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Aug 14, 2014

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Marci Marshall, PT, PRPC

 

Marci Marshall

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

Thinking “out of the box”…I always say to my patients that there are many pieces to a puzzle and we just have to find the right pieces to fit together for them to be on the path to healing. I believe that pelvic rehabilitation requires a multidisciplinary approach. There are many complementary services; such as, dry needling, visceral therapy, massage therapy, acupuncture, mindfulness meditation and yoga that need to be considered. Be open to try something new and to explore as many avenues as feasible. It is so important to give patients back some control in their lives in a positive and empowering manner.

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

Myofascial Release for Pelvic Dysfunction taught by Ramona Horton, MPT. Her techniques helped to further refine my ability to load tissue in multiple planes and allow the tissue to direct me to the restrictions both externally and internally. I found that my fingers could be “softer” and I just needed to “feel & follow” to be just as effective! She provided me with a new tool to put in my tool bag! She is a very captivating instructor and provides a wealth of information!


Aug 13, 2014

This post was written by H&W founder and instructor Kathe Wallace, PT, BCB-PMD. Kathe's book, “Reviving Your Sex Life after Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby” is available now

 

Kathe Wallace, PT, BCB-PMD

In June 2013 the APTA House of Delegates adopted a landmark new vision of the profession of physical therapy: "Transforming society by optimizing movement to improve the human experience." I grinned from ear to ear realizing that the movement of the entire body and the muscles of the pelvic floor are a key experience of human sexuality. Patients with multiple types of dysfunction benefit from physical therapy for the improvement of sexual function, an essential part of the human experience. Evaluating and treating sexual dysfunction is an important part of a pelvic rehabilitation physical therapy practice.

 

I am excited to announce the publication of my book “Reviving Your Sex Life after Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby”. This book demystifies the rarely talked about problem of pelvic floor health targeting the post-partum woman, where many problems begin. It provides information every woman (from 6 weeks to 60 years postpartum) should know about the common birth-related changes in the pelvic floor muscles and pelvic region. It contains specific graphics for performing perineal and abdominal scar massage techniques and using dilator and pelvic floor massage tools for pelvic floor stretching. Readers will learn techniques for pelvic floor control, release and PELVIC FLOOR PLAY™.

 


Aug 12, 2014

c-section

Insights in fascial mobility and dysfunctions are provided in this article by Gil Headley, and instructor who spends a significant amount of time working with anatomical dissections. Visceral fascia, according to Hedley, contains 3 layers: a fibrous outermost layer, a parietal serous layer, and a visceral serous layer. Fascial layers are, for the most part, designed to be able to slide over one another. Dysfunction can occur when there is a fixation in the connective tissues that prevents such sliding. A disruption in visceral fascial mobility may impair the necessary functional movement of the organs. Consider the mobility of the lungs and the heart when neuromuscular functions cause air or blood to expand and contract within the organ spaces. Bringing the concept to pelvic rehabilitation, what impairments are encountered when the bladder cannot easily fill or contract, or when movement of the bowels tugs on fascial restrictions? How are the tissues of the vaginal canal influenced by restrictions in tissues above, behind, or below the structure?

 

Examples of causes of adhesions may include (but not are limited to) inflammation from infections or disease, post-surgical scarring, dysfunctions caused by prior adhesion or limitation, and intentional therapeutic adhesions (think of a prolapse repair). While fibrous adhesions, once palpated, may be manually pulled apart, this is not the recommendation of the article author. Unfortunately, such an approach can result in further opportunity for inflammation and adhesions. One method of improving tissue mobility is to manually facilitate "…movement towards the normal range of motion of the fixed tissues with gentle traction…" timed with deep breathing. This technique may improve the ability of the organs and tissues to slide upon one another, and also may help in prevention of further movement restrictions. Would this type of intervention always require hands-on care? The author provides an example of a patient providing gentle traction by reaching to a pull-up bar, performing deep breathing and various trunk rotation positions following a thoracic surgery.

 

Visceral mobilization techniques may be a part of a patient's healing approach, and these techniques may be therapist-directed, patient-directed, or both. The Institute is pleased to offer two upcoming visceral mobilization continuing education courses next month instructed by faculty member Ramona Horton. Visceral Mobilization of the Reproductive System takes place in Boston, and Visceral Mobilization of the Urologic System is being hosted in Scottsdale.


Aug 11, 2014

This post was written by H&W instructor Dee Hartmann, PT, DPT. Dee will be instructing the course that they wrote on "Assessing and Treating Women with Vulvodynia" in Connecticut this September.

 

Dee Hartmann

Within the last 4 years, two papers have been published looking at pelvic floor muscle function (PFMF) in women with and without provoked vestibulodynia (PVD). Gentilcore-Saulnier et al. sought to compare PFMF of those with and without vulvar pain and to prospectively assess how those with PVD respond PT intervention. In the first phase of their study, PFMF of 11 women diagnosed with PVD was compared to PFMF of 11 age matched controls. Outcome measures included 1) sEMG measurement of superficial and deep pelvic floor muscle (PFM) responses (both at rest and with contraction) to increasingly painful stimuli at the vulva and 2) PFMF as determined by digital internal assessment of tone, flexibility, ability to relax following contraction, and strength. In the second phase of the study, women with PVD attended 8 PT sessions (it is not clear how many were recruited from the first phase for the treatment portion and there were no controls). A specific PT protocol was utilized that included patient education, intravaginal manual therapy (including soft tissue mobilization, stretching, and desensitization), insertion activities with vaginal dilators, pelvic floor sEMG biofeedback followed by intravaginal electrical stimulation, and home exercises that included active, daily PFM exercises and every other day use of vaginal dilators.

 

The sEMG findings suggested that PFMF in women with PVD when compared to controls showed increased superficial PFM response to pain stimuli to the vulva but not for the deep PFMs, and significant PFM hypertonicity in the superficial but not the deep PFMs. Digital findings suggested decreased PFM flexibility and impaired ability to relax PFMs following active contraction. During intravaginal digital assessment- evaluating both superficial and deep muscles concurrently- in those with PVD, the authors found higher levels of pain with maximum voluntary contraction as well as elevated vestibular pressure sensitivity and pain intensity in both superficial and deep PFMs.

 


Aug 09, 2014

Smile

What is the best reason to take a mindfulness or meditation course? Self-care! How many of us make choices in our daily lives that put our own health and wellness first? While we stay busy doing the important work of taking care of our patients, we can often forget to take care of ourselvs. Oftentimes, in addition to perhaps not learning to value self-care as we were growing up in our own families, we don't have strategies or the time-management skills to implement self-care. What is self-care? Self-care, as suggested by compassionfatigue.org, can include healthy lifestyle practices involving physical activity and healthy dietary habits, setting boundaries (saying "no"), having a healthy support system in place, organizing daily life to be proactive rather than reactive, reserving energy for worthy causes, and creating balance in life. (Check out this link for a prior blog post on compassion fatigue!)


The truth is, healthcare providers are stressed and burnout is common. So how does taking a course in mindfulness benefit the health care provider? Recent research including a university center based mindfulness-based stress reduction course was implemented with 93 providers including physicians, nurses, psychologists, and social workers. The training involved 8 weeks of 2.5 hour classes in addition to a seven hour retreat. Participants were instructed in mindfulness practices including a body scan, mindful movement, walking and sitting meditations, and were involved in discussions in how to apply mindfulness practices in the work setting. Outcomes included the Maslach Burnout Inventory and the SF-12. Results of the training, which was offered 11 times over a 6 year period, included improved scores relating to burnout and mental well-being. 

 

But where can you take a course to learn valuable self-care tools? First up, there's the Meditation and Pain Neuroscience continuing education course happening at the beginning of next month. Then there is the Mindfulness-based Biopsychosocial Approach to the Treatment of Chronic Pain taking place in November in Seattle! Join us as we spread the word about how to not only take good care of your patients, but also of yourself. 

 


Aug 07, 2014

Hip

In pelvic rehab, if you ask therapists from around the country, you will most often hear that patients with pelvic dysfunction are seen once per week. This is in contrast to many other physical therapy plans of care, so what gives? Perhaps one of the things to consider is that most patients of pelvic rehab are not seen in the acute stages of their condition, whether the condition is perineal pain, constipation, tailbone pain, or incontinence, for example. 

The literature is rich with evidence supporting the facts that physicians are unaware of, unprepared for, or uncomfortable with conversations about treatment planning for patients who have continence issues or pelvic pain. The research also tells us that patients don't bring up pelvic dysfunctions, due to lack of awareness for available treatment, or due to embarrassment, or due to being told that their dysfunction is "normal" after having a baby or as a result of aging. So between the providers not talking about, and patients not bringing up pelvic dysfunctions, we have a huge population of patients who are not accessing timely care. 

 

 

What else is it about pelvic rehab that therapists are scheduling patients once a week? Is it that the patient is driving a great distance for care because there are not enough of us to go around? Do the pelvic floor muscles have differing principles for recovery in relation to basic strengthening concepts? Or is the reduced frequency per week influenced by the fact that many patients are instructed in behavioral strategies that may take a bit of time to re-train? 

 


Aug 05, 2014

Hip

George Thiele, MD, published several articles relating to coccyx pain as early as 1930 and into the late 1960's. His work on coccyx pain and treatment remains relevant today, and all pelvic rehabilitation providers can benefit from knowledge of his publications. Thiele's massage is a particular method of massage to the posterior pelvic floor muscles including the coccygeus. Dr. Thiele, in his article on the cause and treatment of coccygodynia in 1963, states that the levator ani and coccygeus muscles are tender and spastic, while the tip of the coccyx is not usually tender in patients who complain of tailbone pain. The same article takes the reader through an amazing literature review describing interventions for coccyx pain in the early 20th century. 

 

 

Examination and physical findings, according to Dr. Thiele, include slow and careful sitting with weight often shifted to one buttock, and frequent change of position. He also describes poor sitting posture, with pressure placed upon the middle buttocks, sacrum, and tailbone. Postural dysfunction as a proposed etiology is not a new theory, and in Thiele's article he states that poor sitting posture is "…the most important traumatic factor in coccygodynia…" and even referred to postural cases as having "television disease." 

 

 


Aug 03, 2014

Hip

Posttraumatic Stress Syndrome, also known as PTSD, is an unfortunate consequence of many women's birth experiences. While there are known risk factors, there is not currently a standardized screening method for identifying symptoms of PTSD in the postpartum period. One recent meta-analysis of 78 research studies identified a prevalence of postpartum PTSD as 3.1% in community samples and as 15.7% in at-risk or targeted samples. Risk factors for PTSD included current depression, labor experiences (including interactions with medical staff), and a history of psychopathology. In the targeted samples, risk factors included current depression and infant complications. Other authors have explored the relationships between preterm birth and PTSD, preeclampsia or premature rupture of membranes, and infants in the neonatal intensive care unit. 

 

 

One of the main concerns of failing to identify and treat for PTSD in the postpartum period is the potential negative effect on the family. High levels of anxiety, stress, and depression may impact not only the mother's health, but also may affect her ability to meet her new infant's needs, or complete usual functions in work and home life. One study suggested that "…maternal stress and depression are related to infants’ ability to self-sooth during a stressful situation." Clearly, healthy moms promote healthy families, and each mother deserves the attention that her new infant often receives from the world! 

 

 


Aug 01, 2014

This post was written by H&W instructors Nari Clemons, PT and Dr. Shawn Sidhu, MD, psychiatrist. Nari and Shawn will be instructing the course that they wrote on "Meditation and Pain Neuroscience" in Illinois this September.

 

Shawn Sidhu

We caught up with Dr. Shawn Sidhu, MD, psychiatrist on why he thinks it is good for himself and his patients to have a meditation practice.

Why, as a physician and father, do you meditate?

 

Meditation can do a lot of things for different people. Some people say that it helps them to stay grounded. Others comment that it helps them to focus and organize their mind. I’ve also heard that people feel more in touch with their emotions and their thoughts when they’ve been meditating regularly, even for brief periods of time. While I feel that all of the above are certainly benefits of meditation that I have experienced, the single greatest thing that meditation does for me is to help increase my level of awareness as it pertains to my surroundings. In other words, when I am able to meditate, my observational skills improve significantly. This is incredibly important for a Child and Adolescent Psychiatrist. Those of us who work in mental health must first observe our patients, and really see them clearly through multiple layers if we are going to have any chance of helping them and getting to the root causes of their suffering. Only after observing clearly and effectively can we begin to think about treatment. On days when I don’t meditate and I’m not as in touch with my inner self, I lose a great deal of awareness of the outside world as well. My patients notice it, too, and will comment that I am not as in tune with them or not as engaged on days when I do not meditate. So in a sense meditation sets a great foundation from which I can really reach patients and their families in a meaningful way.


Jul 31, 2014

Hip

While many of the Herman & Wallace Pelvic Rehabilitation continuing education courses focus on study of the pelvic floor muscles, the inclusion and consideration of the trunk, breathing, form and force closure, and posture are also needed to truly understand the pelvis. Our professional education does not prepare us well in regards to understanding the pelvic floor and pelvic girdle, and the foundational concepts that provide clinical meaningfulness come from a variety of research camps. If you feel that you were never provided this foundational information about the pelvic girdle and trunk, and wish to better apply practical concepts in movement and muscle facilitation (or inhibition), you might be looking for the Pelvic Floor/Pelvic Girdle continuing education course that is coming to Atlanta in late September.

 

The course covers interesting topics such as pelvic floor muscle activation patterns in health and in dysfunction, use of load transfer tests such as the active straight leg raise, orthopedic considerations of pelvic dysfunction, pelvic floor muscle (PFM) exercise cues, risk factors for pelvic dysfunction, and treatment of the coccyx. If you (or a friend you want to take a course with) is not quite sure about internal pelvic floor coursework at this time, the good news is that this course addresses pelvic dysfunction using an external approach. Experienced therapists can appreciate the research-based approach to muscle dysfunctions that can cause or perpetuate a variety of symptoms, and newer therapists have the chance to learn how to integrate pelvic floor/pelvic girdle concepts into current practice. A biofeedback lab introduces use of surface electromyography (sEMG) as well.

 

There is still time to sign up for the September course in Atlanta, the only remaining opportunity to take the Pelvic Floor/Pelvic Girdle continuing education course this year. Bring a friend, or a colleague, and work together to combine external and internal approaches to pelvic dysfunction.


Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Oct 24, 2014 - Oct 26, 2014
Location: Marathon Physical Therapy

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College

Pelvic Floor Level 2B - St. Louis, MO
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic

Pelvic Floor Level 3 - Derby, CT
Dec 12, 2014 - Dec 14, 2014
Location: Griffin Hospital

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performace Center

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center

Pelvic Floor Level 3 - Fairfield, CA
Mar 13, 2015 - Mar 15, 2015
Location: NorthBay HealthCare