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Jun 18, 2014

Fascia is finally getting proper respect, rather than being that "white stuff" that was cut away during anatomy labs. Researchers continue to explore the cellular mechanisms and the total body functions that require healthy fascial layers. Fascial planes and connections are increasingly considered in strengthening programs as well, rather than only being considered in the design of stretching or flexibility programs. Tom Myers author of Anatomy Trains, and student of Rolfing founder Ida Rolf, contributes not only to the anatomical knowledge of therapists, but also to the functional applications of fascia in daily life and in exercise regimens.


Within the world of exercise training and physical fitness, muscles have often been considered in isolation, as is pointed out in this article written by Tom Myers in IDEA Fitness Journal. Yet muscles rarely work functionally as an isolated structure. Consider this fact when teaching pelvic floor muscle training. How many times have you instructed a patient to utilize thigh adductor muscles, exhale (respiratory diaphragm), or activate transversus abdominis to augment or facilitate the pelvic floor? While there is value in requesting that a patient focus on or emphasize a pelvic muscle contraction, or in teaching a patient to quiet dominant abdominals or gluteals, rarely do we find it effective to teach total isolation of a muscle in functional re-training.


Mr. Meyers uses anatomical information to drive the emphasis on fascial training, pointing out that there are ten times more sensory nerve endings in fascia than in muscles, and describes fascia as requiring our knowledge of accurate anatomy to engage the fascial planes as an "organ system of stability." Myers makes the case that fascia responds better to variation than to a repeated program when aiming to build fascial resilience. Varied tempo, varied loads, and varied movements are key to improving fascial health and efficiency. Integration of kinesthetic awareness via the fascial tissues rather than the muscles is also an important concept that is discussed- bringing awareness to movement through skin and superficial tissue movement rather than directing attention only to joint motion is another concept proposed for advancing movement training programs.


Considering these concepts may or may not change how you are currently designing your patients' fitness and rehabilitation programs, depending upon how you were trained and upon how you have continued to access continuing education and research. Breaking old habits and re-learning how to train movement does take effort on the part of the rehabilitation therapist, and fortunately, many instructors are integrating concepts of fascial planes into coursework. One such course that focuses clearly on integrating fascial training into sports-specific rehabilitation is Biomechanical Assessment of the Hip and Pelvis taking place this August in Arlington, Virginia. Instructor Steve Dischiavi, physical therapist and athletic trainer to the Florida Panthers, offers an excellent course that includes exercise concepts specific to the idea of fascial "slings" and that is sure to add some new exercises to your tool bag.

Jun 16, 2014



A recent literature review addressing the effectiveness of yoga for depression reports that the positive findings are promising. The 2007 National Health Interview Survey (NHIS) found that yoga was one of the top 10 complementary health approaches used among adults in the United States. (The linked page for the NHIS also includes a video of the scientific results of yoga for health.)


Yoga is not only about bodies bending- ancient yoga traditions offer physical, mental, and spiritual techniques that are designed to be holistic in nature. Many instructors in the US focus on the many physical benefits of yoga, yet there are many types of yoga, many instructors with varied levels of training, and many health issues that require an individualized program of yoga therapy. In relation to the potential effects of yoga on depressive symptoms, theories in neurobiology point to the potential positive effects on the HPA (hypothalamic-pituitary-adrenal) axis, according to the linked article by Lila Louie.


While none of the articles described in the literature review are specific to the one patient group or population, the subjects studied include incarcerated women, older patients, university students, and patients from the general population who struggle with depression. One group of patients known to be at risk for severe depression is postpartum women. The definition of postpartum varies, and a generous definition may include any issue that, once imparted in a postpartum period and left unaddressed, could persist throughout a woman's lifetime. This is commonly seen in the clinic as uncorrected postural dysfunction, pelvic floor dysfunction, or gait changes, for example.

Jun 13, 2014



While information about "core" strengthening and pelvic dysfunction can be found in the athletic literature, often there remains a disconnect between the level of depth of knowledge among many of the coaches, trainers, and athletes when related to issues of urinary continence. The prevalence of urinary and fecal incontinence related to impact sports has been established, and it has been determined that having children is not a necessary precursor to developing symptoms of leakage. It has been my experience that the term "athlete" can mean different things to different professionals. For example, Institute founder Holly Herman has always been adamant about mothers as "athletes" regardless of the level of sport involved; the simple act of lifting strollers, car seats, children, grocery bags, and kneeling, squatting, lunging involved requires a significant level of athletic ability. With this in mind, knowing the actual requirements of the typical daily activities of any patient is critical to providing a meaningful rehabilitation approach.


So how is the pelvic floor related to athletics? Faculty member Michelle Lyons addresses this question in her new course (offered for the first time in the US this August in Ohio) titled The Athlete and the Pelvic Floor. The course is designed to "bridge the gap between pelvic floor therapists and sports medicine practitioners." Gender and sport specific issues will be covered, and participants will have the opportunity to combine concepts from respiratory, pelvic, and orthopedic perspectives.


With regards to urinary incontinence in female athletes, pelvic floor rehabilitation has been demonstrated to be an effective approach. In a study by Rivalta et al., three nulliparous women described urinary leakage during sport (volleyball) and daily life. Intervention included functional electrical stimulation with internal sensor completed 20 minutes 1x/week using a 50 Hz frequency, biofeedback 1x/week for 15 minutes, pelvic floor muscle exercises, and pelvic floor muscle exercises with a vaginal cone, all for three months. The vaginal cones were weighted, of three different weights, and used for up to 10 minutes at a time. Treatment adherence was recorded by a physician at a weekly visit. The pelvic floor muscle strengthening protocol used the "Kegel" protocol from 1952- at least 300 pelvic floor muscle contractions/day divided into six sessions, avoiding coactivation synergies. The chosen protocol is interesting to note as most therapists trained in pelvic rehabilitation would choose a functional approach to exercising, with less emphasis on avoiding co-contractions as long as the patient performs pelvic muscle contractions appropriately. The combination of biofeedback, and electrical stimulation, and cones is also not typical, yet is evidence that pelvic muscle strengthening in a relatively short period of time can ease symptoms of leakage with functional activities.

Jun 12, 2014

Pudendal nerve dysfunction, when severe, is truly one of the most difficult conditions treated by pelvic rehabilitation providers. While peripheral nerve dysfunction anywhere in the body can be challenging to treat, access to the nerve along its many potential sites of irritation is limited when compared to other peripheral nerves. Many research studies have been completed that investigate how structures like the median nerve move in the body, and to what extent the nerve movement changes in cases of dysfunction, yet we still have very little to work with regarding the pudendal nerve. Little, that is, except anatomical knowledge, nerve and tissue mapping and palpation skills, expert listening and evaluation skills, and an abundance of existing and emerging methodology directed to treatment of chronic pain conditions.


The Neuro Orthopaedic Institute (also known as the NOI group)has led the physiotherapy world in seeking and sharing knowledge about the evaluation and treatment of conditions involving the nervous system. In a prior posting within the "noinotes" available as a newsletter from the NOI group, the following is stated: "…for the best clinical exposure of a peripheral nerve problem, take up the part that you think holds the problem first and then progressively add tension to the nerve via the limbs." Let's say, for example, that you gently tension the pudendal nerve by completing an inferior compression of the right levator ani muscle group (towards the lateral portion of the muscle belly versus at the midline). At this point, what limb movement should be performed to increase tension to the nerve? Does a straight leg raise tension the nerve, or hip rotation, hip adduction? What evidence do we have that this nerve tension increases in terms of elongation of the peripheral nerve, and by what connective tissue attachments is this tension proposed to occur? And for using order of movement in the clinic, do we start with a pelvic muscle bearing down or contraction, then add trunk or limb movements?


The "Ordering nerves" post describes listening "…to the patient about the sequence of movements which aggravate them.." so that with clinical reasoning, for evaluation or treatment, the nerve symptoms can be reproduced to an appropriate extent. For example, if a pelvic muscle contraction significantly aggravates a patient's nerve-like symptoms, why should a patient be instructed, or allowed even, to do Kegel muscle exercises to a degree that causes significant pain? If a patient has low grade, annoying symptoms that are only reproduced with posterior pelvic floor stretch combined with an anterior pelvic tilt and passive straight leg raise with internal rotation of the hip, then that position should be incorporated into a clinical and a home program if able.


Just because we don't yet know how patients with true pudendal nerve dysfunction present clinically in terms of nerve gliding ability, and what movements typically engage particular portions of the nerve (such as the proximal portion in the posterior pelvis, the portion that lives along the obturator internus, the portion housed by the Alcock's canal, or even the longest portion of the nerve that extends to the genitals), that does not mean we should default to a one-size-fits-all pelvic muscle strengthening or stretching approach. Each patient must be met with curiosity, and with keen knowledge of anatomy, nerve evaluation principles, and pain-brain centered skills so that an individual approach is designed. As is concluded in this post from the NOI group, we must "Keep playing with order of movement."

Jun 09, 2014

The goals of a recent research article were to determine the degree to which lower urinary tract symptoms (LUTS) are related to quality of life (QOL) and also the reliability of parents to accurately report on QOL disturbance in children who have urinary incontinence (UI). Outcomes tools utilized in the study include the Dysfunctional Voiding Symptom Score (DVSS) and the Pediatric Urinary Incontinence QOL tool (PIN-Q). Parents of forty children ages 5-11 (10 males and 30 females) and diagnosed with non-neurogenic daytime wetting completed the outcomes tools and responded to open-ended questions about incontinence and QOL. All children had daytime wetting, more than 50% of them had recurrent urinary tract infections (UTI's), and 89% reported urinary urgency.



According to the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), night-time wetting affects 30% of children who are 4 years of age, with the condition resolving in about 15% of children each year. Additionally, wetting at night persists in about 10% of 7 year-old, 3% of 12 year-olds, and 1% of 18 year-olds. A summary handout about Urinary Incontinence in Children is available here.


The study found that parents were reliable in reporting quality of life and symptoms in their children, as the outcomes scores completed were not different between them. (I would point out that nearly all parents involved were the patient's mothers; and it may be interesting to know more information about how the responsibility of managing urinary incontinence in children is shared among parents or caregivers.) Confirmed in the research was the knowledge that urinary dysfunction in children causes significant quality of life impact.


Jun 06, 2014


Sacroiliac joint pain can be a challenging condition to treat. One of the clinical pearls that I feel changed my practice for the better is the palpation and direct treatment of the dorsal sacral ligament. At a course many years ago, I listened to Diane Lee describing some of Andry Vleeming's work addressing the potential role of the long dorsal sacral ligament (LDL) in pelvic pain. His valuable research was conducted in women who had complaints of peripartum pain, and it has been my experience that the information is easily extrapolated to other patient populations. 



Vleeming and colleagues describe the long dorsal sacroiliac ligament anatomy as attaching to the lateral crest of the 3rd and 4th sacral segments (and sometimes to the 5th segment), and as having connections to the aponeurosis of the erector spine group, the thoracolumbar fascia, and the sacrotuberous ligament. Functionally, nutation in the sacroiliac joint will slacken the ligamentous tension in the LDL and counternutation will tension the ligament. This structure can be palpated directly caudal to the posterior superior iliac spine (PSIS).



Jun 04, 2014

Carolyn McManus


In the world of pelvic rehabilitation, brain morphology has been a hot topic for several years. Research has identified changes in various brain structures in patients who have specific conditions: irritable bowel syndrome, chronic pelvic pain, among others. (See prior blog about the brain, pain, and pelvic rehab by clicking here.) The research related to meditation is deep and rich, and the medical system continues to acknowledge the potential health benefits and cost savings from this simple technique that requires no equipment. The National Center for Complementary and Alternative Medicine (a division of the National Institutes of Health) states that meditation may work through effects on the autonomic nervous system. The nervous system in turn regulates functions such as breathing, heart rate, and digestion. 


I had the opportunity in 2006 to take a course titled Mindfulness-Based Strategies for Relaxation and Stress Management from Carolyn McManus. In addition to discussing an abundance of research from a variety of disciplines, Carolyn taught us practical strategies and clinical approaches for patient care. She also instructed us in mindfulness techniques so that we increased our own skill set. Carolyn has instructed similar strategies to health care providers from many disciplines and to her patients, many of whom have tried years of other types of therapy. Since that time, I have constantly recommended the CD's that Carolyn created for patients, and with the many approaches she has (including contract-relax and autogenic retraining) I have found that there is something for everyone. The Institute is honored to host Carolyn's continuing education course, Mindfulness-Based Biopsychosocial Approach to the Treatment of Chronic Pain this November in Seattle. Keep in mind that the course is open to many disciplines- would this be a great course to take your student to, or to invite a referral source to attend with you? Undoubtedly, this course will offer beneficial information not just for the patients, but also for the participants to use in their own daily self-care. 


 In addition to Carolyn's new offerings, we are thrilled to host a course that is taught by siblings who represent the fields of physical therapy and psychiatry. How wonderful it will be to hear from Nari Clemons, PT, and Shawn Sidhu, MD, expert clinicians who treat patients from their own perspectives, and to be able to receive information from these different view points. You can sign up for the Meditation and Pain Neuroscience continuing education course taking place in Illinois in September. You can also read about Nari and Shawn's new course in Nari's recent blog post

Jun 03, 2014

Abnormal hip joint development causes 25-50% of all hip disease, according to an article by Goldstein and colleagues on hip dysplasia in the skeletally mature patient. An acetabulum that is dysplastic tends to be shallow and anteverted while the dysplastic femur tends to have a small femoral head and an increased neck shaft angle. These abnormalities cause increased joint contact pressures and lead to joint breakdown in the hip, and are associated with issues such as altered hip and knee biomechanics, hip instability, hip impingement, and labral or chondral dysfunction.



Developmentally, the altered joint surface contact also affects acetabular development: the well-formed contact pressure in healthy hip development helps to deepen the acetabulum. The shape and position of the acetabulum and femoral head will also influence the relative angle of the femoral neck, represented as retroversion or anteversion. Soft tissue changes occur in response to the altered bony mechanics that affect length-tension curves in the muscles and therefore affect muscle performance. Because of the primary and secondary dysfunctions that can occur with hip dysplasia, early recognition of hip dysfunction is important. 



Measurements for hip position are easy to implement in the clinic and can include Craig's Test for femoral anteversion/retroversion. Treatment approaches focusing on hip abduction strengthening have been demonstrated to improve hip stability in patients with dysplastic hip. With shared structures including muscles between the hip and pelvis, pelvic rehabilitation providers must be able to assess the hip's influence on conditions of pelvic pain or other dysfunctions. To learn about detailed examination and treatment of the hip, there is still time to register for the Institute's upcoming continuing education course instructed by Ginger Garner.

May 31, 2014

The addition of the International Fascia Research Congress onto the scene of educational conferences has ignited an increased focus on understanding how fascia works in the body. Of course, we know fascia plays a role in compartmentalizing and separating various structures in the body, yet we also know that fascia must allow communication with the rest of the body. Is fascia simply a structural tissue that plays a mechanical role? Or does fascia hold memories, accessible during bodywork, as discussed in this article



It may seem logical that fascia could contribute to compressive forces on the skeleton, on muscles and neurovascular structures, possibly contributing to musculoskeletal disease. Is myofascial tension sufficient to cause enough mechanical stress to create micro-damage and histochemical responses? Can this then lead to ankylosing spondylitis or axial spondyloarthritis, as discussed in this article published in Arthritis Research & Therapy?  And if fascial thickness and tension is a proposed culprit of conditions such as compartment syndrome, why did these researchers find no correlation and in fact a negative correlation between fascial stiffness in patients with compartment syndrome? 



Do we really know the implications of fascially-directed assessments and interventions at this time? Is the research on fascial therapy being interpreted correctly if science is still trying to figure out what fascia is, how fascia works, how fascial forces affect the body and body functions? If we don't yet understand the intricacies of the neurophysiological mechanisms that drive fascia, should we jump to conclusions about the science that may or may not be measuring the right variables? (To this end, is a test of the fascial strength meaningful if taken from a biopsy now that the tissue is disconnected from the nervous system?)

May 29, 2014

Research led by Mei Fu, associate professor of Chronic Disease Management at New York College of Nursing, offers support for a preventive approach to lymphedema following breast cancer treatment. 140 women who were followed for 12 months were included in the study and outcomes included limb volume measurement from baseline (prior to surgery), 2-4 weeks post-surgery, and at 6 and 12 months. Lymphedema was defined in the study as a 10% or greater increase in limb volume. 134 women completed the study, with 97% maintaining limb volume. 




Of the subjects studied, axillary lymph node dissection was completed in almost 60%, and approximately 40% had sentinel lymph node biopsy. The self-care strategies in the research included shoulder mobility exercises, muscle-tightening deep breathing, muscle-tightening pumping exercises, and large muscle group exercise such as walking, swimming, yoga) to promote lymph health. The participants were also instructed in nutritional information aimed toward maintaining body mass index (BMI.) 97% of the women were also able to maintain BMI at the 12 month follow-up.



Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Minneapolis, MN (SOLD OUT!)
Jul 25, 2014 - Jul 27, 2014
Location: Abbott Northwestern Hospital

Athlete and the Pelvic Floor - Columbus, OH
Aug 02, 2014 - Aug 03, 2014
Location: OhioHealth Neighborhood Care Rehabilitation

Pudendal Neuralgia - San Diego, CA
Aug 09, 2014 - Aug 10, 2014
Location: Comprehensive Therapy Services

Biomechanical Assessment - Arlington, VA
Aug 16, 2014 - Aug 17, 2014
Location: Virginia Hospital Center

Yoga as Medicine for Labor and Delivery and Postpartum - Seattle, WA
Aug 16, 2014 - Aug 17, 2014
Location: Pilates Seattle International

Pediatric Incontinence - Greenville, SC
Aug 23, 2014 - Aug 24, 2014
Location: Proaxis Therapy

Pelvic Floor Level 1 - St. Louis, MO (SOLD OUT!)
Sep 05, 2014 - Sep 07, 2014
Location: Washington University School of Medicine

Meditation and Pain Neuroscience - Winfield, IL
Sep 06, 2014 - Sep 07, 2014
Location: Central DuPage Hospital Conference Room

Visceral Mobilization Level Two - Boston, MA
Sep 12, 2014 - Sep 14, 2014
Location: Marathon Physical Therapy

Coccyx Pain - Nashua, NH
Sep 13, 2014 - Sep 14, 2014
Location: St. Joseph Hospital Rehabilitative Services

Visceral Mobilization of the Urologic System - Scottsdale, AZ
Sep 19, 2014 - Sep 21, 2014
Location: Womens Center for Wellness and Rehabilitation

Care of the Postpartum Patient - Maywood, IL
Sep 20, 2014 - Sep 21, 2014
Location: Loyola University Stritch School of Medicine

Pelvic Floor/ Pelvic Girdle - Atlanta, GA
Sep 27, 2014 - Sep 28, 2014
Location: One on One Physical Therapy

Assessing and Treating Vulvodynia - Waterford, CT
Sep 27, 2014 - Sep 28, 2014
Location: Visiting Nurses Association - Southeastern

Pelvic Floor Level 2B - Durham, NC
Oct 03, 2014 - Oct 05, 2014
Location: Duke University Medical Center