Earlier this year, Herman & Wallace sponsored the first ever pelvic rehab course for physios in Nairobi, Kenya in partnership with The Jackson Clinics Foundation. After returning from that course, Kathy Golic, PT spent months writing a new course, adapting information from Pelvic Floor Level 1, Level 2A, and the Pregnancy and Postpartum series. This October, Kathy (along with co-instructors Casie Danenhauer and Sherine Aubert) returned to teach her follow-up course that expanded on the first module, introducing lectures and labs tailored to the community of pelvic physios in Kenya. This dispatch comes from instructor Kathy Golic, PT, who sent in this article shortly after returning from the course. Huge thanks to Kathy and her colleagues Sherine Aubert and Casie Danenhauer for doing this important work!
It has been a week now, and as I type looking out on the windy rainy day, it is hard to believe that I was so recently in a warm, sheltered classroom sequestered from the hustle and bustle of Nairobi. A place which has captured my heart. Really it is the people, especially my new “sisters” who I spent so much time with during this last two-week course module. Once again, I experienced chill bumps every day from witnessing the growth, the stories, the wisdom and the compassion of these bright, motivated, committed physiotherapists who came back for the 2nd module in our series to help them become experts in the field of Pelvic Health. This module covered topics of Pregnancy, Postpartum care, Prolapse, Colorectal Conditions including fecal incontinence and constipation, and Coccydynia. We had a terrific printed course manual for this 2nd in the series, thanks to the partnership of Herman and Wallace and Jackson Clinics Foundation. With my wonderful and resourceful, skilled colleagues from LA, Casie Danenhaur, and Sherine Aubert, we included comprehensive lectures, lively demonstrations, hands on creative experiential learning opportunities, and awesome supervised lab training sessions. We also had a lot of case study discussions, and live case studies where we assisted the students, who are practicing physiotherapists, in conducting thorough assessments and clinical reasoning processes to treat and make plans to further the progress of their patients.
All of this in itself was incredibly rewarding. But there was more. The power of sacrifice we witnessed. The power of solidarity and true generosity. Most of these women continued to have to work after class even while in this two-week module; in class from 8-4, but then going on their way, some of them through heavy Nairobi traffic, to treat patients in their offices, or to work hospital shifts. One student heading out after a Wed. afternoon class told me that she was going to work from 7- midnight, then would sleep until 4am, then back to work until 7 am, before returning to class at 8 am. She also had to miss one class to participate in her mentorship for her ortho advanced diploma, so had to make up a test with us the next day. (she aced the test!) Now for the generosity. I will share just 1 of many stories. One of the physios asked a patient of hers whom she felt she could use some help with, if she would mind traveling to the KMTC classroom where we were teaching so the other students could learn, while we the visiting instructors, would help guide in her assessment and care. This woman agreed, and got up at 3:30 am, traveled by bus for 3 hours to come for her treatment. She willingly shared her story, and it was tough to hear. She worked as a vegetable vendor carrying produce on her back, lifting it, and sitting on a stone for hours each day. She, a mother of 5 grown children with an unemployed husband. Her physio and the class did quite well in their assessment and with treatment and suggestions. She seemed pleased. Then as she prepared to leave, some of the physio students “passed the hat” and collected 7,000 kshillings (about $70.00) and presented this humble lady with the money so that she could afford transportation home. It is my understanding that most Kenyans spend 50% of their income on food, so sharing with this patient was a true sacrifice. But for these ladies, there was no question about it. This is how they live and how they work. They are themselves so grateful for the knowledge, skills and experience that they are getting through this program, and they will pay it backwards and forwards. My colleagues this time and last time, are also indebted to them for all they have taught us. It is truly an honor and privilege to be part of this great program, and I too am thankful for all the team players in this venture.
As more and more patients seek care for pelvic floor dysfunction, the need for more qualified practitioners is becoming apparent. Many patients prefer to see a clinician who they identify with, which is why it is important for practitioners of all genders to learn to treat pelvic floor dysfunction. Because much of the public's awareness of pelvic rehab comes out of women's health, the vast majority of pelvic health practitioners are women.
There is currently a shortage of male pelvic health practitioners. To help us understand why it is so important to fix that, we reached out to several male clinicians who have attended the Male Pelvic Floor: Function, Dysfunction, and Treatment course to ask them about the need for more men in the field. Here are some answers to the question:
Grant Headley of Bridgetown Physical Therapy of Portland, Oregon (www.bridgetownpt.com)
While as PT’s we all approach our patients with interest in helping them as individuals, some of our patients feel more comfortable sharing certain details with a provider of the same gender. Many of the hang-ups some men have about receiving care from a female provider are related to an older generation, to certain traditional or religious cultural beliefs, or to certain beliefs about propriety related to receiving care.
As acknowledged in our coursework, generally men have cultural barriers that traditionally do not permit sharing of vulnerability or weakness, especially in the sexual domain. Here are a few unsolicited statements I feel encapsulate what my own male patients have told me: Some heterosexual men feel more comfortable sharing the details of their dysfunction with a man because they find it difficult to admit vulnerability in the presence of a female. Some men prefer not to relay the clinically pertinent details of dysfunctional sexual encounters with a female because they do not wish to make the female practitioner uncomfortable. Many men feel that they can relay more detail about the mechanics of the sexual dysfunction or signs of improvement to a male provider. Some men have told me that they felt their sexual dysfunction was minimized or that they have been treated with patronizing language by a female pelvic PT in the past. Unfortunately, these patients attribute this negative experience to the PT being female, and they are not comfortable having a second opinion with a female.
Although we strive to present as open-minded and neutral to our patients, they may have an affinity for a male provider. This could foster a more constructive clinical partnership towards working on their goals if they perceive fewer communication barriers. I can offer my own experience as a past patient suffering with pelvic floor dysfunction; I was so desperate for help and I felt so grateful that there was a physical therapist in my city at all that was willing to help me. I did not care that she was female and that I had to receive treatment at a women's health clinic for new mothers in the University Hospital. Many female therapists reading this article have likely transferred lifesaving PT care to scores of men. This organization of H&W that does so much good for a sensitive aspect of men's care is dominated by women- this needs to be acknowledged as a net positive but also appreciated that much of the education and application of care is an adaptation from what has worked for women in the past. Many men will be so grateful to receive care and get better. Some men unfortunately will have barriers to receiving care and for those patients, we can seek out and encourage our male colleagues to get involved in pelvic rehab so we can all provide more access to care.
Lance Frank of Flex Physical Therapy in Atlanta (www.flexptatl.com)
Personally, as a male provider in pelvic health, I find that the men I treat are much more comfortable and at ease discussing topics like erections (or lack thereof) and sexual dysfunction, as well as incontinence, or pelvic pain. In a female dominated sub-specialty of physical therapy, sometimes as a male it can be intimidating and even embarrassing for some men to discuss these topics at all, let alone with a female; so having the option to speak and be treated by another male who may better understand the changes, anatomy, and problems they’re experiencing may feel a bit less daunting. Our culture has made male masculinity fragile and I think some populations of men who need pelvic floor rehab may feel embarrassed to be treated by a female clinician if their perception of being seen by a female is emasculating. Ultimately, I think there needs to be more men in this field because there needs to be better visibility of male pelvic health providers in general, as well as better representation of men acknowledging that male pelvic floor disorders exist and are willing and able to treat them.
Eddie Gordon of Flow Rehab in Seattle (www.flowrehab.com)
There are far fewer male physiotherapists treating men with pelvic floor dysfunctions, but I am hopeful this will change for the better. Lack of access to male pelvic physios is a relative barrier to care because some men are more comfortable seeing a male pelvic provider the same way most women would prefer seeing a female pelvic physio. In general, men do not typically seek treatment as frequently or early enough the way most women do. If male pelvic physios are not available, then men may more likely delay treatment, which could potentially worsen their problem. Ironically, when it comes to men with pelvic floor dysfunctions, men are underrepresented, but I am hopeful that more male PT’s will be joining the movement to educate the male population.
Milan Patel of Comprehensive Therapy Services in San Diego (comprehensivetherapy.com)
I believe it's important to have male providers in the pelvic health field for many reasons, one being the opportunity for connection. I think we connect best with reflections of ourselves and for men seeking out a pelvic health provider that can be hard to find. In my experience, pelvic physical therapy works best when your patient can be open and honest, and establishing a strong connection between therapist and patient is the first step. Another reason is that people should have options for the provider they want. In San Diego I am the only male pelvic physical therapy provider which means most men seeking pelvic floor therapy have no choice but to see a female. If you switched the genders in the last sentence you could see how that is problematic. Many women prefer to have their pelvic PT be a female, I just think guys should get the same choice.
Steven Lavender of The Physical Therapy Practice NYC in New York (thephysicaltherapypractice.nyc)
In my experience as a gay male practitioner practicing pelvic floor physio on only men:
Gay male patients usually prefer a gay provider because they feel like they don’t have to explain lifestyle issues and choices, they may be unused to being touched by women, and maybe misogynistic.
Some straight men have told me that they think a male practitioner would know more about their pelvic issues than a woman. Some men don’t think women are strong enough nor have long enough fingers to get to the places they need to be. Some straight men report they might be attracted to a female therapist and get an erection or feel embarrassed about appearing unmanly with their particular pelvic condition.
For some men being touched by a woman is a religious issue so many males of the Jewish and Muslim faiths prefer to see a male practitioner.
Some men could not care less who sees them as long as they get better.
One woman called me for advice or for an appointment from some distance because they "figured a gay man in New York City just might know more about my ass and ass pain than any local jack-assed doctor in my neck of the woods." True story.
If you are interested in learning to treat male patients, the Male Pelvic Floor: Function, Dysfunction, and Treatment course is a great place to start! The course is taking place twice more in 2019, this September 13-15, 2019 in Pasadena, CA, and again in Fort Myers, FL on October 19-21, 2019. We are already booked four times in 2020 as well, so be sure to check out the full course schedule for all available dates.
We are thrilled to announce that Herman and Wallace instructor, Carolyn McManus, MPT, will co-present an educational session with internationally recognized pain researcher Etienne Vachon-Pressseau, PhD at APTA’s NEXT meeting in Chicago on June 13. Dr. Vachon-Presseau is an assistant professor at the Alan Edwards Centre for Research on Pain at McGill University and has led pioneering research into stress-associated brain changes in patients with persistent pain.
In a presentation entitled, When Stress Complicates Care for Your Patient in Pain: Evidence-Based Mechanisms and Treatment, Dr. Vachon-Presseau will discuss the latest research and theory illuminating the role of stress in the maladaptive neuroplastic brain changes observed in patients with chronic pain. Carolyn will discuss direct clinical applications of this marterial and highlight research on the role of mindfulness in the self-regulation of stress and pain. She will share a practical model for integrating mindfulness into physical therapy for the treatment of persistent pain conditions.
We are excited that Carolyn has been offered this honor to co-present at NEXT with a world renown researcher in the field of pain and contribute her insights from an over 30-year career specializing in mindfulness and pain. She will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into the field of physical therapy. Hope to see you there!
The following is our interview with Jose Antonio (Tony) Rodriguez Jr, COTA. Tony practices in Laredo, TX where he is also studying Athletic Training at the Texas A & M University. He recently attended Pelvic Floor Level 1 and plans to continue pursuing pelvic rehabilitation with Herman & Wallace. He was kind enoguh to share some thoughts about his experiences with us. Thank you, Tony!
Tell us a bit about yourself!
I am a COTA in Laredo where I was born and raised. My goal is to provide pelvic floor therapy to my community. I have been in school for quite some time. I have associate's degrees as a paramedic and occupational therapy assistant. I studied nursing briefly (finished my junior year). My bachelors is in psychology. I’m currently studying athletic training in Texas A & M International University in Laredo. My ultimate academic goal is acquiring my doctorate in physical therapy.
What/who inspired you to become involved in pelvic rehabilitation?
I first came across pelvic floor when reading the description of a CE course where it mentions its relation to SI joint dysfunction so I figured I could use this as a trouble shooting tool for those athletes that had recurrent low back pain or suspected SI problems. I figured at the very least I would know when I was confronted with something that I needed to refer. Little did I know how important of a “puzzle piece” this type of knowledge would become in helping me see a more complete picture of the human body. I was often confronted with athletes that would have recurring lower back pain, hip pain, glute tightness, sciatic nerve pain, adductor tightness or pain, and felt I was missing something to be able to help them. Even with a basic understanding of pelvic floor rehab I was able to help athletes with the previously mentioned complaints. As my understanding grew, I felt it was necessary I take these Herman & Wallace courses so that I could actually treat my patients in a holistic manner.
What is your clinical environment like, and how can you implement pelvic rehab into your practice?
My clinical environment varies between outpatient pediatrics, outpatient geriatrics, and D2 university athletics. I use my pelvic rehabilitation tool box at the university. Mostly I am still learning but I try to screen for and educate my athletes on the important role the pelvic floor muscles play in every activity they carry through out the day. I try to convey the importance not just in sports but also in activities of daily living such as any difficulty with going to the bathroom to pain during sex. I figure the more young people I educate about pelvic floor therapy the better they’ll be to make an informed decision today or later on in life.
Do you feel your background and training as a COTA brings anything unique to your pelvic rehab patients?
I could probably say that my COTA training makes it easier to pick up on some of the behaviors people might be relying on to carry out their day while dealing with pelvic floor issues. They may or may not be aware they have a pelvic floor dysfunction but simply think that’s just how they are. Behaviors such as avoiding social events because such activities don’t fit well with their voiding schedule.
How does your background as a COTA influence your approach to patient care?
My approach as a COTA would force me to see a balance in life. I would have to ask myself all the ways pelvic floor dysfunction may affect my client's daily activities from the basics like voiding, resting, sleep, to enjoying their leisure activities. A person cannot rest adequately if they’re in pain. He or she cannot enjoy social activities being worried of an urge.
What patients or conditions are you hoping to start treating as you continue learning pelvic rehab?
I wish to continue learning and exposing myself to different areas pelvic floor rehabilitation may take me. I wish to look at this therapy through a wide lens. This way I can learn, help many, and keep myself a well-rounded therapist. If in the future I feel more drawn to a specific area I wish to pull from all the different areas I should have learned by then.
What role do you see pelvic health playing in general well-being?
I often tell my athletes that there is probably not a single gross motor movement that doesn’t cross the pelvic region directly or through fascia connection. It is simply how we are built. To try and pretend or ignore the importance of the pelvic floor is just leaving our patients out of the appropriate care they need. And now that I know about the role pelvic floor muscles have in our body it would be unethical not to advocate for my patients’ COMPLETE well-being, pelvic floor muscles included.
What's next for you and your practice?
My short-term goal is acquiring my athletic training state license. After that continue with the last four or five prerequisite classes I need to apply to a DPT program. The DPT is my ultimate goal within the next five or six years.
This post was written by the teaching team of Nancy Cullinane, PT, MSH, Kathy Golic, PT, and Terri Lannigan DPT, who took their talents to Nairobi, Kenya to teach a modified version of Herman & Wallace's Pelvic Floor Level 1 course.
At the end of week 1 of Kenyan Pelvic Floor Level 1, we are pleased to report that 35 physiotherapists are embracing pelvic health physical therapy. Our students are primarily from the Nairobi area, however a handful have traveled from rural areas. The majority of them have some aspect of women's health in their job duties, however, only two have previously performed internal pelvic floor muscle techniques. On the first day of class, we spent significant introductory time discussing course objectives, students' clinical experience, Kenyan healthcare delivery, and what they hoped to gain from us. One student described teaching herself skills she is using in her clinical practice from watching YouTube videos. Another student commented, "the only tool I have to treat my patients is the kegel exercise and it isn't working for many of my patients. I know I'm missing something and I hope to find it here." The concept of internal pelvic floor muscle evaluation and treatment is new in Kenya and this is the first presentation of this coursework. There was significant anxiety surrounding internal pelvic muscle examination lab in the course. Several participants were not aware what "internal examination" meant in the course description when they registered. One student did not return on day two because of it. Nonetheless, as soon as the first internal assessment lab was completed, the pace picked up considerably.
These pioneering physiotherapists have developed new skills this past week for treating overactive bladder, mixed urinary incontinence, overactive pelvic floor muscles, prolapse, and diastasis recti. We have delved into discussion regarding sexual trauma and how cultural differences here in Kenya will impact the students' potential strategies in initiating conversations with their patients. Nine of our students are employed at Kenyatta National Hospital, the largest public hospital in Nairobi. Several are employed in private hospitals, who serve those citizens who pay to receive care in their respective systems. Many of our students are under-employed and some see patients privately in their homes, often for cash.
We have additional Herman & Wallace Pelvic Floor Level 1 curriculum planned for week two, but we will also present the additional curriculum we have written specifically for these Kenyan physiotherapists. We will dedicate ample time toward connecting these motivated students with global mentoring resources, but we will also lay groundwork in helping them to set up a support network for pelvic health PT with each other.
We are honored and grateful to Herman & Wallace for donating Pelvic Floor Level 1 curriculum and to The Jackson Clinics Foundation for its history in changing physical therapy delivery in Kenya, including the financing of travel for this course. We are also thankful to Kenya Medical Training College for covering the cost of instructor lodging. At the half way mark of level 1, we feel we have already received so much more than we have given. We are especially grateful to the 35 course participants who will be changing the face of women's health physical therapy in Kenya from here on. Improving the quality of life for women improves the quality of life for families, and has an overall positive impact on the community.
The photography from this course is the creation of Marielle Selig, who acted as both technical support and official photographer for the Kenya Pelvic Floor Level 1 course. More of her work will be posted at https://mariselig.pixieset.com/.
Andrea Wood, PT, DPT, WCS, PRPC is a pelvic health specialist at the University of Miami downtown location. She is a board certified women’s health clinical specialist (WCS) and a certified pelvic rehabilitation practitioner (PRPC). She is passionate about orthopedics and pelvic health. In her spare time, you can find her enjoying the south Florida outdoors.
Inflammatory bowel disease (IBD) includes the two diagnosis of Crohn’s Disease and Ulcerative Colitis. While both can cause similar health effects, the differences of the disease pathologies are listed below:1
|Ulcerative Colitis||Crohn’s Disease|
|Pattern of Damage||
Common complications experienced by patients with IBD include fecal incontinence, fecal urgency, night time soiling, urinary incontinence, abdominal pain, hip and core weakness, pelvic pain, fatigue, osteoporosis, and sarcopenia. In a sample of 1,092 patients with Crohn’s Disease, Ulcerative Colitis, or unclassified IBD, 57% reported fecal incontinence. Fecal incontinence was reported not only during periods of flare ups, but also during remission periods.2 One common factor affecting fecal incontinence is external anal sphincter fatigue. External anal sphincter fatigue has also been shown to be present in IBD patients who are not experiencing fecal incontinence or fecal urgency. IBD patients have been shown in studies to have similar baseline pressures versus healthy matched controls, thus indicating the possibility that deficits in endurance versus strength can play a larger role in fecal incontinence.3 Other factors contributing to fecal incontinence include post inflammatory changes that may alter anorectal sensitivity, anorectal compliance, neuromuscular coordination, and cause visceral hypersensitivity. Visceral hypersensitivity may be caused by continuous release of inflammatory mediators found in patients with IBD. It is also important to screen properly for incomplete bowel emptying and stool consistency to rule out overflow diarrhea or fecal impaction. Reports of need to splint digitally for full evacuation may indicate incomplete bowel emptying and defaectory disorders such as paradoxical contraction of the puborectalis muscle or rectocele. Anorectal manometry testing may be highly useful in identifying patients likely to improve from biofeedback therapy.4
Urinary incontinence can also be another secondary consequence to IBD. In a sample of 4,827 patients with IBD, 1/3 of responders reported urinary incontinence that was strongly associated with the presence of fecal incontinence. Frequent toilet visits for defecation may stimulate overactive bladder. Women were more likely to experience fecal incontinence versus men. One possible mechanism for increased fecal incontinence in women is men often have a longer and more complete anal sphincter that may be protective of fecal incontinence.5
Physical activity has been shown to be lower in patients with IBD versus healthy controls. 6, 7 Guiding IBD patients in proper exercises programs can have great benefits. Exercise may reduce inflammation in the gut and maintain the integrity of the intestines, reducing inflammatory bowel disease risk.8 It can also help increase bone mass density, an important factor in IBD patients who are at greater risk for osteoporosis. It has also been shown to help general fatigue in IBD patients. Patients with Crohn’s disease who participate in higher exercise levels may be less likely to develop active disease at 6 months. Treadmill training at 60% VO2 max and running three times a week has not been shown to evoke gastrointestinal symptoms in IBD patients. An increase of BMI predicts poorer outcomes and shorter time to first surgery in patients with Crohn’s disease.6
Conservative physical therapy interventions for treating IBD symptoms can include the following:
|Symptoms resulting from IBD||Physical Therapy Interventions|
|Fecal Incontinence (FI)||
Surgical interventions for IBD are dependent upon what type of disease the patient has and what areas of the intestines are affected the most. Surgery may be considered once the disease has become non responsive to medication therapy and quality of life continues to decline. A colectomy involves removing the colon while a proctocolectomy involves both removal of the colon and rectum. For ulcerative colitis patients, options include total proctocolectomy with end ileostomy or a restorative proctocolectomy with ileal pouch anal anastomosis. Restorative proctocolectomy eliminates the need for an ostomy bag making it the preferred surgery of choice if possible and gold standard for ulcerative colitis patients.10 For patients with Crohn’s disease, options include resection of part of the intestines followed by an anastomosis of the remaining healthy ends of the intestines, widening of the narrowed intestine in a procedure called a strictureplasty, colectomy or proctocolectomy, fistula repair, and removal of abscesses if needed.11
1. Crohn’s and Colitis Foundation. 2019. What is Crohn’s Disease. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/
2. Vollebregt PF, van Bodegraven A, Markus-de Kwaadsteniet T, et al. Impacts on perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease. Ailment Pharmacol Ther. 2018; 47: 1253-1260
3. Athanasios A, Kostantinos H, Tatsioni A et al. Increased fatigability of external anal sphincter in inflammatory bowel disease: significance in fecal urgency and incontinence. J Crohns Colitis (2010) 4: 553-560.
4. Nigam G, Limdi J, Vasant D. Current perspectives on the diagnosis and management of functional anorectal disorders in patients with inflammatory bowel disease. Therap Adv Gastroenterol. 2018 Dec 6: doi: 10.1177/1756284818816956
5. Norton C, Dibley L, Basset P. Faecal incontinence in inflammatory bowel disease: Associations and effect on quality of life. J Crohn’s Colitis. (2013) 7, e302-e311.
6. Biliski J, Mazur-Bialy A, Brzozowski B et al. Can exercise affect the course of inflammatory bowel disease? Experimental and clinical evidence. Pharmacological Reports. 2016 (68): 827-836.
7. Tew G, Jones K, Mikocka-Walus A. Physical activity habits, limitations, and preditors in people with inflammatory bowel disease: a large cross-sectional online survey. Inflamm Bowel Dis. 2016; 22(12): 2933-2942.
8. Vincenzo M, Villano I, Messina A. Exercise modifies the gut microbiota with positive health effects. Oxidative Medicine and Cellular Longevitiy. 2017: Article ID 3831972.
9. Cramer H, Schafer M, Schols M. Randomised clinical trial: yoga vs written self care advice for ulcerative colitis. Aliment Pharmacol Ther. 2017; 45: 1379-1389.
10. Cornish J, Wooding K, Tan E, et al. Study of sexual, urinary, and fecal function in females following restorative proctocolectomy. Inflamm Bowel Dis. 18 (9) 2012. 1601-160
11. Crohn’s and Colitis Foundation. 2019. Surgery Options. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/surgery-options.html
Today's guest post comes from Kelsea Cannon, PT, DPT, a pelvic health practitioner in Seattle, WA. Kelsea graduated from Des Moines University in 2010 and practices at Elizabeth Rogers Pilates and Physical Therapy.
Many studies done on pelvic floor muscle training largely have subjects who are Caucasian, moderately well educated, and receive one-on-one individualized care with consistent interventions. This led a group of researchers to investigate the occurrence of pelvic floor dysfunction, specifically pelvic organ prolapse (POP), in parous Nepali women. These women are known to have high incidences of POP and associated symptomology. Another impetus to perform this research: the discovery that there was a major lack of proper pelvic floor education for postpartum women. These women were commonly encouraged to engage their pelvic floor muscles via performing supine double leg lifts, sucking in their tummies/holding their breath/counting to ten, and squeezing their glutes. These exercises would be on a list of no-no’s here in the United States. In 2017, Delena Caagbay and her team of researchers discovered that in Nepal, no one really knew the correct way to teach proper pelvic floor muscle contractions, preventing the opportunity for women to better understand their pelvic floors. The team then set out to investigate the needs of this population, with the eventual goal of providing effective pelvic floor education for Nepali women.
Caagbay and her team first wanted to know what baseline muscle activity the Nepali women had in their pelvic girdle. Physical examinations and internal pelvic floor muscle strength assessments revealed that surprisingly there was a low prevalence of pelvic floor muscle defects, such as levator avulsions and anal sphincter trauma. Uterine prolapses were most common while rectoceles were comparatively less common. Their muscles were also strong and well-functioning, often averaging a 3/5 on the Modified Oxford Scale. It was hypothesized that these women had low prevalence of muscle injury because instruments were not commonly used during childbirth, they had lower birth weight babies, and the women were typically younger when giving birth (closer to 20-21 years old). But they had a high prevalence of POP even with good muscle tone? Researchers suggested that their incidence of POP is likely stemming from their sociocultural lifestyle requirements, as women are left to do most of the daily household chores and caregiving tasks while men often travelled away from the home to perform paid labor. Physical responsibilities for these women commonly begin at younger ages and while it helps promote good muscle tone, the heavier loading places pressure on the connective tissue and fascia that support the pelvic organs. Because of the demands of their lifestyles, Nepali women are often forced to return to their physically active state within a couple weeks after giving birth.
After assessing the current needs, cultural norms, and prevalence of POP in Nepali women, Caagbay et al created an illustrative pamphlet on how to contract pelvic floor muscles as well as provided verbal instruction on pelvic floor muscle activation. Transabdominal real time ultrasound was applied to assess the muscle contraction of 15 women after they received this education. Unfortunately, even after being taught how to engage their pelvic floor muscles, only 4 of 15 correctly contracted their pelvic floors.
This study highlighted that brief verbal instruction plus an illustrative pamphlet was not sufficient in teaching Nepali women how to correctly contract their pelvic floor muscles. Although there was a small sample size, these results can likely be extrapolated to the larger population. Further research is needed to determine how to effectively teach correct pelvic floor muscle awareness to women with low literacy and/or who reside in resource limited areas. Lastly, it is important to consider the significance of fascial and connective tissue integrity within the pelvic floor when addressing pelvic organ prolapse.
1 Can a leaflet with brief verbal instruction teach Napali women how to correctly contract their pelvic floor muscles? DM Caagbay, K Black, G Dangal, C Rayes-Greenow. Journal of Nepal Health Research Council 15 (2), 105-109.
2 Pelvic Health Podcast. Lori Forner. Pelvic organ prolapse in Nepali women with Delena Caagbay. May 31, 2018.
3 The prevalence of pelvic organ prolapse in a Nepali gynecology clinic. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Napean, University of Sydney.
4 The prevalence of major birth trauma in Nepali women. (2017) F. Turel, D. Caagbay, H.P. Dietz. Department of Obstetrics and Gynecology, Sydney Medical School Nepean, University of Sydney.
Going to the Combined Sections Meeting of the American Physical Therapy Association (CSM2019)? Look for Herman & Wallace instructor Carolyn McManus, MPT, MA at the educational session titled “Pain Talks: Conversations with Pain Science Leaders on the Future of the Field”. Carolyn will be a panelist along with Kathleen Sluka, PT, PhD, Steve George, PT, PhD, Carol Courtney, PT, PhD and Adriaan Louw, PT, PhD. The panel will be moderated by Derrick Sueki, DPT, PhD and Mark Shepherd, DPT, OCS.
These influential leaders will share how they personally became interested in the field of pain and discuss innovative pain treatment, as well as leading edge pain research and its translation into clinical practice. Initiatives to standardize entry-level curriculum, develop pathways to pain specialization and create post-professional opportunities such as pain-specific residencies and fellowships will be explored. The session will conclude with the leaders discussing their views on the future of pain and the role of physical therapy in its management. The audience will be able to submit questions via text or email to the moderator for individual or panel discussion.
We are thrilled to have Carolyn on our faculty and excited that she has been offered this honor to contribute insights from her over 30-year career experience in the field of pain with her colleagues at CSM2019. Carolyn will offer her popular courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland, OH on April 6 and 7, and Mindfulness-Based Pain Treatment in Portland, OR May 18 and 19, and Houston TX, October 26 and 27. We recommend these unique opportunities to train with a nationally recognized leader who pioneered the successful applications of mindfulness to the field of physical therapy. Hope to see you there!
"Over the next 30 years, growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population. Demand for care for pelvic floor disorders comes from a wide age range of women… These findings have broad implications for those responsible for administering programs to care for women, allocating research funds in women’s health and geriatrics, and training physicians to meet this rapidly escalating demand"
- Karl M. Luber, MD, Sally Boero, MD, Jennifer Y. Choe, MD. The demographics of pelvic floor disorders: Current observations and future projections. Presented at the Sixty-seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Kamuela, Hawaii, November 14-19, 2000.
Patients with pelvic floor dysfunction have suffered for many years without knowing the names of their ailments. Chronic pain, constipation, incontinence, sexual dysfunction, and other pelvic conditions have a long history of being under-reported, misdiagnosed, and untreated. Shelby Hadden recounts in her animated documentary "Tightly Wound" being told by her doctor to treat vaginismus with a glass of wine before intimacy. She is not the only woman to be given such advice. It is going to take many voices to break through the years of misinformation and stigma that has impeded patients' ability to get treatment.
Thankfully the healthcare landscape has begun to shift. We seem to be on the cusp of a renaissance in pelvic care as patients become more aware of their treatment options. It is the mission of Herman & Wallace to help patients access a higher quality of care, through our courses and through our practitioner directory at https://pelvicrehab.com/. Patient education resources and practitioner directories are a big step in bringing about this awakening, and we believe that the more information the public has access to, the better. Ours is just one of several websites where patients can find learn about their conditions and find qualified clinicians to evaluate them and craft treatment regimens.
We hope that patients find pelvicrehab.com useful, and also encourage them to check out some other great resources. The Section on Women's Health operates a PT Locator available at https://ptl.womenshealthapta.org, and Pelvic Guru has been doing incredible work (see their robust patient portal at https://pelvicguru.com/for-patients/). Patients can also find helpful information via the International Pelvic Pain Society (IPPS) website at https://pelvicpain.org.
As an Institute, we've had the privilege of working with so many impassioned therapists, and we are excited to see so many of them out there in the world spreading awareness and knowledge so that patients get the care they need. We know there are many others working in the field and we hope you will tag and share your patient resources in the comments on this post.
Authors: Tamara Rial, PhD, CSPS, Kathleen Doyle-Elmer, PT, DPT and Rebecca Keller, PT, MSPT, PRPC
Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care Level 2 and 3 in Princeton, New Jersey in September, 2019. Rebecca Keller and Kathleen Doyle-Elmer are certified Low-Pressure Fitness specialists with training in rehabilitative ultrasound imaging. In this article, the authors discuss and explore the use of transabdominal ultrasound during Low Pressure Fitness on the abdominal and pelvic floor structures.
Real-time ultrasound imaging is a reliable and valid method to evaluate muscle structure, activity and mobility. Over the past few years, there has been increasing interest in the use of transabdominal ultrasound in the field of rehabilitation. The additional value of ultrasound imaging is that it allows for real-time analysis and visual feedback during the performance of pelvic floor and abdominal exercises (Hides et al., 1998). In the field of pelvic health, this is of notable importance when assessing proper movement of the deep abdominal and pelvic muscles during voluntary muscle actions. Transabdominal ultrasound has been found to be a safe, noninvasive, and accurate method to assess and observe muscular and fascial activity (Khorasani et al., 2012). When therapists learn how to properly use and apply ultrasound imaging, this technique can be a comprehensive tool for the clinician and a comfortable procedure for the patient. Moreover, it may be the method of choice for some patients who don’t want to have an internal pelvic examination (Van Delft, Thakar & Sultan, 2015). In this regard, a cross-sectional study found a moderate-to-strong correlation between ultrasound measurements and both digital examination and perineometry for the assessment of pelvic floor muscle actions (Volløyhaug et al., 2016).
Recently, Low Pressure Fitness has gained popularity as a pelvic floor training program aimed at reducing pressure on the pelvic structures while engaging the stabilizing muscles through postural and breathing exercises. In order to evaluate proper execution of Low-Pressure Fitness exercises as well as abdomino-pelvic muscle function during this type of training, real-time transabdominal ultrasound can be a clinically relevant tool.
The amount of movement of the bladder base on transabdominal ultrasound is considered an indicator of pelvic floor muscle mobility during pelvic floor muscle exercises (Khorasani et al., 2012). When properly executed, the Low-Pressure Fitness technique will allow the bladder to lift and the pelvic floor muscles to contract. These observed actions can be cued and progressed due to the real-time imaging biofeedback of the ultrasound. Because of the postural activation and diaphragm lift occurring during Low Pressure Fitness, the bladder fascial support system is tensioned resulting in a desirable bladder lift.
For example, we used a Pathway® Musculoskeletal Rehabilitative Ultrasound Imaging unit with a curvilinear transducer and Prometheus Pathway® rehabilitative ultrasound software utilizing the pre-set parameters (Abdominal Wall 7.5MHz and Bladder 5.0MHz) during a Low-Pressure Fitness basic supine posture. A standardized bladder filling protocol was used before imaging to ensure sufficient bladder filling to allow clear imaging of the base of the bladder and pelvic floor muscles.
For the transverse view, radiologic standards were used, and the ultrasound transducer was placed in the transverse plane suprapubically and angled in a caudal/ posterior direction to obtain a clear image of the inferior-posterior aspect of the bladder. The participant was asked to perform the Low-Pressure Fitness Demeter exercise in the supine position with a neutral pelvis and knees flexed (Figure 1).
The following video illustrates the pelvic floor/urinary bladder during: a) resting position; b) active pelvic floor contraction; c) Low Pressure Fitness Demeter exercise and; d) Low Pressure Fitness Demeter exercise combined with a voluntary pelvic floor muscle contraction. It is noticeable a greater bladder lift and pelvic floor activation with the postural and breathing cueing added to an active pelvic floor contraction than with the pelvic floor contraction alone.
The lateral abdominal muscle ultrasound assessment allows us to observe the structural changes produced in the transversal section of the abdominal muscles in the midpoint between the anterior iliac crest and the costal angle. At low levels of contraction, the extent of transverse abdominis thickening measured using ultrasound is reported to be a valid method of assessment compared with either fine wire electromyographic measures of transverse activity (McMeeken et al., 2004). It is well established in the scientific literature that the lateral abdominal muscles provide stability to the trunk in different functional activities. Therefore, the assessment of the size, thickness and sliding of the abdominal wall is important for patients who present with lumbo-pelvic and/or pelvic floor dysfunctions. In this regard, patients with low back pain show different abdominal wall muscle activation patterns (i.e. less slide of the abdominal fascia and muscle thickness) than those without low back pain (Gildea et al., 2014; Unsgaard-Tondel et al., 2012).
Figure 2 shows the three muscle layers of the lateral wall in the resting position. The superficial layer corresponds to the external oblique, the middle layer to the internal oblique and the deep layer to the transverse abdominal muscle.
A key breathing component of the Low-Pressure Fitness program is the abdominal vacuum which manipulates intra-abdominal, intra-thoracic and intra-pelvic pressures during the breath-holding phase. Another key aspect of Low-Pressure Fitness is the shoulder girdle activation, spine elongation and ankle-dorsiflexion (Rial & Pinsach, 2017). Of note, previous studies have demonstrated greater transverse abdominis activation when performing ankle dorsi-flexion (Chon et al., 2010). We used transabdominal ultrasound to assess the lateral abdominal wall response during ankle dorsiflexion, shoulder girdle activation and the abdominal vacuum during Low Pressure Fitness.
In the following video, a voluntary (active) abdominal contraction is performed in order to distinguish this action from the involuntary abdominal contractions during Low Pressure Fitness. Afterwards, the postural technique of ankle dorsiflexion and shoulder girdle activation are performed in the Demeter exercise with arms in middle position (Figure 1). Lastly, an abdominal vacuum maneuver is added to the postural technique. If the exercises are properly executed, the progressive sliding and thickness of the abdominal muscles throughout exercise sequence should be observable (Figure 3).
Muscle thickness of the transverse and internal oblique as well as a noticeable slide of the anterior abdominal fascia are observable during the Demeter exercise of Low-Pressure Fitness. This exercise pattern reflects an abdominal draw-in maneuver and a “corseting effect”. In this regard, notice the lateral pull or displacement of the edge of the anterior fascial insertion of the transverse the internal oblique muscle.
Navarro et al., (2017) used transabdominal ultrasound to assess the muscular responses of the pelvic floor and abdominal muscles in a group of women who underwent pelvic physiotherapy over two months. They found a significant increase in the transversal section of the transverse abdominis, external oblique, and internal oblique muscles when compared to resting in the supine position. Similar to the position assessed by Navarro et al. (2017), we also assessed the pelvic floor and abdominal muscle responses during a Low-Pressure Fitness supine exercise.
Transabdominal ultrasound can provide a noninvasive and informative visual biofeedback when training patients with Low Pressure Fitness. This ultrasound imaging can be a valuable tool to both the client and the clinician to objectify progress, assist with validating correct Low-Pressure Fitness form with positioning and vacuum/hypopressive maneuver as well as a motivational technique for the client. As demonstrated during our rehabilitative ultrasound imaging, observable bladder lift, pelvic floor activation and desirable lateral abdominal muscular corseting (slide and thicking) occurs during Low Pressure Fitness postural exercises and breathing. Since Low Pressure Fitness is a progressive exercise program, qualified instruction, technique driven progression and understanding pelvic floor health are needed to optimize patient outcomes.
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