Rebuilding the Urge: Where to Start
Restoring bowel urgency is one of the most important portions of a bowel retraining program. When a patient no longer has a normal bowel movement urge due to prior postponing, the slowness of their system, chronic use of enemas, or idiopathic causation, helping the patient retore the natural bowel movement urge may be the immediate focus of the treatment.

Restoring defecatory urge is one of the first steps in the treatment process. Reviewing and understanding colon physiology and determining where the focus of treatment should start, especially in complex patients, is key. Synthesizing new treatment ideas and use of modalities to assist with colonic motility can be one of the first steps to help the patient improve their defecatory urge.

For complex cases, this can involve mapping out where motility is most compromised. Is it a problem of peristalsis? A nervous system misfire? Inflammation in the gut interfering with communication pathways? Or is it something else?

Here’s where innovative thinking and a comprehensive approach come into play.

Treatment Tools and Modalities to Restore Motility
There are many ways to support and enhance colonic motility and restore bowel urgency. These can include:

• Neuromuscular stimulation and biofeedback therapy: These help retrain the pelvic floor muscles and encourage a coordinated bowel response.
• Rectal balloon training: Assists in retraining muscle function and can also enhance patient confidence during bowel movements.
• Behavioral techniques and bowel habit training: Regular scheduling, posture optimization during defecation (hello, squatty potty!), and mindfulness around urges.
• Manual therapy and visceral mobilization: Often used by pelvic floor therapists to reduce adhesions or fascial restrictions.
• Abdominal massage and diaphragmatic breathing: Gentle but effective ways to stimulate internal movement and improve gut tone.

Gut Microbiota: The Missing Piece of the Puzzle
A healthy gut flora is essential to regular and urgent bowel movements. The microbiota helps regulate everything from stool consistency to inflammatory responses in the colon. A disrupted microbiome, such as one lacking microbial diversity or populated by too many pathogenic strains, can slow transit and dull natural urges.

Dietary diversity is key to nurturing a thriving gut ecosystem. Encouraging patients to consume the following foods can make a significant difference in restoring microbial balance and improving colon motility:

• Fiber-rich vegetables and fruits
• Fermented foods (like kefir, kimchi, sauerkraut)
• Resistant starches (like cooled potatoes or green bananas)
• Prebiotic foods (such as garlic, leeks, and onions)

Hormones and the Colon: An Overlooked Connection
Sex hormones, particularly estrogen and progesterone, have a notable impact on gut function. Many individuals report changes in bowel patterns during their menstrual cycle, and hormonal shifts during menopause or andropause can contribute to constipation or erratic bowel habits. Understanding this connection is essential when working with patients whose symptoms appear to cycle with their hormonal changes.

Hormonal imbalances or deficiencies may require a referral for endocrinological evaluation or functional medicine support, especially if gut symptoms persist despite other interventions.

What You'll Learn in the Bowel Pathology and Function Course
Bowel Pathology and Function is a remote course designed for healthcare providers looking to sharpen their skills and deepen their understanding of bowel function restoration. Through a mix of physiology review, clinical tools, and real-world strategies, participants will walk away with a clear plan for helping patients recover their natural urge to defecate.

This bowel course will help you identify where the focus of the patient’s treatment needs to be addressed. Getting to decide where their efforts should be focused and what part of the system seems to be slow or inefficient and helps the healthcare provider narrowing the treatment focus.

Session learning objectives include:

1. In-depth review of colon physiology – Understand the mechanics of motility, nervous system input, and the role of pressure gradients.
2. Use of supportive modalities – Learn how to employ tools like electrical stimulation, manual therapy, and breathwork to enhance gut movement.
3. Microbiota and diet strategies – Dive into microbial diversity and how to coach patients on food choices that support a healthy microbiome.
4. Sex steroids and gut health – Examine the influence of estrogen, progesterone, and testosterone on gut motility and bowel pattern changes.

Restoring bowel urgency isn’t just a digestive issue - it’s a quality-of-life issue. Whether you’re a clinician or a curious patient, understanding the full picture—from gut mechanics to hormones to microbes—can unlock powerful healing. And sometimes, it’s the “down and dirty” details that lead to the biggest breakthroughs. Join me June 7-8^th for Bowel Pathology and Function.

References:

Banibakhsh A, Sidhu D, Khan S, Haime H, Foster PA. Sex steroid metabolism and action in colon health and disease. J Steroid Biochem Mol Biol. 2023 Oct;233:106371. doi: 10.1016/j.jsbmb.2023.106371. Epub 2023 Jul 28. PMID: 37516405.

Barbara G, Barbaro MR, Marasco G, Cremon C. Chronic constipation: from pathophysiology to management. Minerva Gastroenterol (Torino). 2023 Jun;69(2):277-290. doi: 10.23736/S2724-5985.22.03335-6. Epub 2023 Feb 2. PMID: 36727654.

Seo M, Bae JH. [Nonpharmacologic Treatment of Chronic Constipation]. Korean J Gastroenterol. 2024 May 25;83(5):191-196. Korean. doi: 10.4166/kjg.2024.044. PMID: 38783620.

Scott SM, Simrén M, Farmer AD, Dinning PG, Carrington EV, Benninga MA, Burgell RE, Dimidi E, Fikree A, Ford AC, Fox M, Hoad CL, Knowles CH, Krogh K, Nugent K, Remes-Troche JM, Whelan K, Corsetti M. Chronic constipation in adults: Contemporary perspectives and clinical challenges. 1: Epidemiology, diagnosis, clinical associations, pathophysiology, and investigation. Neurogastroenterol Motil. 2021 Jun;33(6):e14050. doi: 10.1111/nmo.14050. Epub 2020 Dec 2. PMID: 33263938.

Yang C, Hong Q, Wu T, Fan Y, Shen X, Dong X. Association between Dietary Intake of Live Microbes and Chronic Constipation in Adults. J Nutr. 2024 Feb;154(2):526-534. doi: 10.1016/j.tjnut.2023.11.032. Epub 2023 Dec 9. PMID: 38072155.

AUTHOR BIO
Lila Bartkowski-Abbate, PT, DPT, MS, OCS, WCS, PRPC

Lila Abbate, PT, DPT, MS, OCS, WCS, PRPC (she/her) is the Director/Owner of New Dimensions Physical Therapy with locations Roslyn, Long Island, and the Noho Section of New York City. Dr. Abbate graduated from Touro College in Dix Hills, NY with a Bachelor’s of Science (BS) in Health Sciences and a Masters 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 has obtained the Certified Pelvic Rehabilitation Practitioner (PRPC) from Herman & Wallace Institute, 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 full-time faculty experience 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 Floor Series of Pelvic Floor 1, 2A and 2B and Pregnancy, Postpartum. 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.

As physical therapists who specialize in treating all genders and all conditions related to the niche practice of pelvic health, it has been a privilege for us to deliver whole-person care, emphasizing self-healing, nervous system regulation, and mind-body integration. We often see patients who are under high stress and anxiety, and even more so when they have no other options except surgical intervention.

One such case was a 71-year-old patient who came in with a rectal prolapse. She had experienced a 10 cm rectal prolapse post-defecation, and it had taken prolonged bed rest for half a day for spontaneous reduction to occur. This happened after every bowel movement. She was told there were no other options except surgery. She was afraid to undergo rectal surgery and was willing to try anything to avoid it. Over the course of the first visit, I also learned that she had a family member who was very ill, and she rated her stress and anxiety levels beyond 10/10.

Rectal prolapse is full thickness protrusion of the rectum through the anal canal. It can occur in both sexes, but is 6 times more likely in women. Overall, about 13% of women will undergo surgery for some form of pelvic prolapse at some point in their lives. The incidence of pelvic prolapse also increases with age, peaking in those over 70 years^1,2. Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, mucous rectal discharge, and fecal incontinence or constipation^2,3,4,5,6.

It is associated with lifestyle-limiting symptoms for the patient and frequently co-exists with other types of pelvic prolapse, making multidisciplinary management key, as it is primarily managed with surgical reconstruction². Multiple surgical approaches exist within the two broad categories of perineal and abdominal. Perineal approaches are considered less physiologically taxing but are associated with higher recurrence rates. Anterior mesh rectopexy appears to balance the best functional outcomes with the lowest risk of recurrence².

There is currently limited evidence to support non-surgical rehabilitation options for this condition. Complementary and Alternative Medicine (CAM) techniques, such as Acupressure, have shown promise in pelvic health, yet are largely underexplored in the context of rectal prolapse.

Given this patient’s high anxiety and impaired bowel function that required prolonged bed rest post-defecation, I decided to use a novel multimodal rehabilitation approach. This approach integrated Acupressure, pelvic floor muscle training (PFMT), manual therapy, breathing and mindfulness techniques, and postural and functional retraining. The goal was to address her symptoms, improve activity tolerance and function, and improve her quality of life.

Acupressure was introduced at the first visit. Over the course of 7 visits, this patient progressed through a gentle pelvic floor strengthening program and had a 90% improvement in her rectal prolapse symptoms. She was also trained to use pelvic floor Acupressure at the Governing Vessel 1 (GV 1) Acupoint to effectively and quickly reduce her rectal prolapse after every bowel movement.

The patient was also taught an Acupressure nervous system self-regulation program that consisted of Acupressure points to help her improve mind-body awareness & connection to down-regulate her nervous system. Several Acupoints, such as Conception Vessel 17 (CV17), Governing Vessel 24.5 (Yintang point), Heart 7, and Pericardium 6, were used to help her manage and control her stress and anxiety. These points were reviewed and reinforced at each session. Her functional gains included restored ability to perform ADLs without post-bowel movement limitations. She also demonstrated improved pelvic floor muscle coordination, increased standing and walking tolerance, and was very pleased that she was able to avoid surgery. Her anxiety levels significantly improved with the daily self-regulation practice, and she felt she now had physical control over her symptoms.

Acupressure is an evidence-based practice that is rooted in Acupuncture and Traditional Chinese Medicine. In Acupressure, we use gentle finger pressure instead of needles to stimulate specific points on the body known as Acupuncture points. These energy points are known to have high electrical conductivity at the surface of the skin and are embedded within the body’s vast fascial network. Because of this, they offer a unique gateway to access and influence the nervous system.

As a Holistic pelvic health practice, Acupressure can be used to:

1. Reduce Pelvic Pain
   Potent acupoints on the abdomen, pubic bone and sacrum can help to relax pelvic floor muscles, ease menstrual cramps and pelvic pain. The Bladder meridian points along the sacral spine (B27–B34) — are for back pain, pelvic tension, and reproductive organ support.
2. Enhance Blood Flow & Energy (Qi)
   Certain acupoints stimulate blood and lymph circulation in the pelvic region, supporting physiological functioning of various sexual and reproductive organs. The Kidney 1 point, located on the sole of the foot — is for grounding, calming, and helps with anxiety and stress stored in the pelvic bowl.
3. Regulate Menstrual & Reproductive Health
   Acupressure can help regulate cycles, reduce PMS symptoms, and support fertility by harmonizing hormonal pathways. The Spleen 6 – Sanyinjiao point, which is located on the inner leg, above the ankle — regulates menstrual cycles, supports fertility, and soothes menstrual cramps.
4. Promote Nervous System Regulation
   Acupressure engages the parasympathetic nervous system and can help to calm the body, improve sleep, and promote relaxation. The pelvis is often a storehouse for unprocessed emotions, especially trauma. Acupressure combined with breathwork or somatic practices can help with these symptoms.
5. Support Bladder & Bowel Function
   Pressing on meridian points associated with the bladder, kidneys, spleen, or large intestine can aid with incontinence, constipation, and other bowel & bladder symptoms. Acupressure can also help with symptoms of Rectal Prolapse as noted in this patient case.

This patient case explores a multimodal rehabilitation program integrating Acupressure with traditional pelvic floor therapy, which may serve as an effective non-surgical intervention for rectal prolapse. Improvements in symptom control, functional mobility, and self-management highlight the potential of Acupressure as a conservative approach for prolapse care.

I am so humbled to share that this patient’s Case study has been accepted at the International Urogynecological Association (IUGA) & European Urogynecological Association (EUGA) joint meeting that is being held in Barcelona, Spain in June this year. This is a great step forward to explore holistic options in pelvic health, and I am grateful to be part of this patient’s journey to wellness.

To learn more about Acupressure, please join the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for June 7- 8^th. The course will introduce participants to the basics of Traditional Chinese Medicine (TCM), Acupuncture & Acupressure. The course introduces the 12 major Meridians or energy channels, focusing on the Bladder, Kidney, Stomach, and Spleen meridians. The course is packed with key potent points that can help to self-regulate the nervous system and help with anxiety, insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, urinary dysfunctions, digestive disturbances, cancer pain, and much more. The course also offers an introduction to Yin yoga and explores Yin poses within each meridian channel that can be integrated with Acupressure and mindfulness practices.

References

1. Bordeianou L, Hicks CW, Kaiser AM, Alavi K, Sudan R, Wise PE. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies.J Gastrointest Surg. 2014;18(5):1059-1069. doi:10.1007/s11605-013-2427-7
2. Romero-Morales C, Bravo-Aguilar M, Abuín-Porras V, et al. Current advances and novel research on minimal invasive techniques for musculoskeletal disorders. Dis Mon. 2021;67(10):101210. doi:10.1016/j.disamonth.2021.101210
3. Yang J, Do A, Mallory MJ, Wahner-Roedler DL, Chon TY, Bauer BA. Acupressure: An Effective and Feasible Alternative Treatment for Anxiety During the COVID-19 Pandemic.& Glob Adv Health Med. 2021;10:21649561211058076. Published 2021 Dec 12. doi:10.1177/21649561211058076
4. Wen J, Chen X, Yang Y, et al. Acupuncture Medical Therapy and Its Underlying Mechanisms: A Systematic Review. Am J Chin Med. 2021;49(1):1-23. doi:10.1142/S0192415X21500014
5. Zhou YF, Zhang GL, Sun N, et al. Acupuncture for emotional disorders in patients with inflammatory bowel disease: a systematic review protocol. BMJ Open. 2022;12(9):e058568. Published 2022 Sep 27. doi:10.1136/bmjopen-2021-058568
6. Gallo G, Martellucci J, Pellino G, et al. Consensus Statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of complete rectal prolapse. Tech Coloproctol. 2018;22(12):919-931. doi:10.1007/s10151-018-1908-9

AUTHOR BIO
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University, New York with a Doctor of Physical Therapy degree. Rachna has since been working in outpatient hospital and private practice settings with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer county in New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. Her clinical practice has focused on an Integrative physical therapy approach blending traditional physical therapy methods with holistic practices that address the whole person - physically, mentally, emotionally, and spiritually. She specializes in working with pelvic health patients who have bowel & bladder issues with high pelvic pain which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional, and energy body.

Five years ago, the COVID-19 pandemic devastated the world on a scale not seen in nearly a century. Hospital systems became overwhelmed as the number of patients requiring hospitalization and mechanical ventilation surged. In the years since, the Centers for Disease Control and Prevention (CDC) has defined terms such as "Long COVID" and "Post-COVID Condition" to describe individuals who continue to experience symptoms well after recovering from the acute phase of the virus. As it relates to our work, a key question emerges: What are the short- and long-term effects of COVID-19 on the diaphragm?

A study by Spiesshoefer et al. (1) examined patients hospitalized with COVID-19 and assessed them approximately two years after discharge. They found that persistent diaphragm muscle weakness and exertional dyspnea remained prevalent. In their study, participants were divided into two groups—one group received six weeks of inspiratory muscle training (IMT), while the control group received a sham intervention. The IMT group demonstrated statistically significant improvements in exertional dyspnea and diaphragm function, although there was no notable change in diaphragm thickness. Importantly, these improvements persisted after the six-week intervention concluded.

Similarly, Ahmad et al. (2) compared diaphragm release techniques with conventional breathing exercises in female patients recovering from COVID-19. After just nine sessions over a three-week period, the diaphragm release group showed greater improvements in chest wall expansion, oxygen saturation, and performance on the six-minute walk test compared to the breathing exercise group.

Together, these studies highlight the importance of incorporating both breathing exercises and manual therapy techniques to optimize breathing mechanics, support chest wall mobility, enhance oxygen saturation, and reduce exertional dyspnea during walking and other functional activities.

In the Breathing and the Diaphragm course taught by Aparna Rajagopal and Leeann Taptich, a systematic and holistic approach to evaluation and treatment will be discussed, covering not only recovery from COVID-19 but also pelvic floor dysfunction, gastrointestinal disorders, and chronic low back pain. To deepen your understanding of the diaphragm’s crucial role in health and rehabilitation, register for the May 31, 2025 course through Herman & Wallace.

References:

1. Spiesshoefer J, Regmi B, Senol M, Jorn B, Gorol O, Elfetur M, Walterspacher S, Giannoni A, Kahles F, Gloeckl R, Dreher M. Potential Diaphragm Muscle Weakness-related Dyspnea Persists 2 Years after COVID-19 and Could Be Improved by Inspiratory Muscle Training. Am J Respir Crit Care Med. 2024; 210(5): 618-628.
2. Ahmad AM, Nawar NM, Dabess HM, Gallab MA. Effect of diaphragm manual release versus conventional breathing exercises in prone positioning on physical functional performance in women with COVID-19: A randomized trial. Journal of Bodywork and Movement Therapies. 2023; 35: 311-319.

AUTHOR BIO
Leeann Taptich DPT, SCS, MTC, CSCS

Leeann Taptich, PT, DPT (she/her) has been a physical therapist since 2006. She graduated with a BS in Kinesiology from Michigan State University and a Doctorate of Physical Therapy from the University of St Augustine. In 2009, she earned her Manual Therapy from the University is St Augustine and her board certification as a Sports Certified Specialist in 2018.

Leeann leads the Sports Physical Therapy team at Henry Ford Macomb Hospital in Michigan, where she mentors a team of therapists. She also works very closely with the pelvic team at the hospital, which gives her a very unique perspective of the athlete. With her combination of credentials and her exposure to pelvic health,h she is able to use a very eclectic but complete approach in her treatment of orthopedic and sports patients. With the hospital system, she is involved with the community promoting health and wellness at local running competitions and events.

Leeann is passionate about educating and teaching and has assisted in teaching multiple courses at the local State a university PT department. She is co-chair of the continuing education committee at her hospital where she writes and develops courses. She is a co-author of the Breathing and Diaphragm class at Herman & Wallace.

Leeann lives in the metro Detroit area with her husband and 2 children. She enjoys hiking, traveling, and watching football.

Have you ever thought about how patients from diverse backgrounds face unique challenges at the intersection of their religious values—such as modesty and conservative views — and the need for pelvic and sexual health support?

Navigating this intersection of pelvic rehabilitation and religious belief systems requires a deep understanding of both the physical and emotional challenges patients may face. In many conservative religious communities, discussions around sexual health are limited, creating significant barriers to seeking care and addressing issues such as pelvic pain, sexual dysfunction, and reproductive concerns.

Let’s take a look at a past patient of mine as an example. Sarah’s case highlights the complexities that arise when religious upbringing, limited sexual education, and physical dysfunction intersect. Her story underscores the need for compassionate, culturally informed care that empowers patients to achieve their health goals while respecting their deeply held beliefs.

Case Study: Sarah
Sarah is a 23-year-old woman presenting for a pelvic health evaluation. When scheduling her appointment, she declined to disclose the specific reason for her visit.

During the patient interview, Sarah shares that she has been married for eight months and that all attempts at intercourse have been unbearably painful. She reports pain at a 14/10 intensity level and describes vocally crying out during any attempt at penetration. She expresses a deep sense of hopelessness, fearing that something is fundamentally wrong with her body, and worries that her vagina is “too small” for intercourse. Sarah admits she has never visually examined her vaginal area, stating it “grosses her out.”

Sarah is otherwise in good health but has never undergone a gynecological exam. Both she and her husband come from conservative religious backgrounds, attended religious schools with limited sex education, and received minimal information about sexual activity prior to marriage. Neither had been sexually active before their wedding. Sarah continues to adhere to her religious beliefs, including a practice that discourages conversations about sex with anyone other than her spouse. She voices a strong aversion to sexual activity, as well as to her husband’s genitalia and semen, and shares feelings of guilt over her inability to have intercourse and “make her husband happy.”

Although Sarah denies any discomfort while sitting or wearing tight-fitting clothing and reports no other general bodily pain, she has recently begun experiencing vulvar pain that precedes any attempt at intercourse. Following these attempts, she has difficulty falling asleep due to persistent pain.

Additional relevant history includes frequent urination (approximately every hour), which she attributes to having a "tiny bladder." Chronic constipation, with bowel movements occurring about once per week, often requiring significant straining (Bristol Stool Scale types 1–2). Regular menstrual cycles, though the first 2–3 days are marked by debilitating pain and the inability to successfully insert tampons.

Sarah’s personal treatment goals are to achieve pain-free intercourse and to become pregnant as soon as possible, aligning with the expectations of her close-knit, religious community.

Let’s think about our next steps with this patient.
What is your next move? Approach the patient with heightened sensitivity, cultural competence, and an awareness of how religious values can shape a patient’s experience of their body, pain, and sexuality. The next steps with Sarah should focus on creating a foundation of trust, safety, and consent while validating her experience and assuring her that treatment will proceed at her comfort level. The initial sessions could prioritize external assessment, observing breathing patterns, posture, and pelvic tension, without internal examination.

What other questions would you like to ask this patient? Gentle, respectful questioning would further clarify the nature of Sarah’s pain, emotional experiences surrounding intimacy, bladder and bowel habits, and her comfort level with educational discussions within her religious framework.

What would your treatment plan look like for this patient? Early treatment could center on pain education, diaphragmatic breathing, pelvic floor relaxation, and bladder and bowel retraining, with mirror therapy and gradual body awareness work being introduced when she is ready. The treatment plan would progress from external desensitization toward eventual internal work and dilator therapy, aimed at achieving pain-free intercourse and healthy pelvic floor function to support future pregnancy.

What other healthcare providers might you refer her to? In addition to pelvic therapy, referrals to a culturally sensitive pelvic health mental health professional, a trauma-informed gynecologist, and possibly a sex therapist and dietitian could be recommended. Throughout care, sensitivity to Sarah’s religious values, empowerment, and compassionate support would be critical to helping her meet her goals.

The Takeaway
As pelvic health providers, we choose this field because we are passionate about delivering the best possible care with sensitivity and compassion. Yet, it can feel overwhelming when we work with patients from religious or cultural backgrounds unfamiliar to us. In our efforts to be respectful, we may find ourselves hesitant to ask the crucial questions necessary for effective care.

I created a course to specifically tackle this sensitive issue; Sex and Religion is a short, one-day remote course held over Zoom that bridges the gap between the worlds of pelvic rehabilitation and religion. This course provides guidance and skills for engaging patients from religiously conservative backgrounds in a culturally sensitive manner. Participants will gain a foundational understanding of the various traditions, customs, laws, and values associated with Muslim, Jewish, Hindu, and Christian faiths as they pertain to sexuality and pelvic health.

Anyone who treats pelvic health concerns can take this course to fill their toolbox with new tools and strategies to enhance their practice. Join Rivki in her upcoming course, Sex and Religion, on May 18^th to ensure that every patient receives the thoughtful, respectful care they deserve.

AUTHOR BIO
Rivki Chudnoff, MSPT

Rivki is a Midwesterner at heart, born and raised in Chicago. At her private practice, Hamakom Physical Therapy, in Bogota, NJ. She focuses on women’s health and pelvic health rehabilitation for women and children. Rivki graduated from Stern College with a BA in Biology and from the University of Medicine and Dentistry of New Jersey (Rutgers) in 1999 with a Master of Science in Physical Therapy. Rivki started her physical therapy career in pediatrics working with children with severe disabilities.

In her practice, Rivki is privileged to work with women at different stages of life. Rivki uses a biopsychosocial approach to guide her patients through the many challenges that they encounter along their journey to healing. Rivki has written extensively on women’s health issues and has presented on pelvic health internationally to sex educators, at community events, and at marriage retreats. In her free time, she enjoys vacationing at Trader Joe’s, burning dinner, and trying to figure out new ways to embarrass her children with her professional life.

When we think of pelvic floor dysfunction, our minds often go straight to adults. We may even consider toddlers or children struggling with conditions like constipation or bedwetting. A population I frequently find missed is the infant! Many providers don’t realize that the pelvic floor issues that show up in infancy don’t have to be waited out.

As pediatric pelvic health providers, we have a unique and powerful role to play in helping babies who struggle with common challenges like reflux, colic, constipation, feeding difficulties, and even motor delays. At the root of many of these concerns lies the pelvic floor—an area often overlooked in traditional pediatric care. These parents will go to their providers, and they’ll be offered advice like “hold them upright for 20 minutes after feeding” or “try a lactation consultation,” but what happens if these interventions are not enough, OR what happens if a rehab provider wants to provide more support to a struggling family.

You may be thinking, “I don’t do pediatrics.” If that is your stance, I recommend you keep reading. You don’t have to be a dedicated pediatric therapist to provide families struggling with cranky or uncomfortable babies. Even if you don’t want to provide specific recommendations and treatment, you can still screen and offer referrals for support and even this step will create improvement in the quality of life of your families.

Understanding the Infant Pelvic Floor: More Than Just Diaper Changes
The abdominal canister in infants is still developing and is deeply interconnected with multiple systems in the body:

• The digestive system (contributing to reflux, gas, and constipation)
• The nervous system (especially for babies with difficulty calming or regulating)
• The musculoskeletal system (torticollis, body tension, abnormal movement patterns)
• The oral-motor system (especially in cases of tethered oral tissues or poor latch)

When these systems are under stress or not functioning in sync, the baby will likely be showing difficulty in performing regular functions, causing them to be uncomfortable. All babies express their discomfort differently, but this can lead to stressful symptoms such as crying, fussing, gassiness, constipation, reflux, and vomiting, leading to abnormal posturing and gross motor delays due to these adverse symptoms.

What Infant Pelvic Floor Dysfunction Looks Like
Pelvic floor issues in babies don’t always look like they do in adults. Instead, rehab providers may notice:

• Chronic straining to poop or lack of bowel movement coordination
• Irregular bowel habits, bloating, and gas
• Body tension that affects feeding or limits comfortable tummy time
• Shallow or inefficient breathing patterns
• Arching or clenching behaviors in response to gas or discomfort
• Difficulty tolerating changes in position or touch

These signs are often dismissed as “just colic” or “something they’ll grow out of,” but we know that targeted therapy can make a significant difference—not just in comfort, but in functional development.

The Role of Rehab Providers: PTs and OTs Working Together
Both physical therapists and occupational therapists play essential roles in assessing and treating infant pelvic floor dysfunction.

Physical therapists focus on:

• Core and pelvic floor coordination
• Alignment and tension patterns affecting bowel/bladder mechanics
• Breathing mechanics and diaphragm coordination
• Tummy time, head shape, and early motor development

Occupational therapists bring expertise in:

• Feeding and oral-motor function
• Sensory integration, especially around elimination and body awareness
• Nervous system regulation and co-regulation strategies for parents
• Positioning to support optimal arousal and digestion

Together, this integrative approach addresses the whole baby, not just their symptoms.

Why This Matters: Long-Term Impacts Start Early
We’re not just aiming to reduce fussiness or help with pooping (although that’s often where we start!). We’re helping to lay the foundation for:

• Healthy bowel and bladder habits
• Confident motor skill development
• Positive body awareness and sensory processing
• Easier transitions to solids and potty training down the road

Early therapy can prevent compensatory patterns and teach families tools that make everyday care easier and more connected.

A Tool for Your Toolbox: Pediatric Pelvic Floor Play Skills
To help bridge the gap between pelvic health and pediatric development, we offer a class called Pediatric Pelvic Floor Play Skills. It’s designed for rehab professionals to learn specific play skills and actionable treatment techniques for each age group of the pediatric client, from the infant to the teen/tween.

For each age category we cover:

• Age-specific considerations, tips, and tricks
• Play-based strategies to support pelvic floor coordination for each age
• How to support pelvic health treatment
• Case studies and hands-on tools for both PTs and OTs
• Problem solving for more difficult cases and situations

If you're looking to expand your skill set, collaborate across disciplines, or just get more confident in treating your littlest patients - this class is for you. Join me next weekend on May 4th!

AUTHOR BIO
Mora Pluchino, PT, DPT, PRPC

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

Dr. Pluchino strives to help all of her 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 present. In 2020, she opened her own practice called Practically Perfect Physical Therapy to help meet the needs of more clients. She has been a guest lecturer for Rutgers University's Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

Sometimes as rehab providers, we find patients have deep posterior pain, or they have a “hitting something” sensation with intimacy. Maybe they have a deep pelvic ache or nerve sensation with sitting or passing bowels.

We know the deep structures all have the word “coccygeus” in them:  iliococcygeus, pubococcygeus, and coccygeus. We also know there are ligaments that attach to this coccyx (sacrospinous ligament and sacrotuberous ligament), creating a web of support in the posterior pelvis, which has very little bony structure. When we are treating someone with deep vaginal or deep posterior pelvic pain, do we really have to “go there” and treat the coccyx internally?

Did you know that actual spinal cord fibers enter the top of the sacral foramen, travel through this tunnel in the sacrum, and come out the bottom, where they fuse with the posterior coccygeal ligament on the dorsal surface of the coccyx? They can be a tremendous source of neural and pain dysfunction in the pelvis.

In addition, the gluteus maximus attaches at the coccyx, as well as attachments from a deep bowl of fascia, called the endopelvic fascia, that lines the pelvis. The endopelvic fascia is a tremendous source of support in the pelvis but is also often a pain generator. On top of this, the massive sacrotuberous and sacrospinous ligaments also attach at the sacrococcygeal junction.

In Sacral Nerve Manual Assessment and Treatment, scheduled for May 31 through June 1, we spend time addressing how to externally treat the deep structures that attach at the posterior pelvic floor and coccyx. We address ways to treat the incredibly dense sacrotuberous and sacrospinous ligaments that attach to the coccyx from the outside. All of the nerves that supply the posterior hip, glutes, and pelvic floor squeeze between the piriformis and the sacrospinous ligament. This site where these nerves, including the pudendal, sciatic, inferior gluteal, nerve to obturator internus, and posterior femoral cutaneous, can also be a common site of dysfunction and compression. We will learn how to decompress all of this in class, as well as the surrounding soft tissues.

So, coming back to our question. With all this soft tissue and ligament work that can be external, can we forego internal rectal work? Actually….no. Both are important. The best way to treat a side-bent coccyx or an excessively flexed coccyx is internally. However, the real magic is addressing the alignment interiorly and then addressing all the softer tissues (ligaments, fascia, skin, muscle) that keep pulling the bone back into its old bad habits and misalignment.

AUTHOR BIO:
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment and Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jenna Ross, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jenna Ross. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel

Have you ever gambled with what you thought was gas, only to find out that it was not? When my son was little, he asked me one day, “Mom did you ever try to fart, but it wasn’t really a fart?” At the time, I told him it was called a “shart.” Of course, being a little boy, he thought that was funny. However, being an adult and thinking you are passing gas, and it not be only gas can be mortifying. Think about how that could affect your quality of life and ability to go out in public. If you can’t trust your anal sphincters and anal canal to not know what you are letting go, it can be stressful!

What can lead to confusion and issues with sensation in this area? There are many different reasons that this area may not function ideally and be able to identify what is within the anal canal. These reasons can range from surgery in the area, radiation therapy, more minor procedures such as hemorrhoid treatment, and even chronically ignoring the urge to defecate. When sensation changes, the function of the sampling response and rectoanal inhibitory reflex (RAIR) or sampling response is changed.

The sampling response is when a small amount of fecal matter accumulates in the rectum, and a stretch occurs in the area. This then triggers a relaxation of the internal anal sphincter, and a contraction of the external anal sphincter that allows a small amount of the fecal matter to drop down into the anal canal. The contents of fecal matter are sampled, and it is determined if it is solid, liquid, or gas. If it is gas, then we can select to expel it; if it is liquid we usually respond with a stronger contraction of the external anal sphincter to hold it in. If it is solid, we can determine whether or not it is a good time to go. If it is, then we head to the restroom; if it is not, we engage the rectoanal inhibitory reflex and hold the stool until we decide there is a better time. You can see, if this sampling and identifying of the contents is off and not functioning properly, then we can have some issues arise and situations with “sharts” that would not be ideal!

We as pelvic rehab clinicians are the perfect people to help people when their sensation is not optimal, and they may have some issues with fecal and flatulence incontinence. Using rectal balloon catheters has been a game changer in my practice when working with these patients that have issues with sensation in their anal canal. The balloon retraining helps with retraining sensation in this area. I use it along with strengthening the pelvic floor and external anal sphincter; along with any manual therapy that may be needed, and defecation training. The addition of the balloons allows me to address sensation. The use of adding or removing small amounts of air in an inflated balloon allows the patient to learn what changes in sensation in the area feel like, which improves sensation and awareness of the contents within the anal canal. If you think about it, there isn’t another way to treat sensation inside of the anal canal. If we can retrain sensation, then we can make it less likely for a patient to think they are safe with expelling gas but be surprised when more comes out!

Join me for the May 17^th course offering of Anorectal Balloon Catheters- Intro and Practical Applications. In this short course, you will learn how to use balloon catheters and even practice a lab using balloons. The purchase of a balloon is needed before the course so that you can participate in the labs. This course can change how you treat your patients who may suffer from fecal incontinence and constipation.

AUTHOR BIO
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC (she/her) has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health, including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion for helping oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman and Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies and physicians.

Outside of work, Allison enjoys spending time with her family, caring for her animals, reading, traveling, and most importantly of all, being a mom! She lives in the Denver metro area with her family.

So often, we think of vulvodynia as a condition of the skin. And it is….kind of. Vulvodynia is a long-term pain (or burning, discomfort, or itching) that is present in the outer genitals, also known as the vulva. This condition is defined as a discomfort that has lasted longer than 3 months. The symptoms of vulvodynia can vary. In some patients, it is provoked (brought on by touch or stimulation), and in some cases, it is unprovoked (present without stimulation). Some patients have pain just in the outer vulva, while others also present with pelvic floor muscle tension or urethra, bladder, or vaginal canal irritation.

The definition of vulvodynia itself states there is no known reason. This means it is not because of a skin disruption, hormonal disorder, herpes or other skin conditions, or active infection, such as yeast. This means we really don’t know just why a person has symptoms once they have been medically ruled out.

When we look at the symptoms of neuralgia (an irritated or overly talkative nerve), we find symptoms listed such as pain, hypersensitivity, burning, tingling, itching, or trigger points. Certainly, there is a lot of overlap between neuralgia symptoms and vulvodynia symptoms.

When there is compression of a nerve, it can create neuralgia of the affected dermatome. In fact, in studies, we find neural proliferation of the peripheral nerve with vulvodynia in cell biopsy in women or in animal models (1, 2). Often, neural compression is part of the problem, and this is why we see treatment models proving effective at times with nerve blocks or nerve decompression (3, 4).

Of course, when treating such patients, we can and should still employ proven topical agents to make the treatments comfortable and effective, such as lidocaine solutions (5). Vulvodynia is best treated and managed as a team, with manual therapy and patient education from pelvic health providers being a very important limb of treatment.

By treating fascial tunnels that nerves run through, treating the fascia around the clitoris, and treating the deep fascia and tissues of the labia majora and mons, we can have an effect on the pudendal nerve branches, as well as the genitofemoral and ilioinguinal nerves supplying this region. In Lumbar Nerve Manual Assessment and Treatment scheduled for May 17-18, and Sacral Nerve Manual Assessment and Treatment scheduled for May 31-June 1, both heavy manual therapy classes, we learn to decompress the neurovascular bundle from proximal to distal and to treat distal soft tissue structures that may be compressing nerves.

Resources:

1. Goetsch MF, Morgan TK, Korcheva VB, Li H, Peters D, Leclair CM. Histologic and receptor analysis of primary and secondary vestibulodynia and controls: a prospective study. Am J Obstet Gynecol. 2010;202:614.e1–614.e8. doi: 10.1016/j.ajog.2010.01.028.
2. Bornstein J. Vulvar disease. Cham: Springer International Publishing; 2019. Vulvar pain and vulvodynia; pp. 343–367.
3. Vulvodynia treatments, National Vulvodynia Association (nva.org)
4. Possover M, Forman A. Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression. Pain Physician. 2015 Nov;18(6):E1139-43. PMID: 26606029.
5. Loflin BJ, Westmoreland K, Williams NT. Vulvodynia: A Review of the Literature. J Pharm Technol. 2019 Feb;35(1):11-24. doi: 10.1177/8755122518793256. Epub 2018 Aug 20. PMID: 34861006; PMCID: PMC6313270.

AUTHOR BIO:
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment and Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jenna Ross, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jenna Ross. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel successful. She also is an advocate for therapists learning how to feel well and thrive as they care for others, which is a skill that can be developed. “Basically, I love helping therapists learn to help themselves and others more while having a lot of fun doing it.” Nari lives in Portland Oregon, where she runs a local study/mentoring group and has a private practice, Portland Pelvic Therapy. Her interests include meditation, working out, nature, and being constantly humbled from raising her three amazing teenagers!

Let me share one of my past patients with you.

Several years and many Herman & Wallace courses later, I started treating patients with dyspareunia and pelvic pain in my private practice. My patients’ expressions of anxiety with the unwrapping, of fear of pain with anticipation of touch seemed familiar, I remembered Joe. The body parts may be different, but the nervous system is one and the same.

While Joe’s injury and source of pain and sensitivity was obvious even to the layperson, our patients with dyspareunia and pelvic pain are suffering with pain whose source is often invisible even to the most trained clinical eye.

Yet, the treatment principles are similar. Every day, we help patients feel safe in their own bodies by providing both gentle treatment and teaching self-treatment techniques that empower patients to help heal themselves. Dilator training can be viewed in this lens as a master class in desensitization and sensory integration of the vagina. We are teaching the pelvic floor muscles and surrounding tissue to gradually accommodate to the increased size of the dilator being inserted without setting off a five-alarm fire and cascade of painful responses in the nervous system.

We load our treatment toolboxes with deep breathing, relaxation techniques, and biofeedback to help rewire and re-educate the body's responses to stimuli.

This treatment is often compounded when patients come from religiously conservative backgrounds and are raised with restrictive sexual values. This places them at a higher risk of experiencing dyspareunia and painful intercourse. In addition to their pain, they may also be struggling with sexual shame and lack of sexual education, creating a greater barrier to treatment and care. Gaining patients' trust and “buy in” may require a higher level of cultural competence and religious sensitivity than other less emotionally charged specialties.

So, let’s talk about it in my upcoming course, Sex and Religion: Treating Conservative Religious Patients with Cultural Sensitivity, on May 18th. I created this course to help both seasoned and newer therapists open their skill sets to reach more diverse patient populations. In this course, I delve into these topics and explore challenges that face patients who come from conservative religious communities as they interface with the wild world of pelvic health. You leave my course with practical skills for patient interviewing, treatment strategies, and creating a safe and comfortable space for both patients and providers.

Resources:

1. Patanwala I, Lamvu G, Mizera M, Fisk M, Blanton E. Learning restrictive sexual values may be associated with dyspareunia. Journal of Endometriosis and Pelvic Pain Disorders. 2020;12(2):61-68. doi:1177/2284026519900108.
2. Schermer Sellers, T. (2017). Sex, God, and the Conservative Church: Erasing Shame from Sexual Intimacy (1st ed.). Routledge. https://doi.org/10.4324/9781315560946.

AUTHOR BIO
Rivki Chudnoff, MSPT

Rivki Chudnoff, MSPT (she/her) is a Midwesterner at heart, born and raised in Chicago. At her private practice, Hamakom Physical Therapy, in Bogota, NJ, she focuses on women’s health and pelvic health rehabilitation for women and children. Rivki graduated from Stern College with a BA in Biology and from the University of Medicine and Dentistry of New Jersey (Rutgers) in 1999 with a Masters of Science in Physical Therapy. Rivki started her physical therapy career in pediatrics, working with children with severe disabilities.

In her practice, Rivki is privileged to work with women at different stages of life. Rivki uses a biopsychosocial approach to guide her patients through the many challenges that they encounter along their journey to healing. Rivki has written extensively on women’s health issues and has presented on pelvic health internationally to sex educators, at community events, and at marriage retreats. In her free time, she enjoys vacationing at Trader Joe’s, burning dinner, and trying to figure out new ways to embarrass her children with her professional life.

As a small business owner, I’m grateful to have weathered the COVID-19 storm. When reflecting on the 5 year anniversary of the shutdown, I remember how we adapted day after day — masking up, running air filtration systems, and feeling grateful that we could continue to do our work safely. Yet, despite prioritizing sleep, nourishing my body with fresh food, staying active, and hydrating well, I sometimes still feel myself carrying a lingering undercurrent of stress and tension in my physical body.

We have spent years holding our breath—both literally and figuratively. The weight of collective uncertainty, change, and grief may have left some imprints on our bodies. I was reminded of this when a sudden flare of lumbopelvic pain forced me to pay closer attention to my own breath patterns. It became clear that I needed to soften, to release layer by layer of held tension, and to deepen my own breathwork and meditation practice.

As healthcare providers, our work extends beyond addressing physical concerns. We are honored to hold space for our patients' grief—whether it stems from physical trauma, medical challenges, gaslighting, or life's hardships.

They trust us, not just for guidance on optimizing their pelvic health, but as guides on their healing journeys. And yet, we too are human. We experience burnout, fatigue, and emotional strain.

We often teach our patients that breath is a bridge—connecting the nervous system, digestion, spine, pelvic floor, and our emotional state. It is one of the most powerful tools we have to remind the body that it is safe. And yet, even with this knowledge, we may find ourselves unconsciously holding our breath because we are humans living in this unpredictable and sometimes challenging world. When we resist feeling something, we don’t breathe. When we are afraid, we hold tension in our ribs. Even in moments when we think we are relaxed, we can sometimes still be bracing our jaw, back, or pelvic floor.

Let’s take a moment to pause.

Notice your body. Try not to make any adjustments to “fix” your posture.

• Where is your ribcage in relation to your pelvic floor?
• Does the breath feel deep or shallow, smooth, or restricted?
• Where do you sense movement—your chest, ribs, belly?
• What temperature is the air as it enters your nose?

What does it feel like to exhale?

• Does your breath release with ease or feel held back?
• Can you soften just a little more with each out-breath?
• Notice if there is a natural pause before your next inhale—what does that moment of stillness feel like?

If you're sitting, allow yourself to slouch for a moment.

• How does your breath feel in this position?
• Is it shallow or restricted?
• Now, gently imagine your head and spine being drawn upward, as if a magnet is lifting you toward the ceiling. Take another breath. Does it feel different? Notice any shifts in ease of expansion or softening more fully after the exhale.

Now, let’s zoom into the intercostal spaces.

• Imagine this space expanding with each inhale and softening with each exhale.
• Can you soften any more in your ribcage?
• Picture your shoulders softening, warm water is dripping down the upper trap and down the arms.
• Let your jaw unclench, your tongue relax, the space between your eyebrows melt.

Take another long, conscious breath.

• What do you notice?
• Does your body feel a little softer, a little more open, or is there still a place holding tension, waiting for a little more attention?

As practitioners, we give so much to others all day long and sometimes forget to remember to check in with ourselves. Staying connected to our own breath and body serves us just as much as it serves our patients. When we remain grounded and at ease, we can reduce fatigue, physical discomfort, and emotional exhaustion.

So, let’s remind ourselves—throughout the day—to take long easy breaths, soften our jaws, and allow our bodies to move with greater ease. It is not only a gift to ourselves to prevent burn out, but also helps us facilitate co-regulation with our patients’ nervous systems.

If you enjoyed this article, then join Dustienne in her upcoming remote course Yoga for Pelvic Health, on May 3-4, 2025. This two-day remote course offers participants an evidence-based perspective on the value of yoga for patients with chronic pelvic pain and focuses on two of the eight limbs of Patanjali’s eight-fold path: pranayama (breathing) and asana (postures) and how they can be applied for patients who have hip, back and pelvic pain. The course will describe the role of yoga within the medical model, discuss contraindicated postures, and explain how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge.

AUTHOR BIO
Dustienne Miller PT, MS, WCS, CYT

Dustienne Miller PT, MS, WCS, CYT (she/her) is the creator of the two-day course Yoga for Pelvic Pain and an instructor for Pelvic Function Level 1. Born out of an interest in creating yoga home programs for her patients, she developed a pelvic health yoga video series called Your Pace Yoga in 2012. She is a contributing author in two books about the integration of pelvic health and yoga, Yoga Mama: The Practitioner’s Guide to Prenatal Yoga (Shambhala Publications, 2016) and Healing in Urology (World Scientific). Prior conference and workshop engagements include APTA's CSM, International Pelvic Pain Society, Woman on Fire, Wound Ostomy and Continence Society, and the American Academy of Physical Medicine and Rehabilitation Annual Assembly.

Her clinical practice, Flourish Physical Therapy, is located in Boston's Back Bay. She is a board-certified women's health clinical specialist recognized by the American Board of Physical Therapy Specialties. Dustienne weaves yoga, mindfulness, and breathwork into her clinical practice, having received her yoga teacher certification through the Kripalu Center for Yoga and Health in 2005.

Dustienne's love of movement carried over into her physical therapy and yoga practice, stemming from her previous career as a professional dancer. She danced professionally in New York City for several years, most notably with the national tour of Fosse. She bridged her dance and physical therapy backgrounds working for Physioarts, who contracted her to work backstage at various Broadway shows and for the Radio City Christmas Spectacular. She is currently an assistant professor of jazz dance at Boston Conservatory at Berklee.

Dustienne passionately believes in the integration of physical therapy and yoga within a holistic model of care. Her course aims to provide therapists and patients with an additional resource centered on supporting the nervous system and enhancing patient self-efficacy.