Yoga offers a compelling mind-body approach to maternal care that is forward thinking and aligns with the World Health Organization and Institute of Medicine’s recommendations for patient-centered care. But let’s take a look at WHY postpartum care MUST change in order to establish need for the entry of yoga into postpartum care.
 
Maternal Health Track Record
 
The United States and similarly developed countries have a very poor track record for postpartum care. The record is so poor that the problem in the US has been labeled a “human rights failure.”¹
 
On its own, the US has the worst track record for not only postpartum care, but for maternal and infant mortality and first-day infant death rate in the developed world (Save the Children 2013). Between 1999-2008, global mortality rates decreased by 34% while the US’s rates doubled for mothers.¹
 
Patient satisfaction also suffers under the current model of care, with many more mothers experiencing postpartum depression, a significant risk factor for both mother and baby during and after pregnancy.
 
The increase in mortality and poor outcomes can, in part, be attributed not to underuse, but overuse of medical intervention during pregnancy and birth. ^2,3,4  Countries that have “access to woman-centered care have fewer deaths and lower health care costs”; and, hospital system reviews in the US show that reducing medical interventions are both reducing cost and improving outcomes.^1,4,5
 
The notorious lack of accountability (reporting system) in maternal health care also plagues the US and suggests that maternal deaths are even higher than currently reported, leading to Coeytaux’s conclusion that the “United States is backsliding.”¹
 
Improving Postpartum Outcomes with Integrated Physical Therapy Care
 
In After the Baby’s Birth, maternal health advocate Robin Lim writes, 
"All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six-week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive, particularly to women suffering from painful physical and/or psychological disorders following childbirth."
 
Physical therapists can be instrumental change agents in improving current postpartum care, especially through the integration of contemplative sciences like yoga. Yoga can be the cornerstone of holistically-driven, person-centered care, especially in comorbid conditions such as pelvic pain and depression, where pharmacological side effects, stigma, can severely diminish adherence to biomedical interventions.⁶ Coeytaux, as well as other authors, clearly correlate the reduction of maternal mortality with improved postpartum care. The World Health Organization recommends that postpartum checkups should include screening for:

• Back pain
• Incontinence (stress)
• Hemorrhoids
• Constipation
• Fatigue
• Breast pain
• Perineal pain
• Depression
• Painful or difficult intercourse
• Headaches
• Bowel problems
• Dizziness or fainting

A physical therapist is a vital team member in not only screening for many of the
listed problems above, but in managing them. It is important to note that other countries, like France, deliver high quality postpartum rehab care plus in-home visits, all while spending far less than the US on maternal care.
 
The World Health Organization, however, clarifies the vital importance of postpartum care delivery by making a significant recommendation for a paradigm shift in biomedical care.⁷
 
Yoga as a “Best Care Practice” for Postpartum Care
 
The WHO recommends the use of a biopsychosocial model of care, which yoga is ideally suited to provide via its ancient, multi-faceted person-centered philosophy. Medical Therapeutic Yoga is a unique method of combining evidence-based rehabilitation with yoga to emerge with a new paradigm of practice. MTY:
 

• Addresses the mother as a person, not as a condition or diagnosis.
• Empowers mothers with self-care strategies for systems-based, not just musculoskeletal or neuromuscular, change.
• Addresses all domains of biopsychosocial impairment.
• Teaches interdisciplinary partnership-based theory, which is integral to creative collaborative discourse and innovation in postpartum care.
• Equips clinicians with business service, website development, practice paradigm, and social media campaign tools to fully develop the new clinical niche of Professional Yoga Therapy practice. 
• Promotes patient advocacy, health promotion, and public health education via mainstreaming yoga into rehabilitative and medical services.
• Provides the gender context for prescription that traditional yoga is lacking.
• Evolves yoga for use in prenatal and postpartum care.

 
Physical therapy screening and intervention in the postpartum is vital, but the addition of yoga can optimize postpartum care and has enormous potential to be a “Best Care Practice” for postpartum care in rehabilitation. 
 
As a mind-body intervention, yoga during pregnancy can increase birth weight, shorten labor, decrease pre-term birth, decrease instrument-assisted birth, reduce perceived pain, stress, anxiety sleep disturbances, and general pregnancy-related discomfort and quality of life physical domains.^8-9
 
In addition to the typical physical therapy intervention for postpartum physical therapy, the MTY paradigm provides:

• self-care strategies for psychoemotional health and social engagement, increasing self-efficacy, confidence, and self-worth,
• a concise container for clinical-decision through its algorithmic programming,
• psychoemotional and neuroendocrine intervention,
• nutritional counseling  and resource utilization,
• energetic adjunct therapies steeped in Ayurvedic science,
• executive functioning and cognitive support,
• epigenetic effect, and
• inter- and intrarelational development.

 
Postpartum integrated physical therapy care can provide more comprehensive care than rehab alone because of its multi-faceted biopsychosocial structure and systems-based model of care. Ginger’s course, Yoga as Medicine for Labor, Delivery, and Postpartum provides evidence-based methodology for prenatal and postpartum practice that streamlines clinical decision-making and intervention through introduction of a yogic model of assessment.
 
To learn more about Ginger’s course, visit Yoga as Medicine for Labor, Delivery, and Postpartum

Coeytauz et al., Maternal Mortality in the US: A Human Rights Failure. Contraception Editorial, March 2011. http://www.arhp.org/publications-and-resources/contraception-journal/march-2011
Kuklina E, Meikle S, Jamieson D, et al. Severe obstetric morbidity in the US, 1998–2005. Obstet Gynecol. 2009;113:293–299.
Tita ATN, Landon MB, Spong CY, et al. Timing of elective cesarean delivery at term and neonatal outcomes. NEJM. 2009;360:111–120.
Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:e1–105.e7.Abstract | Full Text | Full-Text PDF (100 KB)
Oshiro BT. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009;113:804–811.
Buttner, M. M., Brock, R. L., O'Hara, M. W., & Stuart, S. (2015). Efficacy of yoga for depressed postpartum women: A randomized controlled trial. Complementary Therapies in Clinical Practice, 21(2), 94-100. doi:10.1016/j.ctcp.2015.03.003 [doi]
WORLD HEALTH ORGANIZATION., 2002. Towards a common language for functioning, disability and health : ICF. Geneva: World Health Organisation.
Curtis, K., Weinrib, A., & Katz, J. (2012). Systematic review of yoga for pregnant women: Current status and future directions. Evidence-Based Complementary and Alternative Medicine : ECAM, 2012, 715942. doi:10.1155/2012/715942 [doi]
Sharma, M., & Branscum, P. (2015). Yoga interventions in pregnancy: A qualitative review. Journal of Alternative and Complementary Medicine (New York, N.Y.), 21(4), 208-216. doi:10.1089/acm.2014.0033 [doi]

Danielle is among the latest class of Certified Pelvic Rehabilitation Practitioners! Her experience treating patients and owning Core 3 Physical Therapy prepared her to pass the exam in flying colors. Read her bio here and check out our interview below. Congratulations, Danielle!

What/who inspired you to become involved in pelvic rehabilitation?
A patient was the first one to inspire me to improve my knowledge and treatment abilities in pelvic rehabilitation. I was working with a postpartum patient, while carrying my first child, and she felt that my guidance had been so helpful in her care that it made me interested learning more about the pelvic floor. Most of my fellow colleagues could discuss my orthopedic questions but I didn’t have any mentors that could offer advice in more advanced pelvic floor cases so I started attending the Herman and Wallace classes. They have been an invaluable at improving my ability to care for patients with pelvic pain which has even improved my treatment of orthopedic patients with low back pain and sacroiliac dysfunction.

What patient population do you find most rewarding in treating and why?
I enjoy working with chronic pelvic pain patients because it's rewarding to be able to bring relief to someone who has been living with pain, limited quality of life or even social anxiety and has not received any benefit with other treatment options. Being able to help this patient population understand the pelvic floor muscles and function as well as providing justification to why they are in pain and then help them progress through various treatment approaches makes my job rewarding.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
PT's are uniquely trained to provided internal pelvic floor muscle release. This is something that no other health care professional is licensed or has the schedule/time to perform. This technique can provide relief and feedback to your patients that is possible in no other way. If you do not want to address this region or feel comfortable providing this treatment, find a therapist local to you who has experience with pelvic floor and refer when appropriate. Additionally, we as physical therapists are often the first line of defense in recognizing and educating patients about the ability to address a wide variety of symptoms that they believe is "just a normal part of life". Asking the in-depth questions and providing a multimodal approach to their symptoms is not only a boon to the patient but to our profession.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
"Your most valuable tool is your finger." It is rare to treat an orthopedic patient without incorporating any hands on approach and the same holds true for the pelvic floor. With an internal exam you can make your most accurate assessment while providing valuable feedback to the patient.

What makes you the most proud to have earned PRPC?
I think it has helped me gain respect with my fellow health care professionals for my expertise in the area of pelvic floor treatment. It has broadened my knowledge base and provided me a strong guide for furthering my ability to treat patients with pelvic pain and dysfunction.

What is in store for you in the future?
I would like to become involved in research to further evidence based evaluation and treatment of pelvic conditions. I hope to facilitate the effectiveness and value in pelvic floor rehabilitation via physical therapy.

What role do you see pelvic health playing in general well-being?
It should become a staple for all pelvic floor surgeries just like a physical therapy is the staple post total knee surgery. Currently in my region I find it very underutilized despite the research behind our treatment. This is largely due to the general population not being aware of the treatment benefits physical therapy can play in pelvic dysfunction. European countries make it a standard of care in this area and I hope we progress to adopt a similar view of treatment.

More than a year ago, after working on updating the pelvic floor series courses PF1, 2A and 2B, the Institute turned our attention to the final course in our popular series, PF3. To determine what content our participants wanted to learn about in the last continuing education course of the series, we asked that exact question. From a large survey of therapists who had taken all or most of the courses in the pelvic core series, we collected detailed data from therapists about what was needed to round out their comprehensive training. The results of that survey guided hundreds (and hundreds!) of hours of work completed by a team of instructors. This month, in the beautiful city of Denver, the three instructors who created the Capstone course will share their wisdom, clinical experiences, as well as their thoughtfully-designed lectures and labs. You will have an opportunity to learn in depth about topics covered in the prior courses in the series. 

Such topics include lifespan issues and health issues common to different ages, conditions of polycystic ovarian syndrome, endometriosis, infertility, pelvic organ prolapse and surgeries, pelvic fascial anatomy, pharmacology and nutrition. Lab components are detailed and comprehensive for working with specific common implications from conditions in pelvic dysfunction or surgery. This course focuses on the female pelvis, including diving into the complexities of female pelvic health issues. The instructors have all worked in the field for many years, are experienced in working with complex patient presentations, and all excel at manual therapies. I asked each of them to briefly share thoughts about the Capstone course that they each dedicated the last year in developing; following you can read their thoughts.

Nari Clemons

"I'm excited for every therapist who will take this course, as it is made to help you approach your practice at a whole new level.  We are eager to help your hands work dynamically with more intelligence and how to tackle complex restrictions in the pelvis and abdomen that go far beyond releasing muscles.  Additionally, the practitioners will raise their capacity of recognizing and helping the patient manage complex conditions, such as endometriosis, PCOS, fibroids, and IBS." 

Allison Ariail

"One of the best things about the Capstone course is that it provides the participants tools to treat more complicated patients. Topics such as endocrinology, oncology, vulvar dermatology, and surgical procedures are addressed, which will complete the picture for some of those patients that are hard to treat due to the complexity of their case. This knowledge, along with more advanced manual treatment techniques, will add to the skill set of the participants to improve their treatment outcomes. I am excited for the participants to combine their current clinical skills along with some new knowledge and techniques to be able to treat the whole person when working with complex and challenging patients." 

Jennifer van de Vegte

"Designing and creating Capstone with Nari and Allison was an incredible experience. My own knowledge and clinical expertise grew profoundly while researching and writing this material. Capstone is designed to really take the experienced pelvic health therapist to the next level of understanding and treating more complex patients. I can't wait to see the impact this material has on participants and their patients."

There is still time to register for the few remaining seats in Denver this weekend!

Appropriate sun exposure and/or daily supplements provide our bodies with sufficient amounts of Vitamin D. I would venture to guess almost every one of the patients I treated in Seattle had a deficiency of Vitamin D if they were not taking a supplement. Running outside year round has always kept my skin slightly tan and my levels of Vitamin D healthy; however, when I was pregnant in the Pacific Northwest, I had to supplement my diet with Vitamin D, which was a first for this East Coast beach girl. The benefit of Vitamin D has spread beyond just bone health, with studies showing its impact on pelvic floor function.

Parker-Autry et al., (2012) published a study discerning the Vitamin D levels in women who already presented with pelvic floor dysfunction versus “normal” gynecological patients. The retrospective study involved a chart review of 394 women who completed the Colorectal Anal Distress Inventory (CRADI)-8 and the Incontinence Impact Questionnaire (IIQ-7). These women all had a total serum 25-hydroxy Vitamin D [25(OH)D] drawn within one year of their gynecological visit. The authors defined a serum 25(OH)D of <15ng/ml as Vitamin D deficient, between 15-29ng/ml as Vitamin D insufficient, and >30ng/ml as Vitamin D sufficient. In the pelvic floor disorder group comprised of 268 women, 51% were found Vitamin D insufficient, 13% of whom were deficient. The CRADI-8 and IIQ-7 scores were noted as higher among the Vitamin D insufficient women. Overall, the mean 25(OH)D levels in the women without pelvic floor issues were higher than those who presented with pelvic floor disorder symptoms.

Another case-control study in 2014 by Parker-Autry et al., focused on the association between Vitamin D deficiency and fecal incontinence. They considered 31 women with fecal incontinence versus a control group of 81 women without any pelvic floor symptoms, looking at serum Vitamin D levels. The women with fecal incontinence had a mean serum Vitamin D level of 29.2±12.3 ng/ml (insufficient/deficient), while the control group had a higher mean level of 35±14.1 ng/ml (sufficient). The women completed the Modified Manchester Health Questionnaire and the Fecal Incontinence Severity Index, and women with deficient Vitamin D scored higher on the questionnaire, indicating fecal incontinence as a burden on quality of life. The severity scores were higher for Vitamin D deficient women, but there was not a statistically significant difference between the groups.  Once again, the pelvic floor disorder and Vitamin D deficiency correlation prevailed in this study.

An even more recent study looked at postmenopausal women and Vitamin D deficiency (Navaneethan et al., 2015). This prospective case control study involved 120 postmenopausal women, 51 of whom had pelvic floor disorders. The serum 25-hydroxy Vitamin D levels were obtained, and the results revealed a deficiency in those women with pelvic floor dysfunction. Vitamin D levels were found to be significantly lower in women who were 5 years or more into menopause. Overall, Vitamin D was deemed a worthy factor to consider in the pelvic floor disorder population as well as in postmenopausal women.

Taking time to talk to patients about their lifestyle, daily supplements, and diet can often shed light on their ability to benefit from our treatments. If a Vitamin D deficiency sounds possible, discuss current research with them and suggest they get their serum Vitamin D levels checked. Don’t underestimate the power of a little sunshine – it just might have a positive impact on pelvic floor health.

Parker-Autry, C. Y., Markland, A. D., Ballard, A. C., Downs-Gunn, D., & Richter, H. E. (2012). Vitamin D Status in Women with Pelvic Floor Disorder Symptoms. International Urogynecology Journal, 23(12), 1699–1705. http://doi.org/10.1007/s00192-012-1700-8
Parker-Autry, C. Y., Gleason, J. L., Griffin, R. L., Markland, A., & Richter, H. E. (2014). VITAMIN D DEFICIENCY IS ASSOCIATED WITH INCREASED FECAL INCONTINENCE SYMPTOMS. International Urogynecology Journal, 25(11), 1483–1489. http://doi.org/10.1007/s00192-014-2389-7
Navaneethan, P. R., Kekre, A., Jacob, K. S., & Varghese, L. (2015). Vitamin D deficiency in postmenopausal women with pelvic floor disorders. Journal of Mid-Life Health, 6(2), 66–69. http://doi.org/10.4103/0976-7800.158948

The American Society of Clinical Oncology convened their 2016 annual meeting over the weekend, and several of the presentations suggest new methods of preventing breast cancer recurrence.

Extended Hormone Therapy Reduces Recurrence of Breast Cancer

Breast cancer patients who are treated with aromatase inhibitor therapy are generally prescribed the the estrogen drugs for a five year course. A new study has suggested that by doubling the length of hormone therapy, the recurrence rate for breast cancer survivors drops by 34%. The study included 1,918 women who underwent five years of hormone therapy with the drug letrozole. After five years, half of the group switched to a placebo while the other half were given an additional five year treatment.

Drug Used to Treat Type 2 Diabetes May Increase Breast Cancer Survivability

The Univerisity of Pennsylvania School of Medicine has published results from two recent studies which document the effects of Metformin, a drug commonly used to treat type 2 diabetes, on breast cancer and endometrial hyperplasia. The study tracked outcomes for 1,215 patients who were diagnosed and surgically treated for breast cancer. Patients who began to use metformin after their diagnosis were found to have a 50% higher survivability rate than those who did not use metformin.

The timing of metformin use is extremely important when it comes to breast cancer survivability rates. The study also found that patients who used metformin prior to their diagnosis were more than twice as likely to die than those who never used the drug.

Research Suggests a "Mediterranian Diet" May Reduce Breast Cancer Recurrence

A study has indicated that a diet rich in vegetables, fish, and olive oil may decrease the odds of a breast cancer survivor experiencing a relapse or recurrence of their cancer. The study tracked 300 women with early-stage cancer and found that those who ate a normal diet were more likely to experience a breast cancer recurrence. The findings build upon previous research which indicated that a Mediterranean diet, and especially extra virgin olive oil, could reduce breast cancer risk by 68%.

Want to Learn More?

Susannah Haarmann, PT, CLT, WCS is the author and instructor of Physical Therapy Treatment for the Breast Oncology Patient, a course offered through the Herman & Wallace Institute. This continuing education course for medical practitioners offers a rehabilitation perspective for providers who work with oncology rehabilitation patients. Join Dr. Haarmann this in Stockton, CA on September 24-25 to learn evaluation and treatment techniques necessary to make an outpatient therapist an essential member of any oncology team.

1) Paul E. Goss, et al. J Clin Oncol 34, 2016 (suppl; abstr LBA1)
https://www.asco.org/about-asco/press-center/news-releases/ten-years-hormone-therapy-reduces-breast-cancer-recurrence
2) Yun Rose Li. University of Pennsylvania, American Society of Clinical Oncology Annual Meeting 2016
http://www.eurekalert.org/pub_releases/2016-06/uops-ddm060316.php
3) http://www.scienceworldreport.com/articles/41404/20160606/mediterranean-diet-prevent-breast-cancer-recurring.htm

When a 472 pound gentleman recently arrived for an evaluation for low back pain, he came to the clinic for me to help him, not deride him about his weight (which he complained all his doctors have already done). He claimed he had lost 120 pounds but gained back 50, and his low back was extremely painful with transitional movements and daily function. Undoubtedly, this man’s body was a battlefield for inflammation, and no matter how much manual therapy or exercise I implemented, nutrition education seemed vital. Instead of just chatting about baseball or the weather, competently sharing what we’ve studied and learned in continuing education courses is warranted in our practice.

In a 2016 review Klek reveals the most current evidence regarding Omega-3 Fatty Acids in nutrition delivered intravenously. Although physical therapists do not decide the ingredients for patients’ parenteral nutrition, the article thoroughly explains the essential benefits of fatty acids. Aside from being important structural components of cell membranes and precursors of prostaglandins and cholesterol, fatty acids regulate gene expression and adjust pathways of cells regarding inflammation and cell-mediated immune responses. Ultimately, fatty acids modulate metabolic processes in the body, whether locally, in a particular region, or at remote sites. Omega-3 fatty acids have been shown to inhibit synthesis of triglycerides by the liver, prevent cardiovascular disease, reduce cancerous cell growth, and even affect the development of rheumatoid arthritis and Chrohn’s disease. This article not only sheds light on parenteral nutrition for post-surgical, oncology, critically ill, and even pediatric patients but also educates the healthcare professional on the impact fatty acids have on the patients we treat.

In 2015, Haghiac et al. performed a randomized double-blind controlled clinical trial to determine if Omega-3 fatty acid supplementation could reduce inflammation in pregnant woman who are obese. Although the study began with 36 subjects in each group, only 24 women in the experimental group receiving 4 capsules a day of Omega-3 fatty acid (total of 2000mg) and 25 of the women taking 4 placebo capsules a day completed the supplementation over the 25 weeks up until delivery. The authors referenced the findings that low grade inflammation becomes exacerbated in obese pregnant women. While an excess of Omega-6 fatty acids practically promotes inflammation via eicosanoid (hormone) production, a healthy balance of Omega-3 fatty acids lessens inflammatory and immunosuppressive eicosanoid production. This study demonstrated an improvement in inflammation in the women who took the Omega-3 fatty acid as evidenced by a decrease in the expression of inflammatory genes in adipose tissue and placenta as well as reduced plasma C-reactive protein (CRP) at delivery.

Being able to control or reduce inflammation on a cellular level through nutrition could promote an exciting cycle of positive events for obese patients. Decreased inflammation in the body could decrease pain, which could allow and even promote increased activity and likely boost metabolism to equip them to battle obesity. The “Nutrition Perspectives for the Pelvic Rehab Therapist” course should spark the interest of any therapist wanting to guide patients not only on movement and function but also on the appropriate nutrition that best facilitates the body’s ability to heal and perform.

To learn more about nutrition and it's effects on pelvic rehabilitation, check out Nutrition Perspectives for the Pelvic Rehab Therapist this month in Lodi, CA.

Klek, S. (2016). Omega-3 Fatty Acids in Modern Parenteral Nutrition: A Review of the Current Evidence. Journal of Clinical Medicine, 5(3), 34. http://doi.org/10.3390/jcm5030034
Haghiac, M., Yang, X., Presley, L., Smith, S., Dettelback, S., Minium, J., … Hauguel-de Mouzon, S. (2015). Dietary Omega-3 Fatty Acid Supplementation Reduces Inflammation in Obese Pregnant Women: A Randomized Double-Blind Controlled Clinical Trial. PLoS ONE, 10(9), e0137309. http://doi.org/10.1371/journal.pone.0137309

Congratulations to Jane Blair Johe, PT, PRPC on becoming one of the newest Certified Pelvic Rehabilitation Practitioners! Read our interview with Blair below.

Tell us about your clinical practice
I work in a free standing outpatient PT center of a large 4 hospital affiliation. 70% lymphedema 30% pelvic floor rehab.

How did you get involved in the pelvic rehabilitation field?
I was already the lymphedema PT (LANA cert.) when I moved to WV. The women's health PT was moving to another state and asked me to please pick up her bladder incontinence patients.

What patient population do you find most rewarding in treating and why?
I do like pelvic pain clients as I can work with other PT’s on staff to problem solve . Both patients and their doctors are so grateful.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
That you cannot ignore a very important group of muscles (PF) whether you are treating backs, hips etc. or pain and weakness or balance issues…. it plays such a vital role in wellbeing. Any of these clients should be questioned about bowel and bladder issues.

What has been your favorite Herman & Wallace Course and why?
I took my first course from them in September and was so impressed (compared to other courses)

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
the PT pelvic floor assessment. Correct postures , breathing and “safe” effort of bowel movements.

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

What motivated you to earn PRPC?
If I only had one pelvic floor referral, I would like to give the best service possible to that client. My referring MD’s are very happy too.

What makes you the most proud to have earned PRPC?
I thought it was a many faceted subject and combined many aspects of my 45 years of physical therapy practice. It made me feel that I do know my profession that I love.

What advice would you give to physical therapists interested in earning PRPC?
Have a broad back ground in multiple areas of PT then I highly recommend Herman and Wallace courses as the best path.

What is in store for you in the future?
A urologist in town contacted me today to set up referring for pre surgery PT (prostate surgery).

The following guest post comes to us from Angie Johnson, a physical therapist with Kaiser Permanente in Portland, OR.

Did you know that the pelvic floor muscles are actually quite thin? “Pelvic floor muscles are able to produce enough force to overcome changes in intra-abdominal pressure during less rigorous activities of daily living,“ but in activities such as coughing and jumping, “intra-abdominal pressure clearly exceeds the maximum force generated by pelvic floor muscles alone.”¹ But we know that people are continent of urine during these activities, so it begs to question what structures help support the pelvic floor during high force events?

In our journey of pelvic rehabilitation and evidence-based medicine, researchers have determined that contributors to pelvic floor function include trunk stabilization² and co-contraction of the abdominal wall (especially transverse abdominus)^3,4. But this is only the beginning of the story. To add to this picture, new research, recently published in the Journal of Women’s Health Physical Therapy (January/April 2016) validates what we as practitioners already know; hip muscles play a crucial role in optimal pelvic floor functioning.

Knowledge of the anatomy of the pelvic floor and hip musculature helps to give us more understanding of the continence mechanism during high force activity. Obturator internus, which can be easily palpated through the vaginal wall “acts to externally rotate the hip. Interesting, this muscle actually shares a fascial attachment with the pelvic floor muscles.”

Researchers from a team at San Diego State University asked the very pertinent question: If you strengthen obturator internus do you strengthen the pelvic floor muscles too? To answer this question, they conducted a randomized control trial of 40 nulliparous women, aged 18-35, who were assigned to a hip exercise or control group. Both hip external rotator strength and pelvic floor muscle strength (via the Peritron™ perineometer) were measured in all of the women. The exercise group was then asked to perform clamshell exercises, isometric wall external rotation and “monster walks” as their specific hip exercises. The prescription of the exercises were 3 sets of 10 repetitions 3 days per week for 12 weeks. One session each week was supervised in the laboratory to ensure proper execution.

After the 12 weeks, the exercise group had an increase in hip external rotation strength, but also in pelvic floor muscle peak pressure. That was without any specific pelvic floor strengthening exercises at all. Strengthen the hips by doing these three exercises, and pelvic floor strength increases!! This is exciting and fantastic news for us as pelvic floor therapists and a good message to convey to our patients.

The results of this study are preliminary, but if you are treating pelvic floor weakness, hip external rotation strengthening exercises in addition to the traditional kegel strengthening exercises are a must. Go ahead – let’s all get hippie!

Tuttle LJ, DeLozier ER, Harter KA et al. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 2016; 40, 1 pg 15-19
Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther 2004;9(1):31-42
Sapsford RR, Hodges PW, Ricahrdson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neruourol Urodyn 2001;20(1):3-12
Sapsord RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med REhabil. 2001;82(8):1081-1088

“…visceral manual therapy can produce immediate hypoalgesia in somatic structures segmentally related to the organ being mobilized…”

This statement is taken from an article written by MCSweeney and colleagues published in the Journal of Bodywork and Movement Therapies in 2012. The authors, who state that there is a lack of research that explains underlying mechanisms for visceral mobilization, aimed to determine if visceral mobilization could produce local and/or systemic effects towards hypoalgesia. The measurement of hypoalgesia, defined by the IASP as “diminished pain in response to a normally painful stimulus,” was assessed by use of a hand-held manual digital pressure algometer for pressure pain threshold (PPT). Sixteen asymptomatic subjects were recruited from an osteopathic school and were treated on separate occasions with a visceral mobilization of the sigmoid colon, a sham intervention of manual contact on the abdomen, and a control of no intervention. Six females (mean age 23.7) and ten males (mean age 27.7) completed the single-blinded, randomized study.

The visceral manipulation technique was administered in the supine position by contacting the left sigmoid colon and drawing it superomedially for one minute, and repeated at a frequency and duration determined by the therapist base on each individual’s tissue response. The sham treatment included one minute of light tough contact over the umbilical area, and no position of ease or tissue barrier was engaged. The algometer was placed 1 centimeter to the left of the L1 spinous process, a location known to correspond to the segmental level equal to the colon. A site on the hand was used as a distant area for comparison. The authors concluded that visceral mobilization of the sigmoid colon was found to produce analgesia in tissue that is related segmentally.

The clinical practice relevance was difficult to determine, however, this study used new techniques to determine that there is an immediate and measurable effect on the body. While therapists who treat with visceral mobilization and other soft tissue techniques know that the interventions have helped their patients, having further experimental and clinical validation of the value of these techniques is critical. If you are interested in learning more about fascial approaches to easing pain and improving function in your patients, check out the courses offered by faculty member Ramona Horton.

Ramona will be teaching her Mobilization of the Myofascial Layer: Pelvis and Lower Extremities course three times this year, with the next event in Nashua, NH June 3-5. Her Mobilization of Visceral Fascia: The Urinary System course is available three times as well, next in Kirkland, WA on June 24-26. If you're ready for the advanced course, and some wine tasting(!), check out Mobilization of Visceral Fascia: The Reproductive System of Men and Women on October 14-16 in Medford, OR.

McSweeney, T. P., Thomson, O. P., & Johnston, R. (2012). The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. Journal of bodywork and movement therapies, 16(4), 416-423.

In Megan Pribyl’s course on Nutrition Perspectives for the Pelvic Rehab Therapist, she discusses a wide variety of useful topics specific to nutrition and pelvic health. In her lecture on “Nutritional Homeostasis”, Megan counsels against missing an underlying eating disorder when working with a patient who has bowel issues. Work by Abraham and Kellow (2013) is cited, and in their article published in BMC Gastroenterology, the authors concur that many patients who have functional gastrointestinal complaints may also have disordered eating. How then, can we tell these patients apart, and get patients the most appropriate care? First let’s look at their research.

Patients who were admitted to a specialty unit for those with eating disorders in Australia were studied and were found to have conditions such as anorexia nervosa, bulimia nervosa, polycystic ovarian syndrome, treated celiac disease, and treated bipolar depression. All of the 185 patients completed the Rome II Modular Questionnaire to identify symptoms consistent with functional gastrointestinal (GI) dysfunction. They also completed the Eating and Exercise Examination which collected data about behaviors including objective binge eating, self-induced vomiting, laxative use and excessive exercise.

Esophageal discomfort (heartburn and chest pain of non cardiac origin) was associated with excess exercise (more than 5 days/week). Self-induced vomiting was identified primarily in the patients diagnosed with bulimia. One interesting finding the researchers noted is that for patients who have disorder eating, pelvic floor symptoms that are not associated with functional constipation are a prominent feature. This data begs the question, how can we best screen for disordered eating in patients who present with bowel dysfunction that otherwise may fit with the symptoms and presentation of patients who do not have disordered eating?

Our first step may be to include important conditions and symptoms on our written or computer-based intake forms. Is “disordered eating” or bulimia, anorexia-nervosa included on your intake forms for patients? What about symptoms like heartburn, laxative use, or vomiting? (As an important aside, I always remember being surprised by a patient who had urinary incontinence when she told me that she leaked with vomiting. She had gone through a gastric bypass surgery and would vomit several times per week as a reaction to difficulty digesting food. There may be a few good reason therefore to include vomiting on a checklist.) As pelvic rehab providers, we can understand how frequent vomiting may lead to dehydration, intrabdominal and intrapelvic pressure, potential pelvic floor dysfunction, or how disordered eating may lead to other bowel dysfunctions such as constipation and/or fecal incontinence. If we also hold space for eating issues to be a concern, we may find that asking some valuable questions provides more information.

If you would like to learn more about nutrition and the pelvic health connections, you still have time to sign up for Megan Pribyl’s nutrition course which takes place in Lodi, California this June!.

Abraham, S., & Kellow, J. E. (2013) "Do the digestive tract symptoms in eating disorder patients represent functional gastrointestinal disorders?" BMC gastroenterology, 13(1), 1.