The world needs more clinicians who can treat pelvic pain, pelvic organ prolapse, urinary incontinence, diastasis recti, and the many other conditions that constitute pelvic floor/pelvic girdle dysfunction. Most clinicians who specialize in pelvic rehabilitation are Physical Therapists (PT) or Occupational Therapists (OT), though other licenses also allow you to work with patients who have pelvic floor dysfunction. Many doctors, nurses, and internationally licensed medical professionals are beginning to explore the field of pelvic rehabilitation. 

In an interview for the Pelvic Rehab Report, faculty and instructor Tiffany Ellsworth Lee MA, OTR, BCB-PMD, PRPC, shared that "Occupational therapists wishing to pursue pelvic floor have a few options. The first thing is to find a pelvic floor clinical setting...or check to see if they can start a women's health program with a strong focus on the pelvic floor. OTs quite often do not start out in pelvic health directly after school. Since this is a newer area as compared to other certifications such as the NDT and PNF, it takes a little bit of research, time, and effort to find one’s exact niche. To get started, an OT should seek out courses that teach the basics of bladder and bowel management. It is important to understand the anatomy and physiology of the bladder, bowel, and sexual systems."

Once you have a license to practice, you can start learning to specialize in pelvic rehabilitation. The best place to start is with the H&W Pelvic Floor Level 1 satellite lab course, which offers immediately applicable clinical skills for evaluating and treating urinary incontinence or the musculoskeletal components of urogynecologic pain syndromes. Most practitioners who take Pelvic Floor 1 return to study in the next courses in the series.

You can learn all about the colorectal system, and how to treat conditions such as coccyx pain, pudendal neuralgia, and male pelvic pain in the Pelvic Floor 2A course, and in Pelvic Floor 2B you can expand your knowledge in topics such as movement assessment and re-training, prolapse, and pelvic pain. Then in the Pelvic Floor Capstone course, the final advanced course, you dive deep into topics such as hormones and their influence on conditions, surgeries and recovery, and skilled manual therapy techniques. Once you know your patient demographic, you can check out our growing list of specialty courses that include series topics including yoga, oncology, pregnancy, fascial mobilization, and much more.

Once you have gained experience in the field, you may consider sitting for the Pelvic Rehabilitation Practitioner Certification (PRPC). This certification recognizes expertise in pelvic rehabilitation for patients of all genders throughout the lifecycle. To be eligible to sit for the exam, applicants must have completed 2000 licensed hours of direct pelvic patient care in the past eight years, 500 of which must have been in the last two years.

Kate Bailey, PT, DPT, MS, E-RYT 500, YACEP, Y4C, CPI curated and instructs the remote course on Restorative Yoga for Physical Therapists, which is scheduled for September 11-12, 2021. 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. Kate’s pilates background was unusual as it followed a multi-lineage price apprenticeship model that included the study of complementary movement methodologies such as the Franklin Method, Feldenkrais, and Gyrotonics®. Building on her Pilates teaching experience, Kate began an in-depth study of yoga, training with renown teachers of the vinyasa and Iyengar traditions. She held a private practice teaching movement prior to transitioning into physical therapy and relocating to Seattle.

Without a doubt, these past couple of years have been tough with this global pandemic of a virus that caused major shifts in how we work, play, learn and socialize. Wherever you live on this planet, it is nearly impossible not to have been affected by the stress and trauma that the Covid-19 virus has created. Just like with any other stressor, the first step of management is recognition. Check, done.

Step two involves making conscious choices about how we want to live. This is where we have some options, including self-care. “Self-care” is one of my least favorite phrases. Not because at its core, self-care is not important. But because it's another thing on an overflowing to-do list and can create even more of a sense of imbalance, lack of accomplishment, and self-defeat. Yet, learning how to manage stress is a skill we all need: individually and communally.

However, there is a step before stress management that we need to address first. Interoception, defined by Porges, Ph.D., is the process that describes both conscious feelings and unconscious monitoring of bodily processes by the nervous system. As a clinician, this is a key aspect of every single patient care plan. I am a big fan of embodied decision making, and yet our somatic intelligence (or interoceptive skills) is widely underdeveloped.

Just as emotional intelligence is getting some wonderful development, through the work of researchers and educators like Marc Brackett, Ph.D. of Yale Center for Emotional Intelligence, our wellbeing and access to wellness are dependent on our ability to understand the sensations and signals throughout our body and then make a choice. This is important since you can’t make an embodied choice (step 2) before you have the data (step 1 - interoception). An example would be to imagine if you never felt the sensation of hunger, or the ‘hangry’ feeling when it’s been too long since the last boost of nourishment…how would you determine that you are hungry?

So, what to do? Many of us (clinicians and patients alike) live in a world full of overstimulation, productivity requirements, and constant stress. To develop interoception, finding little periods of stillness can be really useful. In yoga, there is a dedicated practice called pratyahara. Translated from Sanskrit to English as ‘withdrawal of the senses.’ The senses, in this case, includes all the sense organs: sight, smell, sound, touch, taste, movement (vestibular), and spatial placement (proprioception). Traditionally this is an aspect of meditation.

In my experience as a yoga teacher and physical therapist, I find this practice more accessible in the restorative yoga practice. It can take some graded exposure, but at the heart of the restorative yoga practice is stillness, darkness, silence, and support from props so that the body doesn’t have to do anything. These are also the essential components described by Herbert Benson, MD in his work on the Relaxation Response. In his work, he showed the relaxation response to be effective in decreasing heart and respiration rate triggering the benefits of the vagal nerve; which we are learning has so much to do with our ability to neuroregulate and participate in individual and communal stress management.

Restorative yoga is a practice of wakefully resting. Immordino-Yang et al, studied the brain in functional MRI when individuals were wakefully resting. The study found that during wakeful rest (without a meditative component where the brain has a task of concentration) the brain goes into a mode of neural processing called default mode. In default mode, the brain supports memory recall, imagining the future, and developing socio-emotional intelligence. In relationship to stress management, this is so important because it re-centers us, and allows for connection for even more neuroregulation.

For my patients, I often joke about lying on the floor. Really, it is not a joke at all. Lying on the floor for 15 minutes is savasana. Savasana is a wakeful resting and a practice of relaxation response. It seems easy: you always have access to a floor. You don’t need anything fancy. Aside from the neuroregulatory benefits of rest, savasana also gives the postural muscles a break. It allows the hip flexors to re-lengthen and the cervicothoracic junction to realign.

It is pretty great, and really accessible for most people. For those who are not comfortable flat, that’s where the props used in restorative yoga come into play. As physical and occupational therapists, we are so well primed to help people learn how to support their bodies in rest to get the benefits of rest.

Burnout, the Secret to unlocking the stress cycle by Emily Nagoski, Ph.D. and Amelia Nagoski, DMA

Polyvagal Theory, Stephen W Porges, PhD

Immordino-Yang et al. - Perspectives on Psychological Science - 2012

The Relaxation Response by Herbert Benson, MD, and Miriam Z Klipper

Mia Fine, MS, LMFT, CST, CIIP is the author and instructor of the Sexual Interviewing for Pelvic Health Therapists remote course scheduled for August 14-15, 2021. Mia’s specialties are sexual health concerns, eroticism, intimacy, alternative sex and relationships (kink/BDSM and non-monogamy), LGBTQIA+ genders/orientations/sexualities, and desire discrepancy. Her course Sexual Interviewing for Pelvic Health Therapists is intended for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit. Mia shares the following blog detailing some of the books that have influenced her.

As a science, psychology, somatics, and sexuality education nerd, books are my go-to psychoeducation sources. The books listed below are resources that I offer to my clients, send to family and friends for birthdays and holidays, and inform the work I do as a clinical supervisor, professor, and therapist. I’m excited to share some of my favorites that might help you and the patients with whom you work.

A prerequisite for anyone with a vulva (or who is partnered with someone with a vulva) is the book Come As You Are written by Emily Nagoski. Before a therapeutic intake session, I invite my clients who have vulvas to read this book. It is important to me that my clients and I share the same language that is offered in this fabulous resource. Nagoski illustrates the Dual Control Model for sexual arousal, interest, and desire in ways that are accessible and digestible for all. When clients understand the difference between Spontaneous Arousal and Responsive Arousal, and why these happen, and when, it is a game-changer for them and their partner. This book is a must for anyone who works with pelvic floor pain. And excitingly, these topics will be covered in my upcoming Herman & Wallace course!

The Politics of Trauma written by Staci Haines (also the author of Healing Sex) is a deep dive into, well, the politics of trauma. In this book, she explores the somatic experiences we humans have when we are activated. Her detailed description of fight, flight, freeze, fawn, and dissociate is nothing short of brilliant. This book is a must for those who are interested in exploring the impact that social justice, racial justice, transformative justice, and restorative justice have on our lived experiences of trauma.

The Body is Not An Apology is another brilliant book by Sonya Renee Taylor. It highlights the many effects of the “isms and obias” (such as Sexism, Racism, Fat-phobia, Transphobia) embedded in our everyday life and how identifying these frees us of the barriers they place on our quality of life. The isms and obias she explores impact the way we view ourselves, talk to ourselves, and relate to others. This book is incredibly inspiring, as is the author, Sonya Renee Taylor.

Additional books I love, many of which are written by close friends and colleagues include:

• Trans Sex by Lucie Fielding
• Wild Side Sex: the Book of Kink by Midori
• Gender Trauma by Alex Iantaffi
• Polyvagal Exercises for Safety and Connection by Deb Dana
• Becoming Cliterate by Laurie Mintz
• Better Sex Through Mindfulness by Lori A. Brotto
• The Art of Giving and Receiving: The Wheel of Consentby Betty Martin, Robyn Dalzen

These books have improved, and informed, my therapeutic work with clients and are recommendations I offer on a weekly, if not daily, basis. For additional resources, check out my website:https://miafinetherapy.com/. I look forward to exploring more comprehensive and accessible resources with you at my upcoming course Sexual Interviewing for Pelvic Health Therapists remote course scheduled for August 14-15, 2021!

The majority of practitioners begin their pelvic rehabilitation journey by taking Pelvic Floor Level 1, which is an excellent starting point. This course provides the basics of anatomy, techniques, and knowledge needed to start treating patients. 

Another option for your pelvic floor journey is the Oncology of the Pelvic Floor Level 1 remote course. Caring for patients with cancer begins at diagnosis, and as a pelvic rehabilitation practitioner, you are an integral part of the oncology team. This course addresses the issues commonly seen in a patient who has been diagnosed with cancer. 

Several cancers can affect the pelvic region and pelvic floor. Such cancers include bladder, colorectal, prostate, and ovarian cancers. Treatments for pelvic cancers include surgery, radiation therapy, hormone therapy, chemotherapy, and pelvic rehabilitation. These treatment options depend on the tumor size, location, or stage and negatively affect pelvic floor function and quality of life. 

Cancer patients also often have intimacy issues that stem from their diagnosis and treatment. Holly Tanner shares that "...cancer treatment can change relational roles, finances, work-life, independence, and other factors including hormone levels. Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido, and performance anxiety can create further challenges." A pelvic rehabilitation practitioner can assist the patient in their recovery and reframing of intimacy.

In addition to sexual function, the pelvic floor helps to maintain bladder/bowel control (emptying, urges), organ support, and stabilization of the spine/pelvis. Pelvic issues that originate from cancer treatment vary from scar tissue restriction or swelling, fibrosis causing narrowing and hardening of tissues, sexual issues, and lymphedema, among other issues. While some patients may not display symptoms at all, others can develop issues immediately after treatment, or even months after treatment has ended. 

There are over 15 million cancer survivors in the United States. In the next 10 years, this number will increase to over 20 million. The need for trained practitioners to treat patients with cancer diagnoses will only be increasing in the future. Join H&W on August 15-16 in Oncology of the Pelvic Floor Level 1 and learn to be part of an interdisciplinary oncology team.

The following is our interview with Jennifer Eller, PT, DPT, PRPC. Jenni recently passed the Pelvic Rehabilitation Practitioner Certification (PRPC) exam. She practices at Enloe Medical Center in Chico, CA and is a Teaching Assistant for local California satellite courses with H&W. Jenni was kind enough to share some thoughts about her career with us. Thank you, Jenni - and congratulations on receiving your PRPC!

Q: Who are you? Describe your clinical practice.

A: My name is Jenni Eller, and I am a pelvic floor physical therapist at Enloe Rehabilitation Center (hospital-based outpatient clinic) in Chico, CA. I specialize in pelvic floor, orthopedic, and oncological diagnoses. Specifically, conditions related to incontinence, pelvic pain, dyspareunia, vaginismus, interstitial cystitis, and the post-surgical pelvis, as well as pelvic floor issues, post-oncological treatment pelvic floor issues, pre and postnatal issues, male pelvic floor dysfunction, and other pelvic floor dysfunctions.

Q: How did you get involved in the pelvic rehabilitation field, and what has your educational journey as a pelvic rehab therapist looked like?

A: I grew up in Oregon and Washington, and completed my undergraduate degree in Exercise Science at Linfield College in 2009. I completed my Doctorate Degree in Physical Therapy at Regis University in Denver, CO in 2013. 

After graduate school, I worked in a small rehabilitation hospital but quickly transitioned to outpatient rehabilitation and started working with the orthopedic and oncological patient population. The hospital system I was in had hired 3 new gynecology oncologists and were interested in developing the pelvic health program there. I started my training for pelvic floor physical therapy with Herman and Wallace in 2015. I have completed the Herman and Wallace Pelvic Floor series in 2017 and passed the Pelvic Rehabilitation Practitioner Certification in May 2021.

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

A: Over the past 6 years, I have enjoyed helping both women and men with issues related to their pelvic floor, connecting it to their spine, hip, abdominal, and lower extremity issues. I help them return to an active lifestyle and feel empowered over something so limiting and invisible to others. 

Patients with pelvic floor dysfunction are often overlooked because their symptoms are too sensitive to speak about. I truly believe they deserve the best care possible and am grateful to be part of a team that focuses on patient-centered care. Treating both pelvic floor dysfunction and the oncological patient population benefits under-served patient populations. Both demographics have my heart for personal reasons. I always knew I wanted to help those who are in need able to get much support.

Q: What has been your favorite Herman & Wallace Course and why?

A: I have enjoyed the whole pelvic floor series, but Pelvic Floor Level 1 and Level 2B, taught by Tina Allen and Holly Tanner, were so great! These courses just inspired me to give my full attention to pelvic health. They are easy to learn from and full of so much knowledge.

Q: What is in store for you in the future as a clinician?

A: Right now, I am focused on building the pelvic health program in this smaller northern California city and hopefully bringing more providers to serve this community. I have a dream of teaching in the future and helping build the next generation of physical therapists and pelvic floor physical therapists.

Portions of this blog are from an interview with Dustienne Miller. Dustienne is the creator of the two-day course Yoga for Pelvic Pain. She passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. 

Have you noticed when you are afraid or don’t want to feel something you hold your breath? Imagine what it's like to have daily pain that limits function and how that could impact rib cage, abdominal and pelvic floor expansion. Dustienne Miller discusses this in her remote course, Yoga for Pelvic Pain, upcoming on July 31 - August 1, 2021. Her course focuses on two of the eight limbs of Patanjali’s eightfold path: pranayama (breathing) and asana (postures) and how they can be applied for patients who have hip, back, and pelvic pain. 

Dustienne explains "We teach our patients how breathing patterns inform our digestion, our spine, our emotional state, our pelvic floor, etc. It’s one of the most powerful tools we have to inform our system that we are safe. Despite this knowledge, we will often find ourselves holding our breath or breathing in non-optimal ways without even realizing it." Dustienne focuses her practice on introducing yoga to patients within the medical model. Yoga can be included in pelvic rehabilitation in so many ways, including incorporating yoga home programs as therapeutic exercise and neuromuscular re-education (both between visits and after discharge). 

Pelvic conditions that can be positively impacted by yoga are interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Treatment for these conditions often involves an individualized approach that may include both pharmacologic therapies (prescription drugs, analgesics, and NSAIDs) and nonpharmacologic interventions such as exercise, muscle strength training, cognitive behavioral therapy, movement/body awareness practices, massage, acupuncture, and nutrition.

A systematic review of the 2017 clinical practice guidelines evaluated 14 randomized controlled trials and found that yoga was associated with lower pain scores (1). Similarly, in 2020 there was a review of 25 randomized controlled trials that examined the effects of yoga on back pain. Out of these trials, 20 studies reported positive outcomes in pain, psychological distress, and energy (2).

The great thing about yoga is that the asanas (postures) can be modified to accommodate your strength, experience, and health conditions. An example of this is the Downward Facing Dog pose. There are so many ways to made Downward Facing Dog work for your body. Use straps, the wall, or the plinth/countertop to provide support for your body as needed, which might look different each day.

Some folks think you need to be flexible to have a yoga practice. Dustienne stresses "What is necessary is to be flexible with understanding that every day might feel different. If you are in an active pain flare your practice will look different than on the days you are feeling better. That can be a challenging aspect of a mindful practice - embracing that every day is different. Have the courage not to judge yourself, but to celebrate that you are meeting your needs with kindness."

People have been doing yoga for thousands of years. It is a mind-body and exercise practice that combines breath control, meditation, and movements to stretch and strengthen muscles. Join Dustienne Miller in Yoga for Pelvic Pain on July 31 - August 1, 2021, to learn more about incorporating yoga into your clinical practice. 

No prior experience with teaching yoga is required to attend the course. However, all participants must possess a working knowledge of pelvic pain conditions and foundational rehabilitation principles. 

1.  Chou R, Deyo R, Friedly J, et al. Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline. Ann Intern Med. 2017; 166(7):493-505.
2.  Park J, Krause-Parello CA, Barnes CM. A narrative review of movement-based mind-body interventions: effects of yoga, tai chi, and qigong for back pain patients. Holist Nurs Pract. 2020;34(1):3-23.