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.
Chon SC, Chang KY, You JS. Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study. Physiotherapy 96: 130-6, 2017.
Gildea JE, Hides JA, Hodges PW. Morphology of the abdominal muscles in ballet dancers with and without low back pain: a magnetic resonance imaging study. J Sci Med Sport. 17(5): 452-6, 2014.
Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology, 80: 673-7, 2012.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19: 337–342, 2004.
Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther. 3:125-131,1998.
Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia 39: 187-94, 2017.
Rial T, Pinsach P. Practical Manual Low Pressure Fitness Level 1. International Hypopressive & Physical Therapy Institute, Vigo, 2017.
Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen J, Vasseljen O. Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up. Br J Sports Med, 46(10): 729-34, 2012.
Van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol, 45: 217-22, 2015. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. Ultrasound Obstet Gynecol 47: 768-73, 2016.
Adina Leifer, PT, DPT, PRPC recently passed the Pelvic Rehabilitation Practitioner Certification exam and was kind enough to discuss her career with us. Adina Leifer, PT, DPT, PRPC practices at ABLe Pelvic Physical Therapy in Atlanta, GA. Thank you for the interview, Dr. Leifer, and congratulations on earning your certification!
How did you get involved in the pelvic rehabilitation field?
After graduating from Touro College, and receiving my Doctorate of Physical Therapy. I began to work in an outpatient sports rehab setting. While looking for continuing education courses, I happened upon Herman and Wallace through the Touro College website. They were hosting PF1 at their New York City campus. I knew nothing about pelvic health and rehabilitation at that time. Holly Herman and Tracy Sher taught that first class, after 3 days of class, I was hooked. I knew that pelvic health and wellness was my calling. It has been 9 years since I took that first course and I could not be happier.
What patient population do you find most rewarding in treating and why?
Not sure I can pick one diagnosis or patient population as my favorite. I feel that with each patient that comes to see me, they have either lost ability or do not have normal function of their bladder, bowel or sexual functioning. When I can treat them successfully and educate patients in proper strength and mobility of their pelvic muscles. When I can provide them with the tools so that they can function in their lives, there is nothing more rewarding then that.
Describe your clinical practice:
I currently have my own outpatient practice in Atlanta, GA. I treat adult men and women with any and all pelvic muscle dysfunction and diagnoses.
What has been your favorite Herman & Wallace Course and why?
My favorite course from Herman & Wallace was the capstone course given by Nari Clemons and Jennafer Vande Vegte. I felt this course was informative with practical hands on information for everyday patient treatment. As well as, really helping me to prepare for the PRPC exam.
What motivated you to earn PRPC?
Having practiced for over 9 years and taken many courses through Herman & Wallace, I felt my knowledge and experience made me a specialist. As I was building my own practice, I felt that I wanted the credentials and letters after my name to prove that I was truly a specialist in this field.
What advice would you give to physical therapists interested in earning PRPC?
Go for it! Study the coursework and anatomy. Trust in the knowledge that you have and take the test! You will be very happy that you did.
Certified Pelvic Rehabilitation Practitioners have experience treating a wide variety of pelvic floor dysfunction conditions in men and women throughout the lifecycle. Each certified practitioner has passed a comprehensive exam, and has directly treated pelvic patients for more than 2,000 hours. To learn more about the Pelvic Rehabilitation Practitioner Certification, visit our certification page.
Faculty member Nari Clemons, PT, PRPC recently created a two-course series on the manual assessment and treatment of nerves. The two courses, Lumbar Nerve Manual Assessment and Treatment and Sacral Nerve Manual Assessment and Treatment, are a comprehensive look at the nervous system and the various nerve dysfunctions that can impact pelvic health. The Pelvic Rehab Report caught up with Nari to discuss these new courses and how they will benefit pelvic rehab practitioners.
What is "new" in our understanding of nerves? Are there any recent exciting studies that will be incorporated into this course?
The course is loaded with a potpourri of research regarding nerves and histological and morphological studies. There are some fascinating correlations we see with nerve restrictions, wherever they are in the body. Frequently the nerves are compressed in fascial tunnels or areas of muscular overlap, then the nerve, wherever the location, frequently has local vascular axonal change, which increases the diameter of the nerve and prohibits gliding without pain. This causes local guarding and protective mechanisms. Changing pressure on the nerve can change that axonal swelling and allow gliding without pain.
New pain theory also supports that much of pain perception is the body perceiving danger or injury to a nerve. By clearing up the path of the nerve and mobilizing it, we can decrease the body's perception of nerve entrapment and thus create change in pain levels.
What do you hope practitioners will get out of this series that they can't find anywhere else?
I hope they will leave the course able to treat the nerves of the region, which is essentially the transmission pathway for most pelvic pain. I don't know of other courses that have this emphasis.
You've recently split your nerve course in two. Why the split?
I didn't want this class to be a bunch of nerve theory without the manual intervention to make change. After running the labs in local study groups, we found it took more time for people's hands to learn the language, art, and techniques of nerve work. To truly do the work justice and for participants to have a firm grasp of the manual techniques without being rushed, we found it takes time, and I wanted to honor that, as well as treating enough of the related factors and anatomy to make real and lasting change for patients.
How did you decide to divide up content?
Basically, we divided them up by anatomical origin:
The lumbar course covers the nerves of the lumbar plexus, the abdominal wall when treating diastasis, and treatment of the inguinal canal (obturator nerve, femoral nerve, iliohypogastric, ilioinguinal, genitofemoral nerves). Also, the lumbar nerves have more effect in the anterior hip, anterior pelvis, and abdominal wall.
The sacral nerve course covers all the nerves of the sacral plexus (pudendal, sciatic, gluteal/cluneal, posterior femoral cutaneous, sciatic, and coccygeal nerves), as well as subtle issues in the sacral base and subtle coccyx derangement work as well as the relationship with the uterus and sacrum, to take pressure off the sacral plexus. The sacral nerves have more effect in the posterior and inferior pelvis and into the posterior leg and gluteals.
What are the main stories that either course tells?
Both courses tell the story of getting closer to the root of the pain to make more change in less time. Muscles generally just respond to the message the nerve is sending. Yet, by treating the nerve compression directly, we are getting much closer to the root of the issue and have more lasting results by changing the source of abnormal muscle tone. Rather than an intellectual exercise of discourse on nerves, we devote ourselves to the art of manual therapy to change the restrictions on the pathway of the nerve and in the nerve itself.
If someone went to the old nerve course, what's the next best step for them?
The first course was initially all the lumbar nerves with a dip into the pudendal nerve. They would want to take the sacral nerve course, as those nerves were not covered in the first round.
Anything else you would like to share about these courses?
Sure. Essentially, we will take each nerve and do the following:
Join Nari at one of the following events to learn valuable evaluation and treatment techniques for sacral and lumbar nerves
Upcoming sacral nerve courses:
Sacral Nerve Manual Assessment and Treatment - Winfield, IL
Oct 11, 2019 - Oct 13, 2019
Sacral Nerve Manual Assessment and Treatment - Tampa, FL
Dec 6, 2019 - Dec 8, 2019
Upcoming lumbar nerve courses:
Lumbar Nerve Manual Assessment and Treatment - Phoenix, AZ
Jan 11, 2019 - Jan 13, 2019
Lumbar Nerve Manual Assessment and Treatment - San Diego, CA
May 3, 2019 - May 5, 2019
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 care” in Princeton, New Jersey in July, 2018. Tamara is internationally recognized for her work with hypopressive exercise and Low Pressure Fitness. In this article she presents the novel topic of hypopressives as a complementary pelvic floor muscle training tool for incontinence after prostate cancer surgery.
Urinary Incontinence is the most common side effect men suffer after prostate cancer surgery along with erectile dysfunction. Although it is not life threatening, urinary incontinence definitely has a negative impact on the patient’s quality of life Sountoulides et al., 2013. Beyond the frustration and embarrassment associated with pelvic floor dysfunction, many patients describe it as depressing, disheartening and devastating.
The first line of conservative treatment - and most often recommended - is pelvic floor muscle training Andersen et al., 2015. Over the past few years, some researchers have also recommended alternative exercise programs with a holistic approach such as Pilates and hypopressives to improve the patient’s quality of life and urinary incontinence symptoms (Santa Mina et al., 2015). These alternative pelvic floor muscle training programs draw upon the connection between the pelvic floor, it’s synergistic muscles (abdominal, pelvic, lumbar) and their interrelated role in posture and breathing Hodges, 2007; Sapsford, 2004; Madill and McLean, 2008; Talasz et al., 2010. Among these complementary exercise programs, hypopressives have gained increasing attention for the recovery of post-prostatectomy urinary incontinence Santa Mina et al., 2015; Mallol-Badellino, et al. 2015.
Although hypopressive exercise has become popular for women, some researchers, clinicians and practitioners have begun to apply these exercises for specific male issues such as urinary incontinence following a prostatectomy. Recently, a case-study I co-authored about an adapted program of hypopressive exercise for urinary incontinence following a radical prostatectomy surgery was published in the Journal of the Spanish physiotherapy association Chulvi-Medrano & Rial, 2018. We describe the case of a 46-year-old male with severe stress urinary incontinence six months after surgery. We used a pelvic floor exercise program consisting of hypopressive exercises as described in the Low Pressure Fitness level 1 practical manual Rial & Pinsach, 2017 combined with contraction of the pelvic floor muscles. Satisfactory results were obtained after the rehabilitation protocol as evidenced by a reduction from 3 daily pads to none. Of note, clinical trails have demonstrated the benefits of initiating a rehabilitation program to strengthen the pelvic floor as soon as possible after prostatectomy. Previously, I’ve studied hypopressive exercise for female urinary incontinence Rial et al., 2015 and for the improvement of female athletes pelvic floor function Álvarez et al., 2016. However, this was the first time we’ve studied hypopressives in the context of male urinary leakage.
In the same light, other researchers have also included hypopressives in their pelvic floor training protocol for post-prostatectomy urinary incontinence. For example, Serda et al (2010) and Mallol-Badellino (2015) used protocols that combined pelvic floor contractions with postural re-education and hypopressives. Both studies found improvements in the severity of involuntary leakages and improvements in the patients’ quality of life. Similar results are also described in the clinical case by Scarpelini et al. (2014) who used hypopressives and psoas stretching exercises to reduce urinary incontinence after prostatectomy.
The hypothesis underlying the use of hypopressives as a complementary pelvic floor and core exercise program is that it retrains the core system with specific postural and breathing strategies while reducing pressure on the pelvic organs and structures. The most striking part of hypopressives breathing technique is the abdominal vacuum. This breathing maneuver involves a low pulmonary volume exhale-hold technique followed by a rib-cage expansion involving the activation of the inspiratory muscles. The rib-cage expansion during the breath-holding phase leads to a noticeable draw-in of the abdominal wall and simultaneously to the rise of the thoracic diaphragm. Recent observational studies have shown how the hypopressive technique was able to elevate the pelvic viscera and to activate the pelvic floor and deep core muscles in women trained with hypopressives Navarro et al., 2017. From an historical point of view, this characteristic breathing maneuver was first described and practiced as a yoga pranayama called Uddiyanha Bandha Omkar & Vishwas, 2009.
In addition to breath control, the hypopressive technique involves a series of static and dynamic poses which operate on the hypothesis of training the stabilizing muscles of the spine, such as the core and pelvic muscles. In this sense, hypopressives are not exclusively a breathing technique, but rather they are an integrated whole-body technique. The practice of hypopressives involves body control, body awareness, postural correction and mindfulness throughout its different poses and postural techniques. The introduction of holistic exercise programs to train the synergist pelvic floor muscles and breathing patterns can be viewed as complementary tools for the restoration of a patient’s body awareness and functionality.
Another hypothesis of the effects of the hypopressive-breathing in the pelvic floor is the ability to move the pelvic viscera cranially as a consequence of the ribcage opening up after the breath-hold. This vacuum lifts the diaphragm and consequently creates an upward tension on the transversalis fascia, the peritoneum and other related fascial structures. In addition to the diaphragmatic suction effect, a correct alignment of the rib cage and pelvis during the exercise contributes to an improved suspension and position of the viscera in the pelvis. The mobility achieved with the breathing and its body sensations may be one of the reasons why hypopressives have also been recommended as a proprioceptive facilitator for those with low ability to “find their pelvic floor” Latorre et al., 2011.
It’s crucial to highlight that a complete surgical resection of the prostate will cause - in most of the cases - post-operative fibrosis and neurovascular damage Hoy-Land et al., 2014. Both, the neurovascular and musculoskeletal injuries are contributing factors for urinary incontinence post-prostatectomy. Subsequently, exercises focusing on increasing local vascular irrigation and re-activating the damaged musculature have been highlighted as the main goals to help patients recover continence. In this sense, breathing movements, fascia manipulation and decreased pelvic pressure can result in increased vascular supply. A previous study has shown an improvement in venous return of the femoral artery during the hypopressive-breathing maneuver Thyl et al., 2009. Collectively, all these factors may favor microcirculation in the pelvic area. Finally, the muscle activation of the pelvic floor and core muscles observed during the practice of hypopressives (Ithamar et al., 2017) and the changes of puborectalis and iliococcygeus muscles after an intensive pelvic floor muscle training (Dierick et al., 2018) are other factors that could have impact on urge incontinence, stress incontinence and overflow incontinence symptoms common after prostatectomy surgeries.
To date, the results from these investigations and clinical reports open new complementary pelvic floor training strategies for the treatment of post-prostatectomy incontinence. Hypopressives and pelvic floor muscle exercises are non-invasive, don’t require expensive material, and provide an exercise-based approach as part of a healthy lifestyle. However, qualified instruction, technique-driven progression and adherence to the intervention are critical components of any pelvic floor and hypopressive training protocol.
Álvarez M, Rial T, Chulvi-Medrano I, García-Soidán JL, Cortell JM. 2016. Can an eight-week program based on the hypopressive technique produce changes in pelvic floor function and body composition in female rugby players? Retos nuevas Tendencias en Educación Física, Deporte y Recreación, 30(2): 26-29.
Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM. 2015. Conservative management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev, 1:CD001843.
Chulvi-Medrano I, Rial T. 2018. A case study of hypopressive exercise adapted for urinary incontinence following radical prostactetomy surgery. Fisioterapia, 40, 101-4. Doi: DOI: 10.1016/j.ft.2018.01.004
Dierick F, Galrsova E, Laura C, Buisseret F, Bouché FB, Martin L. 2018. Clinical and MRI changes of puborectalis and iliococcygeus after a short period of intensive pelvic floor muscles training with or without instrumentation. European Journal of Applied Physiology, doi:10.1007/s00421-018-3899-7
Ithamar, L., de Moura Filho, A.G., Benedetti-Rodrigues, M.A., Duque-Cortez, K.C., Machado, V.G., de Paiva-Lima, C.R.O., et al. 2017. Abdominal and pelvic floor electromyographic analysis during abdominal hypopressive gymnastics. J. Bodywork. Mov. Ther. doi: 10.1016/j.jbmt.2017.06.011.
Latorre G, Seleme M, Resende AP, Stüpp L, Berghmans B. Hypopressive gymnastics: evidences for an alternative training for women with local proprioceptive deficit of the pelvic floor muscles. Fisioterapia Brasil 2011; 12(6): 463-6.
Hodges P. 2007. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn, 26(3): 362-371.
Hoyland K, Vasdev N, Abrof A, Boustead G. 2014. Post-radical prostatectomy incontinence: etiology and prevention. Rev Urol. 16(4), 181-8.
Madill, S., McLean, L. 2008. Quantification of abdominal and pelvic floor muscle synergies in response to voluntary pelvic floor muscle ontractions. J. Electromyogr. Kinesiol. 18, 955-64. doi: 10.1016/j.jelekin.2007.05.001.
Mallol-Badellino J., et al. 2015. Resultados en la calidad de vida y la severidad de la incontinencia urinaria en varones prostatectomizados por neoplasia de próstata. Rehabilitación, 49(4); 210-215.
Navarro, B., Torres, M., Arranz, B. Sánchez, O. 2017. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia. 39, 187-194. doi:10.1016/j.ft.2017.04.003.
Omkar, S., Vishwas, B. 2009. Yoga techniques as a means of core stability training. J. Bodywork Mov. Thep. 13, 98-103. doi: 10.1016/j.jbmt.2007.10.004.
Rial T, Chulvi-Medrano I, Cortell-Tormo JM, Álvarez M. 2015. Can an exercise program based on hypopressive technique improve the impact of urinary incontinence on women´s quality of life? Suelo Pélvico, 11:27-32.
Rial, T., Pinsach, P. 2017. Low Pressure Fitness practical manual level 1. International Hypopressive and Physical Therapy Institute, Vigo.
Santa Mina D, Au D, Alibhai S, Jamnicky L, Faghani N, Hilton W, Stefanky L, et al. 2015. A pilot randomized trial of conventional versus advanced pelvic floor exercises on treat urinary incontinence after radical prostatectomy: a study protocol. BMC Urology, 15. DOI 10.1186/s12894-015-0088-4
Sapsford R. 2004. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther, 9(1): 3-12.
Serdá B, Vesa, A. del Valle, y Monreal P. 2010. La incontinencia urinaria en el cáncer de próstata: diseño de un programa de rehabilitación. Actas Urológicas Españolas, 34(6): 522-30.
Scarpelini P, Andressa Oliveira F, Gabriela Cabrinha S, Cinira H. 2014. Protocolo de ginástica hipopressiva no tratamento da incontinência urinária pós-prostatectomia: relato de caso. UNILUS Ensino e Pesquisa, 11(23): 90-95
Talasz, H., Kofler, M., Kalchschmid, E., Pretterklieber, M., Lechleitner, M. 2010. Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women. Int. Urogynecol. J. 21, 475-81. doi: 10.1007/s00192-009-1060-1.
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Exciting news! Carolyn McManus, Herman & Wallace instructor of Mindfulness-Based Pain Treatment, will be a presenter in programming at the International Association for the Study of Pain (IASP) World Congress on Pain in to be held in Boston, September 11 - 16. This conference brings together experts from around the globe practicing in multiple disciplines to share new developments in pain research, treatment and education. Participants from over 130 countries are expected to attend. The last time it was held in the U.S. was 2002, so it presents an especially exciting opportunity for those interested in pain to have this international program taking place in the U.S. Carolyn will present a workshop on mindfulness in a Satellite Symposia, Pain, Mind and Movement: Applying Science to the Clinic.
Carolyn has been a leader in bringing mindfulness into healthcare throughout her over-30 year career. She recognized early on in her practice how stress amplified patients’ symptoms and, as she had seen the benefits of mindfulness in her own life, it was a natural progression to integrate mindful principles and practices into her patient care. An instructor for Herman and Wallace since 2014, she has developed two popular courses, Mindfulness-Based Pain Treatment and Mindfulness for Rehabilitation Professionals, enabling her to share her clinical and research experiences with her colleagues.
For many patients, pain is not linearly related to tissue damage and interventions based on structural impairment alone are inadequate to provide full symptom relief. Mindfulness training can offer a key ingredient necessary for a patient to make additional progress in treatment. By learning therapeutic strategies to build body awareness and calm an over-active sympathetic nervous system, patients can mitigate or prevent stress-induced symptom escalation. They can learn to move with trust and confidence rather than fear and hesitation.
A growing body of research in mindfulness-based therapies demonstrates multiples benefits for patients suffering with pain conditions. Research suggests that mindfulness training can be helpful to women preparing for childbirth and patients suffering from fibromyalgia, pelvic pain, IBS and low back pain. In addition, for patients with anxiety, mindfulness training may contribute to reductions in anxiety and in adrenocorticopropic hormone and proinflammatory cytokine release in response to stress. Authors of this study conclude that these large reductions in stress biomarkers provide evidence that mindfulness training may enhance resilience to stress in patients with anxiety disorders.
In addition to her presentation at the IASP World Congress Satellite Symposia, Carolyn will be sharing a more in-depth examination and practice of mindfulness in her upcoming course Mindfulness-Based Pain Treatment, August 4 and 5 at Virginia Hospital Center, Arlington VA, and again November 3 and 4 at Pacific Medical Center in Seattle, WA. Please join an internationally-recognized expert for 2 days of innovative training in mindfulness that will both improve your patient outcomes and enhance your own well-being!
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Garland EL, Gaylord SA, Paisson O. Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral sensitivity, catastrophizing and affective processing of pain sensations. J Behav Med. 2012;35(6):591-602.
Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized Clinical Trial. JAMA. 2016;315(12):1240-9.
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The following is a guest submission from Alysson Striner, PT, DPT, PRPC. Dr. Striner became a Certified Pelvic Rehabilitation Practitioner (PRPC) in May of 2018. She specializes in pelvic rehabilitation, general outpatient orthopedics, and aquatics and treats at Carondelet St Joesph’s Hospital in the Speciality Rehab Clinic located in Tucson, Arizona.
Recently, I had a patient present with Complex Regional Pain Syndrome (CRPS) on his right foot. He stated that the pain had started about 10 days after his prostatectomy when someone had fallen onto his right foot. He reported a bunionectomy on that foot 7 years prior and noted an episode of plantar facilities before his prostatectomy. CRPS is defined as “chronic neurologic condition involving the limbs characterized by severe pain along with sensory, autonomic, motor, and trophic impairments” in a 2017 article "Complex regional pain syndrome; a recent update" by Goh, En Lin. The article goes on to discuss how CRPS can set off a cascade of problems including altered cutaneous innervation, central and peripheral sensitization, altered sympathetic nervous system function, circulating catecholamines, changes in autoimmunity, and neuroplasticity.
A recent persistent pain theory to explain the relationship between pelvic floor and his foot could be overflow or ‘smudging’ in his homunculus. The homunculus is the map of our physical body in our brain where the feet are located next to the genitals. Possibly when one has pain, there can be ‘smudging’ of our mental body map from one area into another. I have heard this explained as though a chalk or charcoal drawing has been swipes their hand through the picture. A recent study by Schrabrun, SM et al “Smudging of the Motor Cortex is Related to the Severity of Low Back Pain” found that people with chronic low back pain had a loss of cortical organization which and that this loss was associated with the severity and location of LBP.
There are many ways to improve the organization of the homunculus and create neuroplasticity. One such way was suggested is with Transcutaneous electrical nerve stimulation (TENS) to the bottom of the foot to affect bladder spasms and pain. In recent study, “Transcutaneous electrical stimulation of somatic afferent nerves of the foot relieved symptoms related to postoperative bladder spasms,". Zhang, C et al. 2017 found that participates that had either a bladder surgery or a prostate surgery had improvement in bladder spasm symptoms and VAS scores on day two and three. Their protocol was to use two electrodes over the bottom of the foot at 5 Hz with 0.2 millisecond pulse width until a muscle twitch was achieved and was increased, but still comfortable for an hour (there is a picture of electrode placement in the article). The authors note that this neuromodulation of the foot sensory nerves may inhibit interactions between the somatic peripheral neuropathway and autonomic micturition reflex to calm the bladder and pain.
No matter what we do to help calm nervous systems from the top down; pain neuroscience education, mindful based relaxation, graded motor imagery, or from the bottom up; de-sensitization, biofeedback, or good old-fashioned TENS. The result is the same; a cortical organization and happier patients.
En Lin Goh†, Swathikan Chidambaram† and Daqing Ma. "Complex regional pain syndrome: a recent update". Burns & Trauma 2017 5:2.https://doi.org/10.1186/s41038-016-0066-4"
Schabrun SM, Elgueta-Cancino EL, Hodges PW. "Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain." Spine (Phila Pa 1976). 2017 Aug 1;42(15):1172-1178. doi: 10.1097/BRS.0000000000000938
Chanjuan Zhang, et al. "Transcutaneous electrical stimulation of somatic afferent nerves in the foot relieved symptoms related to postoperative bladder spasms". BMC Urol. 2017; 17: 58. doi: 10.1186/s12894-017-0248-9
Kelly Feddema, PT, PRPC returns in a guest post on Pregnancy Associated Ligamentous Laxity. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. See her post on diastasis recti abdominis on the pelvic rehab report, and learn more about evaluating and treating pregnant patients by attending Care of the Pregnant Patient!
Pregnancy associated ligamentous laxity is something that we, as therapists, are fairly well aware of and see the ramifications of quite often in the clinic. We know the female body is changing to allow the mother to prepare for the growth and birth of the tiny (or sometimes not so tiny) human she is carrying. We also know that the body continues to evolve after the birth to eventually return to a post-partum state of hormonal balance. Do we think much about what this ligamentous laxity can mean during the actual delivery? Does laxity predispose women to other obstetric injury?
A recent study in the International Urogynecology Journal assessed ligamentous laxity from the 36th week of pregnancy to the onset of labor by measuring the passive extension of the non-dominant index finger with a torque applied to the second metacarpal phalangeal joint. They collected the occurrence and classification of perineal tears in 272 out of 300 women who ended up with vaginal deliveries and looked for a predictive level of second metacarpophalangeal joint (MCP) laxity for obstetric anal sphincter injury (OASI). They concluded that the increased ligamentous laxity did seem associated with OASI occurrence which was opposite of their initial idea that more lax ligaments would be at less of a risk of OASI.
In another study from the same journal published in 2017, researchers studied if levator hiatus distension was associated with peripheral ligamentous laxity during pregnancy. This was a small study but they concluded that levator hiatus distension and ligamentous laxity were significantly associated during pregnancy. They did admit the relationship was weak and results would have to be confirmed with a larger study and more specific study methods. However, the likelihood of major levator trauma more than triples during the reproductive years from under 15% at age 20 to over 50% at age 40(University of Sydney) so it seems that these issues warrant continued study with the continued trend toward delayed child bearing in Western cultures.
Gachon, B., Desgranges, M., Fradet, L. et al. Int Urogynecol J (2018). https://doi.org/10.1007/s00192-018-3598-2
Gachon, B., Fritel, X., Fradet, L. et al. Int Urogynecol J (2017) 28: 1223. https://doi.org/10.1007/s00192-016-3252-9
University of Sydney. "Levator Trauma" sydney.edu.au. Accessed 25 April 2018.
The Institute has welcomed occupational therapists since our founding in 2006. In addition, three OTs: Richard Sabel, MA, MPH, OTR, GCFP, Erica Vitek, MOT, OTR, BCB-PMD, PRPC, and Tiffany Ellsworth Lee MA, OTR, BCB-PMD all teach courses as members of our faculty. (Erica Vitek is also one of several OTs who holds certification as a Pelvic Rehabilitation Practitioner through H&W).
Recently, the Institute was contacted by an Occupational Therapist who has attended many of our courses, regarding a challenge she was experiencing obtaining CEUs in her state (Oregon) for courses on Pelvic Rehab and Biofeedback. In light of this, the Institute has been discussing with some of the occupational therapists on our faculty, as well as representatives of the BCIA and Marquette University, and how to spread awareness about and recognition of OT’s roles in pelvic rehab. Below, we’ve asked faculty member Erica to share a bit more about her journey and the role of the pelvic rehab occupational therapist.
As an OT student, I had a professor who brought in practicing clinicians to discuss their unique roles out in the field. Pelvic health happened to be one of the topics of the day. I was completely intrigued by the clinician, who had such passion about the role of OT in pelvic health. It became clear that helping people with impaired basic bodily functions was imperative to fulfilling life roles and participation; it was OT. I knew from that moment that I wanted to help people deal with these challenging, private issues.
In my journey, I did not immediately start out in pelvic health, but instead in an acute care hospital that had a women’s health program with a strong interest in pelvic health. A very experienced OT and her team of 2 additional OTs were doing great work in that department already. The window of opportunity opened for me to mentor with that group and I eventually was able to begin to get my own referrals and develop a robust hospital-based outpatient practice. At that time, ALL of my experience had been with OTs doing this work and I was naïve to the fact that outside of my world, most of the clinicians doing this type of work were physical therapists (PT). I asked to join a highly trained and skilled group within my health system of all women’s health PTs. Overtime, I was able to demonstrate my level of competency within the group of PTs and contribute valuable things to our organization. Herman and Wallace Rehabilitation Institute was instrumental in my quest to demonstrate competency as they allowed OTs a clear pathway for enrollment in their coursework and application for the Pelvic Rehabilitation Practitioner Certification examination. I can be proud to have those credentials to my name.
My challenges in the area of pelvic health practice have thankfully been minimal, nearly nonexistent, and it has come to my awareness in recent weeks that this is not the case for OTs around the country trying to develop themselves as pelvic health practitioners. My original OT mentors reassured me with the AOTA’s published document titled Occupational Therapy Practice Framework: Domain & Process, detailed a clear place in the role of pelvic health. This document has gone through 3 revisions over the course of its first publication in 2002. The 2nd edition was published in 2008 and the 3rd edition in 2014. I’d like to cite a few important areas of the document that I find to be helpful in an OT’s quest to demonstrate our role in pelvic health rehabilitation.
I’d first like to quote the definition occupational therapy according to the 3rd edition, “occupational therapy is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy practitioners use their knowledge of the transactional relationship among the person, his or her engagement in valuable occupations, and the context to design occupation-based intervention plans that facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and social interaction) needed for successful participation. Occupational therapy practitioners are concerned with the end result of participation and thus enable engagement through adaptations and modifications to the environment or objects within the environment when needed. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non-disability-related needs. These services include acquisition and preservation of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. “
As we look closer at the framework and the definition of OT, there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as “…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.” The clearest examples of the OT’s role in pelvic health occupations within this section include: 1) ADL section: toileting and hygiene (continence needs, intentional control of bowel movements and urination) and sexual activity. 2) IADLs section: sleep participation (sustaining sleep without disruption, performing nighttime care of toileting needs). 3) Achieving full participation in work, play, leisure, and social activities, requires one to be able to maintain continence in a socially acceptable manner in which they can feel confident and comfortable to fulfill their roles and duties.
Client factors as defined in this document are “Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations. Client factors include values, beliefs, and spirituality; body functions; and body structures.” Client factors are further identified as affecting the performance skills and participation of the clients we work with. OT’s role per definition is to “facilitate change and growth in client factors”. In order to fully enhance our client’s performance skills/participation related to change and growth in client factors, OT’s have to examine the whole person, including pelvic health impairments, which have a negative influence on performance. Within client factors, the document defines body structures as, “Anatomical parts of the body, such as organs, limbs, and their components that support body function.” Within this category, one can refer to multiple items named that relate to the care that OTs provide in pelvic health rehabilitation, including but not limited to, structures related to the digestive, metabolic, and endocrine systems and structures related to the genitourinary and reproductive systems.
Since the first email from this individual in Oregon, we have been reached by several other OTs asking about similar challenges and questions about scope of practice. Because of our commitment to honoring the AOTA’s Practice Framework, and because we believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions, the Institute is working with members of our faculty and professional network to advocate for recognition of OTs in pelvic rehab and resolve confusion about scope of practice. For those interested in further resources, please check out:
American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68, S1-S48.
Today's guest post comes to us from Kelly Feddema, PT, PRPC. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. To learn more about diastasis recti abdominis, consider attending Care of the Postpartum Patient!
It can be a struggle to treat patients with diastasis recti if they don't seek treatment early after giving birth. Many therapists may often find themselves thinking “if I only could have started them sooner.” Why does this condition often get missed at postpartum examinations? I personally deal with symptoms from an undiagnosed diastasis, and I'm a therapist! I didn’t really pay attention to it until I started down the road of becoming a pelvic floor therapist.
Diastasis recti can be a difficult diagnosis to treat, as the patient may come to us when they are already one year postpartum, and not everyone agrees on the what are the best treatments. To crunch or not crunch? To use a brace or not to brace? It would be great if we had a similar healthcare system to France, where the norm is to have 10-20 postpartum rehabilitation visits with women after child birth. While therapy is available in the United States, women must ask for it.
There are many programs out there from the more well-known Tupler Technique and Mutu programs to others that come up when searching for exercise ideas. The American Physical Therapy Association (APTA) has a basic program to work on isolating the transverse abdominis (TrA) muscle and then progressing movements in the legs while keeping the TrA activated.
Some research by Paul Hodges and Diane Lee from 2016 in the Journal of Orthopedic Sports Physical Therapy indicates that narrowing the inter-rectus distance with a TrA contraction might improve force transfer between the sides of the abdominals and in turn, improve abdominal mechanics.
Another study in Physiotherapy from December of 2014 by AG Pascoal, et.al. utilized ultrasound to determine the effect of isometric contraction of the abdominal muscles on inter-rectus distance in postpartum women. They found that the while the inter-rectus distance in postpartum women was understandably higher than controls, it significantly lowered during an isometric contraction of the abdominal muscles.
One year later, a study in the same journal by MF Sancho, et.al. had similar findings when studying women who had a vaginal delivery and women who had Cesarean deliveries. They found that abdominal crunch exercises were successful in reducing inter-rectus distance, but drawing-in exercises were not.
As with a lot of research, the findings lead to more questions and ideas to explore. I think it is safe to say that starting safe re-education of the muscles as early as possible is going to provide women the most benefit in reducing diastasis recti, and that will help to prevent further issues in the abdominal and pelvic region.
Today we are excited to share an interview with Beth Anne Travis, PT, DPT, PRPC! While Dr. Travis became a certified practitioner in November 2016, she has been plying her trade with pelvic rehab patients specifically since March of 2015, practicing in North Little Rock, AR. Thank you for talking with us, Dr. Travis, and congratulations on the certification!!
Tell us about your practice
Advanced Physical Therapy is an outpatient clinic in North Little Rock, AR where I treat women, men and children with pelvic floor dysfunction and associated orthopedic conditions.
How did you get involved in the pelvic rehabilitation field?
I thought about the pelvic floor rehabilitation in school but took my first job in pediatrics. Soon after accepting the position, I realized it was not what I envisioned and a pelvic floor career opportunity was presented to me. I took Pelvic Floor Level 2B after accepting the pelvic floor position and began treating my first patients a week later. I know this is what the Lord called me to do.
What/who inspired you to become involved in pelvic rehabilitation?
I was inspired by my mentors and how quickly their patients improved within weeks.
What patient population do you find most rewarding in treating?
I truly enjoy treating individuals with pelvic pain. Relieving them of chronic pain they have endured for years and giving them their life back is what I find rewarding.
What has been your favorite Herman & Wallace Course?
Pelvic Floor Level 2B. This was my first course and I took it with very little knowledge of the subject. I had an instructor who helped me the entire time during lab so I could receive the full benefit of the course. It was very important to the instructor that I had complete confidence in what I was learning and doing.
What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Stacy Futterman advised me during her course to not only focus on the pelvis. So many times we tend to forget to look at the motor control aspect of the body in its entirety.
What do you find is the most useful resource for your practice?
My mentors. I worked with a group of women who have been practicing pelvic floor therapy since 1992. Their knowledge has been incredibly beneficial to me. It’s always comforting to know I have other professionals to brainstorm with.
What motivated you to earn PRPC?
I am continually striving to better myself as a clinician. There was only one certified practitioner in Arkansas who I gratefully had the opportunity to work with. It was my goal to obtain more credibility to improve patient rapport.
What makes you the most proud to have earned PRPC?
Many times in pelvic floor therapy, we are presented with skeptical patients. I use this opportunity to talk with the patient about the course and what it took to gain the certification. I have found that after talking with them, they have more confidence in me. With a lot of studying, hard work and dedication, I have complete faith that I became a better clinician. I am now one of two clinicians with PRPC in the state of Arkansas.
What advice would you give to physical therapists interested in earning PRPC?
It is incredibly beneficial. Studying the information allows you to reflect on information your may have forgotten from PT school
If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
Ask questions! Incontinence and pain with sexual intercourse are very common. If your patient has hip, low back pain or abdominal pain that isn’t improving with orthopedic therapy, refer them to a pelvic floor therapist.
What is in store for you in the future?
It is my goal to become a teaching assistant in the Herman & Wallace courses. I would be honored to teach and inspire others to embrace pelvic floor therapy and what it does to help patients get their life back.
What role do you see pelvic health playing in general well-being?
Pelvic health is vital for our bodies and well-being. Pelvic floor therapy improves the quality of life for so many people. I have personally watched patients get back to the things they loved most before their pelvic health deteriorated.