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Jan 30, 2015

Female Pelvis for Drawing

One of the challenges we see in pelvic rehabilitation is an issue that we can observe across many conditions: an individual who may not appear to have significant objective signs can have significant impairments, while someone who presents with major physical dysfunction has mild or no complaints. Within the gynecologic literature, the question of "what is a significant level of prolapse" has been a frequent question, and usually a question that lacks specific answers. Looking at some of the research helps to highlight the clinical query and to demonstrate some of the research conclusions.


- When the authors Swift et al. (2003) attempted to correlate patient symptoms with level of pelvic organ support in a general population of 477 women, they found that women who presented with Stage II and stage III prolapse have increased symptoms. They suggested that these findings may help define POP levels that are symptomatic. (None presented with stage IV prolapse in the study.)

-Broekhuis et al. (2009) make the point that while pelvic organ prolapse (POP) and pelvic organ dysfunction symptoms can occur at the same time, they can also occur independent of each other. The only symptom in their study (n = 69) that correlated positively with degree of pelvic organ prolapse was having a sensation of or being able to see a vaginal bulge.

-In a similar study correlating the level of perineal descent with pelvic symptoms, the authors found that prolapse symptoms were associated with degree of perineal descent, but urinary incontinence and anorectal symptoms were not associated with level of descent. The study states that " …the clinical …impact of perineal descent in urogynecology is still unclear at this time point." (Broekhuis et al., 2010)


Jan 29, 2015

Relaxation Training for UI

How does pelvic floor muscle function differ in women with symptoms of overactive bladder compared to symptomatic women? A study completed by Knight and colleagues included determining if pelvic floor muscle surface electromyography (EMG) and pelvic floor muscle (PFM) performance were different among these groups. Scores regarding anxiety, life stress, and quality of life were assessed. Symptoms of overactive bladder can include urinary urgency, frequency, nocturia, and leakage of urine. Subjects in this study had "dry" overactive bladder, meaning that the patients did not experience leakage associated with the urgency.


28 women with urinary urges and frequency were age-matched to 28 asymptomatic controls. Participants completed the Beck Anxiety Inventory, Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire, and the Recent Life Changes Questionnaire. Surface EMG was utilized to assess pelvic floor muscle function. Results of the study included that women with urinary urgency and frequency had significantly more anxiety than women in the control group. Surface EMG measures (pathway vaginal sensor was used with self-placement) were not significantly different for ability to contract or relax the PFM. Scores on the PFIQ and the RLCQ were significantly higher for women with overactive bladder. The authors conclude that, although a causative relationship could not be made between overactive bladder and anxiety, there exists a relationship between the two conditions.


Another interesting study which compared interventions of yoga versus mindfulness for women who have symptoms of urinary urge incontinence found that mindfulness-based stress reduction was effective for reducing urinary incontinence episodes whereas yoga was not. This study followed a pilot directed by the same primary investigator which showed similar positives results of mindfulness training on urinary urge incontinence.


Jan 28, 2015

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD, PRPC, who will be presenting Pelvic Floor Level 2B in Houston at the end of February.


Allison Ariail

Dyspareunia, or pain during or after intercourse, can be very upsetting and frustrating to a woman. One cause of dyspareunia is vaginal dryness. As estrogen levels decrease, the vaginal tissues can have less moisture, elasticity, and become thinner. This not only can affect postmenopausal women, but also post-partum women, and women who are on estrogen-blocking medication due to cancer or for treatment of fibroids. One of the common and effective treatments for this vaginal dryness includes estrogen creams, or hormone replacement. However, what does a woman do if she is not able to use an estrogen cream, due to an estrogen receptor positive cancer? One possibility is hyaluronic acid. Hyaluronic acid is a substance naturally found throughout connective, epithelial, and neural tissue. You may be more familiar with hyaluronic acid as the substance injected into joints for osteoarthritis. However, there have been some recent published studies comparing the use of hyaluronic acid to estrogen replacement.


In 2011, Ekin et al. published a study comparing the use of hyaluronic acid vaginal tablets with estradiol vaginal tablets. Two groups of postmenopausal women with atrophic vaginitis were studied. One group used estradiol vaginal tablets (n=21) for 8 weeks, while the other group used hyaluronic acid tablets (n=21) for 8 weeks. Outcomes consisted of the degree of vaginal atrophy, vaginal pH, vaginal maturation index, and a self-assessed 4-point scale. Both groups had relief of vaginal symptoms, improved epithelial atrophy, decreased vaginal pH, and increased maturation of the vaginal epithelium. The group on estradiol did have greater improvements, however, it was determined that the hyaluronic acid vaginal tablets was effective enough to be considered an alternative treatment for those who wanted to avoid the use of a local estrogen treatment.


Jan 27, 2015

This post was written by H&W instructor Heather S. Rader, PT, DPT, BCB-PMD, who authored and instructs the course, Geriatric Pelvic Floor Rehab. She will be presenting this course this June in Florida!


Heather Rader

“I have never heard of pelvic floor rehab before.”


This comment poses an added job requirement for us, my fellow pelvic rehab practitioners! You have a responsibility to make this specialty understandable to your patients, referring providers, and the community at large. Therefore, marketing and education become interchangeable.


Jan 23, 2015

Herman & Wallace is proud to feature Elizabeth Fiser, PT, DPT who has completed all four of the Herman & Wallace Pelvic Floor Series courses.


Kelly Carter

Describe your clinical practice

Currently I work in a hospital-based outpatient clinic in Mobile, AL. I see a mixture of patients ranging from urinary incontinence, pelvic pain, sacroiliac joint dysfunction, constipation, to fecal incontinence.


How did you get involved in the pelvic rehabilitation field?

Jan 22, 2015

This post was written by H&W instructor Michelle Lyons, PT, MISCP, who authored and instructs the course, Menopause: A Rehabilitation Approach. She will be presenting this course this February in Florida!


Michelle Lyons

Compared to subject matter that has traditionally been offered in physical therapy curricula, such as musculo-skeletal and neuromuscular coursework, the concept of wellness is a relatively new addition to our skill-set (Fair 2009). ‘A Normative Model of Physical Therapist Professional Education’ includes educational objectives related to wellness, alongside objectives related to orthopaedics and neurology. As patients become increasingly educated about nutrition, complementary and alternative medicine, we as women’s healthcare providers must be able to assist our patients in seeking out healthy lifestyles. Nowhere has this surge in interest been more apparent than in women entering peri-menopause.


Historically, physical therapy has been associated with restoring physical fitness and wellness using manual therapies, exercise instruction and education about healthy lifestyle. Women’s health as a physical therapy specialty was formally established in the U.S. in the late 1970’s by Elizabeth Noble. Initially there was a focus on the reproductive health issues affecting women, primarily obstetrics and gynaecology but today’s physical therapist specializing in women’s health must be well versed in all aspects of menopausal health and wellness to meet the growing demands of women.


Jan 21, 2015

Are you eligible to become pelvic rehab certified?


The rigorous and psychometrically validated Pelvic Rehabilitation Practitioner Certification (PRPC) will be offered for the third examination this year. You still have time to join the nearly eighty practitioners who have earn their letters! (Keep in mind that, different from a "certificate", this certification allows you to use the designation "PRPC" after your name, helping to distinguish you as an expert in pelvic rehabilitation. In case you are uncertain if you are a candidate to sit for the PRPC examination, check out some commonly-asked questions below.


Types of practitioners: Do I have to be a physical therapist?


You do not need to be a physical therapist in order to apply for the PRPC exam. What is required is that you have a license to practice the skills utilized in pelvic rehabilitation. Such a license may include physician (MD, DO, ND), registered nurse (RN), occupational therapist (OT), advanced registered nurse practitioner (ARNP), or physician assistant (PA-C). Any other provider can apply and will be examined on a case-by-case basis.

Jan 20, 2015

This post was written by H&W instructor Susannah Haarmann, PT, WCS, CLT, who authored and instructs the course, Rehabilitation for the Breast Oncology Patient.


Susannah Haarmann

It is holistic and forward thinking for medical practitioners, such as physical and occupational therapists, to consider the interconnectedness of mind and body when creating an effective treatment plan. Today, it is generally accepted that stress weakens the immune system and, the American Medical Association reports that “80% of all diseases are stress related,” (1). Prolonged physical and emotional distress triggers the neuroendocrine system to secrete stress hormones which affect the immune system, specifically, decreasing T-cell production and lowering basal and interferon augmented NK cell activity (NKCA). Knowing this unlocks huge potential for cancer patients who wish to actively boost their immune system during treatment; one of these proven techniques is called mindfulness-based stress reduction (MBSR). A study performed by Witek-Janusek et al, demonstrated a significant increase in NKCA levels in breast cancer patients after just one month of participating in a MBSR program; this is significant because elevated NKCA levels correlate with a decreased incidence of lymph node metastasis and improved survival rates in women with breast cancer (6).


MBSR may be compared to meditation and in the west we are seeing an increased acceptance of patients and practitioners looking to eastern philosophy as an adjunct treatment to western medicine. In fact, yoga is one of the most commonly sought after complementary treatments for breast-cancer related impairments among survivors today (4). Yoga, as a practice, blends mindfulness and movement. Physical exercise and mindfulness practices have both independently been shown to have a positive effect on cancer outcomes (3,6), therefore, it makes sense that patients are seeking yoga during treatment and supports why yoga is beneficial for physical and occupational therapists to include in their tool box of effective interventions.


Jan 16, 2015

Herman & Wallace is proud to feature Kelly Carter, PT who has completed all four of the Herman & Wallace Pelvic Floor Series courses.


Kelly Carter

Describe your clinical practice.

Physical Therapy Connection, Inc. (PTC) in Mountain Home, AR, is a privately owned clinic set within the beautiful Ozark Mountains. The clinic is comprised of two physical therapists, Rowdy Kelly, an orthopedic specialist, and me, plus a physical therapy tech and two office staff. PTC features private, comfortable treatment rooms and houses a complete wellness center to encourage and assist patients in maintaining the gains made during their PT sessions.


How did you get involved in the pelvic rehabilitation field?

Jan 14, 2015

Female Superior Obturator

As a physical therapist I am continually amazed at the myriad of ways the parts of our bodies are connected (and even more so by our brain/body connections, but that is another blog post.) Take one of my favorite muscles for example, the obturator internus. This amazing muscle is known for its relationship to the hip as one of the external rotators, and it’s anatomy is impressive! What other muscle sharply turns ninety degrees from its attachment to its origin? The obturator internus traverses the inside of the pelvis and attaches mid-belly to an important tendon, the Arcuate Tendon Levator Ani (ATLA) , which becomes the means by which the obturator connects to the pelvic floor. (I love to show patients how their hip literally connects to their pelvis!) The ATLA connects with the Arcuate Tendon Fascia Pelvis which connects to the fascia supporting the bladder and urethra.

We know that in our patient who have pelvic pain too much tension or trigger points in the obturator internus can create symptoms of urinary urgency or frequency, pain in the bladder, vagina, rectum, abdomen, pelvic floor and hip. But what happens when the obturator internus is uptrained to treat women with stress urinary incontinence (SUI)? An article in the May/August 2014 Journal of Women’s Health looked at the role of strengthening the obturator internus and the adductors and compared the effects to working the pelvic floor for the treatment of women with SUI. The results were quite interesting.


This research was a pilot study comparing two randomly assigned groups of community dwelling women with SUI. A group of 12 completed resisted hip rotation (RHR) and a group of 15 completed pelvic floor muscle training (PFMT). Each group exercised at home for six weeks with a weekly recheck. Outcome measures included subjective reports of improvement, leak frequency, and scores from the Incontinence Impact Questionnaire (IIQ) and the Urogenital Distress Inventory (UDI). The exercise routines were supposed to take about 5 minutes and be performed twice a day. Subjects were instructed to sit with good posture and with their feet on the floor. The pelvic floor muscle group performed 5-second holds for 20 reps followed by 20 quick contractions. The RHR group exercised by 1) rotating internally and externally with diaphragmatic breathing for 10 breaths , 2) 10 repetitions of resisted hip external rotation with a green band and 5 second work/rest cycle and 3) 10 repetitions of hip internal rotation/adduction against a 9 inch ball with the same 5 second squeeze and rest cycles.


The results of the study showed that BOTH groups had significant and equal improvement in outcome measures by the end of the six weeks, but that the RHR group showed improvements sooner than the PFMT group. The authors discuss the limitations of their study: small sample size, large ranges of participant ages, patients were not medically examined, outcome measures were subjective, and the pelvic floor group only received verbal instruction. This study was thought provoking to me for several reasons. First, it gives me a great platform to talk with my non-pelvic health colleagues about treating pelvic floor weakness dysfunctions with indirect pelvic floor treatment. Virtually any patient could sit and roll their legs in and out against resistance! This exercise could be easily incorporated into a routine for people with bladder leakage or at risk for bladder leakage. Secondly, we often see patients with non-functioning pelvic floor muscles. My typical protocol before discussing the treatment option of electrical stimulation is to uptrain (increase muscle activity) with hip rotation, adduction and transverse abdominus muscle exercises. I have often found that I don’t need to address the pelvic floor directly when the accessory muscles are appropriately engaged. This study points out the importance of muscles outside of the pelvic floor in providing support for continence.

Upcoming Continuing Education Courses

Pelvic Floor Level 2B - Columbus, OH (SOLD OUT)
Apr 17, 2015 - Apr 19, 2015
Location: Ohio Health

Athlete and the Pelvic Floor - New York City, NY
Apr 18, 2015 - Apr 19, 2015
Location: Kima - Center for Physiotherapy & Wellness

Pudendal Neuralgia Assessment and Treatment - Salt Lake City, UT
Apr 18, 2015 - Apr 19, 2015
Location: University of Utah Orthopedic Center

Finding the Driver in Pelvic Pain - Milwaukee, WI
Apr 23, 2015 - Apr 25, 2015
Location: Marquette University

Pelvic Floor Level 1 - Durham, NC (SOLD OUT!)
Apr 24, 2015 - Apr 26, 2015
Location: Duke University Medical Center

Sexual Medicine for Men and Women - Fairlawn, NJ
Apr 24, 2015 - Apr 26, 2015
Location: Bella Physical Therapy

Bowel Pathology and Function - Kansas City, MO
Apr 25, 2015 - Apr 26, 2015
Location: Saint Luke\'s Health System

Pelvic Floor Level 1 - Los Angeles, CA (SOLD OUT)
May 01, 2015 - May 03, 2015
Location: Mount Saint Mary’s University

Pelvic Floor Level 2A - Seattle, WA (Sold Out!)
May 01, 2015 - May 03, 2015
Location: Swedish Medical Center Seattle - Ballard Campus

Oncology and the Female Pelvic Floor - Torrance, CA
May 02, 2015 - May 03, 2015
Location: HealthCare Partners - Torrance

Care of the Postpartum Patient - Boston, MA
May 02, 2015 - May 03, 2015
Location: Marathon Physical Therapy

Pediatric Incontinence - Minneapolis, MN
May 16, 2015 - May 17, 2015
Location: Mercy Hospital

Biomechanical Assessment of The Hip & Pelvis - Durham, NC
May 16, 2015 - May 17, 2015
Location: Duke University Medical Center

Special Topics in Women's Health - Maywood, IL
May 30, 2015 - May 31, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Middletown, CT
May 30, 2015 - May 31, 2015
Location: Middlesex Hospital