An Orthopedic Approach to Coccyx Pain

Blog COX 6.14.24

Most of us spend our day sitting and do not think about the position of our ilia, sacrum, or coccyx during the change from standing to sitting. Weight-bearing through a tripod of bilateral ischial tuberosities and a sacrum that should have normalized form closure should be easy and pain-free.

The coccyx typically has minimal weight bearing in sitting, about 10%, just like the fibula, however, it can be a major pain generator, if the biomechanics of the ilia, sacrum, and femoral head positions are not quite right. A lot of patients will state “My pain is worse with sitting” which can mean thoracic pain, low back/sacral pain, and even lower extremity radicular pain.

Scanning the literature for coccyx treatment does not always yield the best results for physical or occupational therapists. Most literature states what the medical interventions can be, and physical therapy is never at the forefront. However, as we are musculoskeletal and neuromuscular specialists, this is no different in our thinking patterns relating to coccyx pain or painful sitting.

During sitting, the coccyx has normal flexion and extension moments that will change or become dysfunctional once mechanics above and below that joint change. A simple ankle sprain from 2 years ago can result in chronic knee and sacroiliac pain that can lead to coccyx pain over time. Even the patient who has long-standing TMJ (temporomandibular joint) and cervical dysfunction, now has a thoracic rotation and your correction of their coccyx deviation cannot maintain correction.

Coccydynia and Painful Sitting is a course that provides a spark for your orthopedic mindset and encourages clinicians to evaluate the coccyx more holistically.

  • What are the joints doing?
  • How does it change from sitting to standing?
  • Standing to sitting?
  • What is the difference from sitting upright to slump activities?

Working through the basics and the obvious with failed results takes you to the next step of critical thinking within this course. How does the patient present? What seems to be lacking and how to correct them biomechanically to achieve pain-free sitting? Related coccyx musculature and nerve dysfunction can seem like the easiest to treat, but what happens when those techniques fail?

In Coccydynia and Painful Sitting, we look at the entire body, from the cranium to the feet, to determine the driver of coccyx pain and dysfunction. A better understanding of ilial motion, with accompanied spring tests (Hesch Method) normalizing spinal mechanics and lower extremity function is highlighted in this course. Internal vaginal and rectal release of pelvic floor muscles can lead to normalized coccyx muscle tension that is supported via coccyx taping.

To learn more, join Lila Abatte in her next Coccydynia remote course scheduled for July 13, 2024.

 

AUTHOR BIO

Lila Abbate, PT, DPT, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC is the Director/Owner of New Dimensions Physical Therapy with locations in Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor of Science (BS) in Health Sciences and a Master of Arts (MA) in Physical Therapy in 1997. She completed her Advanced Masters in Manual Orthopedic Physical Therapy (MS) at Touro College, Bayshore, NY in 2003 and continued to pursue her Doctor of Physical Therapy (DPT) at Touro in 2005. Dr. Abbate is a Board-Certified Specialist by the American Physical Therapy Association in Orthopedics (OCS) 2004 and Women’s Health (WCS) 2011. She obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from the Herman & Wallace Institute in 2014. She is a Diane Lee/LJ Lee, Integrated Systems Model (ISM) graduate and completed the New York series in 2012.

Dr. Abbate has been an educator for most of her physical therapy career. She has experience as a full-time faculty at Touro College, Manhattan Campus from 2002 to 2006 teaching the biomechanical approach to orthopedic dysfunction and therapeutic exercise as well as massage/soft tissue work that highlighted trigger point work, scar management, and myofascial release.

She is currently on faculty as a Lecturer at Columbia University teaching the private practice section Business & Management course (since 2016) along with the Pelvic Health elective (since 2012). She teaches nationally and internationally with the Herman & Wallace Pelvic Rehabilitation Institute teaching advanced courses of her own intellectual property: Orthopedic Assessment for the Pelvic Health Therapist, Bowel Pathology Function, Dysfunction and the Pelvic Floor, Coccydynia & Painful Sitting: Orthopedic Implications. She was a co-writer for the Pudendal Neuralgia course and teaches the Pelvic Function Series and the Pregnancy and Postpartum Rehabilitation courses. She has written two book chapters in 2016: Pelvic Pain Management by Valvoska and Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies by Chughtai.

She is a member of the American Physical Therapy Association, the National Vulvodynia Association, the American Urogynecology Association, and the International Pelvic Pain Society. Dr. Abbate is also a Senior Physical Therapy consultant for SI Bone, a sacroiliac joint instrumentation company.

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Passion for the Pelvic Floor & Giving back to our Profession

Blog Itzkowitz 6.11.24

This specialty kind of fell into my lap after years of “kicking and screaming,” well, not really, just saying no a lot.

In March of 2018, I attended a continuing education course at Springfield College with a student of mine at the time (who had just completed his final clinical affiliation for split outpatient ortho and acute care in a small community hospital in Connecticut) on pelvic floor therapy. Each year I looked at the offerings for clinical instructors and nothing really excited me, but this time was different. When it was time to choose I sat down with my student and asked him what he was going to and we chose to go to the pelvic health course as he was going into outpatient orthopedics and knew he might come in contact with pregnant or postpartum patients that might need the education on pelvic health. I was excited to learn more about the pelvic floor and what that really entailed. Every time this pelvic floor physical therapist spoke about patients and the conditions she treated and how they exuded confidence going on vacation, going to an event, or even being more intimate with their partners I thought “This might be for me.” I was intrigued and excited to learn, for probably the first time, in at least 2 years.

The next day I was approached by my manager about starting a pelvic health program at our local hospital together as a team; and when I say approached, I mean there was a note on my desk that read “Please see me” and she signed her first initial. My first instinct was, “Oh no, what did I do now?” I had been skeptical for approximately 2 years as the topic came up about every other month at our staff meetings, however, without a doubt or skip in my breath I said “Sure, why not?!” At this point, I thought what do I have to lose? I was getting reimbursed to take these continuing education classes, I was getting to travel, and I was learning alongside a colleague. I went home that night and told my parents what I was going to do and they thought I was joking. My friends and boyfriend said, “You’re going to do what?” Within 1 week we were signed up for our first pelvic floor series courses through Herman & Wallace starting with Pelvic Floor 1 (now Pelvic Function 1) in Virginia Beach, VA. I began seeing patients within 3 months of taking PF1 after developing the history sheet and marketing with local OBGYN/midwife offices. Fast forward to August 2018, we took PF2A and in October 2018, I took PF2B, both in Boston, MA.

As a new pelvic floor therapist, the initial diagnoses included urinary dysfunction, prolapse, pelvic pain, and the postpartum population. Over time and taking more courses I began to treat more complex pelvic pain diagnoses. This allowed me to use more of my manual therapy skills and some more medical skills as these types of patients required an in-depth treatment approach. I took Capstone in October 2019 in Houston, TX and then we all know what happened next. After meeting patient after patient who experienced medical gaslighting, experienced pain for decades, and had run out of doctors to see, I decided to take a deeper dive into chronic and complex pelvic pain diagnoses, ie: vaginismus, vulvodynia, vestibulodynia, endometriosis, adenomyosis and so much more. I love treating each and every patient who comes through the door and into my treatment room, however, I hold a special place in my heart for those who have been told that there is no other treatment for them, or they’ve exhausted all of their outcomes. Since 2018, I haven’t met a patient I haven’t been able to help, even a little bit.

Prior to treating any pelvic floor diagnoses, I took 2-3 doctor of physical therapy (DPT) students each year, some of them shared with another acute care PT. I couldn’t fathom not taking students as I was diving into this much-needed area of physical therapy. I took my first pelvic floor-focused student in January 2020. I developed my own system as there wasn’t any standard of practice that I could find amongst other pelvic floor therapists regarding clinical education. I developed a system that taught a very basic PF1 if the student had not taken it yet that included learning the muscles, nerves, basic diagnoses, treatments, and integration into function. In order to teach a student how to do an internal vaginal assessment, I first conduct an internal assessment on the student, and then I have them perform one on me. When I tell other therapists what my structure and strategy are in order to get students ready for seeing their own caseload I always get a look of “Oh really?” and an eyebrow raise. At the end of the day, how do I know they will be competent enough to perform an internal vaginal assessment on a patient if I don’t know if their pressure is adequate or if they are palpating the correct structures?

I was starting to take more courses and follow more and more groups on social media. I always felt like an outlier as I never felt like I had to force a student who was interested in pelvic health to take PF1 unless they knew downright they wanted to go straight into pelvic health prior to starting their affiliation. They signed up for this affiliation and there is an agreement that I guide them and enhance their learning. We practice until they feel confident and competent and then choose a patient who is willing and gives consent to the student performing the internal vaginal assessment, of course with me in the room, until I feel the student is 100% independent. Since 2020 I have taken 6 DPT students who were interested in pelvic health, with another one scheduled for October 2024. I am beyond happy to say that each student has taken a job with a pelvic health focus after completing their clinical affiliation with me so I have to think I’m doing all the right things!

In January 2021, I was approached by the teaching assistant (TA) coordinator for Herman & Wallace as they were in desperate need of a TA in Danbury, CT for PF1 and I thought “What the heck? I do this day in a day out, I’d be a great TA” and jumped on that opportunity. Through my opportunities as a TA, I have been able to learn from so many amazing pelvic floor therapists all over the country, guide new therapists in their pelvic floor journey, and embark on this new journey for myself as a leader in pelvic health. I have been so lucky to have been able to TA so many courses local to my home in Connecticut over the last 3 years, which has allowed me to form professional connections and network with local to CT physical and occupational therapists, as well as the ability take over a dozen additional courses through H&W ranging from Bowel Pathology & Function to Pharmacology for the Pelvic Floor Therapist to Dry Needling without having to pay out of my own pocket. I am halfway into year 4 of my TA journey with H&W, became a lead TA in October 2023, and I truly look forward to each, and every, course I choose to TA. I love this journey I have created for myself and I am so passionate to share it with anyone and everyone willing to listen.

I am proud of the pelvic floor therapist I’ve blossomed into over the last 6 years. I honestly couldn’t have done any of this without the support of my family, boyfriend, friends, and coworkers who have listened to me talk endlessly about all of the different avenues the pelvic floor can be affected and how to begin to address those issues. My story into the pelvic health world is not like anyone else’s and that’s what makes each and every one of our journeys unique!

 

AUTHOR BIO

Alyssa Itzkowitz, PT, DPT, PCES, PRPC

Alyssa Itzkowitz, PT, DPT, PCES, PRPC Alyssa is always taking new clients at Rockville General Hospital located in Vernon, CT. Ahe treats all genders and ages 15+ (anything younger than that is on a case-by-case basis). Evaluations are 90 minutes and follow-up treatment sessions are based on the needs of the patient and are either 30 or 60 minutes.

You can find our contact information on our hospital website: www.echn.org/services/rehabilitation or email Alyssa to discuss scheduling further: This email address is being protected from spambots. You need JavaScript enabled to view it..

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Anthropometric Changes of The Foot and Pregnancy-Related Musculoskeletal Pain

Blog PREG 6.7.24

So many physiological changes occur to the body during pregnancy, it is no wonder that during pregnancy people have back and lower extremity aches and pains. It is common to experience hormonal changes, weight gain, and reduced abdominal strength during this time, not to mention the anterior shift in their center of mass.

These physiological changes result in altered spinal and pelvic alignment, and increased joint laxity. Also, many individuals report increases in size of their feet and a tendency to have flatter arches during and after pregnancy. Alignment changes may influence pain, and altered alignment could change the physical stresses placed upon different tissues of the body, which that specific tissue was not adapted to, therefore, causing pain or injury to that tissue.

A study published in 2016, in the Journal of Women’s Health Physical Therapy1, investigated if there may be a relationship between anthropometric changes of the foot that occur with pregnancy and pregnancy-related musculoskeletal pain of the lower extremity. The study included 15 primigravid women and 14 weight-matched controls. This study was a repeated-measurements design study, where the investigators measured foot length, foot width, arch height index, arch rigidity index (ARI), arch drop (AD), rear foot angle, and pelvic obliquity during the second and third trimesters and post-partum. The subjects were surveyed on pain in the lower back, hips/buttocks, and foot/ankle.

The author’s findings were that measures of arch flexibility (ARI and AD) correlated with pain in the lower back and the foot and ankle and that medial longitudinal arch flexibility may be related to pain in the lower back and foot. The more flexible arches were associated with more pain in the study participants. They reported the participants in their study did not have very high pain levels in general and recommended further studies to compare pregnant individuals who experience severe pain with those who do not while comparing their alignment factors.

This article is a good reminder for physical therapists to consider the changes that occur to the foot including changes in arch height, arch flexibility, and foot size, and how that influences the pelvis and lower extremity for prevention and treatment of musculoskeletal pain during pregnancy.

Educating our pregnant patients on shoe wear seems even more important now. Making recommendations, unique to each patient based on their objective data, foot type, and arch flexibility status seems like an appropriate addition to a well-rounded treatment plan.

Doesn’t it seem prudent to wear shoes that provide some arch support to hopefully reduce musculoskeletal pain associated with pregnancy changes?

I have observed some patients who are pregnant arrive at their physical therapy appointment wearing unsupportive flip-flops and other poor shoe-wear choices. I understand there are barriers for pregnant patients, I remember from when I was pregnant that reaching your feet to put shoes on can be very difficult, and sometimes your feet are swelling so it may be near impossible to physically get shoes on your feet. You might even need a new pair of shoes, as your shoes may no longer fit.

However, an article such as this one seems like something I could easily share with a patient to help persuade them of the importance of good shoe wear or at least proper arch support. Being able to discuss a recent scientific study with a patient can be powerful and motivating to a patient.

Additionally, an article such as this reminds a practitioner of specific objective data to monitor such as arch height and flexibility as it changes throughout the patient’s pregnancy.

  • How does the patient’s changing arch height and flexibility influence their specific pelvic, hip, knee, and ankle alignment?
  • How does swelling play a part in the patients’ foot anthropometrics day to day, trimester to trimester?
  • Ask more questions about their daily activities, are they ‘barefoot and pregnant’?
  • Could something as simple as having them wear appropriate, arch-supportive shoes while in the home reduce their lower extremity or back pain?"

 

Join us at the next Pregnancy Rehabilitation course scheduled for July 20-21 to learn more about pregnancy-related topics.

 

Reference:

  1. Harrison, K. D., Mancinelli, C., Thomas, K., Meszaros, P., & McCrory, J. L. (2016). The Relationship Between Lower Extremity Alignment and Low Back, Hip, and Foot Pain During Pregnancy: A Longitudinal Study of Primigravid Women Versus Nulliparous Controls. Journal of Women’s Health Physical Therapy, 40(3), 139-146.

 

AUTHOR BIO

Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES

Rachel Kilgore, DPT, OCS, COMT, PRPCC

Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES graduated from Central Washington University with a Bachelor of Science (BS) in exercise science and a minor in nutrition in 2004 where she also captained the collegiate soccer team. Rachel completed her Doctor of Physical Therapy (DPT) at University of Washington in 2007. She has worked in out patient orthopedics and pelvic health since 2007. She furthered her physical therapy training earning Certified Orthopedic Manual Therapist (COMT), Physical Therapy Board-Certified Specialist in Orthopedics (OCS), and Pelvic Rehabilitation Practitioner Certification (PRPC). She is a member of the American Physical Therapy Association (APTA), Section of Orthopedics and Section of Women’s Health, and the Physical Therapy Association of Washington (PTWA).

Currently, Rachel practices in Seattle at Flow Rehab in the Freemont Neighborhood with Holly Tanner and Jake Bartholomy. Her patient care focuses on orthopedics, female athletes, and women’s health conditions for bladder & bowel dysfunctions, pelvic, pain, pregnancy and post-partum issues. 

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My Serendipitous Professional Journey in Pelvic Health PT

Blog Castillo 6.4.24

I arrived to Pelvic Health Physical Therapy by fruitful exposure and a professional demand to fulfill a new employer’s needs. 10 years later, I am all-in serving women and men with bladder, bowel, sexual dysfunction, and abdominopelvic pain to optimally live their lives well more comfortably.

Throughout my PT education at Washington University in St. Louis, I envisioned specializing in Orthopedics using a Movement Systems Impairment (MSI) diagnostic and treatment approach. While a student in my final 3-month clinical experience at a hospital-based Outpatient Orthopedic Clinic, I had the good fortune to be paired with a clinical instructor who was largely Orthopedic-based but treated Pelvic Health 1 day per week as the sole Pelvic Health PT Provider (shoutout Barb Davis!). The setting was a large community-based safety-net institution, Denver Health, which served Denver residents including underserved populations. Patients presented with chronic pain, complex socioeconomic dynamics, and diverse ethnic backgrounds with Denver historically being a migrant and refugee-welcoming city. My pelvic patients were interesting, and my Pelvic Health interest was sparked.

As a new graduate seeking employment, I secured a job at a hospital-based Outpatient Orthopedic Clinic in San Diego, CA at Scripps Health. My new position was created for an Orthopedic PT who was interested in being mentored in Pelvic Health PT due to a growing need to support Pelvic Health patients and providers in North County San Diego. I was offered mentorship and financial support to pursue continuing education to set a foundation in Pelvic Health. I had an interest, there was a clinical need, I seized the opportunity, ran with it, and I am so grateful I did.

My astute Pelvic Health Mentors (Alissa Meredith, PT, MPT and Destiny Bochinski, PT, DPT, PRPC) highly encouraged me to take the foundational Pelvic Floor Series (which has been updated to the Pelvic Function Series this year) through Herman & Wallace. I was already familiar with Herman & Wallace through my exposure at Washington University in St. Louis, where they host various Herman & Wallace courses. I am so glad I chose to follow my Pelvic Health educational path with Herman & Wallace Rehabilitation Institute. I was lucky enough to be taught Pelvic Floor Level 1 (now called Pelvic Function Level 1) by the venerable and entertaining Holly Herman & Kathe Wallace. Fast forward 10 years and I have taken the full Pelvic Floor Series, Ramona Horton’s Visceral Fascia Mobilization Series, Male Pelvic Health, Nutritional Perspectives, Pregnancy Course, IC, Rehabilitative Ultrasound, and a myriad of other Herman & Wallace continuing education courses. I have a wide arsenal of didactic information, manual skills, proficiency in biofeedback modalities use, and clinical experiences to treat the gamut of simple to complex pelvic and orthopedic patients. Citing the incredible Ramona Horton, MPT, DPT, I completely agree that Pelvic Health is applying Orthopedics within the pelvic cavity. I am grateful to have a practice that is largely Pelvic Health-based with a smattering of Orthopedics. In reality, I practice ~65-70% Pelvic Health and 30-35% Orthopedics.

Across my professional journey, I started as the third Pelvic Health PT at the clinic where I work, to now being one of eight Pelvic Health PT providers at that same comprehensive outpatient rehab center, Scripps Rehabilitation Services in Encinitas. I am lucky to be part of a burgeoning Pelvic Health Team at our clinic site as well as across the larger health system. I was lucky to be mentored by two amazing colleagues, including now a Herman & Wallace Instructor, Destiny Bochinski, who I continue to work with and collaborate well with. I am appreciative of the opportunity to continue to grow professionally by serving as a Pelvic Health mentor at my clinic and TA for Herman & Wallace, which I’ve been doing since 2020.

Thank you for letting me share my story, which is one of seizing a ripe opportunity and allowing my career path to evolve with an initial spark that I didn’t early on envision would be my path, but I love where I’ve been and my trajectory forward.

 

AUTHOR BIO

Jackie Castillo, PT, DPT, MSC

Jacqueline CastilloJackie Castillo, PT, DPT, MSCI is a Board-Certified Orthopedic Clinical Specialist based out of San Diego, CA who practices Pelvic Health and Orthopedic Physical Therapy at Scripps Rehabilitation Services in Encinitas. She received her DPT and MSCI (Master of Science in Clinical Investigation) Degrees from Washington University in St. Louis in 2013. She received her BS in Animal Physiology & Neuroscience from the University of California, San Diego in 2005. She has served as a Teaching Assistant for Herman & Wallace since 2020. She intends to sit for the Herman & Wallace PRPC Exam this year. She enjoys running, yoga, walking her puppy, hiking, biking, and exploring good food and drink with her soon-to-be husband, family, and close friends.

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Should you take Pediatric Pelvic Floor Play Skills?

Blog PEDP 5.31.24

Imagine you’re a provider who has foundational information about the pelvic floor. Maybe you’ve just started taking coursework for adults, you may have taken a pediatric pelvic health class or maybe you’ve been treating adults for years. You know the anatomy, the physiology, and the general treatment practice guidelines.

  • Your clinic gets a call about a baby with colic and your supervisor asks you if you could treat it. Do you accept the evaluation?
  • You see a post on a “mommy Facebook group” asking for potty training tips for a child who is withholding stool during potty training. Do you tag your business/practice as a resource that can help?
  • You have a family friend with a child struggling with voiding during the school day and they ask you for advice as a pelvic health provider. Do you have ideas on how to guide them?
  • A patient you are seeing for pelvic floor issues asks you to start treating their teenager because they have “the same issues.” Does this seem scary to you?

Pediatric Pelvic Floor Play Skills is a class written to be a supplement to other pelvic health education classes a pelvic floor therapist has likely taken. This class helps providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. The class shows videos of actual treatment sessions of different children in different age groups showing how to integrate stretching, strengthening, coordination, and other fun activities into a therapy visit.

One of the tricky parts of working with children is including the child in their plan of care and coordinating with caregivers. Pediatric Pelvic Floor Play Skills talks about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective.

This class includes sample home programs, equipment purchase lists (with a budget in mind), tips for helping get families on board with the implementation of care, and resources such as outcomes measures, developmental milestone checklists, and recommendations things parents ask for like how to talk about periods and sex.

The next Pediatric Pelvic Floor Play Skills remote course is scheduled for June 29th, come spend a day learning how to integrate what you already know into a playful session for your tiniest of clients to your angstiest teenager.

 

AUTHOR BIO

Mora Pluchino, PT, DPT, PRPC
Pluchino 2022I am a graduate of Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman and Wallace since 2020 and have over 150 hours of lab instruction experience.

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You took Pelvic Function Level 1, Now What?

NL PF Series 5.28.24

Congratulations on completing Pelvic Function Level 1 (PF1) and entering the world of pelvic rehabilitation. Are you ready for your next course but not quite sure which one to take? Well, you’re not alone. Everyone’s pelvic health educational journey is different based on their interests and patient demographics and there are a lot of course options available.

I’m going to zero in on the intermediate-level courses in the Pelvic Function Series for you as HW does recommend that practitioners take at least one or two of these. If you’ve looked at the course page you’ve noticed that there are three courses with a Level 2 designation – as well as a lab course. What does this mean? These courses are designed to be a progression of knowledge and skills learned in the foundational course Pelvic Function Level 1.

Here are the intermediate courses:

Ready for a more in-depth look at the courses? Here is a more detailed breakdown:

Pelvic Function Level 2A (PF2A) Colorectal Pelvic Health, Pudendal Neuralgia, and Coccyx Pain
This course is intended for the pelvic health clinician who treats patients with common functional gastrointestinal (GI) dysfunctions and is interested in learning internal anorectal examination and the use of balloon re-training.

In this course, you will learn about common functional gastrointestinal (GI) dysfunctions including irritable bowel syndrome, fecal incontinence, and constipation. Course topics provide an introduction to nutrition for bowel health, colorectal conditions, and oncology. Participants will be educated on how diagnoses such as hemorrhoids, fistulas, fissures, and anorectal pain including pudendal neuralgia and coccygodynia may be improved with pelvic rehabilitation.

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic function evaluation with external observation, palpation, and internal anorectal examination of pelvic skeletal and soft tissues. These labs include an external perineal and internal anorectal approach as well as education in the use of balloon re-training.

Pelvic Function Level 2B (PF2B) Urogynecologic Examination and Treatment Interventions
This course is intended for the pelvic health clinician who treats patients with conditions including urinary incontinence, chronic pelvic pain (CPP), and pelvic organ prolapse.

In this course, you will learn, with increased specificity, evaluation for urogynecologic conditions as well as an overview of medical management, and multi-disciplinary pelvic healthcare. Course topics provide a more in-depth understanding of urinary incontinence, chronic pelvic pain (CPP), and pelvic organ prolapse.  Participants will be educated on how diagnoses such as interstitial cystitis/painful bladder syndrome (IC/PBS), urinary tract infections, vaginismus, vulvar pain, dyspareunia, polycystic ovarian syndrome (PCOS), and endometriosis may be improved with pelvic rehabilitation.

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic structures in relationship to the vaginal canal and surrounding structures such as the lumbopelvic nerves, the uterus, urethra, bladder, and rectum. Interventions instructed will include patient management of trunk and pelvic pressure, relaxation training, breathing, and manual therapies for a variety of pelvic dysfunctions. These labs include an external abdominal and pelvic and internal vaginal approach.

Pelvic Function Level 2C (PF2C) Men’s Pelvic Health and Rehabilitation
This course is intended for pelvic health clinicians who are interested in treating male pelvic health conditions.

In this course, you will learn critical detailed information about men’s pelvic health conditions including post-prostatectomy urinary incontinence, erectile dysfunction, and chronic pelvic pain (CPP). Participants will be educated on how diagnoses such as hard/flaccid, urgency/frequency, scrotal, testicular, and penile pain may be improved with pelvic rehabilitation.  

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic health evaluation with external observation, palpation, and internal anorectal examination of pelvic structures and soft tissues. These labs include an external abdominal, gluteal, perineal, and internal anorectal approach. 

Modalities and Pelvic Function (PFMOD) The Pelvic Health Toolkit
This course is for the pelvic health clinician who has the opportunity to use modalities as an adjunct to their patient's care and goes beyond the "Big 3" (E-Stim, Biofeedback, and Ultrasound).

In this course, you will learn about and practice a variety of modalities. Modalities in PFMOD include biofeedback, cold laser/light therapy, electrotherapy, real-time ultrasound imaging, belts, braces, supports, lubricants, myofascial tools/techniques, and “special topics” that can be used to assist in relaxation, bowel and bladder health, and sexual function. Specialized knowledge from experts in different subjects will be shared throughout the course. 

Certain modalities that are impractical to practice live will be shared and demonstrated via video. These Interventions include shockwave, rehabilitative ultrasound imaging, dry needling, and light therapy. 

Practical, trauma-aware, hands-on labs provide supervised instruction to practice utilizing biofeedback and other modalities to allow kinesthetic learning before prescribing and recommending them to patients. 

Previous course sponsors who have provided samples and products have included:

  • Nix
  • Flyte
  • OhNut
  • Replens
  • RockTape
  • Bellies Inc.
  • Ice Soothers
  • BabyBellyBand
  • Intimate Rose
  • The Pro Group
  • Good Clean Love
  • Cushion Your Assets

If you are interested in taking an intermediate-level Pelvic Function Course but still have questions, then please contact us.

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Dry Needling Considerations for the Perinatal Patient Population

Blog DNPH 5.24.24

The journey to and through motherhood is, no doubt, filled with an array of emotional, mental, and physical changes. It can and should be, one of the most empowering times in a person’s life, but it can start to feel overwhelming when there is any degree of uncertainty or when there are obstacles that present themselves throughout the journey. The body is expected to change and grow in ways that are both magical and daunting for the birthing person and the clinicians in the pelvic health arena should be providing the education to help the pendulum swing towards the magic. Unfortunately, access to this education is sparse, recommendations can be conflicting (pending who you're talking to), and an understanding of the services that we can, and should be, providing in the perinatal period are not well defined nor understood by the majority of the healthcare continuum of providers.

During pregnancy, the body transforms with such beautiful intent. The overarching intention is to support adaptation to nurture and accommodate the developing fetus. During this transformation, the body will inevitably undergo physiologic changes in every system of the body, including the neuromusculoskeletal system. These changes in the neuromusculoskeletal system can contribute to the common ailments and complaints of our clients who are pregnant. Pregnancy-related low back pain, pelvic girdle pain, pubic symphysis dysfunction, and neuropathy are amongst some of those ailments whose symptom drivers are the nerves and muscles. As pelvic health clinicians, what is our best effort to treat these tissues during the gestational period?

How does dry needling fit in during pregnancy?
The way we approach tissue dysfunction during the gestational period is no different than at other times in a person’s life. We do, however, have to consider things like the stage of gestation, appropriate zones of treatment, dosage, and patient positioning for certain interventions, one of those being dry needling. In regards to dry needling intervention, we avoid implementing this in the first trimester secondary to the higher risk of spontaneous miscarriage.

There is no evidence to suggest that dry needling intervention would contribute to spontaneous miscarriage. However, as a clinician, we want to protect ourselves so as not to be associated with this unfortunate adverse event. We also withhold implementing dry needling in the zones of the thoracolumbar junction, the pelvic floor musculature, and the anterior abdominal musculature throughout the entire gestational period; this is due to avoiding the region of innervation to the uterus to mitigate association with a possible spontaneous pre-term labor and to abstain placing a needle within geographic proximity to the developing fetus. Otherwise, dry needling is an appropriate intervention for the management of neuromusculoskeletal conditions in this patient population, especially when other clinical approaches for pain mitigation (i.e.: pharmaceutical use) are contraindicated or simply not offered by other healthcare providers. A properly trained clinician can safely implement dry needling as a powerful intervention for pain relief and neuromuscular reset to allow for better activity and load tolerance during the gestational period. Improving activity and load tolerance for the expecting mother has a multitude of benefits for both physical and mental wellness.

Amazing!! What about in the postpartum period?
In the postpartum period, the body will inevitably go through a massive shift in the overall performance of the neuromuscular system. Birth-related neuromuscular dysfunction is common following both vaginal and cesarian delivery due to the mechanical and biochemical stressors placed on the involved tissues, a concept that shouldn’t be surprising for the rehabilitative clinician. Consider your postoperative patient following a total knee replacement; there is a certain degree of expectation surrounding neuromuscular shutdown following the procedure secondary to the inflammatory cascade that follows. Performance for daily activities such as ambulation, transitional movements, and ability to participate in recreational tasks is limited during the acute and subacute recovery period. It takes time to regain mobility of the involved joints and the neuromuscular coordination and strength of the impacted tissues. We progress the patient through our plan of care to reset the dysfunctional tissues, reinforce good movement strategies, and reload the tissues back to function. The neuromuscular performance following a vaginal or cesarean delivery is no different. The muscle groups impacted following birth are typically those of the core canister including the diaphragm, abdominal wall, pelvic floor, and lumbopelvic posterior stabilizers.

One of the best reset tools we have as rehabilitative clinicians is dry needling. We are able to specify treatment to the tissue targets that are unique to each client’s symptom presentation while utilizing electrical stimulation to influence the nervous system for both tissue recovery and performance. Being a bioelectric system, our bodies respond beautifully to this type of input, especially when followed with appropriate interventions to reinforce neuromotor coordination and functional loading. This sequence of interventions optimizes the overall function of the nervous system which ultimately dictates the behavior and performance of the rest of the body. As it relates to our postpartum clientele this should be something we are considering in the immediate postpartum period to optimize birth recovery, especially for the heavily impacted tissues like the abdominal wall, lumbopelvic stabilizers and pelvic floor.

We have a continuously developing body of evidence that supports the utilization of dry needling for tissue health and performance. The mechanisms behind this are biomechanical, biochemical, vascular, and neural in nature. There is also emerging evidence that is exploring the utilization of dry needling with electrical stimulation (aka neuromodulation) for wound healing. The possible impact that we can have on the healing of episiotomy incisions, cesarean incisions, or perineal tears in the acute and subacute postpartum stage is encouraging given the evidence, and has also been seen to be very powerful anecdotally.

If you want to learn more about the implementation of dry needling into your practice as it relates to the perinatal period, join us on an upcoming Dry Needling and Pelvic Health: Pregnancy and Postpartum Considerations! There are two more courses scheduled this year. One this summer in Arlington VA on June 22-23, and the other this fall in Seattle WA on October 18-20.

 

AUTHOR BIO

Kelly Sammis, PT, DPT, OCS, PCES, AFDN-S, CLT

Sammish 2023 SqKelly Sammis is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. Her passion for treatment in physical therapy is in sports performance, pelvic health, and overall wellness. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010).

She is a Midwest native with a strong history of treating persistent pain, pelvic floor, and return to sport dysfunctions. Kelly serves as lead faculty developing and teaching dry needling and pelvic health courses nationwide. When she is not treating clients or teaching you can find her spending time with her husband, two children, and labradoodle, Dexter, exploring our landscapes and the beautiful mountains of Colorado!

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Tell HW What Resources YOU Need for your Practice!

Blog PREFUND 5.22.24

Herman & Wallace offers a number of downloadable products on our website for your clinical practice, and we want to put you in charge of deciding which new products we create and offer!

What is a Prefund?
The HW philosophy is that we should only be making products that are useful to our practitioners. In our efforts to create the most valuable products and keep the price as low as possible, we have launched a new Prefund product development program.

Need more information? Check out the Prefund FAQs.

Here is how it works:

  1. Herman & Wallace creates a product concept, a description of the product and its contents, without fully creating the product.
  2. The product concept can be found on the HW Product Page as a “Prefund” product for a limited period of 7 days. In this case, the products will be available from May 22, 2024 until midnight on May 28, 2024.
    •  All product concepts include:
      • A description of the product
      • Product content list: patient forms, PowerPoint files, handouts, mapping tools, etc
      • Standard retail price of the product once it is launched
      • Prefund retail price of the product - which is 40% lower than the retail price
  3. Practitioners who would like to buy the product can prefund the product concept at a 40% discount on the standard retail price in exchange for receiving the product upon Herman & Wallace completing its development.
  4. If you see a product you'd like to purchase, then prefund it! If the product gets enough pre-funders, then HW will develop the product.
  5. Once the product is developed, we'll email your product to you.

There is NO RISK!
Prefunding a product carries NO RISK. If the product does not receive enough prefunding by the end of the trial period, Herman & Wallace will refund 100% of the amount contributed by each prefunder.

Product concepts to choose from:
Prefund and Downloadable Products are available on the HW Product Page.

    • Inclusivity for Beginners
        • Pricing: Prefund $45, Standard $75
        • This product includes tips and pearls of wisdom to enhance your understanding of diversity, equality, and inclusivity as well as tools like up-to-date terminology and definitions to help practitioners create a safe and welcoming environment for clients.
    • Birth Prep for Pelvic Health Clients
        • Pricing: Prefund $90, Standard $150
        • This product will make it incredibly easy for you to host a Birth Prep class for any audience.
    • Trauma Informed Care Checklist
        • Pricing: Prefund $45, Standard $75
        • This product will help you review the concepts of trauma-informed care and check in with yourself and the practices of your workplace. It will then provide guidelines and tips to provide the best possible trauma-informed care to your clients.
    • Hosting a Pelvic Floor Student
        • Pricing: Prefund $60, Standard $100
        • This is the perfect document to help prepare any clinician for a pelvic health student.
    • Quick Reference Treatment Checklists
        • Pricing: Prefund $45, Standard $75
        • These quick informative checklists include topics like constipation, stress incontinence, urge incontinence, pelvic organ prolapse, hemorrhoid management, and painful insertion.

Carpe Diem
By prefunding a product, you are helping guide what resources HW creates. This keeps prices lower on all products by assuring we don’t spend resources creating products that our audience does not value. If a prefund concept does not get funded, you get a 100% refund. If it does meet the minimum, you will receive the product concept you prefunded at a significant discount!

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The Connection Between Systemic Birth Control and Vestibulodynia

Blog SEXMED 5.17.24

Vestibulodynia is defined as pain at the vestibule, which is the area around the opening of the vagina (introitus). Being diagnosed with vestibulodynia can leave patients feeling frustrated because it doesn’t explain WHY they have pain at the vestibule. There are several types of vestibulodynia including infection, inflammation, neoplastic, neurologic, trauma, and hormonal deficiencies.

The most common type of vestibulodynia is caused by hormonal deficiencies known as Hormonally-Mediated Vestibulodynia. This type is caused by hormonal changes including taking birth control, breast feeding, postpartum, estrogen blockers, and peri or post menopause.

The most common cause of Hormonally-Mediated vestibulodynia in younger women (under the age of 25) is systemic birth control (i.e. oral contraceptive pills (OCPs), depo-shot, NuvaRing). Side effects of birth control (BC) such as breakthrough bleeding, nausea, headaches, increased risk of stroke, and abdominal cramping are more commonly discussed among doctors and patients.

However, what is NOT often discussed with patients prior to starting birth control, especially OCPs, is that systemic BC use causes vestibulodynia, decrease vaginal lubrication, decrease thickness of labia minora, and decreased vaginal introitus size, all leading to dyspareunia (painful sex). These changes can occur as early as 90 days after starting OCPs or with long-term use.

Unfortunately, if the onset of birth control was before the age of 17, there’s even a higher risk of developing hormonally associated vestibulodynia.1

So, WHY and HOW, does this happen?

SEXMED 5.17.24Systemic birth control gets processed through the liver which INCREASES a protein called the Sex Hormone Binding Globulin (SHBG). SHBG binds to the free testosterone in the blood, so even if your body is making testosterone, high levels of SHBG (from the BC) DECREASE the testosterone in your body. This inhibits testosterone from getting to the tissue that needs it to be healthy—–the vestibule. The vestibule is rich with androgen receptors! If those receptors aren’t getting the testosterone (and estrogen) they need because of the increased SHBG then the vestibular tissue can become painful (vestibulodynia)!

Most commonly patients will complain about pain at the opening upon entry, dryness, friction, feeling of tearing, and actual tissue tearing resulting in bleeding, or inability to tolerate penetration at all.

Vestibulodynia can also lead to pelvic floor muscle overactivity which contributes to even more pain! Join the Sexual Medicine in Pelvic Rehab class on the weekend of  June 15th-16th to learn how to identify, treat, and differentially diagnose different causes of sexual dysfunctions to get your patients better faster!

Reference:

  1. Goldstein, A, Burrows L, and Goldstein I. Can oral contraceptives cause vestibulodynia? J Sex Med 2010; 7: 1585-1587

 

AUTHOR BIO

Tara Sullivan, PT, PRPC, WCS, IF

Sullivan 2021

Dr. Tara Sullivan, PT, PRPC, WCS, IF started in the healthcare field as a massage therapist practicing for over ten years, including three years of teaching massage and anatomy & physiology. During that time, she attended college at Oregon State University earning her Bachelor of Science degree in Exercise and Sport Science, and she continued to earn her Masters of Science in Human Movement and Doctorate in Physical Therapy from A.T. Still University. Dr. Tara has specialized in Pelvic Floor Dysfunction (PFD) treating bowel, bladder, sexual dysfunctions, and pelvic pain exclusively since 2012. She has earned her Pelvic Rehabilitation Practitioner Certification (PRPC) deeming her an expert in the field of pelvic rehabilitation, treating men, women, and children. Dr. Sullivan is also a board-certified clinical specialist in women’s health (WCS) through the APTA and a Fellow of the International Society for the Study of Women's Sexual Health (IF).

Dr. Tara established the pelvic health program at HonorHealth in Scottsdale and expanded the practice to 12 locations across the valley. She continues treating patients with her hands-on individualized approach, taking the time to listen and educate them, empowering them to return to a healthy and improved quality of life. Dr. Tara has developed and taught several pelvic health courses and lectures at local universities in Arizona including Northern Arizona University, Franklin Pierce University, and Midwestern University. In 2019, she joined the faculty team at Herman and Wallace teaching continuing education courses for rehab therapists and other health care providers interested in the pelvic health specialty, including a course she authored-Sexual Medicine in Pelvic Rehab, and co-author of Pain Science for the Chronic Pelvic Pain Population. Dr. Tara is very passionate about creating awareness of Pelvic Floor Dysfunction and launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

In March 2024, Dr. Tara left HonorHealth and founded her company Mind to Body Healing (M2B) to continue spreading awareness on pelvic health, mentor other healthcare providers, and incorporate sexual counseling into her pelvic floor physical therapy practice. She has partnered with Co-Owner, Dr. Kylee Austin, PT.

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Calling All Course Hosts!

NL HOST CTA 5.4.24

We are preparing for a busy second half of the year, and are seeking hosts for our satellite and in-person course offerings. If you'd like to cut down on travel and earn a free course registration, consider hosting a course with us this year! Satellites require a minimum space for 16 attendees, and in-person courses need to be able to accommodate 30+.

We always want to hear from those interested in hosting our courses. We work with healthcare organizations of all types, sizes, and locations. Please, Contact us about hosting Pelvic Function Level 1 or any other course!

There are two formats of course which you can host, and they are described below. 

Satellite Lab Courses (such as those in the Pelvic Function Series)
This is when the instructor presents lectures remotely via Zoom to several satellites at once for a scheduled course date while on-site teaching assistants guide participants at each given location with questions and labs.

Satellite lab events can be great for clinics that have space for 16+ participants, and the following equipment:

  • One lab table for every two participants (minimum eight)
  • One chair for each participant to use during the lectures
  • Either an LCD projector and projection screen OR a large television (minimum of 52" screen)
  • Laptop with Zoom downloaded and up-to-date, and any necessary cables to connect the laptop to the projector/TV
  • Speakers that are loud enough for the full room to clearly hear the instructor. We DO NOT recommend Bluetooth speakers.

In-Person Courses (such as Modalities and Pelvic Function)
At in-person courses, registrants, teaching assistants, and instructors gather at a single location for lectures and labs. In-person hosts who are located in densely populated areas are prioritized and who have a demonstrated history of successfully hosting courses.

In-person courses can be great for clinics that have space for 30+ participants, including one instructor and 2-3 teaching assistants, and the following equipment:

  • One lab table for every two participants (minimum eight)
  • One chair for each participant to use during the lectures
  • A lapel microphone for the instructor to use during lecture
  • Speakers that are loud enough for the full room to clearly hear the instructor. We DO NOT recommend Bluetooth speakers.

Remote Courses
Remote courses take place entirely on Zoom and do not gather in lab groups. However, if there is enough interest in taking a course, it is possible to host one of these courses as an in-person course.

 

Find out more and submit your hosting interest form today at https://www.hermanwallace.com/host-a-course.

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