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Jun 20, 2014

This post was written by guest blogger Laura E Nimon OTR/L, CLT-LANA. Laura will be attending Ginger Garner's course that she wrote on "Yoga as Medicine for Labor and Delivery and Post Partum " in Seattle this August.

 

 

From the time a woman hears the words “You’re pregnant” she becomes flooded with information regarding what she should/should not do to have a healthy pregnancy—but how much is accurate, and why is a healthy delivery not further discussed?

 

Over the last decade yoga has become a highly recommended form of exercise to maintain/improve flexibility and cardiovascular status in a gentle and safe manner. There is a plethora of information and sales directed to pregnant women and these women should be wary consumers as not all classes or home videos are safe due to the hormonal changes experienced in pregnancy that can exacerbate a prior joint condition or create one if an exercise is done improperly.

 


Jun 18, 2014

pelvis

When assessing sacroiliac joint (SIJ) stability and function, pelvic rehabilitation providers often use the single leg stand test. During transition from double-leg stance to single-leg stance, dynamic stability is required and there are several ways to describe the observed behaviors in patients. If a patient, for example, loses her balance when transitioning to a single leg stand, what is contributing to her loss of stability? Could it be the SIJ, abdominal and trunk strength, ankle proprioception, visual or vestibular deficits, or hip abductor weakness? Of course, these are not the only potential confounders to postural stability, yet represent some of the considerations of the rehabilitation therapist.

 

A recent study aimed to further define techniques to measure "time to stabilization" in a double-limb to single-limb stance. The authors measured 15 healthy control subjects and 15 subjects who presented with chronic ankle instability (CAI) and the researchers tested the ability to achieve stability in single-leg stance during eyes open and eyes closed tasks as well as with varied speeds of movement.

 

The research found that in subjects who had CAI, following transition to single-leg stance, increased postural sway was noted. In the same subjects, when performing the task with eyes closed, those with a history of ankle instability performed the transition much more slowly than those in the control group when allowed to choose their speed of transition. Prior research (described in the linked article) had postulated that time to stabilization (TTS) following double-limb to single-limb transition was an important variable to measure, yet this research did not find that the TTS was significantly different between the groups studied.

 


Jun 18, 2014

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

 

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

 

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

 

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


Jun 18, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Elizabeth Kemper MPT, PRPC, BCB-PMD

 

Elizabeth Kemper

Describe your clinical practice:

I see both male and female patients in a private practice clinic and devote 100% of my time to pelvic therapy (“pelvic” being loosely defined as from the thorax to the knees). It is a privilege to share in some very personal and complicated portions of each person’s life. Just showing up for pelvic therapy can be daunting and I don’t take that trust lightly. The majority of people I see present with diagnoses of pelvic pain, prolapse, obstetrical issues, elimination dysfunction, abdominal pain and/or sexual dysfunction. I have the luxury and responsibility to give these patients undivided attention with one-on-one scheduling and treatments that are heavily weighted on patient education, manual techniques combined with neurologic re-education and progression into exercise-based support. I try to design the home programs to fit into the lifestyle and interests specific to that client. I love what I do and try to share that enthusiasm for pelvic health with each person who walks through the door!

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

I think the most important message to spread in the PT community is that pelvic rehabilitation is not a completely separate category. A good pelvic therapist integrates portions of all aspects of therapy – orthopedic, neurologic, geriatric, pediatric, oncologic, cardiovascular, etc! As is often found, the cause of the dysfunction with any diagnosis may be local or distant from the actual symptoms. While pelvic therapists specialize in the pelvic region, we have to incorporate the entire body in our evaluation and treatment in order to fully resolve the issue. There is sometimes a false image of pelvic therapists - that we just teach Kegels or do biofeedback - and that couldn’t be farther from the truth.


Jun 18, 2014

This post was written by H&W instructor Ginger Garner, MPT, ATC, PYT. Ginger will be instructing the course that she wrote on "Yoga as Medicine for Pregnancy" in New York this November.

 

yoga

Pregnancy brings the most enormous changes in a woman’s life, and is arguably the most profound change that the body can experience.

 

It is no secret that America claims the most shameful maternal health and birth outcomes in the developed world. For more information, read my previous post on American Childbirth: A Human Rights Failure? However, physical therapy can have quite a bit to do with turning those statistics around. Informing mothers about their right to access physical therapy can help improve birth statistics by improving a mother’s health and well-being, not just treating a case of pregnancy-associated low back pain or sciatica.

 


Jun 17, 2014

This post was written by H&W instructor Michelle Lyons, PT, MISCP . Michelle will be instructing the course that she wrote on "The Athlete and the Pelvic Floor" in Ohio this August.

 

michelle

Ample literature has shown that high impact and high intensity sporting activities are linked to pelvic floor dysfunction (Nygaard 1994, Nygaard 1997) and research has demonstrated that young female athletes participating in high-impact sports may be at particular risk for urinary incontinence.

 

Several epidemiological studies have shown that symptoms of SUI are frequent in populations of nulliparous female athletes. In a landmark study by Bo and Sundgot Bergen in 2001 on the prevalence of urinary incontinence in elite female athletes compared to age matched controls, the participants were asked ‘Do you currently leak urine during coughing, sneezing and laughter, physical activity (running and jumping, abrupt movements and lifting) or with urge to void (problems in reaching the toilet without leaking?’ The authors found equal prevalence of overall SUI and urge incontinence in both groups but the prevalence of leaking during physical activities was significantly higher in the elite athletes.

 


Jun 16, 2014

yoga

 

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

 

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

 

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


Jun 16, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Brook Browning, MPT, PRPC

 

Brook Browning

How did you get involved in the pelvic rehabilitation field?

As a second year PT student, I read a PT Magazine featuring Fatima Hakeem and thought “What?? PT’s do that... and here I have been learning about shoulders!” I was intrigued and got lucky enough to complete a clinical rotation with Susan Giglio, PT at Woman’s Hospital in Baton Rouge. I loved the idea of helping someone with an issue that cannot only be physically debilitating but can also impact the patient’s social and personal life on such an intimate level. Fourteen years later, I still have the magazine in my office as a reminder of my drive and passion for pelvic health.

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

I think that most PTs think we just treat urinary incontinence and have no idea the breadth of diagnoses we treat. I also think that there are many things that ALL PTs could do to improve bowel, bladder and sexual function that are “clothes on” so to speak. Sometimes just a handout on sexual positioning with back pain or a simple bowel massage can make a huge difference in a patient’s quality of life.


Jun 13, 2014

Athlete

 

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

 

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

 

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


Jun 12, 2014

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

 

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

 

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

 

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


Upcoming Continuing Education Courses

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

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

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

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

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

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

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

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

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

Male Pelvic Floor - Tampa, FL
Oct 04, 2014 - Oct 05, 2014
Location: Florida Hospital - Wesley Chapel

Pelvic Floor Level 2A - St. Louis, MO (Sold Out!)
Oct 10, 2014 - Oct 12, 2014
Location: Washington University School of Medicine

Chronic Pelvic Pain - New Canaan, CT
Oct 10, 2014 - Oct 12, 2014
Location: Philip Physical Therapy

Peripartum Special Topics - Houston, TX
Oct 11, 2014 - Oct 12, 2014
Location: Texas Children’s Hospital

Pelvic Floor Level 3 - Maywood, IL
Oct 17, 2014 - Oct 19, 2014
Location: Loyola University Stritch School of Medicine

Lymphatic Drainage - San Diego, CA
Oct 18, 2014 - Oct 19, 2014
Location: FunctionSmart Physical Therapy