"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.

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).

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.

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.

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}.

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.

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.

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.

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.

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.