This week The Pelvic Rehab Report sat down with new faculty member, Emily McElrath PT, DPT, MTC, CIDN, to discuss her pelvic rehab journey and her new course, Pregnancy and Postpartum Considerations for High-Intensity Athletics. Emily is a native of New Orleans, is highly trained in Sports and Orthopedics, and has a passion for helping women achieve optimal sports performance. Emily is also certified in manual therapy and dry needling, which allows her to provide a wide range of treatment skills including joint and soft tissue mobilization. She is an avid runner and Crossfitter and has personal experience modifying these activities during pregnancy and postpartum.

Hi Emily! Can you tell us a little bit about yourself and your clinical practice?

My name is Emily McElrath, and I am an orthopedic and pelvic floor PT. I spent the early years of my career in sports medicine and primarily worked with high school and collegiate athletes, as well as weekend warriors. I myself am a distance runner and Crossfitter and have always had a love for sports. After the birth of my second child, I had a hard time returning to Crossfit due to significant pelvic floor dysfunction and pain. At that time, I became a pelvic floor patient and quickly realized how valuable this specialty was. This began my journey to becoming a pelvic PT.

Since that time almost 4 years ago, I have been blending my orthopedic and pelvic health knowledge and skillset to help women return to the sports they love without pain and pelvic floor dysfunction.  My main goal as a clinician is to educate and empower my patients to feel in control of their own bodies, and to feel confident in daily and recreational activities.

What has your educational journey as a pelvic rehab therapist looked like and how did you get involved in the pelvic rehabilitation field?

It was really a matter of personal experience leading me to the field of pelvic health. I knew the specialty of pelvic health existed, but until I was a patient I did not truly appreciate how valuable it was. Seeing firsthand how significantly pelvic floor physical therapy could improve the quality of a patient’s life gave me a desire to become a pelvic PT. Once I got into my course work with Herman & Wallace, I realized that my background as an orthopedic PT would blend well with pelvic PT. It also gave me a lot of perspective into how significant of a role the pelvic floor plays in the entire kinetic chain. I would even say that my pelvic floor education has helped me be a more thorough orthopedic clinician. It has helped me think outside the box and enabled me to be more thorough in my critical thinking when evaluating patients.

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

I have two patient populations that I find most rewarding. The first is HIIT athletes. I find this population so fun to work with. They are some of the most dedicated and compliant patients I have. Their love of their sport is often a driving force for them to get and stay healthy. Many of these athletes will even come to my clinic without having pain or dysfunction. They are strictly coming for education and prevention, which I love. After all, PTs as a profession are huge proponents of wellness and prevention.  I also love teaching a patient that they can, in fact, continue doing exercises they may have been previously told were not safe to do during pregnancy or postpartum. Giving them hope that they can continue doing what they love after they were afraid they may not is very rewarding.

The second population I love working with is my childbirth prep patients. I LOVE education. I feel like these sessions really highlight that part of physical therapy. These sessions not only address any current concerns a patient is having but also provide education to give them the confidence to birth the way they want. I review everything from what to expect during labor, to different positions for pushing, and how to push. I even have partners come to the sessions so they can learn how to best support the patient during delivery. Hearing from patients that their birth experience was beautiful and just as they had hoped always gives me a lot of joy. I feel honored to be able to be a part of that journey.

What do you find is the most useful resource for your practice?

I find other practitioners the most valuable resource in my practice. There is so much that can be gained from collaborating with other pelvic PTs, doulas, midwives, OB/GYN, sex therapists, etc. Pelvic rehab is so multifaceted, that I believe it truly requires a collaborative approach to provide the best patient outcomes.

What books or articles have impacted you as a clinician?

There was a recent article that came out about the prevalence and significance of Levator Ani avulsion tears. This was an interesting article because I have seen this more and more clinically, but there is very little research on the matter. My favorite books as a clinician are: “The Body Keeps the Score”, “Come As You Are”, and “Pelvic Pain Explained”.

What lesson have you learned in a course, from an instructor, or from a colleague or mentor that has stayed with you?

 I think the biggest thing I have learned is that the objective findings of our evaluations are only a small part of the puzzle. Pelvic rehab is an intimate type of physical therapy, and many of our patients may have had trauma that is still raw to them. If most of your evaluation is spent talking with the patients to ensure they feel comfortable, that’s ok. I have realized that it’s ok if I don’t get to every objective test and measure in the first session. In this line of work, patient comfort is most important. Building a rapport with your patient must take precedent.

What made you want to create this course, Pregnancy and Postpartum Considerations for High-Intensity Athletics?

I wanted to create this course because I saw a need in the Crossfit community for more education on how to safely train pregnant and postpartum athletes, and I feel physical therapy is a great place to start, after all, PTs are experts in the musculoskeletal system. We are seeing more and more of these HIIT athletes becoming moms and wanting to maintain their athleticism throughout pregnancy & postpartum, and I think that’s great!

With that being said, I think there are nuances to training this athletic population. There are so many hormonal, anatomical, and structural changes to consider during pregnancy & postpartum, and that may affect how well an athlete can tolerate strain. However, most of these changes are not contraindications to training. Therefore, we as rehab practitioners and physical therapists need to fully understand the demands of  HIIT, as well as the specific considerations for this population so that we can keep them safely and effectively doing what they love.

What need does your course fill in the field of pelvic rehabilitation?

By and large, people do not fully understand the demands of HIIT activities like Crossfit unless they personally partake in these activities. This includes healthcare professionals like physical therapists. However, many of our pregnant and postpartum athletes will require the care of a  PT (especially pelvic) at some point throughout their pregnancy, and postpartum journey.

My course, Pregnancy and Postpartum Considerations for High-Intensity Athletics bridges the gap between education and experience, for those healthcare professionals who do not personally participate in HIIT to understand the demands of the sport. It also helps those physical therapists who do not specialize in pelvic health to understand the unique demands of this athlete population from a pelvic health perspective.

Who, what demographic, would benefit from your course?

Any PT, PTA, PT student, OT, COTA, or OT student who is looking to better understand the demands of HIIT,  the special considerations for pregnant and postpartum athletes who participate in HIIT, and how to safely train and treat these athletes to help them continue to do what they love.

If you could get a message out to physical therapists about pelvic rehab what would it be?

Oh man, where do I start? There are so many things I want to shout from the mountain tops about pelvic PT. It truly is a gem in the field of physical therapy, and I think is often a missing link in traditional physical therapy care. Pelvic rehab is so much more than urinary leakage and kegels. It can be so impactful to the quality of life of a patient. There is no other area of the body that is critical to so many functions but is also so vastly overlooked and undertreated. The need for research, education, and development in this field is critical if we are going to have a true “whole body” approach to treatment.

Hi Kate, can you tell us about the course you have designed Restorative Yoga for Physical Therapists?

My name is Kate Bailey and I am a pelvic floor physical therapist. I’ve been a pelvic floor PT going on4-5 years now.  Before that, I’ve been a pilates instructor for 20 years and taught yoga for over a decade. This course is a culmination of all of my experiences both with the yoga, pilates, and the pelvic floor population from kiddos through adulthood. It allows us to use the techniques from the yoga and pilates philosophies to support people in their healing process from pelvic pain and also just in their bodies.

What can participants expect to learn when they come to the course?

I wrote this course when the pandemic started. My whole intention was to make the didactic information self-paced and watch the videos as often as you want kind of course. This way, when we have dedicated time together it’s a lot more about discussion and me guiding people through the labs, and in turn, they can guide their colleagues or patients. It is designed so I’m not spending a lot of time lecturing to a screen and our time dedicated to each other is more about a conversation.  I want people to learn about the information in their own time, marinate in it a little bit, and then come with questions.

How do you feel that restorative yoga fits in with the care we provide to our patients with pelvic health conditions?

The restorative yoga component to me is really special because it’s one of the only times we prioritize rest, and not doing, and sitting with ourselves. Not necessarily trying to get strong, or trying to get more flexible. It’s really about allowing our bodies to be. Sometimes that is being in a little bit of discomfort. Sometimes that is just being with the exhaustion that I think we all have a little bit of. Just learning how to be with ourselves for 8, to 12, to 15 minutes and see that as a really productive part of our treatment plan.

How does trauma-informed care influence your course?

One of the things that I highlight in the course is how much trauma occurs in and around the home. So when we’re asking patients to do a home program one of the discussion points we have in the course is “what if the home is inherently triggering or unsafe?” How can we use concepts of graded exposure to get someone from needing a lot of sensory things, like lights on, windows locked, facing the window, eyes open to slowly getting people toward a little bit more safety. If that is not a possibility, finding another location and strategizing how we can prioritize our own safety and our own ability to relax rather than saying I must relax.

The other component of trauma in the course is the unveiling of how prevalent trauma is. In pelvic health, we talk a lot about sexual trauma because we are dealing a lot with the pelvic floor region and the genitals. One of the things I think we sometimes might be able to speak to more is the little subversive types of trauma. Whether it is emotional trauma, whether it is neglect, whether it is transgenerational trauma or intersectionality trauma…

There’s this other component in yoga that is coming out now that is the trauma that has been handed down through the yoga lineages. What I think is not understood is that a lot of people who practice yoga in a deep way have significant trauma from yoga. The question then is how do we reclaim a practice that is so lovely, done with care and kindness and non harming, for people who have maybe experienced it in a very harmful way – and introduce it as a non-harming, caring, compassionate method for people who haven’t experienced it. The whole idea is about how do you be in rest in your body and in empowerment.

Can you give an example of how a pelvic PT or OT would fit restorative yoga into their practice?

As PTs and Ots we are starting to bring mindfulness in, a lot, to our programming in terms of some of the work from Jon Kabat Zen on how great meditation is for so many things. There is still a question of “How do I put this in my plan of care?” The great thing about this class is that we can speak directly to this. Let's say that you are in a hospital-based scenario, you can give restorative yoga to someone n a hospital bed very easily. They’re not going anywhere and what a great thing to give them: a breathing practice, a concentration practice, and a rest practice.

For someone in private practice, such as orthopedics, this is the type of practice where maybe you’re not giving pelvic floor strengthening if someone has a large degree of overactivity in their pelvic floor. But they still need something to do at home, or they need something to do at the office. Maybe restorative yoga is a little bit too far out there for the patient. Maybe they don’t have a space they can lie down on the floor. That’s when we can say, ok how can we then transfer a pelvic floor restorative yoga posture to a desk situation? Can you cross your legs on your chair and lean forward, and modify it that way.

Then there is this component of the class that is all about breathing.  I think we know in pelvic health how wonderful and how great breath-work can be and so some of these techniques can be used as ‘secret exercises’ in your everyday life in addition to being a dedicated practice. We talk about all of that in class.

Watch the full interview with Kate Bailey at the Herman & Wallace YouTube Channel:

Join Kate to learn more about including restorative yoga into your practice with Restorative Yoga for Physical Therapists this year. Courses are scheduled for:

• May 21-22
• November 19-20

Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI owns a private practice in Seattle that focuses on pelvic health for all genders and ages and works under a trauma-informed model where patient self-advocacy and embodiment are a priority. In addition to being a physical therapist, I’ve been teaching Pilates for nearly 20 years and yoga for over 10. Kate’s course, Restorative Yoga for Physical Therapists, combines live discussions and labs with pre-recorded lectures and practices that will be the basis for experiencing and integrating restorative yoga into physical therapy practice. Kate brings over 15 years of teaching movement experience to her physical therapy practice with specialties in Pilates and yoga with a focus on alignment and embodiment.

Yoga is a common term in our current society. We can find it in a variety of settings from dedicated studios, gyms, inside corporations, online, on Zoom, at home, and on retreat. The basic structure of a typical yoga class is a number of flowing or non-flowing postures, some requiring balance, some requiring going upside down, and many requiring significant mobility to achieve a certain shape. At the end of these classes is a pose called savasana, corpse pose (or sometimes translated for comfort as final resting pose). In this pose, which is often a treat for students after working through class, students lie on the ground, eyes closed, possibly supported by props, and rest. It is perhaps the only other time in the day when that person is instructed to lie on the floor in between sleep cycles.

Savasana is one of many restorative yoga postures. In the work created and popularized by Judith Hanson Lasater, PT, PhD¹, restorative yoga has taken a turn away from the active physical postures, breath manipulations, and meditations that are commonplace in how we think of yoga. She has focused on rest and the need for rest in our current climate of productivity, poor self-care, and difficulty managing stress and pain.

In a dedicated restorative yoga class (not a fusion of exercise then rest, or stretch then rest… which are really lovely and have their own benefits), a student comes to class, gathers a number of props, and is instructed through 3 to 5 postures, all held for long durations to complete an hour or longer class. Consider what it would look like to do 3 things over one hour with the intent of resting. It is quite counter-culture. Students have various experiences with this type of practice, but over time many begin to feel the need for rest (or restorative practice) in a similar way that one feels thirsty or hungry.

We know the benefits of rest: being able to access the ventral vagal aspect of the parasympathetic nervous system is what Dr. Stephen Porges² suggests supports health, growth, and restoration. There is the impact on the ventral vagal complex in the brainstem that regulates the heart, the muscles of the face and head, as well as the tone of the airway. To heal, we need access to this pathway. To manage stress, we need to access this pathway. To be able to choose our actions rather than be reactionary, we need to access this pathway. Restorative yoga is an accessible method that may be a new tool in a patient’s toolbox to help manage their nervous systems.

Join Kate Bailey to learn more about restorative yoga in Restorative Yoga for Physical Therapists this year. Courses are scheduled for:

• May 21-22
• November 19-20

1. Relax and Renew: Restful Yoga for Stressful Times by Judith Hanson Lasater PT, PhD
2. Polyvagal Theory by Stephen W Porges PhD

H&W is proud to be able to present a new remote course on ethics from new faculty member, and Sr. TA, Mora Pluchino, PT, DPT, PRPC. Mora is a graduate of Stockton University with a BS in Biology (2007) and Doctorate of Physical Therapy (2009). She has been working at Bacharach Institute for Rehabilitation ever since graduation and has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training.

Mora began treating Pelvic Health patients in 2016 and has experience treating women, men, and children with a variety of Pelvic Health dysfunction. In 2020, she opened her own "after hours" virtual practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients and has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules and has been a TA with Herman & Wallace since 2020 with over 150 hours of lab instruction experience. Mora authored and instructs Ethical Concerns for Pelvic Health Professionals. 

Put yourself in these situations and reflect. How would you feel? What would you do? All of the situations above have a common theme. They present Ethical Concerns for Pelvic Health Professionals. Ethical situations are very common in day-to-day practice for any health care professional. Treating in the pelvic region can add additional complications due to the level of intimacy and vulnerability in this care.

Ethics by definition is “the division of philosophy concerned with how a person should behave in a matter that is considered morally correct or good” that gives us standards, virtues, and rules (Boone, 2017). The professional code of ethics for each professional category and is grounded in virtue ethics. Virtue ethics includes four main concepts including balance of harms and benefits, doing no harm, justice, and autonomy (Kirsch, 2005)

Whether a practitioner is a physical therapist/ physical therapist assistant, occupational therapist, psychologist, social worker, nurse, doctor, or physician’s assistant, their governing professional organization will have a code of ethics and conduct to help guide these practitioners in good decision making. There are many ethical decision-making models to help guide an individual through the process of identifying, defining, examining, and then problem solving any ethical occurrence.

The RIPS Model, originally presented by Arlanian, Swisher & Davis in 2005, presents an ethical framework to help guide practitioners through the steps needed to address ethical concerns. The world of ethical decision-making is typically one of many options, typically being more “gray area” than simply “black” and “white.” Ethical Concerns for Pelvic Health Professionals is designed to help make these decisions easier to define, examine, discuss, and address so we can have these tough conversations!

Ethical Concerns for Pelvic Health Professionals is a one-day remote course that covers ethical considerations for professionals working in the area of Pelvic Health. In general, Health Care Professionals have many day-to-day ethical considerations to “do no harm.” This includes basic decisions for billing, patient care, safety, and compliance. The purpose of this class is to explore the ethical challenges Pelvic Health practitioners may experience including consent, managing trauma and abuse, and preventing misconduct. To learn more join us in Ethical Concerns for Pelvic Health Professionals on June 18, 2022!

Research:

Boone, B. (2017). Ethics 101: From altruism and utilitarianism to bioethics and political ethics, an exploration of the concepts of right and wrong. Adams Media.

Kirsch, N. (2005). Ethics in Physical Therapy: A Case-Based Approach. McGraw Hill Publications. American Physical Therapy Association.

Kristina Koch, PT, DPT, is a board-certified women’s health physical therapist and certified lymphedema therapist who is the author/instructor of the remote course Pharmacologic Considerations for the Pelvic Health Provider. She has been treating pelvic health dysfunction in all ages and genders since 2001. Kristina works in private practice in Colorado Springs, CO, and has served as a guest lecturer for the pelvic health content at Regis University in Denver and the University of Colorado.

Did you know that the median length of time a primary care provider spends with a patient is 15 minutes? This breaks down to approximately 5 minutes for the patient to talk about their health concerns and 5 minutes for the health care provider to speak, with the rest being applied toward paperwork (1). After this appointment, the patient may not be seen again for several months or even a year. Medication side effects that impact the patients’ quality of life, or create new symptoms, can be easily overlooked.

I created the course, Pharmacologic Considerations for the Pelvic Health Provider because, with direct access to physical and occupational therapy services, a greater responsibility has been placed upon the therapist to take on more of a role as a primary care provider. We must ensure that all factors contributing to a patient’s signs and symptoms are considered. This includes reviewing and assessing if medications or supplements may be causative.

As therapists, we typically spend more time with our patients than their primary care providers. We are seeing them for longer periods during a treatment session and will see them numerous times throughout a month or longer. As a result, our patients have a greater opportunity to discuss their signs and symptoms with us versus their physician or primary care provider. Therefore, understanding how medications may be impacting a patient is essential. Being able to educate the patient about the side effects of the medications they are taking and how the medications may be contributing to their complaints can enhance the value of the treatment session.

By possessing this knowledge and understanding of the medications that are prescribed to treat pelvic health, therapists can have educated conversations with our patients and other health care providers involved in their care. The ability to discuss the most recent medications and supplements or complementary alternatives, that may minimize side effects or have fewer impacts on quality of life and enhance function, is an integral part of patient care.

Join Kristina to dive into Pharmacologic Considerations for the Pelvic Health Provider. This one-day, virtual course will discuss the importance of understanding pharmacology and review commonly prescribed medications. Kristina also spends time explaining current research pertaining to the pharmacologic treatment of numerous pelvic and reproductive health conditions, medication side effects, drug interactions, and non-pharmacologic alternatives. Medications discussed include those for constipation and GI dysfunction, pelvic pain conditions (including vulvodynia, chronic prostatitis, and endometriosis), as well as medications and side effects in Gender-Affirming Care for patients who are transitioning.

Upcoming 2022 course dates for Pharmacologic Considerations for the Pelvic Health Provider include:

• May 15
• July 9
• November 19

References:

1. Tai-Seale, M., McGuire, T. G., & Zhang, W. (2007). Time allocation in primary care office visits. Health Services Research. 42(5), 1871-1894. Doi:10.1111/j.175-6773.2006.00689.x
2. Ciccone, C. D. (2007). Pharmacology in Rehabilitation. (4^th). F.A. Davis Company.

This week the interviewer becomes the interviewee as Stacey Futterman Tauriello sits down to interview Holly Tanner on the Male Pelvic Floor course.

Stacey Futterman reached out to Holly Tanner back in 2007 through a phone call to see if they could partner on a lecture covering male pelvic pain. The two had never met in person but decided to collaborate on the three-hour APTA National Conference lecture. Holly shares "I still recall the frequent glances I made to match the person behind the voice I had heard for so many long phone calls.”

This presentation was developed into a two-day education course for Herman & Wallace and contained lectures on male anatomy, post-prostatectomy urinary incontinence, pelvic pain, and sexual health and dysfunction. The big question of the time was “should we allow men to attend?” Holly puts this in perspective, “As strange as this question now seems, it speaks volumes about the world of pelvic health at that time; mostly female instructors taught mostly female participants about mostly female conditions.”

The Male Pelvic Floor course was first taught in 2008 and has since been expanded to include 22 contact hours. This current content includes 7 pre-recorded lectures and 2 full days of live lectures and labs, allowing more time for hands-on skills in examination and treatment. The schedule still covers bladder, prostate, sexual health, and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease.

Because the course often has providers in attendance who have not completed prior pelvic health training, instruction in basic techniques is included. For the experienced therapists, there are multiple lab “tracks” that offer intermediate to advanced skills that can be practiced in addition to the basic skills. Holly adds, “One of the more valuable conversations that we have in the course is how to create comfort and ease in when for most us, we were raised in a culture (and medical training) where palpation of the pelvis was not made comfortable. Hearing from the male participants about their bodies, how they are affected by cultural expectations, adds significant value as well.”

In 2017 Herman & Wallace faculty member, Heather Radar submitted a blog where she wrote about a note that was left on her doorstep by the wife of an older gentleman who had chronic male pelvic pain. When looking into writing this blog I kept coming back to this past blog by Heather, and I have decided to share an abridged version today to accompany Holly Tanner's short interview discussing the Male Pelvic Floor Satellite Lab Course.

We need to continue to create more coursework and more clinical training opportunities so that the representation of those treating male patients improves. If you feel ready to take your training to the next level in caring for male pelvic dysfunction, join us for an upcoming Male Pelvic Floor Satellite Lab Course.

Male Pelvic Floor Satellite Lab Course is scheduled on several dates and satellite locations for 2022, including self-hosted course options. Dates include:

• April 23-24
• June 12-13
• September 24-25
• October 22-23
• December 3-4

Dawn Sandalcidi PT, RCMT, BCB-PMD is known as the go-to expert in the field of pediatric pelvic health. She has been practicing for 40 years this May and has concentrated on the pediatric pelvic floor for 29 of those. When it comes to pediatric pelvic floor issues, there is so much more than bedwetting, and often the practitioner needs to look beyond the pelvic floor.

Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served. This can cause undue stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Many of the techniques used in pediatric pelvic therapy can be translated to the adult population. The question is ‘who’s the driver?’ In pediatrics, it is typically a bowel issue.

The Standard American Diet involves food that is high in calories, saturated fats, trans fats, added sugars, and sodium. It is also lacking in the intake of essential nutrients for the body like fiber, calcium, potassium, and vitamin D. This lack of dietary fiber can cause issues with the digestive tract as well as the colon leading to constipation. Bowel dysfunction including constipation can contribute to urinary leakage and urgency (1). Constipation accounts for approximately 5% of visits to pediatric clinics (2) proving that there is a need for practitioners to know how to treat these pediatric issues.

Dawn focuses much of her pediatric knowledge on her two courses: Pediatric Incontinence and Pelvic Floor Dysfunction (PEDs) and Pediatric Gastrointestinal Disorders (PEDsG). Pediatric pelvic floor basics are covered in PEDs, including instruction in anatomy, physiology, development of normal voiding reflexes and urinary control, and learning how to talk with child patients. Biofeedback and ultrasound (which Dawn fondly calls jelly belly) are also covered and can be helpful as less invasive procedures for children.

PEDsG goes beyond the pelvic floor and opens up the door to look at the big picture of the whole child. Dawn shares that almost 80% of her kiddos with chronic constipation present with diastasis rectus abdominus. They can also have hyperextension in the thoracic spine, and the rib cage is postally rotated – where the kids don’t know how to bring it down.

Dawn is also on the threshold of writing a pediatric pelvic pain course that she expects to be ready later this year. Pediatric pelvic pain is becoming more prevalent, and it can’t be treated the same way as in adults. Dawn explains that “children don’t understand, so we’re actually creating a pediatric pain neuroscience protocol. It is a bio-psycho-social approach, and we use fun things.”

Research tells us that 15% of kids per year will outgrow bedwetting. Children who suffer from bedwetting can feel ashamed and embarrassed, have self-esteem issues, or even act out. There are 5 basics of where you start with a pediatric patient that are taught in PEDs. Dawn also shares 5 basics in her e-book, BEDWETTING BOOTCAMP(3):

1. Avoid things that can irritate the bladder
2. Avoid drinking anything just before bed
3. Drink throughout the day
4. Empty your bladder throughout the day
5. Avoid constipation and straining

Everything in Pediatric Incontinence and Pelvic Floor Dysfunction builds into Pediatric Gastrointestinal Disorders, and everything in PEDsG builds into Pediatric Pelvic Pain. The more practitioners who learn about the pediatric pelvic floor means that more kids get treated and the fewer adults that will have pelvic floor dysfunction. To learn more about treating pediatric pelvic health register for one of Dawn Sandalcidi’s upcoming courses:

Pediatric Incontinence and Pelvic Floor Dysfunction: August 27-28th

Pediatric Gastrointestinal Disorders: May 14-15, November 12-13

References:

1. Sandalcidi (Spring 2018). Paediatric incontinence and pelvic floor dysfunction. Journal of Pelvic, Obstetric and Gynaecological Physiotherapy, 122, 5–8.
2. Thibodeau B. A., Metcalfe P., Koop P. & Moore K. (2013) Urinary incontinence and quality of life in children. Journal of Pediatric Urology 9 (1), 78–83.
3. Dawn Sandalcidi PT, RCMT, BCB-PMD. BEDWETTING BOOTCAMP Frustrated by Bed Wetting? The 5 Ways to Speed Starting Up Dry Tonight! www.kidsbowelbladderPMD.com. https://cdn.fs.teachablecdn.com/YfP5rUfiRtOJxXZSZUso

This is the second installment in our 3 part pediatric blog series written by Amanda Moe DPT, PRPC treats women, men, and children with disorders of the pelvis and pelvic girdleAmanda enjoys assistant teaching with the Herman & Wallace Pelvic Rehabilitation Institute in her free time as well as working out, practicing yoga, and spending time with her family. You can find Amanda online at www.pelvicphysicaltherapyandmore.com and on Instagram @amandampelvicpt.

Just as Mora from @PracticallyPerfectPT mentioned in the previous blog post, Big Issues for Tiny Humans, pelvic health specialists treat pelvic floor and pelvic girdles for all humans of all ages. This blog post aims to introduce why pre-teens and teenagers could need pelvic floor therapy for pee problems!

Pelvic girdle-related dysfunction in young children often manifests as bowel or bladder complaints such as constipation, poo leakage (fecal incontinence or encopresis), and day or nighttime pee leakage (incontinence or nocturnal enuresis). Young children can be potty-trained with NO pee or poo complaints for several years then suddenly develop these very same symptoms in the pre-teen or teenage years! Occasionally there is a cause for the change in pee or poo symptoms such as trauma, the birth of a sibling, moving to a new city, divorce, or other changes in family situation. However, oftentimes there isn’t a signifying event attributed to the onset of these symptoms—which is where assessment and treatment from a skilled Pelvic Physical Therapist (or Occupational Therapist) may be beneficial! 

Pediatric Pelvic Physical/Occupational Therapy

Pelvic Physical and Occupational Therapy in pre-teens and teenagers focuses on a whole-body assessment and treatment. Specifically, the Pediatric Pelvic Therapists will look at pelvic girdle influences on bowel and bladder complaints such as:

• Pelvic muscle tension
• Pelvic muscle strength
• Pelvic muscle coordination
• Abdomino-pelvic pressure management
• Load transfer 
• Breathing
• Pelvic girdle strength
• Core coordination and strength
• Bladder and bowel habits
• Food and fluid contributors

Common Urinary Complaints in Pre-Teens and Teenagers

Potty-training regression can occur and is commonly seen in Pediatric Pelvic Therapy. Below is a list of other pee problems commonly seen in pre-teens and teenagers (often addressed in Pelvic Therapy). 

• Strong urge to pee (urinary urgency)
• Frequent peeing
• Chronic UTI’s
• Urinary stream changes
• Nighttime bedwetting (nocturnal enuresis)
• Daytime leakage (urinary incontinence)
• Leakage with activity or sport (stress urinary incontinence or SUI)

Urinary leakage during sport or physical activity (SUI) can commonly arise in the pre-teen and teenage years. A recent systematic review determined that SUI occurs in 18-80% or an average of 48.58% of adolescent female athletes (7). While stress incontinence is common in women after childbirth, it doesn’t have to be considered “normal” for women OR children. This is where Pediatric Pelvic Therapy comes into play to determine the factors (such as those listed above) that are impacting a child's leakage during sport or activity!

The Lower Urinary Tract (LUT) symptoms listed above and specifically daytime pee leakage are prevalent in 10–17% of children (2, 4, 8). Gastrointestinal (GI) dysfunction such as constipation is commonly associated with these LUT dysfunctions in pre-teens and teenagers. Research has shown constipation in 22-37.5% of children with LUTS (3, 5) with an additional study reporting that greater than 50% of children with LUT symptoms had some type of functional defecation disorder (1). This is why Pediatric Pelvic Therapists often address the GI system when pre-teens and teenagers present with pee problems!

To learn more about the GI systems in adolescents and how these symptoms influence pee problems in Pediatric Pelvic Therapy, check out Dawn Scandalcidi's interview on Friday! Herman & Wallace also offers two pediatric courses featuring assessment and treatment of urinary and bowel functioning:

• Pediatric Incontinence and Pelvic Floor Dysfunction Remote Course - August 27-28th
• Pediatric Functional Gastrointestinal Disorders Remote Course - May 14-15th and November 12-13th 

Resources

1. Burgers R, de Jong TP, Visser M, Di Lorenzo C, Dijkgraaf MG, Benninga MA. Functional defecation disorders in children with lower urinary tract symptoms. J Urol. 2013 May;189(5):1886-91. doi: 10.1016/j.juro.2012.10.064. Epub 2012 Oct 30. PMID: 23123369.
2. Kajiwara M, Inoue K, Usui A, Kurihara M, Usui T. The micturition habits and prevalence of daytime urinary incontinence in Japanese primary school children. J Urol. 2004; 171(1):403–7. [PubMed: 14665943] 
3. Loening-Baucke V. Prevalence rates for constipation and faecal and urinary incontinence. Arch Dis Child. 2007; 92(6):486–9. [PubMed: 16857698] 
4. Malykhina AP, Brodie KE, Wilcox DT. Genitourinary and gastrointestinal co-morbidities in children: The role of neural circuits in regulation of visceral function. J Pediatr Urol. 2017;13(2):177-182. doi:10.1016/j.jpurol.2016.04.036
5. Muhammad S, Nawaz G, Jamil I, Ur Rehman A, Hussain I, Akhter S. Constipation in Pediatric Patients with Lower Urinary Tract Symptoms. J Coll Physicians Surg Pak. 2015 Nov;25(11):815-8. PMID: 26577968.
6. Neveus T, von Gontard A, Hoebeke P, Hjalmas K, Bauer S, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the Standardisation Committee of the International Children's Continence Society. J Urol. 2006; 176(1): 314–24. [PubMed: 16753432] 
7. Rebullido TR, Gómez-Tomás C, Faigenbaum AD, Chulvi-Medrano I. The Prevalence of Urinary Incontinence among Adolescent Female Athletes: A Systematic Review. Journal of Functional Morphology and Kinesiology. 2021; 6(1):12. https://doi.org/10.3390/jfmk6010012
8. Sureshkumar P, Jones M, Cumming R, Craig J. A population based study of 2,856 school-age children with urinary incontinence. J Urol. 2009; 181(2):808–15. discussion 815–806. [PubMed: 19110268] 

This week The Pelvic Rehab Report is featuring faculty member (and senior TA) Mora Pluchino, teaching assistant Amanda Moe, and faculty member Dawn Sandalcidi on the topic of pediatric issues from infancy through adolescence. Our first guest blogger, Mora Pluchino, PT, DPT, PRPC has published two books. The first of which is titled The Poop Train: Helping Your Child Understand Their Digestive System. This is a rhyming, kid-friendly book to help children understand how their poop is made. It has resources in the back to help parents and caregivers manage a child's digestive system for optimal function including proper voiding positions, ideas for activities to help voiding, fiber recommendations, fiber-filled food options, and belly massage instructions. Her second book, Practically Perfect Pelvic Health 101: A Visual Tour of the Pelvic Floor is a visual tour of the pelvic floor to help all genders and all ages understand general pelvic health. You can find Mora online at https://www.practicallyperfectpt.com/ and on Instagram @practicallyperfectpt.

As a pelvic health specialist, I treat the pelvic floors for all humans of all ages. I am frequently asked the question “Why would a child need pelvic floor therapy?” The response is “So many reasons!” 

Colic, gastroesophageal reflux disorder (GERD), and constipation are the top reasons for visits to a pediatrician in the first year (Indrio Et Al, 2014). As the mother of a child that struggled with all of these things, I can attest to the quality of life impact these diagnoses can create. A pelvic health specialist can help caregivers to manage these conditions with manual therapy, gross motor development assistance, and other infant care ideas to help manage the infant’s gastrointestinal system for better comfort and function.

Sillen (2001) reports that the neonatal bladder is controlled by neuronal pathways connecting with the cerebral cortex. The neonatal bladder function is characterized by small, frequent voids of varying volumes (Sillen 2001). Preterm infants had slightly different results thought to be due to an immature nervous system and this interrupted voiding disappeared for most as the children approached potty training age (Sillen, 2001). Still, infants born prematurely may be more at risk for pelvic floor issues!

What does this mean? There is a certain point in every child’s life where the bladder function, nervous system, and cognitive awareness match up. Ideally, this allows them to learn to hold and then void waste on a toilet. When toddlers are seen for pelvic floor issues, it is usually due to problems that arise during the potty training phase if they haven’t carried along with another pelvic floor issue from infancy. Pediatric pelvic floor issues, if not addressed early on, can continue on into preschool and elementary-aged children. 

Pediatric Incontinence and Pelvic Floor Dysfunction, instructed by Dawn Salicidi, reviews the basics of pediatric pelvic floor treatment. Pediatric pelvic floor issues can be divided into three categories: storage, voiding, and “other.” Storage issues include things like: increased or decreased voiding frequency, continuous incontinence, intermittent incontinence, enuresis, urgency, nocturia, constipation, and encopresis. Voiding dysfunctions present with hesitancy, straining, weak stream, intermittency, and dysuria. Other pediatric pelvic floor issues include symptoms like excessive holding, incomplete emptying, post micturition dribble, spraying, and pain in the bladder/ urethral/ genital areas. 

Pediatric pelvic health requires the knowledge and skills used for treating adults with the additional abilities to relate to the child and their caregivers to help them manage and improve their symptoms. There is no age limit on the benefits of pelvic floor treatment!

Join us on Wednesday for the next installment of the pediatric pelvic floor three-part series: Pee Problems in Pre-Teens and Teens by Amanda Moe, DPT, PRPC. Amanda has written a book, Pelvic PT for ME: Storybook Explanation of Pelvic Physical Therapy for Children. You can find Amanda on Instagram @amandampelvicpt. The series will conclude on Friday with an interview with long-time faculty member, Dawn Sandalcidi PT, RCMT, BCB-PMD. Dawn Sandalcidi is a trailblazer in the field of Pediatric Bowel and Bladder Disorders and can be found on Instagram @kidsbowelbladder.

References:

• Indrio F, Di Mauro A, Riezzo G, et al. Prophylactic Use of a Probiotic in the Prevention of Colic, Regurgitation, and Functional Constipation: A Randomized Clinical Trial. JAMA Pediatr. 2014;168(3):228–233. 
• Sillén U. Bladder function in healthy neonates and its development during infancy. J Urol. 2001 Dec;166(6):2376-81. 

The Birth Healing Summit is a virtual summit that runs from April 4th through April 14th. Faculty member Nari Clemons will be speaking on Sunday, April 10th!

H&W is partnering again this year to bring the Birth Healing Summit virtually to you. Lectures throughout the summit present practical information, instruction, and tools that can be implemented in your practice right away. The summit is scheduled to run from April 4th to April 14th with 2 recordings going live each day with the intention to help practitioners to help moms heal body, mind, and spirit after birth! Also, twice during the summit, there will be a LIVE Facebook Q & A which is a great opportunity to speak to the experts and ask any questions you may have.

You can register for the summit now or get more information on the website here:
https://courses.instituteforbirthhealing.com/birth-healing-summit/ibh/77

As physical therapists and bodyworkers, the majority of training is focused on anatomy, physiology, and techniques to apply force to the body. While this is an effective way to treat the body, the summit is going to explore “out-of-the-box” solutions to achieve deeper healing. All 20 interviews will introduce you to a new approach to treating the common postpartum issues that women face.

These interviews are so packed with valuable information, instruction, and tools that you will want to listen to them over and over again. The All-Access Pass – Video or Video Plus, will allow you to review each at your own convenience or refer back to the information for a specific client case. It’s like having a reference library at your fingertips whenever you need it.

DAILY ACCESS: You receive 20 interviews with experts, plus their gifts for FREE!
Here is how it works:
- Starting April 4th, 2 speaker video-recorded interviews will be released each day.
- You will have 48hr to view, learn and enjoy the interviews.
- Sorry, no CEU’s available

VIDEO ALL-ACCESS PASS: You receive immediate access to all 20 interviews and the gifts.
Here is how it works:
- Starting March 21, you can purchase to gain full access to all the video-recorded interviews and gifts.
- You will have lifetime access to learn and enjoy the interviews.
- Sorry, no CEU’s available.

VIDEO PLUS ALL-ACCESS PASS: You receive immediate access to all 20 interviews and the gifts.
Here is how it works:
- Starting March 21, you can purchase to gain full access to all the video-recorded, audio, and transcripts plus the gifts.
- You will have lifetime access to learn and enjoy the interviews.
- Sorry, no CEU’s available.

Herman & Wallace's own Nari Clemons will be one of the 20 speakers talking about 'Mediation and Intention as Tools to Decrease Burnout' which is close to her heart! If you join Nari's lecture and enjoy the subject, she also co-instructs a course with Jennafer Vande Vegte for H&W to further deep dive into this topic called Boundaries, Self-Care, and Meditation which can be found on the H&W Online Courses page.

A few of the other lecturers and topics that you may be interested in:
- Lynn Schulte, PT - Pregnancy and Postpartum Impact on the Organs
- Rachel Shapiro, CNM - The Uterosacral LIgament - Sex and Postpartum Wellness
- Kathleen Kendall Tackett A New Paradigm for Depression in New Mothers
- Raylene Phillips, MD - Preventing and Minimizing Birth Trauma
- Rixa Freeze - Making Breech Birth Safe Again


Better support your client's pregnancy and labor and speed up their recovery by listening in. H&W hopes to see you at the Summit! Join the Summit Here: https://courses.instituteforbirthhealing.com/birth-healing-summit/ibh/77