Is there a consensus among physical therapists about the use and perceived effectiveness of Pilates exercise for low back pain? 30 Australian physiotherapists experienced with Pilates exercise were surveyed and asked about Pilates as an indication for low back pain. The results were published in Physical Therapy. Consensus at 100% was reached for benefits, indications, and precautions of Pilates exercise, and only 50-56% for risks and contraindications, respectively. Therapists agreed on indications such as maladaptive movement patterns, poor body awareness, poor flexibility, decreased lumbar spine mobility, poor breathing and postural control.

The contraindications that were agreed on (but not as strong an agreement as the indications) included pre-eclampsia and unstable fractures. Agreement was reached that participation in Pilates exercise requires caution in the presence of unstable spondylolisthesis or significant lower extremity radiculopathy. The contraindications that were no agreed upon included cancer, severe osteoporosis, significant hypertension, and yellow psychosocial flags.

The physiotherapists did all agree that Pilates may help patients who have chronic low back pain by increasing function and confidence with movement, exercise, and activities, and additionally, that body awareness, postural control, and movement patterns may improve. Potential adverse events that may occur following Pilates exercise (and that were agreed upon) included aggravation of low back pain, or increased muscle tension. In relation to other potential risks of participating in Pilates exercise, inadequate training of instructors and inappropriate exercise prescription was listed. If you would like to learn more about Pilates exercise prescription for specific women’s health issues such as pelvic floor dysfunction, peripartum issues, and perimenopausal issues such as osteoporosis, check out the Institute’s new course on Pilates.

Does prior training in pelvic floor muscle exercises contribute to a woman’s ability to contract the pelvic floor shortly after childbirth? Researchers aimed to study this question and other variables in a prospective observational study involving 958 women. Within one week of childbirth, and in the hospital setting, participants were instructed by a physiotherapist (specializing in pelvic floor) to contract the pelvic floor in a supine position. Confirmation of a contraction was determined by visual observation of the perineum moving inward. The women were also asked by a physiotherapist if they had prior knowledge or experience with pelvic floor muscle training, and if not, the women were briefly instructed in the location and function of the pelvic floor muscles. The women who had some knowledge of the pelvic floor muscles including exercise experience “…were asked if they considered themselves able to perform correct…” pelvic muscle contractions.

All women was asked to complete three pelvic muscle contractions in a row and were assessed visually using a score of 0 (no movement of the perineum), 1 (weak movement), or 2 (strong inward displacement/lift of perineum). The physiotherapist gave feedback if the women completed a correct, insufficient, or incorrect contraction. Further verbal instruction was provided to those who could not adequately contract, and a re-assessment was completed with a quantification of any change in ability to contract. After providing feedback on pelvic muscle contractions, 73.6% of the women were able to perform a better contraction. In 500 of the 958 women, no inward displacement of the perineum was observed. Additionally, a significant number of the women (33%), believed that they were doing a contraction correctly but in fact were not. Another interesting point is that women with urinary incontinence before or during pregnancy had more knowledge about pelvic floor function and training.

Although in this study, 47.8% of the participants were able to perform a pelvic floor muscle contraction shortly after giving birth, “Knowing about the function and location of the pelvic floor was a positive predictor for being able to complete a pelvic floor muscle contraction.” Interestingly, having prior training in pelvic muscle exercises was not predictive of being able to complete a contraction. The value of assessing the ability to contract the pelvic floor is evident in this study, and with methods that are quick, easy, and non-invasive, women can be empowered with an improved ability to improve performance of a pelvic muscle contraction which is necessary for an effective pelvic muscle training program.

Megan Pribyl, MSPT is the author and instructor for Nutrition Perspectives for the Pelvic Rehab Therapist. Megan is passionate about nutritional science and manual therapy. Megan holds a dual-degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) from Kansas State University, and has actively sought to fill in missing links between orthopedics and nutrition.

APTA Landmark Motion Passes
RC 12-15: The Role of the Physical Therapist in Diet and Nutrition
Is nutrition within our scope of practice? As the instructor for “Nutrition Perspectives for the Pelvic Rehab Therapist” offered through Herman & Wallace, I hear this question frequently! To me, the answer has always been a clear “yes*!”; now the APTA is endorsing this view. It’s an exciting time to be a rehab professional, especially for those looking to broaden clinical perspectives and scope of services to include basic nutrition and lifestyle information.

At the APTA House of Delegates in early June 2015, a landmark motion passed - RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. As our profession advances towards a more integrative model, this motion symbolizes an acknowledgement of the rehab professional’s broader role as a health care provider. We, as physical therapists, are uniquely positioned to offer patients more comprehensive lifestyle-related education including discussion of nutrition. Both the World Health Organization (WHO, 2008) and the Physical Therapy Summit on Global Health (Dean, et.al, 2014) have called upon all health care providers to stand in unity to help the public with epidemics of lifestyle-related diseases; the APTA has given it’s nod of approval as well.

The motion states: “as diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patient, clients, and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist*.” Further, “this motion clearly incorporates the intent of the new Vision Statement for the Physical Therapy Profession by transforming society and improving the human experience.” (APTA, 2015)

This powerful development provides us with both challenge and opportunity. How can we, as pelvic rehab professionals, be armed with the most cutting edge nutritional information available? What nutrition information lies within our scope of practice? How can we apply this information to our pelvic rehab patient population? For the answer to these pressing questions and much more, plan now to attend Nutrition Perspectives for the Pelvic Rehab Therapist” March 5 & 6, 2016 in Kansas City, MO. It is my passion to share this information and I welcome you to join me for this timely CEU opportunity. It is designed to help you obtain the skills needed to confidently identify nutritional correlates in pelvic rehabilitation.

References:

ATPA (2015) http://www.apta.org/uploadedFiles/2015PacketI.pdf

Dean, E., de Andrade, A. D., O'Donoghue, G., Skinner, M., Umereh, G., Beenen, P., . . . Wong, W. P. (2014). The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract, 30(4), 261-275. (http://www.ncbi.nlm.nih.gov/pubmed/24252072)

World Health Organization. (2008). 2008-2013 Action plan for the global strategy for the prevention and control of non communicable diseases. Geneva, Switzerland: WHO. (http://www.who.int/mediacentre/news/releases/2015/noncommunicable-diseases/en/)

photo credit: Walmart’s locally grown produce via photopin (license)

Today we get to hear from Mitch Owens, MsPT, COMT who is the author and instructor of "Neck Pain, Headaches, Dizziness, and Vertigo: Integrating Vestibular and Orthopedic Treatment". Join Mitch in Rockville, MD on November 14-15 in order to learn more about treating patients with head trauma.

Following a whiplash injury, concussion or vestibulopathy patients will complain of the same cluster of symptoms: neck pain, dizziness, and headache. In order to properly treat patients complaining of these symptoms a clinician must first be able to determine the source and understand the physiology at work to reason out the best plan of care.

Treating individuals for dizziness, neck pain and headaches requires a refined understanding of the systems involved, the clinical tests that can be used to differentiate symptom generation and then finally which evidence based interventions should be deployed.

A patient who presents with a complaint of dizziness or vertigo following a trauma to the head or neck will challenge the examination skills of even the best practitioners. The list of differential diagnosis includes a number of conditions that could prove to be quite threatening to the patient with or without intervention. These conditions include: vertebral basilar insufficiency, cervical fracture, dislocation or instability, stroke, traumatic brain injury, concussion, and peripheral vestibulopathy to name a few. The ability to clinically reason and properly assess these individuals is crucial to the effective management of any orthopedic or neurologic case load.

Clinicians treating either population need skill sets that bridge the orthopedic and neurologic expertise gap that often exist if clinicians. The need to close this gap is highlighted the following facts:

- 15-20% of Benign Paroxysmal Positional Vertigo is caused by trauma (Gordon, Carlos et al. 2004).
- 19% of cases of whiplash demonstrated vestibulopathy with videonystagmography (VNG) testing within 15 days of their accident (Nacci, A. et al 2011).
- 60% of cases of whiplash with head trauma demonstrated vestibulopathy (Nacci, A. et al. 2011).
- Dizziness is reported 20-58% of whiplash patients (Wrisley DM et al. 2000).
- Between 40%-70% of individuals with persistent whiplash associated disorders complain of dizziness (Treleaven, Julia et al. 2003).
- The incidence of cervicogenic dizziness has been reported to be 7.5% of all dizziness (Ardic FN, et al. 2006)

Recent evidence has shown that sensory dysfunction is as much a part of dizziness as it is a component of chronic neck pain (Treleaven, Julia et al. 2003).

Interventions directed at training cervical proprioception have been show to significantly reduce pain and has improved function in patients with chronic neck pain (Revel, Michel, et al 1994). Manual therapy techniques directed at the upper cervical spine have also been shown to effectively treat dizziness in randomized control trials (Reid, Susan A., et al. 2013).

Thus we are learning the ability to effectively measure and treat neurologic dysfunction is an important part of address cervical spine issues. It is equally true that being able to assess and treat cervical spine dysfunction is an important part of treating patients who complain of dizziness.

Enhancing your neurologic and orthopedic skill set is clearly useful for any clinician and will help improve your outcomes across all patient populations. Continued training in these areas will expand what patients you can see, add to your clinical tool belt, and improve your confidence within your current caseload.

References:
Ardic FN, Topuz B, Kara CO. Impact of multiple etiology on dizziness handicap. Otol Neurotol. 2006;27:676 – 680.
Gordon, Carlos R., et al. "Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?." Archives of Neurology 61.10 (2004): 1590-1593.
Nacci, A., et al. "Vestibular and stabilometric findings in whiplash injury and minor head trauma." Acta Otorhinolaryngologica Italica 31.6 (2011): 378.
Reid, Susan A., et al. "Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial." Physical therapy (2013).
Revel, Michel, et al. "Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study." Archives of physical medicine and rehabilitation 75.8 (1994): 895-899.
Treleaven, Julia, Gwendolen Jull, and Michele Sterling. "Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error." Journal of Rehabilitation Medicine 35.1 (2003): 36-43.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM: Cervicogenic dizziness: a review of diagnosis and treatment. Journal of Orthopaedic & Sports Physical Therapy 2000, 30(12):755-766.

The Pelvic Rehab Report had an opportunity to interview Dawn Sandalcidi, the creator and instructor of "Pediatric Incontinence and Pelvic Floor Dysfunction". Dawn has developed a pediatric dysfunctional voiding treatment program in which she lectures on nationally. Dawn has published articles in the Journal of Urologic Nursing, the Journal of Manual and Manipulative Therapy, and the Journal of Women’s Health Physical Therapy. Let's hear more from Dawn about her Pediatric Incontinence and Pelvic Floor Dysfunction course!

What essential skill does your course add to a practitioner’s toolkit?

Adding pediatrics to your practice truly allows you to treat the pelvic floor through the lifespan. If you are a pediatric therapist adding this most important specialty will complete the picture of your entire patient.

Will your course allow practitioners to see new/more patients?

There are so many therapists who tell me that while treating a parent they share a story about their child being a bed wetter or having incontinence. That has opened up many doors for including this population into my practice. Be careful though! Once the pediatricians, school nurses, pediatric urologists and GI docs know there is someone out there that can take care of kids you will be flooded with patients!!

Why did you develop this course?

I began treating pediatrics after having success with adult patients in a large urology practice over 25 years ago. One of the urologists called me and asked me to take care of this little girl who had already been operated on twice and was headed toward kidney transplants. My reply was "what is wrong with kids?????" So my journey began- observing surgery and learning how children developed pelvic floor dysfunction. This kiddo had vesicoureteral reflux or a back flow of urine form the bladder to the kidneys causing frequent infections and kidney damage. My goal in this course is to take the basic knowledge we have as therapists and apply it to a population of children who suffer terribly with urinary and fecal incontinence. The psychological side effects from incontinence are significant and we now have the tools to help!!

What are the attributes and barriers to care for college-aged women who have pelvic pain? This is a question asked by researchers who published an original article on the topic in the Journal of Minimally Invasive Gynecology. To complete the study, a random sample of 2000 female students at the University of Florida were sent an online questionnaire. Included in the questionnaire was basic demographic data, general health and health behavior questions, psychosocial factors, measures assessing different types of pelvic pain such as dyspareunia, dysmenorrhea, urinary, bowel, or vulvar pain, and information about barriers to care for pelvic pain and quality of life measures. A total of 390 women completed the survey, and the mean age was 23 years old. Most of the women in the sample identified as white, with 9.6% identifying as black or African-American. Most of the respondents had never been pregnant. The chart below lists some of the data.

Barriers to receiving care included difficulty with insurance coverage and providers’ “…lack of time and knowledge or interest in chronic pelvic pain conditions.” An interesting finding was that among the women who had pelvic pain, those who were sexually active reported lower scores on physical and mental health. Even among the women without pelvic pain, those who were sexually active reported lower mental health scores.

How can this study encourage us as pelvic rehabilitation providers? Can we reach out to providers and share the potential benefits of pelvic rehab care to decrease the burden on the patient in finding services? It seems that in addition to continually spreading the word that pelvic pain can be eased with rehabilitation efforts, we can provide the interest and knowledge in the subject so that the patient can feel validated and can be instructed in self-management tools.

Over the past 28 years, my pelvic floor has endured at least 20,000 miles of running, including racing on the collegiate level and then completing 10 marathons. Add to the high-impact sport two 8.1 pound natural childbirth deliveries 26 months apart, and you can imagine why I accepted the invitation to blog for this well-respected institute. One of my elderly patients once told me my uterus was going to drop out from so much running (which, thankfully, has NOT happened); however, I have to admit, urinary stress incontinence and frequent urination were unwelcome enough consequences! On the positive side, it all initiated my journey to understanding the pelvic floor.

In 2014, Poswiata et al used the Urogenital Distress Inventory (UDI-6) to assess how prevalent stress urinary incontinence may be among elite female skiers and runners. Of the 112 female athletes in the study, 50% reported leaking a small amount of urine. Coughing and sneezing provoked leakage for 45.54% of those women, indicating stress incontinence, and 58.04% of the women in the study reported frequent urination. Are those acceptable statistics? I would have to say no.

Research results can be comforting so athletes can be told they are not alone regarding a quite personal aspect of their lives. When I could supposedly empty my bladder, stand to wash my hands and have to go again, walk down the hall to put on my sneakers and go once again before heading out the door for a run, it was nice to know someone else was probably experiencing the same issue that morning. Just because it is common, though, does not make it “normal.” We are not meant to leak just because we stress our bodies beyond normal ADLs.

A very recent study by Luginbuehl et al (2015 July 21), just published online, attempted to explore the electromyography (EMG) activity of pelvic floor muscles with variable running speeds (7, 9, and 11km/h) over 10 steps. The highest pelvic floor muscle activity was recorded at 11km/h, which would sensibly suggest the muscles produce a greater contraction the faster someone runs. If a runner has developed a decreased ability to activate the pelvic floor muscles, stress urinary incontinence will likely become a highly irritating problem with fast running speeds over time. But how do they know, and where do they go?

Without health practitioners trained in rehabilitation of pelvic floor dysfunctions, consider how chronic an issue urinary stress incontinence would be for a large athletic population. So many women (and men) do not even recognize their leakage or frequent urination as treatable “issues” and never mention them to anyone. Often times, we are treating an athlete for a hip or lumbar injury and purposefully yet discretely have to ask the right questions and then educate the patient how some of their symptoms are secondary to pelvic floor deficits. Someone has to explain what is normal, and, better yet, someone HAS to make an effort to fix what is “broken” and restore the pelvic floor to a higher level of function. With the proper training, perhaps that someone can be you.

References:
1. Poświata, A., Socha, T., & Opara, J. (2014). Prevalence of Stress Urinary Incontinence in Elite Female Endurance Athletes. Journal of Human Kinetics,44, 91–96. doi:10.2478/hukin-2014-0114.
2. Helena Luginbuehl, Rebecca Naeff, Anna Zahnd, Jean-Pierre Baeyens, Annette Kuhn, Lorenz Radlinger (2015 July 21). Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Archives of Gynecology and Obstetrics. doi: 10.1007/s00404-015-3816-9.

Today we hear from Martina Hauptmann, PT, PMA-CPI, instructor of "Pilates for the Pelvic Floor: Pelvic Floor Dysfunction, Osteoporosis and Peripartum". Join Martina this September 19-20 in Chicago, IL to learn how to incorporate Pilates into your treatment plans!

Because the cost of staying in business is increasing and the insurance reimbursement rates are dropping, many physical therapy clinics are looking for cash based supplemental services (medically-orientated gym memberships, Pilates classes, yoga classes, durable exercise supplies etc). Offering Pilates as part of the physical therapy clinic’s therapeutic interventions will differentiate your clinic and may be marketed to physicians and the community to increase your clinic’s market share. Post rehabilitation, the offering of cash based Pilates wellness classes can increase the clinic’s bottom line, allowing for further rehabilitation of the client beyond the time frame allowed by insurances and improve retention of clients.

Pilates is a system and philosophy of exercises based on the work of Joseph Pilates (1883-1967) that focuses on precision and optimal alignment. This approach requires the client to focus her mind on the exercise in order to increase motor control. Women are attracted to the Pilates method because of its gentle but effective nature. Offering Pilates as part of your therapeutic offerings is a great marketing tool to physicians and to the community as well as an effective method for instructing specific muscle re-training.

My course will focus on the application of the Pilates method to women’s health issues: incompetent pelvic floor, hyperactive pelvic floor, chronic pelvic floor pain, pre-natal, post-natal and osteoporosis with small props. The course will utilize equipment that you may have in the clinic already (physio balls, foam rollers, resistance bands, small balls BOSUs and introduction to the Hooked on Pilates MINIMAX and HANDIBANDs).

The course specifically will incorporate Pilates exercises that increase the function of the pelvic floor via the intrinsic and extrinsic synergists of the pelvic floor muscles. Rationale for modified Pilates exercises for clients that exhibit hyperactivity in the pelvic floor muscles (Carriere & Feldt, 2006), pre-natal (ACOG, 2002) and osteoporosis (Sinaki, 1984 and Sinaki, 2002) will be discussed and modified exercises performed. Finally discussion of post-natal issues of lumbo-pelvic pain and pubic symphysis pain will be incorporated and specific exercises for these issues performed (Richardson and Jull, 1995).

This course has a heavy emphasis on exercise. Participants in this course will be able to utilize all instructed exercises immediately following the course. I hope to see you there!

References:
Carriere & Feldt (2006). The Pelvic Floor. Stuttgart, Germany: Georg Thieme Verlag.
American College of Obstetricians and Gynecologists (2002).
Sinaki, Mikkelsen (1984). Post-menopausal spinal osteoporosis: Flexion versus extension exercises. Arch Phys Med Rehab. Vol 65, Oct, 593-596.
Sinaki et al. (2002). Stronger back muscles reduce the incidence of vertebral fractures: A prospective 10 year follow-up of postmenopausal women. Bone. 30(6); 836-841.
Richardson, Jull (1994). Muscle control-pain control. What exercises would you prescribe? Manual Therapy. 1, 2-10.

An article promoting the beneficial role of a thorough clinical assessment was published last year in the Scandinavian Journal of Urology, and although the article is directed to medical providers, serves as an excellent summary for pelvic rehabilitation providers. Doctors Quaghebeur and Wyndaele describe a “four-step plan” that can help direct treatment efficiently, and that emphasizes the muscular and neurologic systems as potential referral sources. While you may not be surprised about several of the steps, you may find this article to be a useful tool, particularly for the terrific chart about neuralgia-type pain that you can find in the linked article.

Step 1 should include history taking with attention to information about the following:

- urinary frequency, urgency, and nocturia
- bowel habits
- sexual complaints and quality-of-life impact
- pain description with significant detail
- use of questionnaires

Step 2 emphasizes review of prior assessments and reports, including:

- imaging (x-rays, MRI, CT)
- lab work

Step 3 involves a thorough clinical assessment. This includes a neurologic assessment of the lumbosacral plexus, with evaluation of motor and sensory functions as well as reflexes. The nerves suggested for testing are the sciatic, iliohypogastric, ilioinguinal, genitofemoral, obturator, lateral cutaneous femoral, perineal and dorsal, and the medial, lateral, and inferior cluneal nerves. (An excellent chart listing each of these nerves and their dynamic tests is included in the article.) Of note in the chart is the lack of neurodynamic tests for the deep peroneal nerve, pudendal, perineal, dorsal nerve of the clitoris or penis, and the interior cluneal- these can be tested for symptom reproduction with direct palpation according to the authors. Other Step 3 tests are listed below.

- neurodynamics tension testing and nerve palpation
- EMG testing if needed
- evaluation for hernia (abdominal, inguinal, or femoral)
- exam of external genitalia (rash, secretion, abscess, fistula, atrophic disorders, signs of trauma, palpation)
- rectal and/or vaginal exam

Step 4 involves an extensive musculoskeletal system examination. This includes the spine, pelvic girdle, muscles, tendons, and pain points.

- spinal mobility (palpation, AROM, PROM)
- joint play of SI joints, pubis and sacrococcygeal joints
- muscular pain or other soft tissue pain reproduction

The physicians recommend a multidisciplinary team of providers including physical therapy. The true value of this article, from a rehabilitation standpoint, may be the emphasis on a thorough musculoskeletal examination as well as attention to recognizing neuralgias. We might utilize an article such as this to dialog with medical providers, or to assess our own “thorough” list of examination techniques. Herman & Wallace offers several courses which can benefit the practitioner seeking to gain new evaluation techniques. "Manual Therapy for the Lumbo-Pelvic-Hip Complex" is a great option which will be available this October 17-18 in beautiful Napa, CA.

Isa Herrera, MSPT, CSCS teaches the "Low-Level Laser Therapy for Female Pelvic Pain Conditions" course for Herman & Wallace. Join her on October 3-4 in New York, NY to learn about this new modality!

Physical therapists deal with chronic pain that can be problematic to treat and manage on a daily basis. There is an arsenal of tools, exercises and techniques at their disposal, but many times using a modality can help accelerate the pain-relieving process.

At my healing center in New York City, we treat an extremely difficult type of chronic pain loosely classified under the umbrella term "pelvic pain". Pelvic pain can express itself as sacroiliac pain, hip bursitis, symphysis pubic dysfunction, and vulvodynia. Chronic pelvic pain is sometimes perceived as a "woman's issue", but we treat both men and women who have suffered for years with their conditions. We are challenged to think outside the box to provide relief for these patients.

'Secret Weapon' for Pain

Chronic pelvic pain is very different from other types of pain because it's intimately connected to our emotional, spiritual and psychological states, and can involve many symptoms in the nervous, endocrine, visceral, gynecological, urological and muscular systems. It can be very difficult to treat, and can require from six months to one year of physical therapy, depending on patient presentation and history.

This lengthy course of treatment requires a fresh approach to therapy and modalities. When I started treating this population I had many difficulties when it came to controlling their pain and I had to think differently. Electrical stimulation and ultrasound were not working as well as I'd hoped, and were providing insufficient pain relief to these patients.

I needed a modality that, when incorporated with my pelvic pain treatment protocols, could help produce immediate and long-lasting pain-relieving effects. I needed a modality that could significantly decrease pain within one session, and that my patients could believe in because of the results.

Low-level laser therapy (LLLT) proved to be my secret weapon when treating women with chronic pelvic pain. (I frequently call it "light therapy", because many patients are put off by the term "laser.")

I have been successfully using light therapy for nearly ten years. It helps my patients keep their pain at bay, and many request that I use it as part of their therapy. Of course, light therapy is only as good as the therapist using it. You have to apply this modality correctly, and use the science properly to maximize results.

LLLT was approved by the FDA in 2002. At that time, the modality was hailed by the New England Patriots and the U.S. Olympic Committee, among others, for its ability to help top athletes quickly return from injury. Endorsements from these organizations piqued my interest and I decided to research its principles.

I realized that LLLT could be used on many levels. LLLT is unique: it is a cellular bio-stimulator and is used to increase vitality of cells as well as processes that occur within the cell. Not all lasers are "created equal," and you have to be careful with the type you purchase.

Principles that must be taken into consideration include wavelength in nanometers, power in milliwatts, and total energy delivered in joules. In my pelvic pain protocols, I use LLLT on sensitive and painful tissues that are unable to tolerate any heat production.

Many lasers claim to be great therapeutic lasers, but actually produce heat within the tissue and cells. Any heat production has the potential to harm cells and destroy them. Heat production indicates the delivery of too many joules of energy per cycle. The goal with LLLT is to stimulate health and vitality within the cell to produce effects such as pain relief, collagen synthesis, resetting nerve potential, anti-inflammatory effects, and endorphin production.

New Look at Modalities

LLLT has changed the way I treat all pain syndromes. It's had such a positive impact that I've created laser protocols for vulvodynia, scar and bladder pain. I also created a special class for the Herman and Wallace Institute class for physical therapists who treat chronic pelvic pain. I encourage any colleagues specializing in this population to investigate this remarkable modality and to attend the class in October. If you are looking for something different and a modality that will change the way you treat come and learn how to use if effectively.