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Advice for the Male Therapist Treating Female Pelvic Pain Patients

The following insight comes from Herman & Wallace faculty member Peter Philip, PT, ScD, COMT, PRPC, who teaches Differential Diagnostics of Chronic Pelvic Pain: Interconnections of the Spine, Neurology and the Hips for Herman & Wallace, as well as the Sacroiliac Joint Evaluation and Treatment course. Peter has been working with pelvic dysfunction patients for 15 years, and he has some insights and advice for male practitioners who are nervous about treating female patients.

As a male treating female patients suffering with pelvic pain, many considerations must be taken to ensure that the patient is comfortable partaking in the patient/clinician relationship. As clinicians treating the most intimate of pain, we all must be highly aware of the sensitivities that each of our patients has as it relates to their genitalia. Many patients wish to maintain their modesty while simultaneously wishing to eliminate that which is ailing them. It is common that the observation, and contact to the pelvis and genitalia be a component of our patient’s evaluation and subsequent treatment in order for an accurate diagnosis to be made. So, in order to best protect our patients and ourselves it will behoove us to take a few simple steps.

  1. During the course of the oral history, listen to what the patient is saying. What structures may be involved at referring to the outlined region in question? Can these structures be addressed externally and without exposure of the pelvis?
  2. If a pelvic examination appears to be warranted, provide the patient with an understanding of what you will be evaluating and why. How does your evaluation reflect their pain? What are your expected findings?
  3. Provide the patient the opportunity to read-and-sign a waiver that explicitly states that the evaluation may include: exposing, visualization and contact to the pelvic region inclusive of internal contact.
  4. Provide a means of audio-recording the evaluation and subsequent treatments. Federal guidelines dictates that there be signs on the doors of any room or office space that is recorded, and having the patient sign permission to the audio-recording further protects themselves and the clinician.
  5. Always ask permission to expose, visualize, and touch when and if any of the above are to be involved in the treatment of the day. Do this every visit, every time, and prior to initiating a new maneuver or treatment strategy.
  6. Sit aside the plinth. Once observations are complete, there will be nothing to visualize. Drape accordingly and allow the patient to maintain modesty.
  7. Test-retest. During the course of your evaluation, there will likely be an asterisks or correlational finding. Apply your treatment, and re-test. Appropriate treatments should provide both patient and clinician immediate feedback as to the efficacy and specificity of the functional diagnosis that the clinician is making.
  8. Hold the patient accountable for their actions, and importantly their corrective actions whilst not in physical therapy. Our patients may see us for two hours a week, and if they are not complicit in maintaining that which we provide their healing will be compromised.
  9. As for the male/female component. Some women and men will not be comfortable with a male clinician. Many women wish to maintain their modesty and/or have been violated and will have anxieties towards contact by a male clinician. The aforementioned strategies help not only to maintain a patient’s modesty, but also provide the ultimate control of who touches them, when and where. More importantly it provides the patient the opportunity to say “no” and to cease contact at their discretion. For the male:male patient:clinician relationship there may be equally as many difficulties. Some have been violated, and many have a subconscious concern of how well they ‘size up’ in comparison. Not that a comparison would ever be made, but the underlying anxieties will often be omnipresent.
  10. Be honest and sincere with your patients and yourself. If you’ve made a clinical assessment that did not produce the immediate pain relief expected, state that to the patient, and continue your evaluation. If you don’t know the exact driver of the pain, or dysfunction, refer out to a local specialist and discuss your findings so as to better address your suffering patient’s needs.
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Peter Philip - Featured Herman & Wallace Instructor

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Peter Philip, PT, ScD, COMT, PRPC

Peter Philip

How did you get started in pelvic rehab?

While treating an MD, OB-GYN, he asked me a question regarding a patient that he was treating that was suffering from dyspareunia. I’d just completed my Master's in orthopedic physical therapy and realized that there was an entire section of the body that was "full of muscles, ligaments and nerves” of which I had virtually no knowledge. This bothered me, so I began my own independent research, study and application of skills learned through continuing education, and application of what are typically considered to be ‘orthopedic’ techniques to the pelvic pain/dysfunction population. To my (continued) wonderment, the patients responded exceptionally well, and efficiently.

Who or what inspired you?

Dr. Russell Woodman and Dr. Holly Herman have provided me with the foundational skills and motivation to help and heal those patients suffering.

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

Many patients have suffered for years prior to ‘finding’ me. Many are despondent, and have given up hope for a cure; resigning themselves to a life of pain. Providing the means of restoring comfort and wellness is gratifying, rewarding and quite frankly, humbling. What an honor it is to help those that suffer regain the life that they thought they’ve lost.

What do you find more rewarding about teaching?

Having the opportunity to assist clinicians (MDs, PTs, DCs) more effectively, efficiently evaluate and treat their patients provides me with the same gratification that treating the patients myself. This, in addition to being able to help those that have not been helped attain their wellness and health they’ve been seeking, often for years.

What was it like the first time you taught a course to a group of therapists?

The first course I taught was in NYC. The air conditioning was broken, and the office had a few, small windows. The ambient temperature was upper nineties, and no breeze. Through the tortuous temperatures, and ‘first time jitters’ I persevered, and the staff were incredible hosts and provided me with guidance that I appreciate to this day!

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

Manual medicine and non-surgical interventions are being more recognized as very viable means to address, and eliminate pain while improving biomechanics and function. Medical practitioners from all fields are consulting with specialists in the field of pelvic pain to better address their patients' suffering. We are at the forefront of interventional treatments, and patients are seeking effective means to eradicate their pain and dysfunction.

If you could get a message to all therapists about pelvic rehab, what would it be?

Review, re-read, re-learn all the anatomy, neuroanatomy, kinematics and never forget to think, think, think.

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Case Study from Peter Philip, PT, ScD, COMT, PRPC

This post was written by H&W instructor Peter Philip, PT, ScD, COMT, PRPC, who authored and instructs the Sacroiliac Joint Evaluation and Treatment course. The next SI Joint course will be taking place this January in Seattle.

Peter Philip

Patient one:

55 year old female with complaints of pelvic pain. States that her pain is noted along the deep inguinal region, involving her pubis and labia majora. States that intercourse is difficult, and that she is quite anxious to initiate or participate. She denies trauma, only that she’d been increasing her fitness activities as she’s going to Florida for a winter get-away. She denies changes in her bowel and bladder function, other than intermittent SUI with ‘heavy exercise’.

Clinical testing:

ALROM is negative. During forward flexion there was no reversal of the lordosis.

Segmental myotomal and dermatomal testing is unremarkable.

ASLR and PSLR are negative.

Gillet’s and forward flexion are apparently negative.

There are palpable “marbles” to palpation along bilateral SIJ, and the sacrum is ~40? of nutation.

FABER, FAIR and McCarthy tests are negative. Iliac compression is modestly provocative for patient’s symptoms, while the sacral thigh thrust was provocative for ipsilateral symptom provocation.

While in prone, the patient demonstrated a positive Dead Butt Syndrome bilaterally and there were significant restrictions to fascial rolling throughout the lumbosacral region.

The clinical question is: What to do next? What would you do?

I chose to provide a local traction to each SIJ, followed by a mobilization with movement directed at S3 to promote counter nutation. After treatment, the patient arose from the plinth and remarked that her pain was significantly reduced. On follow up, her pain was 10% that of her initial pain at evaluation.

My questions to you are:

1. What caused her “pelvic pain”?
2. Why did her pain subside? 3. Would you have done an internal evaluation?

These and other questions will be addressed at Sacroiliac Joint and Pelvic Ring Evaluation & Treatment in Seattle, Washington January 25th to the 26th.

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Mysterious Marbles of the Sacroiliac Joint

Jennafer Vande Vegte

This post was written by H&W faculty instructor Peter Philip, PT, ScD, COMT. Peter instructs the Differential Diagnostics of Chronic Pelvic Pain and the Sacroilliac Joint Evaluation and Treatment courses.

Have you ever palpated “marbles” - rolling masses along the SIJ that just don’t seem to go-away? Let’s take into consideration that you are a competent clinician, and that your patient is compliant with all of your requests. Clinical testing is negative for lumbar involvement, and both provocation and movement tests alike indicate involvement of the SIJ. Despite countless treatments directed at core training, and pelvic stabilization, the “marbles” persist.

Clinically speaking, often what is seen is that the innominate structures attain a more neutral alignment, where the sacrum maintains its hyper-nutated position. As a synovial joint, the SIJ is prone to swelling and subsequent scarring when placed under mechanical stress - hence the “marbles”. With great sincerity, the patient and clinicians alike focus on core strengthening, which often produces the correction of the innominate, but for reasons “unknown” to many clinicians and patients alike, the relative angle of the sacrum remains unchanged. Why would this be, how could this occur?

As a clinician, have you ever considered evaluating, and subsequently treating the anterior SIJ ligament? Running obliquely across from the sacrum to the innominate, the anterior SIJ ligaments have been found to be an underlying cause of chronic lower back pain, and sacroiliitis. As ligaments will do under mechanical stress, the anterior SIJ ligaments will stretch and scar, forming fibrous unions that limit their flexibility and hinder your manual techniques to improve SIJ osteokinematic motion. Akin to other ligaments of the body, once the origin of the mechanical insult has been addressed, the ligament can be directly treated via cross fiber massage, and to the surprise of many clinicians and patients alike heal in an expedient fashion; regardless of symptom duration. To best serve their patients, it would behoove the clinicians to take into consideration the concepts of central sensitization and knowledge that the anterior portion of the SIJ is innervated by segments L4 to S3! These and other strategies are discussed and implemented in both the Differential Diagnostics of Pelvic Pain, and The Evaluation and Treatment of the Sacroiliac Joint & Pelvic Ring courses.

Want more from Peter? You can catch him teaching his course on the SI Joint in Baltimore in July and the Differential Diagnostics course in New Canaan, CT in October.

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Upcoming Continuing Education Courses

Boundaries, Self-Care, and Meditation - Remote Course

Sep 12, 2020 - Oct 11, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Atlanta, GA (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Emory Healthcare

Nutrition Perspectives for the Pelvic Rehab Therapist - Winfield, IL (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Houston, TX (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Texas Children’s Hospital

Sacral Nerve Manual Assessment and Treatment - Vancouver, WA (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: PeaceHealth Southwest Medical Center

Pelvic Floor Level 1 - Mequon, WI Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Health In Balance Physical Therapy

Pelvic Floor Level 1 - Atlanta, GA (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Emory Healthcare

Coccydynia and Painful Sitting - Philadelphia, PA (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Core 3 Physical Therapy

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Milwaukee, WI (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Aurora Medical Center

Pelvic Floor Level 1 - Columbia, SC (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Columbia Rehabilitation Clinic

Pelvic Floor Level 1 - Self-Hosted

Sep 26, 2020 - Sep 27, 2020
Location: Self-Hosted Course

Pelvic Floor Level 1 - Decatur, GA Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Emory Healthcare

Pelvic Floor Level 1 - Columbia, SC Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Columbia Rehabilitation Clinic

Pelvic Floor Level 1 - Minnetonka, MN Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Viverant

Pelvic Floor Level 1 - Marietta, GA Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Southern Pelvic Health

Pelvic Floor Level 1 - Satellite Lab Course

Sep 26, 2020 - Sep 27, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Orland Park, IL Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Palos Community Hospital

Pelvic Floor Level 1 - Columbus, OH Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Fitness Matters

Pelvic Floor Level 1 - Colorado Springs, CO Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Strive Physical Therapy

Pelvic Floor Level 1 - Torrance, CA Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Women's Advantage Inc

Pelvic Floor Level 1 - Kenosha, WI Satellite Location (Sold Out)

Sep 26, 2020 - Sep 27, 2020
Location: Aurora Health Care

Pelvic Floor Level 1 - Lansing, MI Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Physical Therapy Services of Lansing

Mobilization of Visceral Fascia: The Urinary System - Phoenix, AZ (Postponed)

Oct 2, 2020 - Oct 4, 2020
Location: Banner Physical Therapy and Rehabilitation

Male Pelvic Floor - Colorado Springs, CO

Oct 2, 2020 - Oct 4, 2020
Location: St. Francis Medical Center

Mobilization of Visceral Fascia: The Urinary System - Medford, OR Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: Asante Rogue Valley Medical Center

Mobilization of Visceral Fascia: The Urinary System - Self-Hosted

Oct 2, 2020 - Oct 4, 2020
Location: Self-Hosted Course

Mobilization of Visceral Fascia: The Urinary System - San Diego, CA Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: FunctionSmart Physical Therapy

Mobilization of Visceral Fascia: The Urinary System - Colorado Springs, CO Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: Manual Edge Physiotherapy