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Yoga as Medicine for Postpartum Care: A Compelling Art & Science

Yoga offers a compelling mind-body approach to maternal care that is forward thinking and aligns with the World Health Organization and Institute of Medicine’s recommendations for patient-centered care. But let’s take a look at WHY postpartum care MUST change in order to establish need for the entry of yoga into postpartum care.
 
Maternal Health Track Record
 
The United States and similarly developed countries have a very poor track record for postpartum care. The record is so poor that the problem in the US has been labeled a “human rights failure.”1
 
On its own, the US has the worst track record for not only postpartum care, but for maternal and infant mortality and first-day infant death rate in the developed world (Save the Children 2013). Between 1999-2008, global mortality rates decreased by 34% while the US’s rates doubled for mothers.1
 
Patient satisfaction also suffers under the current model of care, with many more mothers experiencing postpartum depression, a significant risk factor for both mother and baby during and after pregnancy.
 
The increase in mortality and poor outcomes can, in part, be attributed not to underuse, but overuse of medical intervention during pregnancy and birth. 2,3,4  Countries that have “access to woman-centered care have fewer deaths and lower health care costs”; and, hospital system reviews in the US show that reducing medical interventions are both reducing cost and improving outcomes.1,4,5
 
The notorious lack of accountability (reporting system) in maternal health care also plagues the US and suggests that maternal deaths are even higher than currently reported, leading to Coeytaux’s conclusion that the “United States is backsliding.”1
 
Improving Postpartum Outcomes with Integrated Physical Therapy Care
 
In After the Baby’s Birth, maternal health advocate Robin Lim writes, 
"All too often, the only postpartum care an American woman can count on is one fifteen minute appointment with her doctor, six weeks after she has given birth. This six-week marker ends an arbitrary period within which she is supposed to have worked out most postpartum questions for herself. This neglect of postpartum women is not just poor healthcare, it is abusive, particularly to women suffering from painful physical and/or psychological disorders following childbirth."
 
Physical therapists can be instrumental change agents in improving current postpartum care, especially through the integration of contemplative sciences like yoga. Yoga can be the cornerstone of holistically-driven, person-centered care, especially in comorbid conditions such as pelvic pain and depression, where pharmacological side effects, stigma, can severely diminish adherence to biomedical interventions.6 Coeytaux, as well as other authors, clearly correlate the reduction of maternal mortality with improved postpartum care. The World Health Organization recommends that postpartum checkups should include screening for:

  • Back pain
  • Incontinence (stress)
  • Hemorrhoids
  • Constipation
  • Fatigue
  • Breast pain
  • Perineal pain
  • Depression
  • Painful or difficult intercourse
  • Headaches
  • Bowel problems
  • Dizziness or fainting

A physical therapist is a vital team member in not only screening for many of the
listed problems above, but in managing them. It is important to note that other countries, like France, deliver high quality postpartum rehab care plus in-home visits, all while spending far less than the US on maternal care.
 
The World Health Organization, however, clarifies the vital importance of postpartum care delivery by making a significant recommendation for a paradigm shift in biomedical care.7
 
Yoga as a “Best Care Practice” for Postpartum Care
 
The WHO recommends the use of a biopsychosocial model of care, which yoga is ideally suited to provide via its ancient, multi-faceted person-centered philosophy. Medical Therapeutic Yoga is a unique method of combining evidence-based rehabilitation with yoga to emerge with a new paradigm of practice. MTY:
 

  • Addresses the mother as a person, not as a condition or diagnosis.
  • Empowers mothers with self-care strategies for systems-based, not just musculoskeletal or neuromuscular, change.
  • Addresses all domains of biopsychosocial impairment.
  • Teaches interdisciplinary partnership-based theory, which is integral to creative collaborative discourse and innovation in postpartum care.
  • Equips clinicians with business service, website development, practice paradigm, and social media campaign tools to fully develop the new clinical niche of Professional Yoga Therapy practice. 
  • Promotes patient advocacy, health promotion, and public health education via mainstreaming yoga into rehabilitative and medical services.
  • Provides the gender context for prescription that traditional yoga is lacking.
  • Evolves yoga for use in prenatal and postpartum care.

 
Physical therapy screening and intervention in the postpartum is vital, but the addition of yoga can optimize postpartum care and has enormous potential to be a “Best Care Practice” for postpartum care in rehabilitation. 
 
As a mind-body intervention, yoga during pregnancy can increase birth weight, shorten labor, decrease pre-term birth, decrease instrument-assisted birth, reduce perceived pain, stress, anxiety sleep disturbances, and general pregnancy-related discomfort and quality of life physical domains.8-9
 
In addition to the typical physical therapy intervention for postpartum physical therapy, the MTY paradigm provides:

  • self-care strategies for psychoemotional health and social engagement, increasing self-efficacy, confidence, and self-worth,
  • a concise container for clinical-decision through its algorithmic programming,
  • psychoemotional and neuroendocrine intervention,
  • nutritional counseling  and resource utilization,
  • energetic adjunct therapies steeped in Ayurvedic science,
  • executive functioning and cognitive support,
  • epigenetic effect, and
  • inter- and intrarelational development.

 
Postpartum integrated physical therapy care can provide more comprehensive care than rehab alone because of its multi-faceted biopsychosocial structure and systems-based model of care. Ginger’s course, Yoga as Medicine for Labor, Delivery, and Postpartum provides evidence-based methodology for prenatal and postpartum practice that streamlines clinical decision-making and intervention through introduction of a yogic model of assessment.
 
To learn more about Ginger’s course, visit Yoga as Medicine for Labor, Delivery, and Postpartum


Coeytauz et al., Maternal Mortality in the US: A Human Rights Failure. Contraception Editorial, March 2011. http://www.arhp.org/publications-and-resources/contraception-journal/march-2011
Kuklina E, Meikle S, Jamieson D, et al. Severe obstetric morbidity in the US, 1998–2005. Obstet Gynecol. 2009;113:293–299.
Tita ATN, Landon MB, Spong CY, et al. Timing of elective cesarean delivery at term and neonatal outcomes. NEJM. 2009;360:111–120.
Clark SL, Belfort MA, Byrum SL, Meyers JA, Perlin JB. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol. 2008;199:e1–105.e7.Abstract | Full Text | Full-Text PDF (100 KB)
Oshiro BT. Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstet Gynecol. 2009;113:804–811.
Buttner, M. M., Brock, R. L., O'Hara, M. W., & Stuart, S. (2015). Efficacy of yoga for depressed postpartum women: A randomized controlled trial. Complementary Therapies in Clinical Practice, 21(2), 94-100. doi:10.1016/j.ctcp.2015.03.003 [doi]
WORLD HEALTH ORGANIZATION., 2002. Towards a common language for functioning, disability and health : ICF. Geneva: World Health Organisation.
Curtis, K., Weinrib, A., & Katz, J. (2012). Systematic review of yoga for pregnant women: Current status and future directions. Evidence-Based Complementary and Alternative Medicine : ECAM, 2012, 715942. doi:10.1155/2012/715942 [doi]
Sharma, M., & Branscum, P. (2015). Yoga interventions in pregnancy: A qualitative review. Journal of Alternative and Complementary Medicine (New York, N.Y.), 21(4), 208-216. doi:10.1089/acm.2014.0033 [doi]

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Hip Preservation: Yoga Reconsidered

Faculty member, Ginger Garner PT, L/ATC, PYT will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more.

Yoga is, unarguably, a popular contemplative science, enjoying 36.7 million practitioners in the US alone, up from 20.4 million in 2012.1 A 16 billion dollar industry, yoga is one of the most widely utilized methods of complementary and integrative medicine in America today. In 2008, the editor of Yoga Journal declared “yoga as medicine” as the next great wave. That was right in the middle of the Great Recession, when the last thing on the collective healthcare industry’s mind was yoga.

What happened during the same time frame as the interest in yoga surged?

Our expanded knowledge of hip anatomy, physiology, and pathophysiology exploded onto the medical scene, providing more information than ever about how to address, preserve, and otherwise attend to the hip joint. Prior to this new age of research, the hip was relegated to a joint worthy of no more than a tendonitis, bursitis, or osteoarthritis diagnosis. A person was simply a hip replacement candidate or not. There was no other option once a hip joint had prematurely degenerated. Now, that has all changed, thanks to technological advances in diagnostic testing and investigation.

Yet, the worlds of hip preservation and rehabilitation and yoga have yet to join hands. Many of my patients and colleagues have suffered from unnecessary hip injuries, from labral tears, all types of impingement, and compounding secondary diagnoses such as torn hamstrings, sports hernias, gluteal tendinopathy, to pelvic pain, all due to yoga practice. Some suffered injuries in yoga class during a single traumatic injury, and some injuries were drawn out over years of accumulated microinjury to capsuloligamentous, bony, or cartilaginous structures.

Hip labral injuries (HLI) have vastly increased over the last 10 years, perhaps making HLI the newest orthopaedic diagnosis of the 21st century. This discovery also makes surgical and conservative management of HLI uncharted territory. Conservative therapy includes nonsurgical and post-surgical rehabilitation, and since the average time from injury to diagnosis is 2.5 years, there are many people with hip, pelvic, back, or sacroiliac joint pain that have undiagnosed hip labral tears.

I should make myself quite clear, however. I am not out to demonize yoga or fear-monger the practice of yoga or how it may wreck a person’s body (to use recently controversial language).

My purpose is two-fold: To clarify 1) “what” and “how” yoga can be a safe, effective form or physical therapy and rehabilitation for the hip and pelvis, as well as to 2) underscore the areas where yoga posture practice should be evolved to prevent injury.

To that end, I have written and will be presenting a new 4-hour workshop entitled, Hip Preservation: Yoga Reconsidered, at the Montreal International Symposium on Therapeutic Yoga (MISTY) this weekend in Canada. The lecture is relevant for yoga teachers, yoga enthusiasts, yoga therapists, and health care professionals who are interested in learning how to prevent hip injury in yoga practice.

The workshop will introduce identification of imbalances that could contribute to HLI, as well as understand the common mistakes made in yoga practice that could increase HLI or hip impingement. Understanding the pain patterns that surround HLI are also critical to safe and therapeutic yoga practice and will be discussed. Discussion of structure, function, ability and “dis”ability of the hip, including their major substrates, will help identify the “red flags” in yoga practice, identifying high risk populations and those who need postural modification(s) and/or outside referral to physical therapy.

I am looking forward to instructing a high energy, action-packed hands-on learning session at MISTY on March 19-20, along with my presenting a 2-hour lecture on maximizing public speaking impact through Vocal Liberation: The Voice as Therapy.

Want to learn more?
Bring Ginger’s 16 hour continuing education course, Differential Diagnosis for Hip Labral Injuries to your facility in 2017 through Herman & Wallace Pelvic Rehabilitation Institute.

Yoga in America 2016 Survey. Yoga Alliance and Yoga Journal. January 2016.

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Vocal Preservation: Liberating the Voice

Herman & Wallace Pelvic Rehabilitation Institute faculty member, Ginger Garner PT, L/ATC, PYT, will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more. Read below as Ginger shares why the voice is a linking science.

The Voice as a Linking Science for Clinical and Business Efficacy

Your voice can be the key to your success. Forbes magazine’s #3 habit in an article, Five Habits of Highly Effective Communicators, is “Find your own voice.” London’s think tank Tomorrow’s Company declares in a recent report on efficacy in business leadership, “Having a voice really matters for employees today.” The director of the Involvement and Participation Association (IPA) and vice-chair of the London-based MadLeod Review on employee engagement says, “Voice is extremely important because there are many changing business concepts and one of the essential ones is trust. Our voice is one of the things we really need to change old management paradigms and build trust in an organization.”

If you are an instructor, teacher, educator, therapist, or all four, having a voice is synonymous with having a job. You can’t do your job without a voice. And yet, we don’t spend much time thinking about vocal physiology, much less how to maintain and even improve it.

The most powerful change agent or therapeutic modality you have - is your voice. Yet, the voice is often overlooked as a therapeutic tool. Think of how important it is for someone giving a TED talk to have good vocal quality, for example. Now consider how important it is for others, like you, who may have to speak for hours on end each day. The vocal folds must be cared for just like we attend to the mind and body during postural yoga practice or movement therapy.

What were the other findings of the report?

  • Voice is the foundation of sustainable business success. It increases employee engagement, enables effective decision-making and drives innovation.
  • Finding your voice involves both cultural and structural pursuit. First, we need to be culturally competent and sensitive. Only then can we provide the right process through which our voice can be heard.

The power of the voice cannot be ignored, particularly for those who have allergies, respiratory issues, or struggle to make a powerful impact or to establish themselves as an effective team member or thought leader. Oftentimes, the voice is the single variable that holds us back from making the success we are seeking in our work. US News World and Report states,

“Whether you are an aspiring leader or in a support role, developing your communication skills can impact your success. First, let’s take a look at the complexities of communication. It's more than the words you use. It's how and when you choose to share information. It's your body language and the tone and quality of your voice.”

Psychology Today and National Public Radio have recently reported on the relationship between vocal quality and job success and effectiveness. Both agree that speech rate, tone of voice, facial expression, and diction have a great deal of power to make or break effective communication. If tone doesn’t match facial expression, for example, neural dissonance occurs, which erodes trust, increase skepticism, and cooperation.1 In fact, warm vocal tone is a sign of transformational leadership, which generates “more satisfaction, commitment, and cooperation between team members”.2 Changing pitch increases therapeutic potential and improves the chances of your being understood by colleagues, especially when diction is congruent with emotion.1 Additionally, training mindfulness during public speaking can improve prefrontal cortex activity, which allows for improved social awareness, mood-regulation, decision-making, and empathy.4 Vocal awareness and training can slow your pace of speaking, which is shown to deepen others’ respect for you and simultaneously calm anxiety, traits which are bridge-building and healing for all relationships, business and personal.

About MISTY

MISTY is a not-for-profit organization and event dedicated to teaching others about therapeutic yoga.
Ginger’s workshop, “Vocal Liberation,” will introduce techniques for developing and preserving the voice, including projection, quality, longevity, and therapeutic impact through fusion of nada yoga and ENT physiology, which Ginger has developed over her career in public speaking and vocal performance. Want to learn about therapeutic yoga at MISTY? There’s still time to join Ginger and a host of other talented speakers and therapists. Learn more and register at http://www.homyogaevents.com.


Use of affective prosody by young and older adults. Dupuis K, Pichora-Fuller MK. Psychol Aging. 2010 Mar;25(1):16-29.
Leadership = Communication? The Relations of Leaders' Communication Styles with Leadership Styles, Knowledge Sharing and Leadership Outcomes. de Vries RE, Bakker-Pieper A, Oostenveld W. J Bus Psychol. 2010 Sep;25(3):367-380.
Short-term meditation training improves attention and self-regulation. Tang YY, Ma Y, Wang J, Fan Y, Feng S, Lu Q, Yu Q, Sui D, Rothbart MK, Fan M, Posner MI. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17152-6.

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Diastasis Recti Abdominis: A Narrative Review

The following post comes to us in part from Ginger Garner, PT, ATC, PYT, who teaches three yoga courses for Herman & Wallace; Yoga for Pelvic Pain, Yoga as Medicine for Pregnancy, and Yoga as Medicine for Labor and Postpartum. Check out her poster at the Combined Sections Meeting this weekend in Anaheim!

Maternal health care in the United States is abysmal. Especially wretched is care and support of women post-partum. Our insurance system is partially to blame by dictating that women receive only one visit with the provider who participated in the delivery of their baby 6 weeks after the baby is born, no matter the method of delivery. This is often after most of the scary, unexpected side effects of delivery, like heavy bleeding, nipple pain, urinary incontinence, difficulty with bowel movements, scar pain and tremendous mood swings have begun to ease. Only the women who are the most persistent, or those who have chosen unique care models (like out of hospital births with midwives), seem to get real support post-partum, leaving marginalized and less self-driven women to fend for themselves.

What if research could show that immediately treating some of the side effects of birth, like diastasis recti abdominus, which occurs in 50-60% of post-partum women, could result in improved outcomes in the long run? What if someone could prove that retraining and strengthening the abdominal wall as part of a biopsychosocial model empowering women could change the costly effects of prolapse and urinary incontinence treatment later on in life? What if that research aimed to show that treating women in partnership will all care providers was the most effective? These are big questions, but through research beginning with Diastasis Recti Abdominis (DRA), some Women’s Health Physical Therapists trained in Medical Therapeutic Yoga are hoping to highlight some answers.

At CSM in San Diego next month, these researchers (listed below) are presenting a poster via the Section on Women’s Health showcasing their paper, Diastasis Recti Abdominis: A Narrative Review. They found that good, solid research focusing on the co-morbidities and treatment of DRA is really lacking. Most well-done studies focus on the reliability and validity of measurement techniques, showing that calipers and ultrasound are the most valid and reliable ways to measure the gap. There is not even agreement on what precise measurement technically constitutes a DRA, though most agree that normal inter-recti distance is 15-25mm supraumbilically among parous females with digital calipers. (Chiarello 2013).

Besides the obvious cosmetic and general strengthening concerns, why do we care about physical therapy care for a post-partum DRA? Spitznagle’s retrospective chart review of women presenting for gynecological care with a mean age of 52 found that 52% had DRA and 66% of them had a least one support-related pelvic floor muscle dysfunction. Those with DRA were more likely to have pelvic organ prolapse, urinary incontinence and fecal incontinence. Another study by Parker found a DRA prevalence of 74.4% among women with back or pelvic area pain who had delivered at least one child and sought PT. They found a significant difference in VAS pain levels in those with DRA and abdominal or pelvic pain compared to those without DRA. More well-done, prospective studies are really needed to correlate these sequalea in later life to DRA post-partum.

The topic of how to retrain the abdominal wall to restore optimal function and cosmetic appearance is hot in the blogosphere right now. Does it matter if the width of the diastasis recti is reduced? Or is it a matter of having tension in the linea alba as the clinician sinks his/her fingers toward the spine? Biomechanically we know that in order to improve stiffness in the trunk, we need synergistic and symmetrical firing of the diaphragm, transversus abdominis, multifidus and the pelvic floor with proper timing and contraction of the hip and external abdominal muscles. Benjamin completed a review of the research on the effects of exercise in the antenatal and postnatal periods and concluded that antenatal exercise may be protective against the formation of a DRA, but that the available studies are of such poor quality and varied in the way that abdominal/core strengthening was applied in the post-partum population, that it is impossible to tell how or why exercise may or may not help with DRA!

There is clearly a huge hole in the literature and as usual, new mothers are suffering. Women are spending money on programs they find on the internet that are not backed by solid research, because there is not any! Regarding DRA, post-partum women in our country desperately need well-done, high quality studies promoting a specific and well-described exercise for healing. In addition, in our patriarchal health care model, we need to show without a shadow of a doubt that treating post-partum muscle weakness, body mechanics issues and DRA is essential for saving money in the long run on prolapse and urinary incontinence surgery, as well as decreasing expenditure on back pain treatments.

If our discipline could provide this research, ALL women could have access to personal, post-partum recovery. As an established part of the health care system and with longer treatment times and the chance to get to know our patients better, physical therapists are the IDEAL healthcare practitioners to ensure that post-partum women are getting adequate physical retraining, but also psycho-social support that is so lacking in the United States.

The Women’s Health Poster Presentations at CSM in Anaheim will be on Saturday, Feb 20 from 1-3PM. I look forward to meeting with some of you and visiting about what you are working on to further the cause of improving maternal health care and DRA treatment.


Ginger Garner PT, ATC, PYT, Professional Yoga Therapy Institute, Emerald Isle, NC
Elizabeth Trausch, DPT, PYT Des Moines University, Des Moines IA
Stefanie Foster, PT, PYT Asana with Intelligence, Houston, TX
Paige Raffo, PT, PYT, CPI, Balance+Flow Physio, Bellevue, WA
Janet Drake, PT, LCCE, FACCE, PYT, Central Bucks Physical Therapy, Doylestown, PA
Stacie Razzino, PT, PYT, Free Motion Physical Therapy, Melbourne, FL
Blog post by Libby Trausch, DPT

Spitznagle T, Leong F, Van Dillen L, Prevalence of diastasis recti abdominis in a urogynecological patient population, International Urogynecology Journal. 2007; 18: 321-328.
Chiarello CM, Mcauley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. Orthop Sports Phys Ther. 2013; 43(7): 495-503
Benjamin DR, et al., Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar;100(1):1-8.

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Hip or Pelvic Pain – The Chicken or the Egg?

The following is contributed by faculty member Ginger Garner, who teaches the Hib Labrum Injury course. You can read more about that course on the Herman & Wallace course page.

Hip labral injury (HLI) is a relatively new diagnosis in the last 10 years of orthopaedic and rehabilitative care. However, just because HLI is a new diagnosis doesn’t mean the injury is new. In fact, HLI is posited to be responsible for the premature aging and osteoarthritis of the hip joint and pelvis that leads to hip replacements. HLI is also a major source of hip pain, with groin pain being the most common subjective complaint.However, groin pain is not the only complaint that is associated with HLI. Pelvic pain commonly goes hand-in-hand with hip pain.

What does this mean for patients? If you have hip or pelvic pain you should be evaluated by an HLI specialist, which can be a PT, surgeon, or osteopath who has received additional training on managing HLI. It is critical that you see someone who specializes in HLI. If HLI or other hip or pelvic injury is suspected, it is important that you follow up with a physical therapist who has had advanced training in HLI rehab for the best chance of recovery.

I find the premenstrual cycle pain (usually 1-5 days before the cycle begins) is a common phenomenon with many women with HLI (operative and non-operative), which is an area that needs more attention in research. Some women say it feels like they have retorn their labrum, and as a result, they get fearful – which affects not just their physical functioning but their psychoemotional and social well-being.

They limit activity which can exacerbate faulty neuromuscular patterning and deconditioning and result in increased pain from faulty structural support. Their realm of social activity and self-efficacy can suffer, which is also not good for long-term well-being.

Additionally, sleep can be interrupted with HLI and pelvic pain, which can dysregulate the HPA (hypothalamic pituitary adrenal) Axis and cause further problems with issues like pain centralization, cortisol dysregulation, and digestion. A recent study correlated vulvodynia and FAI (femoracetabular impingement), a type of hip impingement commonly found with HLI. The study found that those women who received early surgical intervention received the most relief from vulvodynia, while those who had a longer duration of pain did not experience the same level of improvement.

The take-home message is that early intervention for HLI is absolutely critical for the best long-term prognosis, and that pelvic pain, which can include anything from vulvodynia, dyspareunia, interstitial cystitis, non-relaxing pelvic floor/myalgia, pudendal neuralgia or entrapment, athletic pubalgia, and/or continence issues, although a common occurrence with HLI, is not normal and should be addressed by a trained pelvic rehab professional.

Want more? Read my post about Hip Labrum Tear Risk: Why Early Care is Critical, is absolutely necessary for the best long-term prognosis.

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An Interview with Ginger Garner of the Herman & Wallace Faculty

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Ginger Garner, PT, MPT, ATC.

How did you get started in pelvic rehab?

My entry point into pelvic rehab was a bit unorthodox and as a result, my colleagues at the time (back in the 90’s), considered my practice quite eccentric and frankly, a bit strange.
In fact, although I can see lots of humor in it now, I was actually pushed out of a practice because what I was doing was “too individualized” and patient specific. Of course, that “eccentric” entry point into pelvic rehab was integrative medicine, using a yoga-based biopsychosocial model of practice.

Who or what inspired you?

To answer that question I think you first have to be able to recognize and appreciate times when you have not been well supported or inspired, kind of like having to know adversity before you can recognize and value success.

Here’s my short story:
Early on in my education (in sports medicine, athletic training, physical therapy, yoga, and pilates) I realized that the biomedical model, although stellar at handling life-threatening emergencies, was not always so great at addressing chronic conditions and preventing disease processes and injury. So the answer to what inspires me – is the privilege of being able to be on the prevention end of injury and disease.
Back in the 90’s, I had a faculty instructor who encouraged me to keep pursuing my passion – in spite of the pushback I got from many directions, including within the department at the university. She found a way for me to pursue lateral work in the School of Public Health, which I felt was necessary in order for me to become a successful patient advocate. It was a great experience where I was able to work with the Governor’s Council on Physical Fitness and Health and conduct a pilot study. Her encouragement inspired me to keep following my dream, which is why I strongly believe in this quote by Mark Twain,


“Keep away from people who try to belittle your ambitions. Small people always do that, but the really great make you feel that you, too, can become great.”


Fast forward almost 20 years, and my most influential mentors, sources of my biggest inspiration, have been 1) Dr. Riane Eisler, holocaust survivor, attorney, social scientist, and founder of the not-for-profit organization, Caring Economics, which works to end violence against women and raise the status of caregiving; and 2) my three children. Experiencing pregnancy three times was an enormous gift, which allowed me the privilege giving birth not just to my three boys, but also to the framework for using yoga in prenatal, childbirth, and postpartum to prevent and manage injury and pain. The mothers I work with also inspire me. The work I do is for them and their future children.

 

What have you found most rewarding in treating this patient population?

There is go greater reward than empowering women, especially mothers and mother-to-be.
Women are too frequently disempowered by our current medical model. Their concerns are often marginalized and the care they get can be dehumanizing and humiliating, especially during maternal and childbirth care. I believe that above being a physical therapist, an athletic trainer, and an integrative clinician, I am first and foremost a patient advocate. Each woman I work with is a personal investment of my time, energy, and dedication. The reward of seeing a woman be able to pursue the compassionate birth she wants and deserves, to find relief from pelvic pain, and to know what questions to ask to get the best care from her health care providers, all because of the time I have spent with her – is worth more than gold.

What do you find more rewarding about teaching? (this could be one story or something you always find magical about the experience)

The two most rewarding aspects of teaching are 1) changing the course and paradigm of practice in rehab and medicine by fostering creativity and a shift toward person-centered, integrative practice, and 2) getting to be constantly immersed in research.
I love learning and am the perpetual student. I’m currently working toward my doctorate at UNC Chapel Hill, and love the interchange and partnership that is nurtured by being in education.

What trends/changes are you finding in the field of pelvic rehab?

The full circle return to seeing the person as whole, and not broken or as a part, is incredibly encouraging.
I am seeing this through the integrative courses that H&W is embracing, including my own courses in yoga, but also and perhaps more importantly, through the ground swell of individual health care consumer action. Folks realize “health care” doesn’t just consist of drugs and surgery, and they are seeking out integrated care now more than ever. Still yet, access to pelvic rehab can be vastly improved, which is a great segue into the next question.

 

If you could make a significant change to the field of pelvic rehab or the field of PT, what would it be?

As a patient advocate, I believe our biggest responsibility as clinicians is to improve access to pelvic rehab and integrated care.
Integrated care I define as “integrative medicine + rehab.” PT’s are not yet the practitioner of choice in many areas, including back and pelvic pain and orthopaedic injury. So we have our work cut out for us – to improve public health education and health literacy about physical therapy and specifically, pelvic PT.
If I had the chance, I would absolutely become involved in evolving the scope of practice and increasing the reach and influence of PT on a legislative and policy level.

What have you learned over the years that has been most valuable to you?

Relationship is more important than anything else.
You can be the most skilled clinician on the planet, and plan the best integrated, “wholistic” biopsychosocial plan of care the world has ever seen – and yet, if you haven’t connected with the patient and nurtured a therapeutic landscape that fosters compassionate care and a safe environment, then patient outcomes will falter. What’s more is, patient frustration and clinician burnout will be high.
When in doubt about what you are doing, return to nurturing relationship.

What is your favorite topic about which you teach?

My courses are like my children. I can’t choose a favorite. I love teaching integrated hip labral care, because it’s difficult and complex subject matter and urgently needed in this rapidly developing new field of hip rehab. But I equally love helping women toward the pregnancy and birth they desire and deserve.
Overall, no matter what the course is, yoga is the entry point for the zen I experience when teaching, practicing integrated physical therapy, and in my personal life. Ultimately, guiding my students and patients toward their own version of that mountain-top experience of personal and professional transformation – that is the real deal.

Ginger Garner, PT, MPT, ATCOther Credentials: PYT, ERYT500, CPI
GingerGarner.com
H&W Courses: HLI, YPREG, YPOST

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Resurfacing after Hip Labral Surgery

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in March!

Ginger Garner

Lots of you have reached out with questions about “best care” practices after hip surgery. There isn’t a whole lot in scientific literature written about rehab, and over many months of fielding questions on my closed HIP LABRAL PHYSIOTHERAPY FB page, I am finally ready to share what Best Care Practices after Hip Labral Surgery may look like.

Today is Post 1 of this series, which will follow me day-by-day, week-by-week, through the highs and lows of my recovery and rehabilitation. Here we go!

First, “What IS Hip Labral Surgery?”

A relatively new term, the surgery is presently called “Hip Preservation.” However I like to call a spade a spade – this surgery is a bona fide hip reconstruction.

This surgery is a major undertaking for surgeon and patient and is constantly charting new territory in surgical techniques and discoveries. A brilliant way to preserve the hip joint, a surgeon is charged with essentially piecing the hip back together and reshaping it to work better than before surgery. It comes with risks AND benefits, many of which I will address in posts to come. It requires serious dedication and a wicked good physical therapist to get you back to fighting shape after surgery. But success begins with choosing a good surgeon who is a specialist in this type of surgery (more on that later).

Not a hip replacement, hip labral surgery rarely ONLY consists of repair of the labrum. Most of the time, a torn hip labrum is an issue secondary to a whole slew of hip disorders that make up a quagmire of highly technical and complex systems that converge during hip reconstruction. Whew, that was a mouthful.

A few of those technical things include hip dysplasia, impingement syndromes (and oh are there lots of different kinds we will be discussing), tendinosis, bursitis, pelvic pain, sexual dysfunction, snapping hip phenomenon (internal and external), anteversion, retroversion, and well, that’s enough to get us started.

Passion for Hip Labral Rehab

Let me tell you that this surgery was everything I thought it was going to be, and a hell (there’s just no other way to put it) of a lot more. I would have LOVED to avoid surgery, and heck, to avoid the injury that led to surgery – because I don’t know a single person who would prefer to gain clinical expertise by actually suffering through the injury or surgery. But alas, adversity is often what makes us better.

As you may guess, I did experience a single traumatic injury – which then proceeded to give birth to a perpetually poorly behaved, havoc-wreaking monster of a chronic condition. The funny thing was before the injury, my area of clinical expertise was ALREADY orthopaedics and women’s health. You can see I was kind of in for a colossal butt-kicking lesson from the universe. Oh the irony…

I did try to prepare myself for the road to recovery though. Read my post on Shutting Down to Move Forward: The Therapist Becomes the Patient.

But trust me, I would rather NOT have gleaned clinical expertise on hip labral and pelvic injury through personal tragedy.

Nonetheless, I knew that my journey from hip reconstructive surgery back to health, was going to help more than just me. I could use it to help so many others who wrestle with that same monster.

But yea, there are a few challenges to recovery:

  • I am mother. Of three boys. Ranging in age from 3-9.
  • I was/still am trying to finish my doctorate.
  • I completed a book chapter for a colleague’s new text on Fostering Creativity in Rehabilitation and a research manuscript during early post-op.
  • I had to maintain a full teaching schedule that required walking and stair climbing (which I couldn’t do) and lots of standing (which I also could not do).
  • The final straw was, midway through rehab, my oldest son received a special needs diagnosis.

Nevermind having clean laundry and healthy meals to foster healing (and maintain sanity). I mean, a human can only do so much. The point is – I didn’t live tweet or post about my recovery in real time.

The Bright Side

The good side though – is my delay in posting has given me much needed time to reflect on what variables are most critical to the recovery process.

If you are considering hip labral surgery, please read Top Five Must Have Hip Labral Surgery Tips to help you prepare.

Other colleagues I know have released blog series in real time, a chronicle to their injury and recovery. Shelly Prosko and her traumatic Achilles Tendon rupture, is one of those colleagues. Also a physioyogi, I highly recommend Shelly’s series on her recovery. Read here or cut and paste: http://www.gingergarner.com/2014/10/28/medical-therapeutic-yoga-achilles-tendon-rupture-missing-link-rehabilitation/

Now onward and forward, I am (finally) sitting down to write, 5 and a half months AFTER my surgery.

I hope you’ll join me on my journey through Hip Preservation, er, Reconstruction Surgery and that, most of all, you’ll find something that will inspire you to more complete healing and recovery.

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Four “Must Know” Tips for Identifying Hip Labral Injuries

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in March!

Ginger Garner

1. Early Intervention Is Key

Acetabular labral tears are reported to be a major cause of hip dysfunction in young patients and a primary precursor to hip osteoarthritis. New technology is helping with improved identification of tears, however the time of injury to diagnosis is still on average 2.5 years, making long-term prognosis for hip preservation poor.

Because of the lengthy delay many patients are still experiencing, the importance of early intervention cannot be overemphasized.

2. Getting the Best Outcomes: Patient Stories & Details Matter

Patient stories, the subjective reports of the individual, are incredibly important in aiding diagnosis of a hip labral tear. Knowing the morphological classification and common areas for tears in the hip labrum is also important, especially when it comes to identifying and managing adverse biomechanical stressors, such as anterior joint loading in the hip. Quite often in conservative treatment of hip labral injury, it is more important to change or retrain nonoptimal movement strategies rather than to issue exercise, strengthen, or elongate tissues.

Up to 55% of active people with mechanical hip pain are typically confirmed as having acetabular hip labral (ALT) tears, which is affirmed across several research studies. And since 2003, the most commonly cited area of hip pain for labral tears is anterior, followed by lateral, then posterior.

3. Study History to Affect the Future

Suzuki, in 1986, described the acetabular labral tear arthroscopically for the first time, while Altenburg, in 1977, documented the first report of “nontraumatic tearing of the acetabular labrum,” according to Groh and Herrara 2009, Schmerl 2005, and Altenburg 1977. And yet, it is possible for an ALT to go undiagnosed and pain-free, since up to 96% of cadaver hips with a mean age of 78 years old are found to have ALT in the anterosuperior quadrant.

A paucity of studies existed on hip disorders from 1977-2011, having located approximately 70 during early research on the topic. Plante et al (2011) and Margo et al (2003) confirm these findings, stating “there is no clear consensus on diagnosis or terminology” (concerning ALT).However, the increasing interest in ALT is a welcome phenomenon, and in a a second literature review from 2011 to present I located and reviewed over 100 new studies relating to ALT and its often comorbid sister condition, femoracetabular impingement (FAI).

4. What Matters Most in Symptomology?

There are some moderately reliable tests that have undergone scrutiny as to their sensitivity (SN) and specificity (SP) for clinical utility and validity; however, that is a discussion for another post. For now, what matters most in diagnosing ALT?

The short answer is the patient story. Listen to a patient’s onset of symptoms and mechanism of injury (if there is one, oftentimes there isn’t unless the mechanism is pregnancy or postpartum-related. For more information, read my post on postpartum hip labral injury risk. Listen carefully the most typical (and reliable) symptomology for a suspected ALT. Those symptoms would include:

  • Pain in the groin (reported 95-100% SN)
  • Mechanical symptoms, which can include sharp pain, clicking, locking or catching, or giving way (reported 85-100% SP, SN, respectively)
  • Minor hip ROM (range of motion) limitations (same SP and SN as above)

Could There Be a Future Hip Labral Injury (HLI) Scale?

The last symptom that can be incredibly telling (read: reveal the degree of functional impairment and degree of ALT), is night pain. Similar to the RTC impingement degrees of impairment (Stages l I, II, and III), ALT injury is similar. Once a patient’s sleep is interrupted, and is accompanied by any of the symptoms found above, the risk of their having an ALT or other intra-articular (internal) hip derangement is high. Night pain could then be characterized by the most impaired stage, Stage III, lending itself to the possibility of a future HLI Scale.

The findings reported in this post are supported by more than two dozen references, which are a part of the literature review included in the Hip Labral Injury and Differential Diagnosis course that Ginger authored and teaches for Herman and Wallace Pelvic Rehabilitation Institute.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

 

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Extra-articular Hip Impingement: A New Discovery for Hip Preservation

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

There are two accepted forms of hip impingement currently documented in the literature. The two types are 1) CAM type FAI (femoracetabular impingement) and 2) Pincer type FAI. These two types are found inside the joint, meaning they are considered intra-articular bony anomalies.

FAI is a common comorbidity found with hip labral injury (HLI); and in fact, FAI is a risk factor for HLI. Specifically, FAI is a bony impingement that arises in the femoral head-neck function and the rim of the acetabulum (see photo at right). The two types of FAI also generally occur together more than they do in isolation. However, it is possible that, combined with other issues like acetabular undercoverage or hip instability, CAM or Pincer-type FAI can be found a singular diagnosis.

Surgical Intervention

However, the arena of impingement in the hip is now evolving to consider other locations. In the past 5 years there has been buzz about other types of FAI. They aren’t classically considered FAI issues since this new type of identified impingement occurs outside (extra-articular) the joint. One type newly identified is known as anterior inferior iliac spine/subspinal hip impingement (AIIS). In a 2011 study of 3 case reports, AIIS was found and treated with arthroscopic AIIS decompression with positive results. A more recent 2012 study found excellent results at short-term follow up for surgical decompression of AIIS.

Identification & Diagnosis of AIIS

Both personal and professional experience in the area of AIIS has shown that AIIS is not always discovered on an AP (anterior-posterior) radiograph. However, it is possible to see a larger AIIS on an AP film. Another helpful (but not always definitive) diagnostic test is a CT scan with MRI 3D reconstruction (and no contrast). Bony contrast is more reliable with CT scan than the typically preferred MRA (which is better for soft tissue contrast).

In addition, the rectus femoris (RF) could be implicated in AIIS pathology because the same area receives the proximal attachment of the RF. The same 2011 study reported that the morphology and role of the RF in extra-articular impingement is “not well reported at this time.”

Likewise, the identification of AIIS as a primary driver of pathology in intra-articular hip injury (FAI and/or HLI) is rare. Some cases of AIIS are being found during hip arthroscopy to correct identified existing deficits such as FAI and/or HLI. This means that AIIS may be missed and should be included as a potential mechanism of injury, especially for anterosuperior labral tears in the 2 to 3 o’clock region.

Patients who have AIIS may present like a typical HLI patient, which means they may have a positive Thomas test, FADDIR test, or mechanical symptoms such as popping, clicking, grinding or giving way. It is important to note these signs and symptoms and work in a team approach with surgeons and physical therapists who specialize in hip preservation and reconstruction.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

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Gait Patterns and Intra-articular Hip Injury

This post was written by H&W instructor Ginger Garner. Ginger will be presenting her Hip Labrum Injuries course in Houston in 2015!

Ginger Garner

One of the easiest ways to determine if someone is in pain is to watch the way they move. And perhaps the most commonly observed and universal movement pattern is gait. From a subtle loss of trunk rotation or pelvic translation to a gross loss of reciprocal gait, a dynamic assessment of walking is a very valuable tool in the physical therapist’s toolbox.

In evaluation of the hip, gait assessment is a critical element of the physical therapy exam. Pain-free ambulation is an essential part of measuring a person’s quality of life (QOL) and is a clinically significant functional outcome measure. Loss of hip extension and knee hyperextension prior to or at heel strike are part of several self-limiting patterns that arise from intra-articular hip injury. Dynamic gait assessment can give the therapist distinct clues as to hip pathophysiology etiology.

It was previously assumed that surgery to correct intra-articular pathology, such as in CAM-based femoracetabular impingement (FAI), would result in correction of deficiencies in gait patterning. CAM FAI limits and creates pain in the direction of hip osteokinematic flexion, adduction, and internal rotation range of motion and is caused by a lack of sphericity of the femoral head and neck, causing impingement of the labrum and/or chondral contact at the acetabulum.

A recent study published in 2013 in Gait and Posture, shows that previous assumptions about gait are incorrect. The study compared the gait of healthy controls to those with FAI and hypothesized that gait abnormalities would resolve status post surgery.

Gait measures were obtained both preoperatively and postoperatively. Researchers were surprised to find that gait abnormalities found presurgically did not automatically resolve postsurgically. Another pertinent finding is that the surgical patients not only retained their old faulty antalgic gait patterns and habits, they also adopted new abnormalities that resulted from surgical intervention, such as those arising from scar tissue, soft tissue pathology, neuromuscular patterning, or loss of arthrokinematic motion in the hip. These findings underscores the importance of early intervention via physical therapy for both operative and nonoperative patients if we want our patients to enjoy or return to a high quality of life.

Although the patients in the study who underwent FAI surgery did demonstrate decreased pain, nonoptimal preoperative gait patterns that persist postoperatively can put these patients at risk for reinjury (e.g. labral retears) or related cobmorbidities like pelvic pain, back pain, or sacroiliac joint dysfunction.

Further, a separate study published in 2009 established the presence of altered hip and pelvic biomechanics during gait, finding that those with hip FAI had decreased peak hip abduction, attenuated pelvic frontal ROM or translation, and less sagittal ROM than controls. Soft tissue restriction including scar tissue from previous or current surgeries, myofascial restriction, or neuromuscular patterning problems are, again, all important variables which must be differentially diagnosed for their possible contribution to the loss of ROM and function. Other considerations that can alter gait pattern and increase injury or reinjury risk assessment of capsular mobility, ligamentous integrity, and sacroiliac joint contributions to limited hip ROM and excursion.

To learn more about nonoperative and operative hip labral and FAI management, check out faculty member Ginger Garner's continuing education course on Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management. The next opportunity to take the course is March of 2015 in Houston.

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