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A Patient's Pelvic Rehab Journey

The following comes from a male patient who wanted to share his story about finding care for his pelvic floor dysfunction. His story highlights the important role pelvic rehab practitioners can play, and why we need to continue training more therapists in this field.

I’m 65 year old male and I developed pudendal neuralgia and pelvic floor issues as a result of an accident about four years ago. Shortly after my accident I started to experience pain in my testicles and perineum.  At the time, I did not think that one had anything to do with the other. I made an appointment with my urologist who did an ultrasound and assured me that there was nothing physically wrong. I don’t think my testicles quite believe that but mentally I felt relieved. But the pain persisted and started to spread. Now it was also in my groin and penis.  I was also having problems with chronic constipation, urinary retention and erectile dysfunction. Since I did have back surgery years ago I started to suspect my low back was causing the problem. I made an appointment with a well-respected orthopedic surgeon in New York. While he gave me his analysis with regards to my back problems he clearly avoided addressing the pelvic issues. I left there feeling lost. Suffice it to say that over the course of the next couple of years I saw several other specialists who either skirted around the issue or told me that nothing was wrong. A couple of years passed but the pelvic issues just continued to get worse and worse. I started seeing a new primary care physician who indicated that perhaps the source of the pelvic pain was coming from the pudendal nerve and felt that physical therapy might help. She gave me a prescription for physical therapy to evaluate for pudendal nerve.

Well, I have a diagnosis now so I start researching pudendal neuralgia and land on the Pudendal Hope website. Wow! What an eye opener that was.  I’m reading the information on the website and it was like I had an epiphany.  I realized that I was not going crazy and that Pudendal Neuralgia and pelvic pain are very real issues.

OK, so where do I go from here? With prescription in hand I’ll make an appointment with a physical therapist that deals with pudendal neuralgia. Ha, I thought getting a diagnosis was tough but finding a physical therapist that treats pudendal neuralgia and pelvic issues was no easy task. To make things even more challenging, finding a physical therapist who treats men was even harder. I made a few calls and kept looking online without much success.  Desperate to find a physical therapist that treats men, I sent an email off to a therapist in California asking if by some chance she could recommend a physical therapist here in New Jersey. As luck would have it, I got both a response and a referral. With that, I called Michelle Dela Rosa at Connect Physical Therapy. I had to wait about six weeks for an appointment but finally the day arrived.  OK, so now, I had set my expectations. I’ll go for a few weeks of physical therapy, the pain will go away and it will be back to a normal life. Well, not so much… the journey and education were just getting started.

There are days when I am in so much pain that I ask myself if the pelvic therapy is really doing me any good. But then I reflect back to how things were before I started the therapy. Funny thing about pain… often times it makes us forget how things were in the past and shift our focus to the here and now. That being said, I quickly realize how much I have truly progressed since starting therapy.

So what have I learned?  Well, the first thing is to understand the anatomy and how all the pelvic muscle groups and nerves are integrated. After all you can’t fix what you don’t know is broken. Therapy has certainly helped educate me in that respect; I’ve learned the importance of proper breathing and strengthen the core muscles.  I know that when I was in pain I would tighten up the pelvic muscles and hold my breath which would only make things worse, as the muscles would get into a knot, and make it even more difficult to get relief.  I’ve learned a whole new set of exercises that I now have in my arsenal to help fight this battle. To help me deal with the chronic constipation I’ve learned how to massage my abdomen to help move things along. For those folks dealing with chronic constipation, well, we all know what happens when we push just a little too hard… flare time! I could go on and on. I learned to use tools, such as the TheraWand, to help break the tension for those internal pelvic muscles. Pelvic therapy has taught me the importance and benefits of the proper use of cold packs, glides, exercise, breathing, relaxing the pelvic floor and on and on and on.

I was a bit embarrassed getting started but the prospect of relieving some of the pelvic pain and the professionalism of my therapist quickly turned my embarrassment into a non-issue.

I want to express my thanks and gratitude to all those physical therapists who have the courage and vision to take on this problem. You are truly making a difference in the lives of the people you are helping.

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My Experience at 'Care of the Pregnant Patient'

The following testimonial comes to us from Karen Dys, PTA. Karen recently attended the Care of the Pregnant Patient course, and she was inspired to send in the following review. Thanks for your contribution, Karen!

I have been working as a physical therapist assistant for 11 years and worked in a variety of settings. In the past two year I have become more focused on pelvic floor rehabilitation. During that time frame I have had a handful of pregnancy patient including being a pregnant woman myself. Since taking this course, my mind has been opened up of how I can treat my patients and educate them for their best future outcomes. I also can see now how I would have benefited myself if I knew some of these techniques that I’ve now learned. With knowing with my personal story and that my PT could have helped me more with avoiding bed rest and staying active longer with pregnancy, it has become my goal now to treat my pregnant patients differently. I am thankful for Herman and Wallace courses to gain these wonderful techniques to reach out and help so many people.

Within the first few moments of meeting the teacher at a continue education class I can tell if is going to be a good class or not. This course started out great with a very friendly and kind person. Sarah’s compassion and knowledge brightly shined throughout the weekend of teaching. It was very refreshing having a teacher who also has experienced some of the same problems are patients go through. It gave it a good personal perspective of how we can affect our patient outcomes.

One thing that I really appreciated at this course was the comfort level felt during the entire weekend. Right from the beginning Sarah made it clear that no question was stupid to ask. She explained that we are all at different learning stages in our career and that we are working together to gain this knowledge to be better therapists. I really appreciated hearing that and I know it made some of the new pelvic floor therapists feel more comfortable as well. I enjoyed having different labs throughout the weekend to practice these new techniques with new therapists of different educational levels. Sometimes I attend courses being more confused on techniques because the teacher, assistant or other course mates don’t have the time or knowledge to explain in further detail. At any of my Herman and Wallace courses I have attended, especially this one, I have not felt that way.

So I attended this wonderful class and now what? Well during the class I was thinking of my pregnant friends who are expecting multiples and how I can help them with their already felt extra swelling and low back pain. I also was thinking of some of my post-partum pelvic floor patients and how if I would have known some of this information sooner I could have impacted their pregnancy. Some things I would have changed were compression stock wear, abdominal binder/ brace wear, labor positioning techniques and strengthening more with education for post-partum phase. So now I have brought back to my company more knowledge of how to evaluate, assess more correctly and treat pregnancy patients. I have led a in-service for my coworkers who are primarily orthopedic based . They had a good take away of how to help patients with orthopedic complaints of pain who also happen to be pregnant.

I am thankful for this course I attended and look forward to making it a regular event I attend. Herman and Wallace courses never disappoint. Thank you.

Karen R Dys, PTA

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Helping Our Patients Take One Step Forward

Jennafer Vande Vegte, PT, BCB-PMD, PRPC is a H&W faculty member and one of the developers of the advanced Pelvic Floor Capstone course. In this guest post, she reflects on her own clinical and personal experience that informed her work on this advanced course, and her approach with patients.

Rodel Studios Herman Wallace 004Most days I feel like I am on a journey. Some days I make big strides forward, other days I might fall back. But I am always learning, and eventually I hope to grow. I think it is much the same for our patients. And also for ourselves.

My youngest daughter was diagnosed with eczema, allergies (food and others) and asthma at an early age. In my hubris I felt if I could learn all I could about what was going on in her body I could "fix" her. So began a journey that took me outside the realm of traditional medicine into holistic care. I learned so much! My daughter got a lot healthier. The rest of my family got a lot healthier. I got healthier too. And I began to recognize patients in my practice that needed more holistic care. Guess what, they got healthier too.

When she was in first grade she was diagnosed with ADHD. I retraced the steps of my previous journey that had helped her so much with her allergies, eczema and asthma. But ADHD proved to be resistant to diet , supplements, and homeopathy. We visited an OT and got some good suggestions. A family therapist helped us a ton as parents, but I'm not sure how much he helped my daughter. We tried Ritalin to no avail. Energy therapy and essential oils followed before I finally made an appointment with a ADHD child specialist MD. We will see where that step leads. Why

Why am I telling you all this you may ask? Because I realized that my journey with my daughter is very much like our journey walking next to our patients with chronic pain. They/we may try so many things trying to find the "fix" to make their pain go away. As we grow on our own life journeys and experiences and we add quality clinical tools to our toolboxes we very well may be able to help more people experience freedom from pain, improvements in function, and meeting their goals. But there will be always still be those that we feel like we didn't help. Don't despair dear friends. Every person we have come in contact with in the quest to better equip and understand my daughter's mental and physical health has been a wealth of information, inspiration, and resources. Some things I learned some years ago (essential oils for example) and only now am putting into practice. I wasn't ready before but I am now! I realized that there is a similar dynamic for our patients. We may help them take just one step forward. We may walk a whole journey to healing beside them, or we may never know what the impact of our treatment had on them. But in the end we both end up exactly where we needed to be.

Insignia Health developed the PAM (Patient Activation Measure) Survey (http://www.insigniahealth.com/products/pam-survey) to help heath care providers determine where along the pathway of activation of self care a patient falls. What is interesting about the tool is that a single point increase correlates to a 2% decrease in hospitalization and a 2% increase in medication adherence. The science behind the PAM shows that helping our patients to move forward just one step can have a profound influence on their health. The trick is meeting them where they are at.

Pelvic Floor Capstone was a joy to develop with Nari Clemons and Allison Arial. Our goal was to equip you to take one more step in your learning journey in pelvic health. We delve into intense topics like endocrine disorders, pelvic surgery, gynecological cancer, nutrition and pharmacology. Labs are focused on evaluating and treating myofascial restrictions utilizing a gentle, indirect three dimensional system that invites the brain to reconnect with connective tissue in a safe way for powerful change. We would love to see you at Capstone and hear your stories later on how our time together empowered you to help your patients take one more step.

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Personal Pregnancy Series: 1 - Pregnancy

The following is the first in a three-part blog series which chronicles the peripartum journey of Rachel Kilgore.

I. Pregnancy

In April, I had my first child, a sweet and healthy baby girl. Reflecting on the last year, what a ride! I have had many of my friends, family members, patients, and acquaintances discuss the journey and challenges of motherhood with me, however, experiencing it first hand was a memorable voyage. I thought I was very prepared and knew what I was getting into, but as usual, nothing compares to first-hand knowledge and experience. From an academic standpoint, I had done my research on everything from conception, what to expect each trimester of pregnancy, and reviewed the many options for labor and delivery. I even was lucky enough to assist in the Herman and Wallace Care for the Post-Partum Patient course with Holly Tanner while I was pregnant! As a practitioner, I love treating pregnant and post-partum patients, it is one of my favorite populations to treat. I love helping these strong, motivated women with pain relief and to teach them management skills to adapt to a new lifestyle and a changed body that has unique musculoskeletal needs.

First Trimester: Information, Nausea, and Fatigue

I had always had a preconceived notion that I would exercise diligently and eat super healthy through my pregnancy. After all, that was how my lifestyle was before pregnancy, why should it change? That lasted about 6 weeks, until 24-hour episodes of nausea and vomiting overwhelmed me, which continued until the start of the second trimester. I basically just tried to make it through the day without vomiting at work, and would go straight to bed whenever I had the chance. I even had to miss several days of work! I thought it was termed “morning sickness” implying that it went away after morning, but apparently it should be renamed to “forever nausea” as that is what it felt like at the time. Because of the nausea, I wanted nothing to do with food, which in turn lead to constant concern about the baby not getting enough nourishment. Of course, my regular activity levels plummeted. In addition to nausea was constant fear of miscarriage and whether my regular activities were somehow harmful to my baby. Instead of ice cream and pickles, I craved information. What should I be doing, and what should I not be doing?

Second Trimester: Return of Energy, Excitement, Planning and Doing!

When the first day of the second trimester hit, the nausea just went away. I was ecstatic! I got my energy back and was finally enjoying the pregnancy again! I was able to exercise regularly and eat healthy, two of my favorite things. Everything was going well, and it was time to start figuring out this whole baby thing. Luckily, most of my friends are mothers themselves, and they helped guide me. They directed me to great resources to satisfy my quest for knowledge about everything I needed to know for pregnancy, labor delivery, and the baby itself. They helped me decipher what all these baby products were, and what do you actually need. All the fun stuff was happening! We painted the baby’s room, ordered furniture, and planned a baby shower.

Third trimester: Waiting, Exhaustion, Heart Burn, and Reduced Mobility

Everything that happens to my patients happens to me. Third trimester was when I started to really “feel pregnant”. Daily mobility became challenging. I never realized how many times in a workday I show patients correct lifting mechanics or how often I set things on the ground or pick up weights. I started to dread every time I had to pick up something. At work, I would drop my pen on the ground so many times, and why had I never noticed that I did it so often? Luckily, I used my “physical therapy knowledge and skills” and did things I tell my pregnant patients to do; the results were minimal problems with musculoskeletal pain. Techniques such as: Using proper mechanics throughout my day, pulling in my core, and wearing a maternity support if my back was hurting a little. I never really developed severe back pain as is the case for many pregnant women. I completed hip and trunk exercises I usually give my pregnant patients and found they were easy to do and made me feel better... shocking right? Of course I was doing my kegels too! While my musculoskeletal system was doing well, my gastrointestinal system was not. I had never really had heart burn before, but now had it constantly, and found it to be very frustrating and depressing. I love cooking and eating but neither are enjoyable when you have heartburn. The heartburn was so bad it would wake me up every night coughing and chocking on my own acid reflux. Between lack of sleep, heartburn, and reduced mobility, I was getting pretty excited to be done with pregnancy and to finally meet “Baby K” as we had begun calling her. Overall, being pregnant was a very informative experience for me as a person and as a clinician. I often hear my patients tell me of their uncomfortable symptoms during pregnancy involving their musculoskeletal and gastrointestinal systems, however, now I empathize on another level.

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Evidence-based Therapeutic Interventions for Individuals with Osteoporosis

Nancy Cullinane PT, MHS, WCS is today's guest blogger. Nancy has been practicing pelvic rehabilitation since 1994 and she is eager to share her knowledge with the medical community at large. Thank you, Nancy, for contributing this excellent article!

Clinically valid research on the efficacy and safety of therapeutic exercise and activities for individuals with osteoporosis or vertebral fractures is scarce, posing barriers for health care providers and patients seeking to utilize exercise as a means to improve function or reduce fracture risk1,2. However, what evidence does exist strongly supports the use of exercise for the treatment of low Bone Mineral Density (BMD), thoracic kyphosis, and fall risk reduction, three themes that connect repeatedly in the body of literature addressing osteoporosis intervention.

Sinaki et al3 reported that osteoporotic women who participated in a prone back extensor strength exercise routine for 2 years experienced vertebral compression fracture at a 1% rate, while a control group experienced fracture rates of 4%. Back strength was significantly higher in the exercise group and at 10 years, the exercise group had lost 16% of their baseline strength, while the control group had lost 27%. In another study, Hongo correlated decreased back muscle strength with an increased thoracic kyphosis, which is associated with more fractures and less quality of life. Greater spine strength correlated to greater BMD4. Likewise, Mika reported that kyphosis deformity was more related to muscle weakness than to reduced BMD5. While strength is clearly a priority in choosing therapeutic exercise for this population, fall and fracture prevention is a critical component of treatment for them as well. Liu-Ambrose identified quadricep muscle weakness and balance deficit statistically more likely in an osteoporotic group versus non osteoporotics6. In a different study, Liu-Ambrose demonstrated exercise-induced reductions in fall risk that were maintained in older women following three different types of exercise over a six month timeframe. Fall risk was 43% lower in a resistance-exercise training group; 40% lower in a balance training exercise group, and 37% less in a general stretching exercise group7.

These studies allow us to unequivocally conclude that spinal extensor strengthening and therapeutic activities aimed at improving balance and decreasing fall risk are tantamount as therapeutic interventions for osteoporosis. But postural education/modification and weight bearing activities aimed at stimulating osteoblast production intended to improve BMD are a reasonable component of an osteoporosis treatment plan, despite the lack of concrete evidence for them. Nutrition and mineral supplementation with calcium and vitamin D have been shown to reduce morbidities, and hence we should incorporate this education into our treatment plans as well8, 9. Studies on the efficacy of vibration platforms hold promise, but thus far, have not been substantiated as an evidence-based intervention to improve BMD.

Too Fit To Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fractures1,2 is a multiple-part publication in the journal Osteoporosis International, based upon an international consensus process by expert researchers and clinicians in the osteoporosis field. These publications include exercise and physical activity recommendations for individuals with osteoporosis based upon a separation of patients into to three groups: osteoporosis based on BMD without fracture; osteoporosis with one vertebral fracture; and osteoporosis with multiple spine fractures, hyperkyphosis and pain. This group of experts emphasize the importance of teaching safe performance of ADLs with respect to bodymechanics as a priority to accompany strength, balance, fall & fracture prevention, nutrition and pharmacotherapy management. They promote establishment of an individualized program for each patient with adaptable variations of these concepts, with the most accommodation allotted for individuals with multiple vertebral compression fractures. An example of such an adaptation is altering prone back extensions such as those documented in the studies by Sinaki and Hongo, into supine shoulder presses, thus strengthening the back extensors in a less gravitationally demanding posture. Osteoporosis Canada has adapted the main concepts from these publications into a patient-friendly, instructional website with reproducible handouts at http://www.osteoporosis.ca/osteoporosis-and-you/too-fit-to-fracture/

A firm conclusion from the Too Fit to Fracture project is that higher quality outcomes studies are desperately needed to assist all healthcare providers in managing osteoporosis more effectively and comprehensively, and to do so prior to the onset of debilitating fractures that tend to produce serious comorbidities.

1. Giangregorio et al. Too Fit to Fracture: exercise recommendations for individuals with osteoporosis or osteoporotic vertebral fracture. Osteoporosis International. 2014; 25(3): 821-835
2. Giangregorio et al. Too Fit to Fracture: outcomes of a Delphi consensus process on physical activity and exercise recommendations for adults with osteoporosis with or without vertebral fracture. Osteoporosis International. 2015; 26(3):891-910
3. Sinaki et al. Stronger back muscles reduce the incidence of vertebral fractures: a prospective 10 year follow-up of postmenopausal women. Bone. 2002; 30: 836-841 4. Hongo et al. Effect of low-intensity back exercise on quality of life and back extensor strength in patients with osteoporosis; a randomized controlled trial.Osteoporosis International. 2007; 10: 1389-1395
5. Mika et al. Differences in thoracic kyphosis and in back muscle strength in women with bone loss due to osteoporosis. Spine. 2005; 30(2): 241-246
6. Liu-Ambrose et al. Older women with osteoporosis have increased postural sway and weaker quadriceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontology, Series A Biolog Sci Med Sci. 2003; 58(9): M862-866
7. Liu-Ambrose et al. The beneficial effects of group-based exercise on fall risk profile and physical activity persist 1 year post intervention in older women with low bone mass: follow-up after withdrawal of exercise. J Am Geriat Soc. 2005; 53 (10): 1767-1773
8. Ensrud et al. Weight change and fractures in older women: study of osteoporotic fractures research group. Archives Int Med. 1997; 157 (8): 857-863
9. Kemmler et al. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results. Med and Sci in Sports Ex. 2002; 34 (12): 2115-2123

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Electrical Stimulation as part of a treatment program for urgency urinary incontinence

Today's blog is a contribution from Kristen Digwood, DPT, CLT, of the Elite Pelvic Rehab clinic in Wilkes-Barre, PA.

Urgency urinary incontinence (UUI), which is the involuntary loss of urine associated with urgency, is a common health problem in the female population. The effects of UUI result in limitations to daily activity and quality of life.

Current guidelines recommend conservative management as a first-line therapy in urinary incontinence, defined as "interventions that do not involve treatment with drugs or surgery targeted to the type of incontinence".

By Yeza - Own work, GFDLElectrical stimulation is commonly used as part of a treatment program for women with UUI. There are several methods and parameters that can be used to improve urge incontinence, however the magnitude of the alleged benefits and best parameters is not completely established. Studies have suggested that the use of electrical stimulation to inhibit an overactive bladder functions to modulate unwanted detrusor contractions by way of sensory afferent stimulation of S2 and S3. This causes parasympathetic inhibition.  In addition to this effect, contraction of the pelvic floor muscles results in inhibition and relaxation of the detrusor muscle which reduces urinary urgency.

Common methods of electrical stimulation include suprapubical, transvaginal, sacral and tibial nerves stimulation.

As with any medical treatment, practitioners seek the most effective methods and parameters to achieve the patient’s goals. A recent systematic review of electrical stimulation in the treatment of UUI included nine trials to treat UUI were included with total of 534 female patients. Most patients in the trials were close to 55 years of age. Five articles (total of nine) described a frequency of twice-weekly therapy and sessions of 20 minutes. Twelve weeks was the most common duration of therapy. All the studies applied an intensity of stimulation below 100 mA, with four of them (4/9) using 10 hz as the frequency. Intervaginal electrical stimulation showed the greatest subjective improvement and was the most effective.

The most frequent outcome measure was bladder diary, used in all papers; subjective satisfaction was used in 8; and quality-of-life questionnaires in 6, from a total of 9 papers.

The study noted that reports about electrical stimulation generally lack information on its cost-effectiveness. This is an important point, especially because in therapies with similar benefits cost may be one of the factors to indicate the most appropriate treatment. If we consider the relatively few adverse effects, low cost, and similar effectiveness when compared to medication, intravaginal electrical stimulation, according to available data, appears to be a good alternative treatment for UUI.

1. Thüroff JW, Abrams P, Andersson KE, Artibani W, Chapple CR, Drake MJ, et al.: EAU guidelines on urinary incontinence. Eur Urol. 2011; 59: 387-400.
2. Kralj B. The treatment of female urinary incontinence by functional electrical stimulation. In:Ostergard DR, Dent AD (eds). Urogenecology and Urodynamics. 3rd ed. Baltimore, MD: Williams and Wilkins; 1991.
3. Eriksen, BC. Electrical Stimulation. In: Benson JT editor. Female pelvic floor disorders: investigation and management. New York:Norton, 1992; 219-231.
4. Lucas Schreiner  , Thais Guimarães dos Santos  , Alessandra Borba Anton de Souza, et al. Int. braz j urol. vol.39 no.4 Rio de Janeiro July/Aug. 2013.

 

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Low-Level Laser Therapy for Female Pelvic Floor Conditions: A New and Exciting Online Course

The following is a guest post from Isa Herrera, MSPT, CSCS owner of Renew Physical Therapy in New York, NY. Isa recently launched her new online course "Low Level Laser Therapy For Female Pelvic Pain Conditions" found at www.PelvicPainRelief/laser.

Physical therapists deal with chronic pain that can be problematic to treat and manage on a daily basis. There is an arsenal of tools, exercises and techniques at their disposal, but many times using a modality can help accelerate the pain-relieving process for their patients. Pelvic floor physical therapists in particular treat an extremely difficult type of chronic pain loosely classified under the umbrella term "pelvic pain." Pelvic pain can express itself as vulvodynia, clitorodynia, provoked vestibulodynia, pudendal nerve neuralgiavaginismus and/or dyspareunia. These conditions are common, with 1 in 3 women suffering from pelvic and/or sexual pain in the United States. It is estimated that approximately 30 million suffer from this silent epidemic. As physical therapists we are on the first line of defense and we must be prepared to provide the pain relief that these women so desperately seek.

Secret Weapon for Pelvic Pain Is Finally Here

Chronic pelvic pain is very different from other types of pain because it's intimately connected to our emotional, spiritual and psychological states, and can involve the nervous, endocrine, visceral, gynecological, urological and muscular systems. It can be very difficult to treat, and can require anywhere from six months to one year of physical therapy, depending on patient presentation and history.

This lengthy course of treatment requires a fresh approach to therapy and modalities. When I started treating this population I had many difficulties controlling their pain and I had to think differently. Electrical stimulation and ultrasound were not working as well as I'd hoped, providing insufficient pain relief to these patients. I needed a modality that, when incorporated with my pelvic pain treatment, could help produce immediate and long-lasting pain-relieving effects. I needed a modality that could significantly decrease pain within one session, and that my patients could believe in because of the results.

Low-level laser therapy (LLLT) proved to be my secret weapon when treating women with chronic pelvic pain. (I frequently call it "light therapy," because many patients don't like the term "laser.") I have been successfully using light therapy for nearly ten years. It helped my patients keep their pain at bay, and many request that I use it as part of their therapy. I have had incredible patient outcomes when I use LLLT. Of course, for light therapy to work with this difficult population a foundational knowledge and established protocols are required.

LLLT was approved by the FDA in 2002. At that time, the modality was hailed by the New England Patriots and the U.S. Olympic Committee, among others, for its ability to help top athletes quickly return from injury. Endorsements from these organizations piqued my interest and I decided to research its principles. I now know firsthand about the miraculous effects of LLLT. From my own personal experience and from treating thousands of patients I realized that LLLT could be used on many levels.

LLLT is unique: it is a cellular bio-stimulator and is used to increase vitality of cells as well as processes that occur within the cell. The goal with LLLT is to stimulate health and vitality within the cell to produce pain relief, collagen synthesis, anti-inflammatory effects, and endorphin production. Pain- relieving results can be felt in the first visit.

New Look at Low-Level Laser Therapy

My ten years of experience using LLLT have led me to develop low-level laser protocols for female pelvic floor conditions. These protocols are extremely useful for any practitioners wanting to purchase a laser as a new pain-relieving modality for their clinic.

LLLT has changed the way I treat all pain syndromes. It's had such a positive impact that I've created laser protocols for vulvodynia, scar and bladder pain. I also created a special class for the Herman and Wallace Institute program for physical therapists who treat chronic pelvic pain. I encourage any colleagues specializing in this population to investigate this remarkable modality and to attend the online class. If you are looking for something different and a modality that will change the way you treat, come and learn how to use if effectively. My Low-Level Laser Therapy for Female Pelvic Floor Conditions online course incorporates evidence-based science into the low-level laser protocols that you can bring into your practice immediately. This online continuing educational course is designed to provide a thorough introduction to LLLT and its application to female pelvic pain conditions. It is approved for 13 CEU’s and contains ten modules. All ten modules provide step-by-step treatment protocols, videos and PowerPoints. This online class includes protocols for bladder pain, scar pain, coccyx pain, vulvodynia, clitorodynia, provoked vestibulodynia, pudendal nerve neuralgia, vaginismus and dyspareunia.

This new and exciting online class will put you and your practice on the forefront finally providing pain relief for your patients that lasts and improves your outcome measures.

For more info on the low-level laser online training class for female pelvic floor conditions go to www.PelvicPainRelief/laser.


Basford et al. Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Arch Phys Med Rehabil (1999) vol. 80 (6) pp. 647-52.

Bjordal et al. A systematic review of low level laser therapy with location-specific doses for pain from chronic joint disorders. Aust J Physiother (2003) vol. 49 (2) pp. 107-16.

Chow et al. The effect of 300 mW, 830 nm laser on chronic neck pain: a double-blind, randomized, placebo-controlled study. Pain (2006) vol. 124 (1-2) pp. 201-10.

Harlow BL, Kunitz CG, Nguyen RHN, et al. Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. Am J Obstet Gynecol. 2014; 210:40.

Kostantinovic et al. Low level laser therapy for acute neck pain with radiculopathy: a double-blind placebo-controlled randomized study. Pain Medicine (2010) vol. 11 pp. 1169-1178.

Mathias SD1, Kuppermann M, Liberman RF, et al. Chronic pelvic pain: prevalence, health-related quality of life, and economic correlates. Obstet Gynecol. 1996;87(3):321–327.

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Dr. Sarah Capodagli, DPT - Herman & Wallace's Featured Practitioner of the Week!

Congratulations to Dr. Sarah Capodagli, DPT, our featured practitioner of the week! Dr. Capodagli owns and operates CorrEra Physical Therapy, and she is in the process of expanding her practice in Buffalo, NY. We were curious to hear more from her about running a practice in Buffalo, and Sarah was kind enough to write in. Thanks, Sarah!

Dr. Sarah Capodagli, DPTAlthough Buffalo is considered the second largest city in the state of New York, we often operate like a small town. We value community and for just about any business, the best marketing tool is word of mouth. If you need a new roof, new car, or a good doctor, well, ask around and I guarantee that you will find someone who “knows a guy,” to help or advise. I cannot speak for every city, though when I think of Buffalo, NY, I think of family. When you see your family in need, you help.

A few years ago I was working in a large oncology hospital and one of my primary roles was running the pelvic floor rehabilitation program for men living with or being treated for prostate cancer. I loved this work; however, I saw greater need in our community for not only the proper conservative care and treatment, but also for the information about pelvic health to be shared more publicly with men and women. Although opening my own clinic in a suburb of this “City of Good Neighbors” was not always the plan, when given the opportunity to grow into my own practice by a chiropractor friend, I jumped at the chance and have never looked back. It was a big jump, but for me, the fear of regret in never trying was so much worse than the fear of failure.

The greatest challenge was in actually starting my practice and beginning to educate the community and physicians. In a larger metropolis there is more awareness of this specialty and referrals come more naturally when conservative options are made known to patients. In the beginning I reached out to a mentor, utilized many tools available on the Herman & Wallace website, held free community events, and spent my first few months focused on networking. Once introduced to some fabulously conservative docs, birthing professionals, and physical therapists who were aware of the benefits of pelvic floor rehab, I really started to see the growth. I became an advocate for patients – a navigator in this sometimes confusing and frustrating system. People want conservative options and when happy patients return to their physicians with improved symptoms and quality of life, well, now your reputation establishes you as one of the “go-to” practitioners in the community.

Though patience and persistence are crucial in this process of growth, I’m also a firm believer that, as Dr. Francis Peabody stated, “the secret of the care of the patient is in caring for the patient.” This belief is what sets me apart, and in a small community this is what really matters. One of my favorite books is The Go-Giver by Bob Burg and John D. Mann. I always want my practice and the growth of my business to reflect the strategies of value, service, influence, and authenticity emphasized in this story. In a community where community is valued, I truly believe that if you stay teachable and positive, the care you put into your practice will always pay off.

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Diastasis Recti Abdominis: A Narrative Review

The following post comes to us in part from Ginger Garner, PT, ATC, PYT, who teaches three yoga courses for Herman & Wallace; Yoga for Pelvic Pain, Yoga as Medicine for Pregnancy, and Yoga as Medicine for Labor and Postpartum. Check out her poster at the Combined Sections Meeting this weekend in Anaheim!

Maternal health care in the United States is abysmal. Especially wretched is care and support of women post-partum. Our insurance system is partially to blame by dictating that women receive only one visit with the provider who participated in the delivery of their baby 6 weeks after the baby is born, no matter the method of delivery. This is often after most of the scary, unexpected side effects of delivery, like heavy bleeding, nipple pain, urinary incontinence, difficulty with bowel movements, scar pain and tremendous mood swings have begun to ease. Only the women who are the most persistent, or those who have chosen unique care models (like out of hospital births with midwives), seem to get real support post-partum, leaving marginalized and less self-driven women to fend for themselves.

What if research could show that immediately treating some of the side effects of birth, like diastasis recti abdominus, which occurs in 50-60% of post-partum women, could result in improved outcomes in the long run? What if someone could prove that retraining and strengthening the abdominal wall as part of a biopsychosocial model empowering women could change the costly effects of prolapse and urinary incontinence treatment later on in life? What if that research aimed to show that treating women in partnership will all care providers was the most effective? These are big questions, but through research beginning with Diastasis Recti Abdominis (DRA), some Women’s Health Physical Therapists trained in Medical Therapeutic Yoga are hoping to highlight some answers.

At CSM in San Diego next month, these researchers (listed below) are presenting a poster via the Section on Women’s Health showcasing their paper, Diastasis Recti Abdominis: A Narrative Review. They found that good, solid research focusing on the co-morbidities and treatment of DRA is really lacking. Most well-done studies focus on the reliability and validity of measurement techniques, showing that calipers and ultrasound are the most valid and reliable ways to measure the gap. There is not even agreement on what precise measurement technically constitutes a DRA, though most agree that normal inter-recti distance is 15-25mm supraumbilically among parous females with digital calipers. (Chiarello 2013).

Besides the obvious cosmetic and general strengthening concerns, why do we care about physical therapy care for a post-partum DRA? Spitznagle’s retrospective chart review of women presenting for gynecological care with a mean age of 52 found that 52% had DRA and 66% of them had a least one support-related pelvic floor muscle dysfunction. Those with DRA were more likely to have pelvic organ prolapse, urinary incontinence and fecal incontinence. Another study by Parker found a DRA prevalence of 74.4% among women with back or pelvic area pain who had delivered at least one child and sought PT. They found a significant difference in VAS pain levels in those with DRA and abdominal or pelvic pain compared to those without DRA. More well-done, prospective studies are really needed to correlate these sequalea in later life to DRA post-partum.

The topic of how to retrain the abdominal wall to restore optimal function and cosmetic appearance is hot in the blogosphere right now. Does it matter if the width of the diastasis recti is reduced? Or is it a matter of having tension in the linea alba as the clinician sinks his/her fingers toward the spine? Biomechanically we know that in order to improve stiffness in the trunk, we need synergistic and symmetrical firing of the diaphragm, transversus abdominis, multifidus and the pelvic floor with proper timing and contraction of the hip and external abdominal muscles. Benjamin completed a review of the research on the effects of exercise in the antenatal and postnatal periods and concluded that antenatal exercise may be protective against the formation of a DRA, but that the available studies are of such poor quality and varied in the way that abdominal/core strengthening was applied in the post-partum population, that it is impossible to tell how or why exercise may or may not help with DRA!

There is clearly a huge hole in the literature and as usual, new mothers are suffering. Women are spending money on programs they find on the internet that are not backed by solid research, because there is not any! Regarding DRA, post-partum women in our country desperately need well-done, high quality studies promoting a specific and well-described exercise for healing. In addition, in our patriarchal health care model, we need to show without a shadow of a doubt that treating post-partum muscle weakness, body mechanics issues and DRA is essential for saving money in the long run on prolapse and urinary incontinence surgery, as well as decreasing expenditure on back pain treatments.

If our discipline could provide this research, ALL women could have access to personal, post-partum recovery. As an established part of the health care system and with longer treatment times and the chance to get to know our patients better, physical therapists are the IDEAL healthcare practitioners to ensure that post-partum women are getting adequate physical retraining, but also psycho-social support that is so lacking in the United States.

The Women’s Health Poster Presentations at CSM in Anaheim will be on Saturday, Feb 20 from 1-3PM. I look forward to meeting with some of you and visiting about what you are working on to further the cause of improving maternal health care and DRA treatment.


Ginger Garner PT, ATC, PYT, Professional Yoga Therapy Institute, Emerald Isle, NC
Elizabeth Trausch, DPT, PYT Des Moines University, Des Moines IA
Stefanie Foster, PT, PYT Asana with Intelligence, Houston, TX
Paige Raffo, PT, PYT, CPI, Balance+Flow Physio, Bellevue, WA
Janet Drake, PT, LCCE, FACCE, PYT, Central Bucks Physical Therapy, Doylestown, PA
Stacie Razzino, PT, PYT, Free Motion Physical Therapy, Melbourne, FL
Blog post by Libby Trausch, DPT

Spitznagle T, Leong F, Van Dillen L, Prevalence of diastasis recti abdominis in a urogynecological patient population, International Urogynecology Journal. 2007; 18: 321-328.
Chiarello CM, Mcauley JA. Concurrent validity of calipers and ultrasound imaging to measure interrecti distance. Orthop Sports Phys Ther. 2013; 43(7): 495-503
Benjamin DR, et al., Effects of exercise on diastasis of the rectus abdominis muscle in the antenatal and postnatal periods: a systematic review. Physiotherapy. 2014 Mar;100(1):1-8.

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Retreat for Patients Suffering from Pelvic Pain

The following is a guest post from Nancy Fish, LCSW, MPH who will be presenting at the Alliance for Pelvic Pain Retreat on May 20-22 in Ellenville, NY. Check out this flier to learn more about the retreat.

Gaining a Sense of Hope and Empowerment

Nancy Fish, LCSW, MPH (co-author, with Deborah Coady,M.D. of Healing Painful Sex)
About the Alliance For Pelvic Pain Retreat, May 20-22, 2016, Ellenville, NY

When thinking about registering for the Alliance for Pelvic Pain Patient Retreat, I imagine you are asking yourself “Why would a person suffering from pelvic pain, with more medical appointments than is humanly possible to handle, add another item on an already overwhelming “to do” list?” It would be completely understandable if that is your initial reaction. So why is this retreat a must in your path to physical and emotional healing? There are so many reasons why this retreat can be a life-altering event but I’ll just name a few compelling ones. As a psychotherapist who specializes in pelvic pain (I am also a pelvic pain patient) the primary challenges I hear from most of my clients are:

  • “I feel so alone.”
  • “This is too embarrassing to talk about with ANYONE.”
  • ”I feel so hopeless and that there is nothing that can help me.”
  • “I feel like I will never have sex again.”
  • “Who will want me?”
  • “No doctor understands this and no doctor can help me.”

If you are reading this blog, I’m sure you can identify with a few if not all of these statements. If only ONE of these statements is something you relate to, then the AFPP retreat is an event you cannot afford to miss. It will provide you with invaluable tools to address all of your concerns. You will have access to some of the world’s most renowned medical, physical therapy, and mental health professionals specializing in the integrative treatment of pelvic pain who will be able to answer any of your questions or concerns. There will be opportunities to register for significantly discounted one on one sessions with expert physical therapists, an Acupuncturist, a yoga instructor, and services from the EarthMind Wellness Center at Honors Haven. You will also be with other individuals who share the same concerns and challenges and you will not have to explain issues like “why you can’t sit” or “why this pain makes you feel you are going crazy.” For the first time in a long time you will not have to justify behaviors or decisions that you are confronted with on a daily basis – you can just be you.

One of the greatest tools you will gain from this retreat is empowerment. Pelvic pain can be so disempowering and our goal is give you the ability to empower yourself so you begin or continue on the path of self-healing through a combination of medical and integrative health techniques. I never ask any of my clients to use a technique that I don’t use myself. And I have found that medical interventions are often essential but not enough. Overcoming pelvic pain takes an “East meets the West” approach using a daily practice of mindfulness, meditation, and other integrative techniques. Participants leave the retreat with a new support system, a sense of self-empowerment, and a host of self-healing practices (such as a physical therapy home program) that will be invaluable on your journey to recovery – and most important, A RENEWED SENSE OF HOPE.

(Spaces are limited so please book your reservation as soon as possible. Also, for funding opportunities, all participants should go to Gofundme.com.)

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Upcoming Continuing Education Courses

Oct 11, 2019 - Oct 13, 2019
Location: Houston Methodist

Oct 11, 2019 - Oct 13, 2019
Location: Physical Therapy Services of Lansing

Oct 11, 2019 - Oct 13, 2019
Location: Northwestern Medicine

Oct 11, 2019 - Oct 13, 2019
Location: Florida Hospital - Wesley Chapel

Oct 12, 2019 - Oct 13, 2019
Location: Evolution Physical Therapy

Oct 18, 2019 - Oct 20, 2019
Location: The George Washington University

Oct 18, 2019 - Oct 20, 2019
Location: University Hospitals

Oct 19, 2019 - Oct 21, 2019
Location: Lee Memorial Health System

Oct 25, 2019 - Oct 27, 2019
Location: Core 3 Physical Therapy

Oct 26, 2019 - Oct 27, 2019
Location: Texas Children’s Hospital

Nov 1, 2019 - Nov 3, 2019
Location: Adena Rehabilitation and Wellness Center

Nov 1, 2019 - Nov 3, 2019
Location: Asante Rogue Valley Medical Center

Nov 1, 2019 - Nov 3, 2019
Location: Cancer Treatment Centers of America - Chicago, IL

Nov 1, 2019 - Nov 3, 2019
Location: Upper Chesapeake Health

Nov 2, 2019 - Nov 3, 2019
Location: University Hospitals

Nov 2, 2019 - Nov 3, 2019
Location: Griffin Hospital

Nov 3, 2019 - Nov 5, 2019
Location: Touro College: Bayshore

Nov 8, 2019 - Nov 10, 2019
Location: Washington Regional Medical Center

Nov 9, 2019 - Nov 11, 2019
Location: Comprehensive Therapy Services

Nov 9, 2019 - Nov 10, 2019
Location: Summa Health Center

Nov 9, 2019 - Nov 10, 2019
Location: STI PT and Rehab

Nov 9, 2019 - Nov 10, 2019
Location: Providence Holy Cross Medical Center of Mission Hills

Nov 15, 2019 - Nov 17, 2019
Location: Banner Physical Therapy and Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Ability Rehabilitation

Nov 15, 2019 - Nov 17, 2019
Location: Huntington Hospital

Nov 16, 2019 - Nov 17, 2019
Location: Princeton Healthcare System

Dec 6, 2019 - Dec 7, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Swedish Covenant Hospital

Dec 6, 2019 - Dec 8, 2019
Location: Franklin Pierce University

Dec 6, 2019 - Dec 8, 2019
Location: Florida Hospital - Wesley Chapel