Cancer and oncology treatments have several common side effects like fatigue, changes in appetite, and pain. However, patients who have bladder or gynecological cancers can also experience side effects that affect the bladder, bowel, and sexual functioning. The pelvic floor muscles of these patients can be negatively impacted by many things including surgery, radiation, and in some cases, the tumor itself. Pelvic rehab programs can play a crucial role in improving pelvic floor function and overall quality of life for patients who have been diagnosed or treated for these cancers. Don't underestimate the impact of pelvic rehab on regaining both the quality and satisfaction of life after treatment.

Radiation for gynecological cancers, for instance, has been reported to cause vaginal stenosis resulting in generalized pelvic pain and dyspareunia.¹ Surgical options including tumor debulking, hysterectomy, and salpingo-oophorectomy can result in scar tissue that can cause tissues or muscles to shift. As pelvic rehab professionals, it is our privilege to offer an evidence-based and solution-focused approach for the often overlooked pelvic health issues faced by people undergoing treatment for pelvic cancers. Our role is crucial in providing much-needed support and care for these patients.

Pelvic rehab therapy can improve and sometimes even prevent the detrimental impacts on the pelvic and abdominal area that negatively impact the patient’s quality of life. Some of the most common therapy options to help improve your patient's pelvic functioning are:

Can you tell me a little bit about who you are and your journey to pelvic rehab?
I graduated from Physical Therapy school year 2002 with a bachelor’s degree in physical therapy and finished my transitional doctorate here in the United States. Never did I imagine that I would find my path one day to treating pelvic floor disorders. My experiences were combinations of orthopedic rehabilitation, and pain management with in-patient and out-patient settings. I started practicing in the Philippines, went to the Middle East, and finally found my way to Illinois in 2011.

I am fascinated with how postural alignment and the coordination of the full body can affect one region of the body from distally to proximal, to centrally and peripherally. How a single whip of one body part - how the coordination of breathing and moving, stabilization of core/spine/pelvic floor/scapula can affect even your distal body region.

Mora Pluchino, PT, DPT, PRPC sat down this week with Holly Tanner in an interview to discuss her new courses, Ethical Concerns for Pelvic Health Professionals and Ethical Considerations from a Legal Lens. She is a pelvic therapist who works in an outpatient clinic, has her own side company (Practically Perfect PT), has written 2 books available on Amazon, and is a senior TA and faculty member with Herman & Wallace. Mora joins the Herman & Wallace faculty with her new course series in ethics: Ethical Concerns for Pelvic Health Professionals and Ethical Considerations from a Legal Lens. 

What are your core values as a pelvic health practitioner? Depending on your practitioner license these may include (1):

• Accountability - Active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist and physical therapist assistant including self‐regulation and other behaviors that positively influence patient and client outcomes, the profession, and the health needs of society.
• Altruism - The primary regard for or devotion to the interest of patients and clients, thus assuming the responsibility of placing the needs of patients and clients ahead of the physical therapist’s or physical therapist assistant’s self‐interest.
• Collaboration - Working together with patients and clients, families, communities, and professionals in health and other fields to achieve shared goals. Collaboration within the physical therapist‐physical therapist assistant team is working together, within each partner’s respective role, to achieve optimal physical therapist services and outcomes for patients and clients.
• Compassion and Caring - Compassion is the desire to identify with or sense something of another’s experience; a precursor of caring. Caring is the concern, empathy, and consideration for the needs and values of others.
• Duty - The commitment to meeting one’s obligations to provide effective physical therapy services to patients and clients, to serve the profession, and to positively influence the health of society.
• Excellence - The provision of physical therapist services occurs when the physical therapist and physical therapist assistant consistently use current knowledge and skills while understanding personal limits, integrating the patient or client's perspective, embracing advancement, and challenging mediocrity.
• Integrity - Steadfast adherence to high ethical principles or standards, being truthful, ensuring fairness, following through on commitments, and verbalizing to others the rationale for actions.
• Social Responsibility - The promotion of mutual trust between the profession and the larger public that necessitates responding to societal needs for health and wellness.

Annual CEU requirements for license renewals don’t just look at hands-on skills. Many states also require a number of ethics credits including California, Georgia, Illinois, New Jersey, and Utah (2).  In her interview, Mora Pluchino explains that one day she and her colleague were at lunch talking about course options for their ethics CEU requirement. They had taken the same course over and over at Stockton University and wanted to do something different this time. This led to Mora reaching out to Herman & Wallace and Holly Tanner who helped her start writing the course. Mora’s new courses focus on this ethics requirement, provide 6 contact hours, and registration is $175.00 for each: 

The popularity of yoga continues to rise with over 36 million yogis living in the United States of America and over 300 million practitioners worldwide. Yoga has several therapeutic effects that make it a beneficial addition to home exercise programs for practitioners and personal practice.

Dustienne Miller discussed some of the benefits of yoga in her March blog (March 8, 2022 - A yoga practice can change your neuroanatomy!). These benefits extend beyond the musculoskeletal system and include improved mood and depression, changes in pain perception, improved mindfulness and associated improved pain tolerance, and the ability to observe situations with emotional detachment.

The physical benefits are well documented in several research studies and include improved flexibility, strength, and stability as well as enhanced respiratory and cardiovascular function. Supporting documentation also shows that yoga can help alleviate the symptoms of chronic pain. Dustienne Miller shared that in a study by Villemure et al, they determined “that the insula-related interoceptive awareness strategies of the yoga practitioners being used during the experiment correlated with the greater intra-insular connectivity...concluding that the insular cortex can act as a pain mediator for yoga practitioners.”

Dawn Sandalcidi PT, RCMT, BCB-PMD is known as the go-to expert in the field of pediatric pelvic health. She has been practicing for 40 years this May and has concentrated on the pediatric pelvic floor for 29 of those. When it comes to pediatric pelvic floor issues, there is so much more than bedwetting, and often the practitioner needs to look beyond the pelvic floor.

Despite the growing number of pelvic rehab specialists treating men and women with PF dysfunction, children in this patient population remain woefully under-served. This can cause undue stress for the child and family, as well as the development of internalizing and externalizing psychological behaviors. Many of the techniques used in pediatric pelvic therapy can be translated to the adult population. The question is ‘who’s the driver?’ In pediatrics, it is typically a bowel issue.

The Standard American Diet involves food that is high in calories, saturated fats, trans fats, added sugars, and sodium. It is also lacking in the intake of essential nutrients for the body like fiber, calcium, potassium, and vitamin D. This lack of dietary fiber can cause issues with the digestive tract as well as the colon leading to constipation. Bowel dysfunction including constipation can contribute to urinary leakage and urgency (1). Constipation accounts for approximately 5% of visits to pediatric clinics (2) proving that there is a need for practitioners to know how to treat these pediatric issues.

Megan Kranenburg, PT, DPT, WCS created the course Doula Services and Pelvic Rehab Therapy to present the unique challenges of merging a rehab practice with Doula services. Megan is a physical therapist who has balanced her solo outpatient pelvic health practice and Doula work since 2016. She lives and works in the nexus of Doula training near Seattle, Washington - which has provided plenty of opportunities to observe and participate in birth conversations and process the experience through the Physical Therapist's mind and heart.

As a pelvic floor practitioner, you may know that nearly 24% of women in the United States have pelvic floor dysfunction (as reported by the National Institutes of Health) and that this frequency increases with age. Childbirth can contribute to pelvic floor dysfunction, and it can be beneficial for pelvic therapists to know the doula's toolkit

So what is a doula? Doulas are often the first and sometimes the only people with whom a birthing person will feel comfortable discussing pelvic floor-related issues. Dona International defines a doula as a trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.

In a 2018 article by Holly Tanner, she explains how managing a medical crisis such as a cancer diagnosis can be overwhelming for an individual. ‘Faced with choices about medical options, dealing with disruptions in work, home, and family life often leaves little energy left to consider sexual health and intimacy. Maintaining closeness, however, is often a goal within a partnership and can aid in sustaining a relationship through such a crisis.” Research shows that cancer treatment is disruptive to sexual health. Intimacy is a larger concept that may be fostered even when sexual activity is impaired or interrupted.

Prostate cancer treatment can change relational roles, finances, work-life, independence, and other factors including hormone levels. (1) Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido, and performance anxiety can create further challenges. (1, 3, 4) Recovery of intimacy is possible, and reframing of sexual health may need to take place. Most importantly, these issues need to be talked about, as a renegotiation of intimacy may need to take place after a diagnosis or treatment of prostate cancer. (2)

If a patient brings up sexual health, or the practitioner encourages the conversation, many research-based suggestions can be provided to encourage recovery of intimacy including:

Manual Therapy for the Abdominal Wall allows practitioners to review how everything interplays within the myofascial system and apply specific techniques. These techniques include how to assess the tissue for mobility, how to treat tissues that are restricted in the abdominal wall, and how to treat scar tissue. How do we help somebody who can’t lay flat because their abdominal wall has become restricted for so long because of possible pain? Possibly due to surgery. Possibly due to fear. How do we help those patients get back to function?

Over the past 10 plus years of teaching the pelvic series with Herman & Wallace, Tina Allen noticed that for some of the participants there was a gap in confidence in palpation skills and treatment techniques applied to the pelvic floor region. For most, it’s confidence in where they are and what they are feeling on the patient. Manual Therapy for the Abdominal Wall came out of wanting to fill that gap. This course is really about taking some of those skills and then applying them to the abdominal wall.

Abdominal pain can arise from many origins including abdominal scars, endometriosis, IC/PBS, and abdominal wall restrictions that impact pelvic girdle dysfunction. An older study, back in 2007 by Geoff Harding focused on back, chest, and abdominal pain and whether it was spinal referred pain and employed manual therapy as part of his treatments for his case studies. Harding found that “More specific treatment of the origin of the pain may then include manual therapy, including mobilization (gentle rhythmic movement), …  applied to the affected segment can be very effective in reducing movement restriction – and pain. These simple treatments were used in all three case studies to good effect.” (1)

The hip flexor muscles include the Iliopsoas group (Psoas Major, Psoas Minor, and Iliacus), Rectus Femoris, Pectineus, Gracillis, Tensor Fascia Latae, and Sartorius. When the hip flexors are tight it can cause tension on the pelvic floor. This can pull on the lower back and pelvis as well as change the orientation of the hip socket, lead to knee pain, foot pain, bladder leakage, prolapse, and so much more. The ramifications of iliacus and iliopsoas dysfunctions are discussed in a contemporary and evidence-based model with Steve Dischiavi in the Athletes & Pelvic Rehabilitation remote course.

A common issue with the iliacus and hip flexors is that they can shorten over time due to a lack of stretching or a sedentary lifestyle. When this happens, the muscle adapts by becoming short, dense, and inflexible and can have trouble returning to its previous resting length. A muscle that resides in this chronic contraction can become ischemic, develop trigger points, and distort movement in the body.

If you are treating patients with pain in their lower abdomen, sacroiliac joint, or that wraps around the lower back and buttocks, it could be because the hip flexors are tight. Traditional testing performed by medical practitioners tends to come back negative as many tests do not evaluate soft tissue issues. The best way to diagnose these concerns is through assessment with skilled palpation and structural evaluation.

This is a common question that faculty member, Mercedes Eustergerling, is asked. To paraphrase this question – why does H&W (a pelvic rehabilitation institute) offer a breastfeeding course – Breastfeeding Conditions? Well, if you consider that new parents who are breastfeeding have just experienced a birthing event then the answer is – it has plenty to do with pelvic rehabilitation.

Most pelvic therapists have exposure to patients who have given birth and are experiencing a range of postpartum pelvic issues including painful intercourse, prolapse, and incontinence. Have you considered how breastfeeding affects these issues? After giving birth the body’s levels of estrogen drop and the levels of prolactin rise. Prolactin is the hormone responsible for stimulating milk production and will remain elevated during breastfeeding. Thus, estrogen levels remain low during this time and can result in vaginal dryness, delayed menses, low libido, and painful sex.

Women or any person who has experienced childbirth, with pelvic organ prolapse (POP) are often told that the condition will improve after breastfeeding. While many do see improvement after weaning their child there is no correlation between breastfeeding slowing the healing of pelvic floor muscles or worsening POP long-term (1). POP has been linked with sleep quality (2). Which anyone with a newborn can tell you is in short supply. Not surprisingly, sleep is important for your body to recover from birthing, managing postpartum mood disorders, and of course, staying awake to take care of your baby. For breastfeeding parents, sleep deprivation is a way of life as they are waking up every 2-3 hours to feed their baby and establish a strong milk supply. It may be beneficial at this point for the new parent to work with a lactation consultant. These professionals can guide new parents through latching, feeding, milk supply issues, breast pump use, and can help reduce stress and promote optimal rest and recovery postpartum.