies, modalities, movement therapy, manual therapy, treatment directed to neurodynamics, and general wellness education may all play a role in helping patients recover from procedures for Tarlov cysts.


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Upcoming Continuing Education Courses

Pelvic Floor Level 2B - Houston, TX
Feb 27, 2015 - Mar 01, 2015
Location: Texas Children’s Hospital

Pelvic Floor Level 1 - Bayshore, NY (SOLD OUT!)
Mar 01, 2015 - Mar 03, 2015
Location: Touro College: Bayshore

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

Pilates for the Pelvic Floor - Denver, CO
Mar 07, 2015 - Mar 08, 2015
Location: Cherry Creek Wellness Center

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

Male Pelvic Floor - Nashville, TN
Mar 14, 2015 - Mar 15, 2015
Location: Vanderbilt University Medical Center

Pelvic Floor Level 1 - Denver, CO (SOLD OUT!)
Mar 20, 2015 - Mar 22, 2015
Location: University of Colorado Hospital

Pelvic Floor Level 2A - Madison, WI (SOLD OUT!)
Mar 20, 2015 - Mar 22, 2015
Location: Meriter Hospital

Coccyx Pain - Torrance, CA
Mar 28, 2015 - Mar 29, 2015
Location: HealthCare Partners - Torrance

Hip Labrum Injuries - Houston, TX
Mar 28, 2015 - Mar 29, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Seattle, WA (SOLD OUT!)
Apr 03, 2015 - Apr 05, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Myofascial Release for Pelvic Dysfunction - Tampa, FL
Apr 10, 2015 - Apr 12, 2015
Location: Florida Hospital - Wesley Chapel

Lymphatic Drainage for Pelvic Pain - Scottsdale, AZ
Apr 11, 2015 - Apr 12, 2015
Location: Evolution Physical Therapy

Assessing and Treating Vulvodynia - Minneapolis, MN
Apr 11, 2015 - Apr 12, 2015
Location: Park Nicollet Clinic--St. Louis Park

Pelvic Floor Level 2B - Columbus, OH
Apr 17, 2015 - Apr 19, 2015
Location: Ohio Health