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Jan 23, 2015

Herman & Wallace is proud to feature Elizabeth Fiser, PT, DPT who has completed all four of the Herman & Wallace Pelvic Floor Series courses.


Kelly Carter

Describe your clinical practice

Currently I work in a hospital-based outpatient clinic in Mobile, AL. I see a mixture of patients ranging from urinary incontinence, pelvic pain, sacroiliac joint dysfunction, constipation, to fecal incontinence.


How did you get involved in the pelvic rehabilitation field?

Jan 22, 2015

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Menopause: A Rehabilitation Approach. She will be presenting this course this February in Florida!


Michelle Lyons

Compared to subject matter that has traditionally been offered in physical therapy curricula, such as musculo-skeletal and neuromuscular coursework, the concept of wellness is a relatively new addition to our skill-set (Fair 2009). ‘A Normative Model of Physical Therapist Professional Education’ includes educational objectives related to wellness, alongside objectives related to orthopaedics and neurology. As patients become increasingly educated about nutrition, complementary and alternative medicine, we as women’s healthcare providers must be able to assist our patients in seeking out healthy lifestyles. Nowhere has this surge in interest been more apparent than in women entering peri-menopause.


Historically, physical therapy has been associated with restoring physical fitness and wellness using manual therapies, exercise instruction and education about healthy lifestyle. Women’s health as a physical therapy specialty was formally established in the U.S. in the late 1970’s by Elizabeth Noble. Initially there was a focus on the reproductive health issues affecting women, primarily obstetrics and gynaecology but today’s physical therapist specializing in women’s health must be well versed in all aspects of menopausal health and wellness to meet the growing demands of women.


Jan 21, 2015

Are you eligible to become pelvic rehab certified?


The rigorous and psychometrically validated Pelvic Rehabilitation Practitioner Certification (PRPC) will be offered for the third examination this year. You still have time to join the nearly eighty practitioners who have earn their letters! (Keep in mind that, different from a "certificate", this certification allows you to use the designation "PRPC" after your name, helping to distinguish you as an expert in pelvic rehabilitation. In case you are uncertain if you are a candidate to sit for the PRPC examination, check out some commonly-asked questions below.


Types of practitioners: Do I have to be a physical therapist?


You do not need to be a physical therapist in order to apply for the PRPC exam. What is required is that you have a license to practice the skills utilized in pelvic rehabilitation. Such a license may include physician (MD, DO, ND), registered nurse (RN), occupational therapist (OT), advanced registered nurse practitioner (ARNP), or physician assistant (PA-C). Any other provider can apply and will be examined on a case-by-case basis.

Jan 20, 2015

This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course, Rehabilitation for the Breast Oncology Patient.


Susannah Haarmann

It is holistic and forward thinking for medical practitioners, such as physical and occupational therapists, to consider the interconnectedness of mind and body when creating an effective treatment plan. Today, it is generally accepted that stress weakens the immune system and, the American Medical Association reports that “80% of all diseases are stress related,” (1). Prolonged physical and emotional distress triggers the neuroendocrine system to secrete stress hormones which affect the immune system, specifically, decreasing T-cell production and lowering basal and interferon augmented NK cell activity (NKCA). Knowing this unlocks huge potential for cancer patients who wish to actively boost their immune system during treatment; one of these proven techniques is called mindfulness-based stress reduction (MBSR). A study performed by Witek-Janusek et al, demonstrated a significant increase in NKCA levels in breast cancer patients after just one month of participating in a MBSR program; this is significant because elevated NKCA levels correlate with a decreased incidence of lymph node metastasis and improved survival rates in women with breast cancer (6).


MBSR may be compared to meditation and in the west we are seeing an increased acceptance of patients and practitioners looking to eastern philosophy as an adjunct treatment to western medicine. In fact, yoga is one of the most commonly sought after complementary treatments for breast-cancer related impairments among survivors today (4). Yoga, as a practice, blends mindfulness and movement. Physical exercise and mindfulness practices have both independently been shown to have a positive effect on cancer outcomes (3,6), therefore, it makes sense that patients are seeking yoga during treatment and supports why yoga is beneficial for physical and occupational therapists to include in their tool box of effective interventions.


Jan 16, 2015

Herman & Wallace is proud to feature Kelly Carter, PT who has completed all four of the Herman & Wallace Pelvic Floor Series courses.


Kelly Carter

Describe your clinical practice.

Physical Therapy Connection, Inc. (PTC) in Mountain Home, AR, is a privately owned clinic set within the beautiful Ozark Mountains. The clinic is comprised of two physical therapists, Rowdy Kelly, an orthopedic specialist, and me, plus a physical therapy tech and two office staff. PTC features private, comfortable treatment rooms and houses a complete wellness center to encourage and assist patients in maintaining the gains made during their PT sessions.


How did you get involved in the pelvic rehabilitation field?

Jan 14, 2015

Female Superior Obturator

As a physical therapist I am continually amazed at the myriad of ways the parts of our bodies are connected (and even more so by our brain/body connections, but that is another blog post.) Take one of my favorite muscles for example, the obturator internus. This amazing muscle is known for its relationship to the hip as one of the external rotators, and it’s anatomy is impressive! What other muscle sharply turns ninety degrees from its attachment to its origin? The obturator internus traverses the inside of the pelvis and attaches mid-belly to an important tendon, the Arcuate Tendon Levator Ani (ATLA) , which becomes the means by which the obturator connects to the pelvic floor. (I love to show patients how their hip literally connects to their pelvis!) The ATLA connects with the Arcuate Tendon Fascia Pelvis which connects to the fascia supporting the bladder and urethra.

We know that in our patient who have pelvic pain too much tension or trigger points in the obturator internus can create symptoms of urinary urgency or frequency, pain in the bladder, vagina, rectum, abdomen, pelvic floor and hip. But what happens when the obturator internus is uptrained to treat women with stress urinary incontinence (SUI)? An article in the May/August 2014 Journal of Women’s Health looked at the role of strengthening the obturator internus and the adductors and compared the effects to working the pelvic floor for the treatment of women with SUI. The results were quite interesting.


This research was a pilot study comparing two randomly assigned groups of community dwelling women with SUI. A group of 12 completed resisted hip rotation (RHR) and a group of 15 completed pelvic floor muscle training (PFMT). Each group exercised at home for six weeks with a weekly recheck. Outcome measures included subjective reports of improvement, leak frequency, and scores from the Incontinence Impact Questionnaire (IIQ) and the Urogenital Distress Inventory (UDI). The exercise routines were supposed to take about 5 minutes and be performed twice a day. Subjects were instructed to sit with good posture and with their feet on the floor. The pelvic floor muscle group performed 5-second holds for 20 reps followed by 20 quick contractions. The RHR group exercised by 1) rotating internally and externally with diaphragmatic breathing for 10 breaths , 2) 10 repetitions of resisted hip external rotation with a green band and 5 second work/rest cycle and 3) 10 repetitions of hip internal rotation/adduction against a 9 inch ball with the same 5 second squeeze and rest cycles.


The results of the study showed that BOTH groups had significant and equal improvement in outcome measures by the end of the six weeks, but that the RHR group showed improvements sooner than the PFMT group. The authors discuss the limitations of their study: small sample size, large ranges of participant ages, patients were not medically examined, outcome measures were subjective, and the pelvic floor group only received verbal instruction. This study was thought provoking to me for several reasons. First, it gives me a great platform to talk with my non-pelvic health colleagues about treating pelvic floor weakness dysfunctions with indirect pelvic floor treatment. Virtually any patient could sit and roll their legs in and out against resistance! This exercise could be easily incorporated into a routine for people with bladder leakage or at risk for bladder leakage. Secondly, we often see patients with non-functioning pelvic floor muscles. My typical protocol before discussing the treatment option of electrical stimulation is to uptrain (increase muscle activity) with hip rotation, adduction and transverse abdominus muscle exercises. I have often found that I don’t need to address the pelvic floor directly when the accessory muscles are appropriately engaged. This study points out the importance of muscles outside of the pelvic floor in providing support for continence.

Jan 13, 2015

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


Amanda Alling

Describe your clinical practice:

I am the Clinical Director at Tidewater Physical Therapy’s Westchester Commons location in Richmond, VA. The clinic is Tidewater’s newest facility in Richmond opening in February of 2014. We see a variety of orthopedic conditions, gait and balance disorders, along with pelvic floor conditions.


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

Jan 12, 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

1. Early Intervention Is Key

Acetabular labral tears are reported to be a major cause of hip dysfunction in young patients and a primary precursor to hip osteoarthritis. New technology is helping with improved identification of tears, however the time of injury to diagnosis is still on average 2.5 years, making long-term prognosis for hip preservation poor.


Because of the lengthy delay many patients are still experiencing, the importance of early intervention cannot be overemphasized.

Jan 09, 2015


When examining a patient clinically for pelvic wall relaxation or pelvic organ prolapse, we know that verbal cues given, position of the patient, time of day, bladder fullness, and other variables can affect the outcome of the prolapse evaluation. What about the number of attempts at bearing down or straining during the examination? Is one attempt at bearing down enough to provide clear information about the level of descent or relaxation in the pelvic walls or organs? If research based on dynamic MRI's is any indication, the answer may be "no."


40 women with an anterior wall prolapse that extended at least 1 cm beyond the hymenal ring were evaluated with dynamic MRI scans. The subjects were instructed in and evaluated for their ability to properly bear down prior to the scans. Between the first, second, and third maximal efforts at bearing down, or Valsalva, bladder descent was measured during dynamic magnetic resonance imaging (MRI). In 95% of the women, prolapse measurements were more significant by the third effort at bearing down. 40% of the women demonstrated more than a 2 centimeter increase in prolapse from the first to third attempt at Valsalva. In this research study the mean age of the subjects was about 60 years old, and 80% of the women were Caucasian. Childbirth history averaged 2 vaginal births and eight of the women had a prior hysterectomy.


While the authors discuss the value of using this diagnostic information to create improved dynamic MRI protocols, there may also be implications for the pelvic rehabilitation provider. When we are assessing for the integrity of the pelvic supporting structures, are we getting a reliable effort from the patient? Are we asking for more than one attempt at bearing down? In addition to considering relevant issues like the time of day or the position of the patient during an examination, we can also consider the number of times that the testing is completed. If we ask for only one attempt at bearing down, perhaps we are not being provided with the most accurate information. What we do with that information is the next important step in developing a plan of care or communicating with the referring provider. In the Pelvic Floor Level 1 (PF1) continuing education course, therapists learn how to assess for pelvic organ prolapse, and in the PF2B course therapists learn additional information about the fascial layers that, when not intact, can contribute to pelvic organ displacement. Providing interventions that address myofascial dysfunction and functional use patterns of the trunk and limbs can help a woman overcome symptoms of prolapse, and working together with medical providers to help women with prolapse can be very rewarding.

Jan 08, 2015

Herman & Wallace is proud to feature Elisa Marchand PTA who has completed all four of the Herman & Wallace Pelvic Floor Series courses.


Elisa Marchand

Describe your clinical practice.

I work in a small, privately-owned office that is a women's only clinic. I signed on as the owner's first employee, and the process of working with her in the last year has been incredibly rewarding. She is a WCS through the ABPTS, and is incredibly supportive in my desire to sit for the PRPC exam. Her vision- as well as mine- for our community is to see women free from pain and the limitations that pelvic floor dysfunction can cause. We have so many untapped passions and dreams for the women in our area! Personally, I also have a passion for pregnant and newly postpartum women.


How did you get involved in the pelvic rehabilitation field? What/who inspired you to become involved in pelvic rehabilitation?

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Upcoming Continuing Education Courses

Menopause: A Rehabilitation Approach - Orlando, FL
Feb 21, 2015 - Feb 22, 2015
Location: Florida Hospital Sports Medicine and Rehabilitation

Breast Oncology - Phoenix, AZ
Feb 21, 2015 - Feb 22, 2015
Location: Spooner Physical Therapy

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

Special Topics in Women's Health - San Diego, CA
Feb 28, 2015 - Mar 01, 2015
Location: Comprehensive Therapy Services

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
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