The following comes to us from Carolyn McManus, PT, MS, MA, our resident expert in the power of mindfulness and it's applications to rehabilitation. Carolyn was recently featured in a video from the Journal of the American Medical Association for her contributions to a newly published research article. Join Carolyn at her course, Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain on May 14th and 15th in California's Bay Area!

Neuroimaging studies show that cortical and sub-cortical brain regions associated with cognitive and emotional processing connect directly with descending pain modulating circuits arising in the brainstem. As diminished nociceptive inhibition by descending pain modulation is a likely contributing factor to the persistence of pain, these cortical and sub-cortical connections to relevant brainstem regions provide a means by which maladaptive cognitive and emotional processing can contribute to the persistence of pain¹. It is possible that strategies to help patients self-regulate cognitions and emotions could promote pain reduction through restoring the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

To be mindful is to rest the mind in the present moment with stability and acceptance and without additional cognitive or emotional elaboration. Mindful body awareness is a central component. Training in mindful awareness has been shown to improve attention regulation, emotional processing and body awareness and contribute to reduced pain intensity, catastrophizing, depression and anxiety^2,3,4,5. Training in mindfulness has also been shown to modulate brain activity in areas associated with body awareness and pain processing^6,7. It is possible that the adaptive modulation of cortical and sub-cortical areas engaged with mindful cognitive, emotional and physical self-regulation could contribute to reducing pain through improving the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

One of my patients reflected the clinical benefits of mindfulness training when he said, “I needed to learn how to not freak out when my exercises or daily activities increased my pain. Focusing my mind on the present moment was enormously helpful. I would tell myself, “Breathe. Just be here. Calm down.” By breathing and relaxing I could take control of how I was reacting and I immediately saw a difference. My pain did not increase out of control.”

I am thrilled to be sharing my 30+ year experience in mindfulness and patient care in my upcoming course through Herman and Wallace.

1. Ossipov M, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8(2):143-151.
2. Holzel BK, Lazar SW, Guard T, et al. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Science. 2011;6: 537–559.
3. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013 Feb;14(2):230-42.
4. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013 Aug 26;8(8):e71834.
5. Schutze , Slater H, O’Sullivan P, et al. Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Front Psychol. 2014 Aug 4;5:839.
6. Zeidan F, Martucci KT, Kraft RA, et al. Brain mechanisms supporting modulation of pain by mindfulness meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
7. Nakata H, Sakamoto K, Kakigi R. Meditation reduces pain-related activity in the anterior cingulated cortex, insula, secondary somatosensory cortex and thalamus. Front psychol. 2014;5:1489.

“Please stress the need to examine men…For some reason, most female PT`s shy away from a male’s private parts totally. It would be great if females were taught that it's important to go there…And treat us as equals in this arena.”

This is an excerpt from a recent email we received at Herman & Wallace headquarters, and it highlights a common theme, that of patient access to care. While there are many factors driving patient access to pelvic health, availability of therapists trained in various conditions is certainly one major issue. By the time any patient is referred to pelvic rehabilitation, they have already overcome the challenge of many providers not being aware that there is help for pelvic health issues, and insurance or payment hurdles that can also cause a patient to delay or avoid recommended treatment. Many physical therapy programs have done an outstanding job in developing and marketing women’s health programs, with men’s health programs addressing post-prostatectomy care or male pelvic pain coming along almost as an afterthought.

So what is really limiting the care of men who wish to overcome urinary, pain, or sexual dysfunction? For many locations around the country, there simply is not enough awareness of the scope of pelvic rehab, the nearest pelvic rehab provider may be far away geographically (or have a months-long waiting list), or the clinic may limit pelvic healthcare to women. If the clinic chooses to only provide care to women, what are we being discriminating about? The word “discriminate” has at least two rather distinct definitions, one that is more negative, and meaning that we are acting in an unjust or prejudicial manner, and another that simply means we are recognizing a difference between patient groups. If we choose to discriminate against treating men in a pelvic health setting, it’s easy to understand that if a therapist has never been instructed in how to examine a male patient, it may be prudent to avoid such evaluation until training is completed. We can find examples of this situation in other aspects of clinical care: if I have never taken proper training in evaluation of the vestibular system, for example (a condition that historically has not always been comprehensively instructed in school), then it’s in my best interest (and that of the patient) to only provide such care once I have taken appropriate training.

If our care of male pelvic health conditions is due to lack of specific training, what is our professional responsibility for acquiring training in conditions such as post-prostatectomy urinary incontinence, male genital pain, or erectile dysfunction? If we are to serve the pelvic health populations well, our training should progress to include lifespan issues for all ages and all genders. If we actively choose to avoid treating a population or condition, is that fair to the community seeking care? The ethics of choosing not to treat patients of a particular gender or condition are interesting to consider, but are not the scope of this post. On the other hand, the business side of being able to market to and welcome male patients in our clinics is very positive, and of course, all of our patients tend to be grateful for what we offer.

If you are interested in learning more about male pelvic healthcare, the Institute has several courses that can help you do so. These courses include an introduction to men at the Pelvic Floor Level 2A course, the Male Pelvic Floor: Function, Dysfunction and Treatment course (3 days dedicated to evaluation and treatment of urinary, sexual, and pain dysfunction), the Post-Prostatectomy course, as well as several manual therapy courses such as our myofascial courses. It is understandable that pelvic health for men may be less familiar territory for many of us based on our graduate training and experiences. If fear or discomfort is holding us back, at least attending a training course can help provide strategies and tools for gaining more comfort in treating men. We are at an exciting time in the pelvic health field when treating men is gaining more ground. If you are not already, join this exciting movement by signing up for one of the many classes available to you!

Faculty member Lila Bartkowski- Abbate PT, DPT, MS, OCS, WCS, PRPC teaches the Bowel Pathology, Function, Dysfunction and the Pelvic Floor course for Herman & Wallace. Join her in Tampa on April 2-3, or one of the other two events currently open for registration.

Constipation, an often under reported health issue, afflicts about 30% of Americans. ¹ The diagnosis of chronic constipation may seem like a simple concept, however the etiology of chronic constipation presents itself in many different forms. Dyssynergic defecation is one of many factors that can lead to a presentation of chronic constipation in a patient. Dyssynergic defecation or “paradoxical contraction” occurs when the muscles of the abdominals, puborectalis sling, and external anal sphincter function inappropriately while attempting a bowel movement. ² The lack of coordination of these muscles results in a contraction versus a lengthening of the pelvic floor muscles with baring down. Dyssynergic defecation is different than a structural issue such as a rectocele or hemorrhoids causing the inability to pass stool effectively or constipation due to slow colon transit time or pathological disease. Making the diagnosis of dyssynergic defecation by symptoms alone is often not reliable secondary to overlap of similar symptoms with chronic constipation due to factors such as a structural issue, irritable bowel syndrome (IBS), or irritable bowel disease (IBD). The diagnosis of dyssynergic defecation can be difficult and is often made through physiologic testing such as balloon expulsion testing or MRI with defecography. ² However, physical therapists can often manually feel that a paradoxical contraction is happening when asking a patient to bare down on evaluation.

Patients with dyssynergic defecation may present to pelvic floor physical therapy with complaints of: ¹ ²

1. Abdominal symptoms such as bloating, pain, and cramping
2. Poor response to laxatives and fiber supplementation that does not fully resolve their issue
3. Have had testing for anatomical or neurological abnormalities with no significant findings
4. Complaints of concomitant pelvic pain due to over activity of the pelvic floor muscles

Physical Therapists specializing in pelvic floor rehab can be a valuable part of the medical team with treating these patients. Biofeedback training by physical therapists has been shown to decrease anorectal related constipation symptoms and abdominal symptoms in patients with dyssynergic defecation. In a sample of 77 patients with dyssynergic defecation, physical therapists provided biofeedback training for 6-8 weeks that included manual and verbal feedback, surface EMG, exercises using a rectal catheter, rectal ballooning to improve rectal sensory abnormalities, ultrasound, pelvic floor and abdominal massage, electrical stimulation if needed, and core strengthening and stretching to improve the patients’ maladaptive habits while attempting to pass a bowel movement. Significant decreases were seen on all three domains (abdominal, rectal, and stool) on the PAC-SYM (Patient Assessment of Constipation) questionnaire post biofeedback training. ² It is noteworthy that 74% of these patients presented to the clinic with complaints of abdominal symptoms such as bloating, pain, discomfort, and cramping.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab secondary to overlapping symptoms of different causes of chronic constipation. Physical therapists are able to provide these patients with conservative treatment that can effectively improve or eliminate their problem, recognize dyssynergic defecation as a possible differential diagnosis, and refer to the appropriate medical professional for further testing. Recognizing and treating dyssynergic defecation is something physical therapists will learn how to become effective at in the upcoming Herman and Wallace Course: Bowel Pathology, Function, Dysfunction & the Pelvic Floor April 2-3 in Tampa, FL and October 8-9 in Fairfield, CA.

1. Sahin M, Dogan I, Cengiz M et al. (2015). The impact of anorectal biofeedback therapy on quality of life of patients with dyssynergic defecation. Turk J Gastroenterol. 26(2):140-144

2. Baker J, Eswaran S, Saad R, et al. (2015). Abdominal symptoms are common and benefit from biofeedback therapy in patients with dyssynergic defecation. Clin Transl Gastroenterol. 30(6)e105. doi: 10.1038/ctg.2015.3

Many therapists start their career feeling a bit intimidated to work with women who are pregnant. A common and understandable concern is that something the therapist will do during examination or treatment may harm the patient. While there are certainly things to avoid when working with a patient who is pregnant there are also many therapeutic strategies that can help a woman thrive during her pregnancy and beyond. When women have pre-existing issues such as a disease or physical challenge, or when she develops an illness during pregnancy, the therapist needs to rely upon more knowledge- this knowledge is something she rarely learns in school, but more likely in continuing education environments. A recent article asked the question “are women getting sicker, and are there more high-risk pregnancies now than ever before?”

Researchers studied trends in maternal morbidity and mortality in the United States in order to answer this question, and the answer is a definitive “yes”. Several studies describe increases in the rates of maternal morbidity, with issues such as cardiac and pulmonary complications, and the severe blood pressure fluctuations associated with eclampsia. Gestational diabetes, and postpartum rates for hemorrhage, perineal lacerations, and maternal infections have also risen. Part of the reason for more women carrying pregnancies more successfully or longer when they are ill may be contributed to newer treatments for conditions such as diabetes, yet this does not explain entirely the increase in maternal morbidity. Increased cesarean births, longer labors with epidural anesthesia, pre-pregnancy obesity, rates of multifetal pregnancies, and the rising age of mothers are other factors to be considered.

The more we know as health care providers about how maternal morbidity affects our rehabilitation efforts, the more we can contribute to a woman’s pregnancy and postpartum health. If you would like to learn more about caring for women during pregnancy and during the postpartum period, Herman & Wallace offers the Pregnancy and Postpartum Series. The following courses are available this year:

Care of the Pregnant Patient - Somerset, NJ
Apr 30, 2016 - May 1, 2016

Care of the Pregnant Patient - Akron, OH
Sep 10, 2016 - Sep 11, 2016

Peripartum Special Topics - Seattle, WA
Nov 12, 2016 - Nov 13, 2016

Tillett, J. (2015). Increasing Morbidity in the Pregnant Population in the United States. The Journal of perinatal & neonatal nursing, 29(3), 191-193.

Faculty member, Ginger Garner PT, L/ATC, PYT will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more.

Yoga is, unarguably, a popular contemplative science, enjoying 36.7 million practitioners in the US alone, up from 20.4 million in 2012.1 A 16 billion dollar industry, yoga is one of the most widely utilized methods of complementary and integrative medicine in America today. In 2008, the editor of Yoga Journal declared “yoga as medicine” as the next great wave. That was right in the middle of the Great Recession, when the last thing on the collective healthcare industry’s mind was yoga.

What happened during the same time frame as the interest in yoga surged?

Our expanded knowledge of hip anatomy, physiology, and pathophysiology exploded onto the medical scene, providing more information than ever about how to address, preserve, and otherwise attend to the hip joint. Prior to this new age of research, the hip was relegated to a joint worthy of no more than a tendonitis, bursitis, or osteoarthritis diagnosis. A person was simply a hip replacement candidate or not. There was no other option once a hip joint had prematurely degenerated. Now, that has all changed, thanks to technological advances in diagnostic testing and investigation.

Yet, the worlds of hip preservation and rehabilitation and yoga have yet to join hands. Many of my patients and colleagues have suffered from unnecessary hip injuries, from labral tears, all types of impingement, and compounding secondary diagnoses such as torn hamstrings, sports hernias, gluteal tendinopathy, to pelvic pain, all due to yoga practice. Some suffered injuries in yoga class during a single traumatic injury, and some injuries were drawn out over years of accumulated microinjury to capsuloligamentous, bony, or cartilaginous structures.

Hip labral injuries (HLI) have vastly increased over the last 10 years, perhaps making HLI the newest orthopaedic diagnosis of the 21st century. This discovery also makes surgical and conservative management of HLI uncharted territory. Conservative therapy includes nonsurgical and post-surgical rehabilitation, and since the average time from injury to diagnosis is 2.5 years, there are many people with hip, pelvic, back, or sacroiliac joint pain that have undiagnosed hip labral tears.

I should make myself quite clear, however. I am not out to demonize yoga or fear-monger the practice of yoga or how it may wreck a person’s body (to use recently controversial language).

My purpose is two-fold: To clarify 1) “what” and “how” yoga can be a safe, effective form or physical therapy and rehabilitation for the hip and pelvis, as well as to 2) underscore the areas where yoga posture practice should be evolved to prevent injury.

To that end, I have written and will be presenting a new 4-hour workshop entitled, Hip Preservation: Yoga Reconsidered, at the Montreal International Symposium on Therapeutic Yoga (MISTY) this weekend in Canada. The lecture is relevant for yoga teachers, yoga enthusiasts, yoga therapists, and health care professionals who are interested in learning how to prevent hip injury in yoga practice.

The workshop will introduce identification of imbalances that could contribute to HLI, as well as understand the common mistakes made in yoga practice that could increase HLI or hip impingement. Understanding the pain patterns that surround HLI are also critical to safe and therapeutic yoga practice and will be discussed. Discussion of structure, function, ability and “dis”ability of the hip, including their major substrates, will help identify the “red flags” in yoga practice, identifying high risk populations and those who need postural modification(s) and/or outside referral to physical therapy.

I am looking forward to instructing a high energy, action-packed hands-on learning session at MISTY on March 19-20, along with my presenting a 2-hour lecture on maximizing public speaking impact through Vocal Liberation: The Voice as Therapy.

• The Voice as a Linking Science for Clinical and Business Efficacy
• Hip Preservation: Yoga Reconsidered
• Ginger’s lecture overview - Montreal International Symposium for Therapeutic Yoga

Want to learn more?
Bring Ginger’s 16 hour continuing education course, Differential Diagnosis for Hip Labral Injuries to your facility in 2017 through Herman & Wallace Pelvic Rehabilitation Institute.

Yoga in America 2016 Survey. Yoga Alliance and Yoga Journal. January 2016.

Herman & Wallace faculty member Eric Dinkins, PT, MS, OCS, Cert. MT, MCTA teaches the Manual Therapy for the Lumbo-Pelvic-Hip Complex: Mobilization with Movement and Laser-Guided Feedback for Core Stabilization course for Herman & Wallace. He is one of only 13 practitioners in America credentialed to teach the Mulligan Concept of Manual Therapy, and is a published author. Join him in Arlington, VA on August 20-21, 2016 to learn new joint mobilization, evaluation, and treatment skills.

Much research has been published regarding evaluation and diagnosis of the Sacroiliac Joint (SIJ). Low back pain and pelvic girdle pain is a common complaint with patients in all clinic settings. Laslett (Manual Therapy 2005) gave our profession valuable insight into categorizing a cluster of tests to try to ensure Physical Therapists and Chiropractors know if the SI joint is a pain source of our patients. We now also have several articles reaffirming the validity of the Active Straight Leg Raise (ASLR) and Stork testing for SIJ dysfunction (Manual Therapy 2008; JBMR 2012; PT 2007). However, after talking with clinicians who attend my Mobilization with Movement classes, as well as many colleagues in the outpatient orthopedic setting, there is a definitive lack of understanding how to use this information to translate over to successful treatment. This is understandable considering there have been several articles published regarding the poor validity and consistency between clinicians regarding palpation skills and bony landmarks in the lumbar spine and pelvis (ex: Manual Therapy 2012). But perhaps the fault is not in the clinician proficiency, but rather in the nature that we are attempting to diagnose an SIJ dysfunction?

If you were to consult with experts in body kinematics, gait analysis, and biomechanics regarding the true movement of the SIJ, there will be many different answers depending on the action that they were describing. Particularly when it comes to dysfunction. Disagreements abound when describing conditions such as “upslips”, “inflares”, etc and virtually all back their arguments with clinical anecdotal success rates. These arguments often leave clinicians with inconsistencies in treatment and increased failures.

This blog is meant to be a persuasive argument for using function-improving or pain- eliminating techniques for diagnosis and treatment of SIJ dysfunction. The logic of this approach is often misunderstood. But if applied correctly, satisfies most theory surrounding the SIJ, and provides immediate feedback for knowing how to resolve the condition and what you are treating.

We have pain provocative testing that is most commonly used in attempting to diagnose a SIJ dysfunction. However, after interpreting these tests, the clinician is still left without a true diagnosis as to the nature of what is happening at this joint to cause pain or dysfunction. This is likened to the "painful shoulder" or "low back pain" prescription we see. The error rates, even in the cluster, still leaves room for inaccurate assessment and therefore potential misguided treatment. Lumbar facet, musculature, hip capsule imbalance, are just some examples that can produce false positives on the typical SIJ tests that are used in clinic. Therefore, it is necessary to understand that pain provocative testing ONLY tells us that pain is coming from that structure that is being tested. And NOT that it is “THE” source of the dysfunction.

Now consider using function-improving or pain-eliminating techniques for your evaluation. The ALSR test, as an example, function improving special test. Compression applied to various aspects of the pelvis or supporting musculature yield a positive finding if the SLR is now easier if the force is applied. Combing this information with the faulty kinetic testing of the Stork and/or leg pull test to determine the involved side yield an immediate feedback for both the clinician and the patient as to what forces are needed to correct the dysfunction that is limiting the functional activity and restore normal motion. Treatment would then be applied by creating a force on the innominate, sacrum, or both and would then be maintained throughout the movement and can be considered a form of active exercise (manual assisted active exercise). If retesting of the affected motion yields a sustained improvement, the accurate diagnosis has now been made. And surely this diagnosis would be upheld if the patient returned at a later date to demonstrate no regression occurred.

If the force applied to the pelvis was directed toward posterior rotation at the innominate and/or an anterior rotation at the sacrum, and the affected motion cleared without pain or limited motion, it would be confirmed that these forces were necessary to correct the dysfunction on the involved side regardless of the "ambiguous diagnosis' including the potential of a previously held thought of an anterior rotation of the pelvis (making the argument of what actually happened at the pelvis mute). This may have been achieved through altering inputs viewed as a potential "threat" by the system, or mechanics stresses, etc. Regardless, if manual correction of this condition was applied and the dysfunction was correction through re-creating this without pain, one would conclude that this dysfunction was the primary eitiology of the symptoms. If the symptoms returned or the functional test was not normalized, an easy conclusion would then be that despite manual correction eliminating pain during the activity, this correction was not addressing the source of the dysfunction. And therefore the clinician should consider treatment elsewhere.

In essence, the body is capable of directing what it needs in order to return to a normal functioning homeostasis…without the application of pain. Now this pain-eliminating testing becomes your assessment, treatment and potentially your home exercise program!

To conclude, it is my suggestion to all manual based physiotherapists and chiropractors to strongly consider pain-eliminating techniques for both evaluation and treatment in their practice.
Did I mention yet that your patient already voted for that….?

Laslett, M, et al. "Diagnosis of Sacroiliac Joint Pain: Validity of individual provocation tests and composites of tests" Manual Therapy 10 (2005) 207-218
M. de Groot, et al. "The active straight leg raising test (ASLR) in pregnant women: Differences in muscle activity and force between patients and health subjects" Manual Therapy 13 (2008) 68-74
Hungerford, B, et al. "Evaluation of the Ability of Physical Therapists to Palpate Intrapelvic Motion with the Stork Test on the Support Side" Phys Ther. 2007 Jul;87(7):879-87.
O'Surrivan PB, Beales DJ. "Diagnosis and classification of pelvic girdle pain disorders—Part 1: A mechanism based approach within a biopsychosocial framework" Man Ther. 2007 May;12(2):86-97.
Arab AM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. "Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for sacroiliac joint" Man Ther. 2009 Apr;14(2):213-21. doi: 10.1016/j.math.2008.02.004. Epub 2008 Mar 25.

Depression and anxiety can limit ability to care for one’s self, limit ability to care for a new baby or developing fetus, and can cause mood swings, impaired concentration, and sleep disturbance. Disorders of depression and anxiety are common in the perinatal period (immediately before and after birth) with depression rates around 20% and perinatal anxiety present in about 10% of women. These mood disorders greatly diminish quality of life for mother and baby. Medication may be effective, however, side effects are often unknown, and potentially adverse for the perinatal patient. Many women worry that using medication to treat these disorders may harm the fetus, negatively affect mother child bonding, and poorly influence child development. As health care providers, being aware of alternative treatments for depression and anxiety is essential. Having alternative treatments can allow our patients to combat these common perinatal problems which will improve quality of life, improve bonding between baby and mother and improve the overall perinatal experience. In the general population, positive mental and physical health benefits have been continually demonstrated by yoga participants in current research. Can yoga be an effective, alternative treatment to help perinatal patients improve mental health and well-being?

A recent 2015 systematic literature review published in the Journal of Holistic Nursing reviewed 13 studies to examine existing empirical literature on yoga interventions and yoga’s effects on pregnant women’s health and well-being. The conclusion of the review found that yoga interventions were generally effective at reducing depression and anxiety in perinatal women and the decrease in depression and anxiety was noted regardless of the type of outcome measure used and results were optimized when the study was 7 weeks or longer. Other positive secondary findings noted with the regular yoga participation in the perinatal participants were: improvements in pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being. What is yoga and what form of it may help battle perinatal depression and anxiety?

Yoga by definition is a Hindu philosophy that teaches a person to experience inner peace by controlling the mind and body. Merriam-Webster defines yoga as a system of exercises for attaining bodily or mental control and well-being. All styles of yoga include some combination of physical poses, breathing techniques, and meditation-relaxation techniques. Hatha yoga is the most common form completed in the United States and consists modernly of various postures, breathing, and meditation. In the 13 reviewed studies, all interventions consisted of different forms of yoga and the overall conclusion of the systematic review was the decrease in depression and anxiety was significant no matter the form of yoga completed. Physical and emotional issues such as hormonal changes, sleep deprivation, inability to handle new tasks, self-worth, and body issues, during the perinatal period can contribute to increased anxiety and depression. As health care providers we need to have alternative treatments to help our perinatal patients’ battle depression and anxiety. Yoga is a promising alternative to medication to help decrease depression and anxiety. Additionally it may be helpful for management of pain, anger, stress, gestational age at birth, birth weight, maternal-infant attachment, power, optimism, and well-being.

Interested in learning more about how you can apply therapeutic yoga in your practice? Check out "Yoga as Medicine for Pregnancy this April in Washington, DC!

Sheffield, K. M., & Woods-Giscombé, C. L. (2015). Efficacy, Feasibility, and Acceptability of Perinatal Yoga on Women’s Mental Health and Well-Being A Systematic Literature Review. Journal of Holistic Nursing, 0898010115577976.

As pelvic rehabilitation providers, it may be safe to assume a lot of us are treating adults with bladder and bowel dysfunction. Often we get questions from these patients about treatment for children with voiding dysfunction. How comfortable are we treating children for these problems and what would we do? Pediatric voiding dysfunction and bowel problems are common and can have significant consequences to quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated. No clear gold standard of treatment for pediatric voiding dysfunction has been established and treatments range from behavioral therapy to medication and surgery.

A randomized controlled trial in 2013 that was published in European Journal of Pediatrics, explores treatment options for pediatric voiding dysfunction. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral striated sphincter during voluntary voiding. The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and abnormal flow of urine from bladder back up the ureters (vesicoureteral reflux).

The 2013 study compared 60 children over one year who were diagnosed with dysfunctional voiding into two treatment groups. One group received behavioral urotherapy combined with PFM (pelvic floor muscle) exercises while the other group received just behavioral urotherapy. The behavioral urotherapy consisted of hydration, scheduled voiding, toilet training, and high fiber diet. Voiding pattern, EMG (electromyography) activity during voids, urinary urgency, daytime wetting, and PVR (post-void residue) were assessed at the beginning and end of the one year study with parents completing a voiding and bowel habit chart as well as uroflowmetry with pelvic floor muscle sEMG (surface electromyography) was administered to the child for voiding metrics.

All parents and children in both groups received education about urinary and gastrointestinal tract function as well as healthy bladder habits, effects of high fiber diet, scheduled voiding, and normal mechanics of toilet training. For the group that completed PFM exercises and education, they participated in 12 sessions (2x/week for 30 minutes) to learn the PFM exercises under the guidance of a single physical therapist. There was bimonthly follow up for both groups throughout the 12 months to ensure retention and application of the behavioral urotherapy.

The goal of the PFM exercises for the children was too restore the normal function of the PFM’s and their coordination with abdominal muscles. The exercises that the children completed, included exercises with and without a swiss ball. The exercises without a swiss ball included breathing with the diaphragm, Transversus Abdominus muscle isolation, hip adductor squeeze (isolation), bridging with PFM relaxation, and cat/camel to improve lumbopelvic coordination. Swiss ball exercises included seated PFM contraction and relaxation exercise with a seated lift and relax, supine bridge with roll out on the ball with PFM contraction, and supine swiss ball lift with the legs and pelvic contraction. (Pictures and more details about how the exercises were carried out in the article itself.)

The conclusion of the study was that the functional PFM exercises with swiss ball combined with behavioral urotherapy reduced the frequency of urinary incontinence, PVR (post void residue), and the severity of constipation in children with voiding dysfunction. The children in the combined group showed improvements with voiding pattern, reduced EMG activity during voids, reduced urgency, reduced daytime wetting, and improvements with more complete emptying with voids (reduced PVR).

The Functional PFM exercises are easy to teach and easy for children to complete. They are a safe, inexpensive, and effective treatment option for children with dysfunctional voiding. PFM exercises combined with behavioral urotherapy seems to be a logical treatment option for treating pediatric voiding dysfunction.

To learn more about pediatric bowel and bladder dysfunction and treatment for it consider attending Dawn Sandalcidi's Pediatric and Pelvic Floor Dysfunction course. The three opportunities in 2016 are Pediatric Incontinence - Augusta, GA April 16-18, Pediatric Incontinence - Torrance, CA June 11-12, and Pediatric Incontinence - Waterford, CT on September 17-18.

Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.

As a child, I remember my grandmother rubbing my lower back to help me pass my stubborn stool, a problem which landed me in the hospital twice before I turned 10. Decades later, after the birth of my first baby, I had a grade III perineal tear that made me afraid I would never be able to control my stool from passing. At the time of each situation, I had no idea how many people of all ages experience the two extremes of bowel dysfunction. Thankfully, for patients struggling with either issue, whether it is chronic constipation or fecal incontinence, healthcare practitioners are becoming knowledgeable in how to treat both effectively through classes such as the Herman & Wallace course, “Bowel Pathology, Function, Dysfunction & the Pelvic Floor.”

In 2014, Kelly Scott, MD, authored an article entitled, “Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence.” She reviews the current literature and notes this area of study lacks high quality randomized controlled trials, and further research is needed to provide evidence on the efficacy of different treatment protocols. Up to 24% of the adult population has been shown to experience fecal incontinence. Under the umbrella of pelvic floor rehabilitation lies pelvic floor muscle training, biofeedback, rectal balloon catheters for volumetric training, external electrical stimulation, and behavioral bowel retraining. The goals of various biofeedback methods include the following: provide endurance training specifically for the anal sphincter and pelvic floor; improve rectal sensitivity and compliance; and, increase coordination and sensory discrimination of the anal sphincter. Overall, the success rate of pelvic floor rehabilitation for fecal incontinence in most of the studies is 50% to 80%, and it is considered safe as well as effective.

On the other end of the spectrum, Vazquez Roque and Bouras (2015) published an article regarding management of chronic constipation. Chronic constipation (CC) in the general population has a prevalence of 20%, and the elderly population has a higher rate than the younger population. Chronic constipation is commonly treated with stool softeners, fiber supplements, laxatives, and secretagogues. However, as in all areas of healthcare, a thorough examination needs to be performed to assess the source of the problem. Determining whether a patient exhibits slow transit constipation or a true pelvic floor dysfunction (PFD) via blood work, rectal exam, and appropriate PFD tests is essential to provide the appropriate treatment. When the CC culprit is dysfunction of the pelvic floor, clinical trials have proven the efficacy of pelvic floor rehabilitation and biofeedback, making them optimal treatments.

When research indicates a particular type of rehabilitation is effective for treating a wide scope of issues in an area of the body, learning how and when to implement the techniques is paramount for a well-rounded practitioner. Most of us do not dream of treating chronic constipation or fecal incontinence; but, as we mature in our clinical practice, the spectrum of dysfunctions we discover through diagnostic testing and experience grows. Continuing education in previously unexplored territories can only expand the population to whom we provide relief.

Scott, K. M. (2014). Pelvic Floor Rehabilitation in the Treatment of Fecal Incontinence. Clinics in Colon and Rectal Surgery, 27(3), 99–105.
Vazquez Roque, M., & Bouras, E. P. (2015). Epidemiology and management of chronic constipation in elderly patients. Clinical Interventions in Aging, 10, 919–930.

The following post comes to us from Herman & Wallace faculty member Tina Allen, PT, BCB-PMD who teaches many courses with the institute. Tina's new course, Manual Therapy Techniques for the Pelvic Rehab Therapist, will be debuting this October in San Diego, CA.

As a physical therapist who has been treating pelvic floor dysfunction for 20 years, the patient who still impacts me the most happens to be the second patient I ever treated. The patient was a 22 year old woman who, before she even was referred to me for pelvic pain, had already seen 14 medical providers and experienced 10 procedures including a hysterectomy. She had been told by more than half of her providers that this pain was “in her head”, that “she needed counseling”, and that there was no reason for her pain. With 4 years of clinical experience at the time, I felt discouraged and wondered how I was going to help her. Then I remembered that no one else could look at her muscles and biomechanics like a PT could.

I started out by educating her about the muscles “down there”, observed how she moved with her daily tasks and then I completed her seemingly first ever muscular evaluation of the perineum. After 6 sessions of down training, muscle reeducation, manual therapy, strengthening of her hip and teaching her how to self mobilize the tissues of the perineum, she reported a pain level of 3/10- the lowest her pain level had been since she was 13 years old! Of course, she asked why it took so long for her to be referred to PT.

While this felt like an extreme story to me at the time, I now know that this is still the reality for many of the clients that we work with as pelvic floor PT’s. This experience set up the aspiration for me to have medical residents in my clinic with me to teach them what PT can do for patients and so that the residents can better evaluate their patients. As pointed out in research in the Journal of Graduate Medical Education, residents in obstetrics and gynecology do not feel adequately prepared to manage the care of women who have chronic pelvic pain^{Witzeman & Kopfman, 2014}. Specifically, residents reported negative attitudes towards patients with pelvic pain, and feelings of not having enough time to address their patients’ needs. When asked about how they preferred to learn more about care of patients with pelvic pain, the residents were interested in one-on-one clinical teaching as well as use of diagnostic algorithms. At this point in time I have medical residents with me at least 2 days per month. It’s a start!

So, what does a typical day look like with a 1st year OB/GYN resident in your clinic?

First, I always do my best to let my clients know in advance that a physician will be with me that day. The patient can always decline but most patients are accommodating. I have found that most of our patients want to advocate for themselves and others by having that physician with us in our session to teach them about how PT has helped them.

I spend the first 30 minutes when the resident arrives by bringing out the pelvic floor muscle model and explaining the function of all the muscles and how those muscles impact function. I also describe how this function is impacted by fascia, the muscles of the trunk, biomechanics and mind/body connections. Then we start seeing patients. After I have reviewed the patient’s current status, we begin our session. The patient is asked to give the resident their history and medical history. It’s been wonderful to watch my patients teach the residents and to hear the patients be able to explain their condition including procedures and functional restrictions.

The residents will then be instructed to palpate and learn about restricted tissues, observe how the patient uses their pelvic floor muscles, core, trunk and legs with their daily tasks. The residents have the opportunity to observe how we progress the patient’s self care in therapy.

While the session may start with the resident feeling frustrated that they are not able to be seeing their own patients or preparing for their tests, it usually ends with the resident asking when they can come back to the clinic to learn more about what we do and how we can help patients.

I urge all of us to reach out and invite physicians, PA’s, ARNP’s, midwives, naturopaths and nurses into our clinics to learn. With a little advanced planning we can get patients the help they need as soon as possible.

Witzeman, K. A., & Kopfman, J. E. (2014). Obstetrics-Gynecology Resident Attitudes and Perceptions About Chronic Pelvic Pain: A Targeted Needs Assessment to Aid Curriculum Development. Journal of graduate medical education, 6(1), 39-43.