What are you saying when giving directions to men during pelvic floor muscle training, and how do those instructions affect the effectiveness of a contraction? These questions are tackled in a study that is very interesting to therapists working in pelvic dysfunction. 15 healthy men ages 28-44 (with no prior training in pelvic floor training) were instructed to complete a submaximal effort pelvic muscle contraction. Tools utilized to acquire data in the study include those below:

Participants sat upright on a plinth (backrest reclined at ~20 degrees with their knees extended). Directions for the submaximal efforts were given by telling the men to produce a level 3/10 effort with 10 being a maximal contraction. The men were instructed to hold the contraction for 3 seconds, and they were given 10 seconds rest between each of the 4 contractions using different verbal cues. (This series of 4 contractions was repeated with randomization for verbal cues, with a 2 minute rest in-between.) Verbal instructions were intended to target specific contractile tissues as described below- some of this theory could be validated via the fine wire EMG.

Displacement, IAP, and abdominal/anal EMG were compared for the different verbal instructions. The greatest dorsal displacement of the mid-urethra and striated urethral sphincter activity was noted with the instruction to "shorten the penis." "Elevate the bladder" encouraged the greatest increase in abdominal EMG and IAP, while "tighten around the anus" induced the greatest anal sphincter activity. Displacement of pelvic landmarks correlated with EMG readings of the muscles thought to produce the targeted movement. The authors conclude that the therapist's choice of verbal instructions can influence the muscle activation and urethral movement in men. They suggest "shorten the penis" and "stop the flow of urine" for optimal activation of the striated urethral sphincter. They also point out the fact that by using the fine wire EMG and correlating muscle activation to observations with the transperineal ultrasound, the study validates the use of the less invasive method. If you are ready to jump into more education about male pelvic rehabilitation, join us in Denver in early August, or Seattle in November.

Today we get the opportunity to hear from Herman & Wallace faculty member Elizabeth Hampton PT, WCS, BCIA-PMB! Elizabeth has been kind enough to offer her insights about the diagnosis of pelvic rehabilitation patients. Join Elizabeth at Finding the Driver in Pelvic Pain this November in Houston, TX in order to learn evaluation tools for complex pelvic pain clients!

Having taught for Herman and Wallace since 2006, I have a few observations that have been consistent over the years. Clinicians want their clients to get better, so much so that they are ready to jump in to treatment before having a solid problem list and validated findings. I can understand this: after a 3 day course we have clients Monday morning at 8 a.m. who have been waiting for us to take this course so we can get them better! We had better be smart ASAP! But what do we do when we are treating symptoms rather than understanding the primary, secondary and tertiary factors in their condition?

Finding the Driver in Pelvic Pain is a course that is a foundational first step in screening the pelvic pain client. It is a great place to start. I developed the course because there was no evidence based comprehensive factors that had been established as fundamentals for screening a pelvic pain client.

The other thing I have learned after teaching Pelvic Floor Function, Dysfunction, & Treatment – Level 2B for 9 years is that the majority of clinicians who take this intermediate level course cannot perform a precise vulvar and intrapelvic muscle mapping assessment. Close your eyes and pretend you are mapping a client’s left iliococcygeus: can you place your finger in the proper orientation and know 100% you would be palpating it? Indeed, this takes training and repetition. Internal pelvic floor muscle mapping is a key part of the Finding the Driver screening system.

What do you do when you have a pelvic pain client on your schedule and a 45-60 minute slot? How do you screen findings and get the plan of care within such a short period of time? Finding the Driver is a comprehensive pelvic floor and musculoskeletal screening to rule in or rule out drivers of the pain from all sources including spine, pelvic ring, neural entrapment, intra-articular hip, load transfer, biomechanics and motor control. There is a clear flow to the screening process and an emphasis on how to organize that information, as we know with pelvic pain, it is the copious amount of information that is the challenge. We have two case studies with either participants or clients of a local Physical Therapist who come in and we go through the entire screen, prioritize treatment and provide that treatment during the course. The participants walk away with clear clinical reasoning for their treatment and prioritization of treatment as primary, secondary, and so on. The goal of the course is to help the clinician sort through the extraordinary amount of information we gather on our pelvic pain client and organize it in a way that we can explain to the client as well as create our plan of care. Treatment is not linear, as we are frequently treating many aspects at the same time. However being able to organize the information is key in designing that plan of care. For example, with a prone knee bend that reproduces labial pain, we find that the genitofemoral nerve is causing referred pain. However that referral may be due to constipation, irritable bowel, inguinal entrapment due to hernia surgery, intra-abdominal adhesions due to endometriosis, osteitis pubis or facilitated segment at the upper lumbar spine. How do we tease that out? How do you sequence nerve glide, visceral work, soft tissue mobilization, joint mobilization and dietary components for colonic motility? The treatment with all of those components are very different indeed. Finding the Driver is a hands on course with systematic screening tools and, with case studies, we go through treatments appropriate to that client. The focus is on what we, as physical therapists, can do to understand the drivers.

At the last Finding the Driver course in Milwaukee, WI, we had two case studies in pelvic pain. One client reported chronic psoas and adductor tightness with deep left sided pelvic pain. As a professional aerialist, she was extraordinarily flexible and demonstrated positions of tightness that concerned her, which included lateral splits with her hips in slight horizontal abduction and extension (yes, yikes!) When she reported that her adductor felt tight in this position, I explained it was because it was trying to keep her leg attached to her body! She was 9/9 on the Beighton scale and had severe multidirectional instability in her hips, impaired load transfer through her pelvis, respiratory dysfunction with efforts at pelvic floor and transverse abdominis contraction, as well as repeated choice of activities that were profoundly provoking. Interestingly, she was better at load transfer during handstands (bilateral or unilateral) vs. in standing and we discussed her course of treatment addressing the primary, secondary and tertiary aspects of her condition. Another client had severe labial pain, and despite multiple abdominal and intravaginal surgeries, her symptom onset was 4 months prior. She certainly had visceral, postural, joint restrictions, movement dysfunction and many other factors. But her primary driver was a labral tear in her hip and she needed surgery. After surgery, her pain was 100% resolved and in her post op rehab, the other factors could be addressed.

It is safe to say that it can be difficult to perform a comprehensive screen in 45-60 minutes on ALL clients. We all know that many of our clients need to tell their story and because of fear or previous negative history, we may choose as clinicians how to spend that session to best honor the needs of the client. That being said, Finding the Driver is a course which provides a solid start in differential diagnosis so you can drill down into more specifics on subsequent visits.

Visceral therapy is increasingly used by manual therapists, and research continues to emerge that attempts to explain the underlying mechanisms of the techniques. A study published in the Journal of Bodywork & Movement Therapies in 2012 reports on the effects of visceral therapy on pressure pain thresholds. Osteopathic visceral mobilization was applied to the sigmoid colon in 15 asymptomatic subjects. Pressure pain thresholds were measured at the L1 paraspinal muscles and 1st dorsal interossei before and after intervention. Pressure pain thresholds at the level assessed improved significantly immediately following the visceral mobilization. The effect was not found to be systemic. Hypoalgesia, therefore, may be a mechanism by which visceral mobilization affects patients who are treated with this technique.

Another research study that aimed to assess the effects of visceral manipulation (VM) on low back pain found that the addition of VM to a standard physical therapy treatment approach did not provide short term benefits. However, when the 64 patients were reassessed at 2, 6, and 52 weeks following treatment, the patients in the group with visceral manipulation were found to have less pain at 52 weeks. The patients were randomized into 2 equal groups and were provided physical therapy plus a placebo visceral treatment or a visceral treatment in addition to physical therapy. The authors propose that there may be long-term benefits of including visceral therapy in rehabilitation approaches.

If you would like to learn more about visceral techniques as well as theory and clinical application, check out the schedules for Ramona Horton's Visceral Mobilization 1 (VM1): The Urologic System, and Visceral Mobilization 2 (VM2): The Reproductive System. The first opportunity to take VM1 is in November in Salt Lake City and VM2 is scheduled in September in Ohio.

Recently in the Pelvic Rehab Report blog we discussed the beneficial role of pelvic rehabilitation for symptoms of dysmenorrhea. Additional research was published this year that supports the use of pranayama for improving quality of life and pain in girls with primary dysmenorrhea. Breathing within yoga studies is a rich field, with well-defined variations in stages and kinds of breathing, techniques and postures, and use of different hand positions and breathing through the nostrils and/or mouth. The Oxford online dictionary defines pranayama as a practice coming from Hindu yoga and related to regulating the breath through specific techniques.

In the study, the practice of both slow pranayama (Nadi Shodhan) and fast pranayama (Kapalbhati) was instructed to the women to be completed in the mornings on an empty stomach for 10 minutes per day. Ninety unmarried young women (ages 18-25) diagnosed with primary dysmenorrhea were randomly and equally assigned to either Group A (slow pranayama) or Group B (fast pranayama). Outcomes included the Moos menstrual distress questionnaire (MMDQ), numerical pain rating pain scale, a quality of life scale "by American chronic pain association" and the assessments were administered at baseline, after the first menstrual cycle, and after the second menstrual cycle. To read more details about the methods and results, the full article can be accessed here.

Prior and recent research has also studied the effects of similar breathing techniques on cognitive functions in healthy adults and also on perceived stress and cardiovascular parameters in young healthcare students. While it may not be new to compare fast and slow pranayama techniques with health conditions, this is the first study to address pranayama's effects on symptoms of dysmenorrhea. The authors conclude that practicing slow pranayama compared to fast pranayama improved quality of life and pain scores related to dysmenorrhea. Furthermore, the authors suggest that because pranayama can decrease absenteeism and stress levels, the practice should be implemented in college students to improve quality of life.

If you are looking to learn more about pranayama and other methods of self-management of conditions including, but certainly not limited to, dysmenorrhea, come to the city-New York City- next month for Meditation for Patients and Providers instructed by faculty member Nari Clemons. It's sure to be hot in the city, so chill out indoors with Nari, and hang out at night with your new favorite colleagues that you'll meet. A benefit of this course is that not only can you learn to care better for your patients, but also for yourselves, and you deserve it.

Today we present Part II of Michelle Lyons' discussion on sex after gynecologic cancer. Michelle will be teaching a course on this topic in White Plains in August!

In Part One of this blog, I looked at the sexual health issues women face after gynecologic cancer. In Part Two, I want to explore different treatment options that we as pelvic rehab specialists can employ to help address the many implications of cancer and cancer treatment

Treatment for gynecologic cancers, including vulvar, vaginal, cervical, endometrial and ovarian cancers, may include surgery, radiation therapy, chemotherapy, and/or hormonal therapy. We know that any of these approaches can have an adverse effect on the pelvic floor, as well as systemic effects on a woman’s body. Issues can include pain, fibrosis, scar tissue adhesions, diminished flexibility, fatigue and feeling fatigued and unwell. The effects on body image should not be under-estimated either. In their paper ‘Sexual functioning among breast cancer, gynecologic cancer, and healthy women’, Anderson & Jochimsen explore how ‘…body-image disruption may be a prevalent problem for gynecologic cancer patients…more so than for breast cancer patients’. The judicious use of manual therapy and local and global exercise prescription may be excellent pathways for a women to re-integrate with her body.

Many women will have to learn to care for a new colostomy or how to catheterize a continent urostomy. A woman who has had a vulvectomy will need sensitive counselling to understand that she can still respond sexually. Patients who have had a vaginectomy with reconstruction as part of a pelvic exenteration will need extensive rehab to help them achieve successful sexual functioning. We as pelvic rehab practitioners are in a uniquely privileged position – not only can we ask the questions and discuss the options but we are licensed to be ‘hands on’ professionals, using our core skills of manual therapy, bespoke exercise advice and educating our patients about a range of issues from the correct usage of lubricants, dilators, sexual ergonomics and brain/pain science. I am in the habit of describing pelvic rehab as the best specialty in physical therapy but I think this is especially true when it comes to the junction of oncology and pelvic health. This is where we can integrate our knowledge of neuro-science, orthopaedics, the lymphatic system and pelvic health to deal with the effects of pelvic cancers and their treatment.

In Farmer et al’s 2014 paper, ‘Pain Reduces Sexual Motivation in Female But Not Male Mice’ , the authors found that ‘Pain from inflammation greatly reduced sexual motivation in female mice in heat -- but had no such effect on male mice’. Unfortunately ongoing pelvic pain is a common sequela of treatment for gynecologic cancers – reasons ranging from post-operative adhesions, post-radiation fibrosis or vaginal stenosis or genital lymphedema. It is also worth bearing in mind the ‘rare but real’ scenario of pudendal neuralgia following pelvic radiation, as discussed by Elahi in his 2013 article ‘Pudendal entrapment neuropathy: a rare complication of pelvic radiation therapy.’

The good news is that we have much to offer. Yang in 2012 (‘Effect of a pelvic floor muscle training program on gynecologic cancer survivors with pelvic floor dysfunction: A randomized controlled trial’) showed that pelvic rehab improved overall pelvic floor function, sexual functioning and QoL measures for gynecological cancer patients. Yang’s pelvic rehab group (administered by an experience physiotherapist) displayed statistically significant differences in physical function, pain, sexual worry, sexual activity, and sexual/vaginal function. Gynecological cancer and treatment procedures are potentially a fourfold assault: on sexual health, body image, sexual functioning, and fertility. Sexual morbidity is an undertreated problem in gynecological cancer survivorship that is known to occur early and to persist beyond the period of recovery (Reis et al 2010). We have a good and growing body of evidence that pelvic rehab, delivered by skilled therapists, has the potential to address each of these issues. And perhaps, most encouraging, here is Yang’s conclusion: ‘…‘Pelvic Floor Rehab is effective even in gynecological cancer survivors who need it most.’ (Yang 2012)

Interested in learning more about the role of pelvic rehab in gynecologic cancer survivorship? Join me in White Plains in August!

The following comes to us from Herman & Wallace faculty member Michelle Lyons. Michelle travels the world spreading the word about pelvic rehabilitation and the powerful benefits it can have on a patient's everyday life. Michelle will be teaching her newest course, "Oncology and the Female Pelvic Floor: Female Reproductive and Gynecologic Cancers" in White Plains, NY this August 14 - 15. Join her to learn more about evaluating and treating oncology patients.

According to the Scientific Network of Female Sexual Health and Cancer, ‘Sexuality is an experience that really is at the intersection of mind, body and relationship, and cancer treatment can impact all three of those elements”. Dr Sharon Bober of Dana Farber says ‘Part of the problem is that doctors are so focused on saving a cancer patient's life that they forget to discuss issues of sexual health. My sense is that it's not about physicians or health care providers not caring about your sexual health or thinking that it's unimportant, but that cancer is the emergency, and everything else seems to fall by the wayside".

If you harness the power of Google to look up female sexual dysfunction after gynaecologic cancer, you may see phrases like ‘Possible sexual side effects…’ or ‘Cancer treatment can cause physical changes that make having sex more difficult’ or even ‘cancer treatments may make intercourse painful’. To call these descriptions ‘understatements’ does not really do them justice.

For many women post-gynaecological cancer, resuming sexual function can be a multi-faceted problem. Issues can range from dealing with Cancer Related Fatigue and nausea, vomiting or diarrhea to physical changes in the size and shape of the vaginal canal. Cancer treatments can also cause hormone imbalances and tissue damage. Add to this issues with post-surgical/radiation adhesions, a disruption to the ability to produce lubrication, challenges to the musculo-skeletal systems within the hips and the pelvis as well as the onset of medically induced menopause….well you get the picture.

In a 2009 paper, ‘Interventions for sexuality after pelvic radiation therapy and gynaecological cancer’, Katz talks about the fact that ‘…very little attention has been paid to the sexual difficulties women experience after radiation to the sexual organs. There are a limited number of interventions for the woman who has been treated for gynaecological cancer with radiation. These focus on the provision of information and some specific suggestions related to treating vaginal dryness, the need for vaginal dilatation after radiation therapy, and management of fatigue. In ‘A systematic review of sexual concerns reported by gynaecological cancer survivors’ (Abbot Anderson 2012), the author points out that common concerns in the physical dimension were dyspareunia, changes in the vagina, and decreased sexual activity.

In the psychological dimension, common concerns were decreased libido, alterations in body image, and anxiety related to sexual performance. And in the social dimension, common concerns were difficulty maintaining previous sexual roles, emotional distancing from the partner, and perceived change in the partner's level of sexual interest.

The good news is that you can return to a normal sex life after surviving gynaecological cancer – particularly with the help of a skilled pelvic rehab provider.

In part 2 of this blog series, I will look at specific interventions in sexual rehab for the gynaecological cancer survivor. Interested in learning more about pelvic rehab and oncology? Join me in White Plains in August!

Pain associated with menstruation is known as dysmenorrhea, and more than half of women have pain related to their period for 1-2 days per month, according to The American College of Obstetricians and Gynecologists. Primary dysmenorrhea is related to menstruation, and often begins within a short period of time once menses occurs, whereas secondary dysmenorrhea is often related to a condition within the reproductive tract such as endometriosis or fibroids. In the medical office, a medical history, a pelvic exam, and possibly an ultrasound or laparoscopy will be completed. Treatment may include medications such as NSAIDs which target the prostaglandins that often lead to symptoms of dysmenorrhea, birth control pills, or surgeries.

A recent literature review asked if physiotherapy can help with symptoms of primary dysmenorrhea. Of the articles reviewed, 186 were chosen, and included a range of articles from descriptive, experimental studies to prospective, randomized controlled studies. A variety of interventions and approaches were included in the review, such as TENS, abdominal massage, acupuncture, cryotherapy and thermotherapy, connective tissue, Pilates, and belly dance. All of the approaches demonstrated some therapeutic benefit, either in response to the immediate application of the intervention, or up to a few months after the intervention was applied or instructed.

This literature review echoes a prior systematic review that evaluated the effectiveness and safety of acupressure, acupuncture, aspirin, behavioral interventions, oral contraceptives, and other supplements, procedures, and complementary and alternative medical interventions. Click here to view the full-text article. In that particular review, the authors reported the following:

- high-frequency TENS reduces pain (but less so than ibuprofen)
- acupressure may be as effective as ibuprofen
- topical heat may be as effective as ibuprofen and more effective than paracetamol

The bottom line from this research should be that we as pelvic rehabilitation providers need to help patients address pain and symptoms from dysmenorrhea. Clearly, there are many pathways to achieve symptom reduction, and some, such as TENS or topical heat, are easily carried out on an independent basis. How are you reaching adolescent girls who may develop primary dysmenorrhea? In clinical practice, talking with their parents, or reaching out at the community level to schools, churches, camps, gyms, or coaches may provide an opportunity to provide education and help. If you would like to learn more about myofascial release techniques for the abdomen and pelvis, check out the Myofascial Release for Pelvic Dysfunction continuing education course taking place next month in Illinois!

Today we hear from Herman & Wallace instructor Dustienne Miller CYT, PT, MS, WCS. Dustienne instructs the Yoga for Pelvic Pain course. Join her next month at Yoga for Pelvic Pain, Cleveland, OH on July 18 and 19!

We all know yoga can help chronic headaches, insomnia, anxiety, low back pain, and a myriad of other conditions. How can we apply the principles and benefits of yoga to the treatment of chronic pelvic pain?

Breathing
As rehab professionals who treat chronic pelvic pain, we know how critical it is for our clients to learn how to downtrain the nervous system. Breath awareness and training are a useful tool in reducing sympathetic nervous system override. Some clients may not have the awareness that they are holding their breath because of pain, or even anticipation of pain. Because of the direct mechanical relationship between the diaphragm and the pelvic floor, breath holding can lead to pelvic floor muscle holding. By building awareness, which is a learned skill, the client begins to notice and eventually control non-optimal breathing patterns.

Yoga offers several types of pranayama, or breathing techniques. Integrating breath with gentle movement has proven to be highly beneficial for men and women with chronic pelvic pain. Simple belly breathing lowers heart rate, blood pressure, and anxiety levels. For more detailed instructions on two pranayama, dirgha (3 part breath) and ujjayi (ocean-sounding breath), please click here.

Grounding
Grounding techniques decrease dissociation and anxiety. Two easy postures to practice in the clinic are Seated and Standing Mountain Pose (Tadasana). When practicing Seated Tadasana, encourage your patient to feel the ischial tuberosities heavy into the chair while imagining a string lifting up the spine and through the top of the head. When practicing Standing Tadasana, offer the imagery of a magnetic pull from the soles of the feet into the earth. For more detailed instruction on Tadasana, please click here.

Being Present
Negotiating medical system can leave clients with chronic pelvic pain feeling traumatized. Sadly, the percentage of men and women who have experienced additional traumas (ie: verbal abuse, sexual abuse) are quite high. Training the mind-body-spirit connection is helpful for the client to stay in the present moment rather than think about past painful experiences or anticipate future expectations of pain. Encourage the client to move at their pace and comfort level. Teach them gentle, loving acceptance of themselves and where they are in their healing journey. Clinicians must be mindful to avoid any potential trauma triggers (ie: teaching Supta Badha Konasana, butterfly/adductor stretch, in an open gym area). An excellent book to read to enhance your understanding of the delicacy of this subject is Overcoming Trauma through Yoga by Emerson and Hopper.

Calling all Pelvic Rehab tweeters! On June 24th, there will be a tweetchat hosted by 'Living Beyond Breast Cancer' to discuss and explore the effects of breast cancer on sexual health. Topics will include:
- How diagnosis and treatment side effects can affect intimacy and sexuality
- How to communicate with your cancer care team and partner
- Tips and suggestions for managing these side effects

Now, while I think it is brilliant that we are talking about sexuality during and after cancer, the panel has no input from pelvic rehab providers! We have so much to offer women in terms of sexual rehab in an oncology setting but if our colleagues and patients don't know about us.....

So some along and join the conversation on twitter on the 24th - don't forget to use the hashtag #LBBCchat. Hope to see you there to help raise the profile of pelvic rehab in the world of oncology.

Interested in learning more about sexual rehab after gynecologic cancer? Join me in White Plains NY this August!

Today we hear more from Susannah Haarmann, PT, WCS, CLT about how pelvic rehabilitation practitioners are suited to contribute to a breast oncology patient's medical team. Susannah will be sharing more insights and treatment tools at the Rehabilitation for the Breast Cancer Patient course taking place June 27-28 in Maywood, IL.

Most pelvic rehab practitioners are incredible problem solvers and independent thinkers. We understand that often our referrals from a physician occur after a battery of tests and ineffective medical interventions. We may agree to treat a patient only to find that the diagnosis is vague and the patient often feels lost and broken. So we take out our sleuth caps, ask as many subjective questions as it takes and see where our objective examination leads us. Afterwards we paint a picture of our findings, focus the patient on what is working, tell them where we are going to start and how we are going to build one brick at a time.

The same is true for rehabilitation and breast oncology. Most physicians don’t understand how our work as therapists can complement and alleviate the side effects of mainstream medical intervention, but when the pain medication no longer works, we are there. When the range of motion no longer exists to get the patient’s arm into a cradle for breast radiation, we are there. And when the patient walks in our door, we are there, quite often for a period of time that extends well beyond after treatments cease, because the potential side effects of breast cancer, if they occur, may take years or even decades to show up. The rehab practitioner understands how to prepare the patient, without fear, for what the road ahead may look like. The purpose of this education is to empower patients to serve as their own best advocates. Pelvic practitioners and breast oncology specialists are noted for their exceptional manual skills. We are also versed to pounding the pavement educating physicians, patients and other therapists alike about who we can serve and how we can be of service. We are definitely a unique breed of therapists.

The Rehabilitation for the Breast Cancer Patient course will add to the pelvic rehab practitioner's current knowledge allowing them to become a specialist. Consider the following:
A therapist understands the biomechanics of a shoulder joint and function, but do they understand how the effects of radiation, reconstruction procedures and impairments in the lymphatic system as a side effect of cancer treatment might prevent optimal upper extremity function?
A therapist may understand peripheral neuropathy and balance training or osteoporosis and aging, however, do they understand which chemotherapeutic and hormone therapies may cause these side effects and how the prognosis may differ depending upon which medical intervention was used?
A therapist may commonly treat back pain, but do they understand how a plan of care might be altered to accommodate for a patient who experienced a TRAM flap or latissimus dorsi reconstruction?
A therapist may be able to initiate a post-operative rotator cuff strengthening program for the upper extremity, but if the patient has a history of lymphedema, how do these parameters change?
A therapist may have advanced manual therapy skills, but how might one use these skills to identify and treat lymphatic cording or set safe parameters for working around radiated tissue to restore optimal function?
These are just a few of many examples of what constitutes a specialist in the field of breast oncology and each of these questions and more will be covered in detail in the course Rehabilitation for the Breast Cancer Patient.