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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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The Role of the PTA

The following is a contribution from Elisa Marchand, PTA, PRPC. Elisa is the first PTA to become a Certified Pelvic Rehabilitation Practitioner! Elisa started a Pelvic Floor program with a locally-owned rehab company where she mentored 3 different PT's through the years. In that time, Elisa also taught as an adjunct with the local PTA program. Elisa works at McKenna Physical Therapy in Peoria, IL.

As a physical therapist assistant, the following should cause me to rethink my passion for and practice within women's health PT. "The SOWH is opposed to the teaching of internal pelvic assessment and treatment to all supportive personnel including physical therapist assistants." (Position Statement on Internal Pelvic Floor Assessment and Treatment: Section on Women's Health, APTA; Feb 2014) It should have stopped me from sitting for and becoming the first-ever PTA certified as a PRPC. Fortunately, this is not the case.

I want to be clear from the start; I understand the need for clear boundaries with regards to the scope of practice of PTAs. However, the interpretation of these rules can get quite muddy. In the APTA's "Guide for Conduct of the PTA", the following clarifications are made, including their interpretations:

3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge, there may be areas of physical therapy interventions in which he or she displays advanced skills...To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence.

 

3E. [PTA's] shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient/client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient/client status indicate that modifications to the plan of care may be needed.

Through the years of working as a PTA, I have practiced in a variety of settings. Some of these settings have allowed for a high level of autonomy (such as in my current workplace), and some have operated in quite the opposite-- where my treatments were dictated step-by-step by the PT. No matter the state in which one lives, physical therapy clinics will vary in their method of treatment and utilization of PTAs. In Illinois, where I practice, the following is the detailed description of a PTA per the Illinois Practice Act:

"'Physical therapist assistant' means a person licensed to assist a physical therapist and who has met all requirements as provided in this Act and who works under the supervision of a licensed physical therapist to assist in implementing the physical therapy treatment program as established by the licensed physical therapist. The patient care activities provided by the physical therapist assistant shall not include the interpretation of referrals, evaluation procedures, or the planning or major modification of patient programs." (http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapterID=24)

Additionally, per the APTA's Standards of Ethical Conduct for the Physical Therapist Assistant: "6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy." (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) Personally, I take this as a green light for PTA's to immerse themselves in whatever their niche or passion may be. Thus, if a PTA is following this standard, and the advances in PT call for more trained therapists with an understanding of the pelvic floor, and the appropriate oversight provided-- as in my case; what is the hold-up?

Counter to the above expectations, the Section on Women's Health's Position Statement on Internal Pelvic Floor Assessment and Treatment states:

"Any internal pelvic (vaginal or rectal) myofascial release or soft tissue mobilization techniques that would require a continuous ongoing re-evaluation and reassessment should be performed by the physical therapist and not delegated to supportive personnel including physical therapist assistants. The SOWH recognizes that therapeutic exercise, neuromuscular reeducation and behavioral retraining techniques for pelvic floor dysfunction at times requires ongoing critical decision making while at other times are relatively routine. In the routine circumstances, those techniques may be delegated. When the higher level of critical decision making is necessary those techniques should be performed by the physical therapist and not delegated to support personnel including the physical therapist assistant."

In this above set-up, PTA's are made to sound as if incapable of using any critical thinking skills. Or, at the least, able to operate with very limited critical reasoning. Furthermore, in the typical treatment of pelvic floor conditions, how is the decision-making process required for individualized treatment any different than that to the external pelvis, or the low back, or the foot for that matter?! The skill and awareness that was required in transferring a patient in the ICU when I was a new grad was in some ways more complex with more of a direct impact on a person's survival and well-being, than what I do now. Yet, how am I not qualified to do something in which I have extensive training? This seems inconsistent.

In my opinion, the PTA is more than just "supportive personnel". On the other hand, I also believe that new PTA grads may not have a place in pelvic floor PT. There are complexities within, and knowledge required of anatomy and physiology of the pelvis, which the PTA does not get from his or her program. Though doctorate students entering the PT world today also do not have much exposure to the pelvic floor, they at least have gone through a more thorough coverage of anatomy, physiology, and disease processes. Despite the differences in schooling, MANY physical therapists see their assistants as vital assets to their clinics.

One incredibly positive aspect of being a PTA is the follow-through I have with my clients. I LOVE getting to know my patients, and feel that I am allowed this luxury more frequently than PT's whose schedules may need to stay open for new evaluations. I frequently have clients say to me, "I would never have dreamed that I'd be talking about (fill in the blank) with ANYBODY!" Usually, this is after a few sessions of working together. I cherish seeing the freedom and healing that comes when people feel comfortable enough to open up their physical, emotional, and spiritual selves.

Yes, as a PTA we are limited by the scope of practice placed before us. However, I do not see that as a set of limitations that binds us to a very narrow existence. With the training one receives through continuing education such as with Herman & Wallace, the PTA can gain the necessary skills for treatment. And from this, the possibilities are endless!

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My introduction to the World of Pelvic Floor

Reema Thakkar, PT, DPT has been a practicing Physical Therapist in Manhattan since 2011, specializing in orthopedics and vestibular rehabilitation. Reema has offered to share insights about her journey into pelvic rehabilitation.

Working as a physical therapist for 4+ years in Manhattan, I soon realized the need for pelvic floor rehabilitation within the pre- and post- natal community, as well as the geriatric community. Much of our population did not even know that this type of rehabilitation was effective or even available. Others, were simply embarrassed by the topic altogether. I decided - a complete novice in this field - to attend a Herman & Wallace PF course and see what was available as a resource for me, and my patients.

"I can happily report that as more and more patients catch wind of what I’m working on, their interest spurs."

My first course was definitely overwhelming. I had studied beforehand, like any eager student would, but I still felt as though it was my first day of PT school and I was scared I would “break” the patient. The candor and wit, in which each topic was presented to us that weekend, completely eased my mind. The pelvic floor, like any other daunting body part we had studied through our careers as PTs, was equally as influenced by the pulls and strains of our daily lives…and the muscles and joints needed our help.

I returned from my course full steam ahead. I felt equipped to at least begin this journey with my patients, and decided to further pursue my pelvic floor education, already registering for a follow up course in a few months. One thing that was imperative to my pelvic floor pursuit, was understanding the confines of an outpatient clinic. Even with having curtains around, patients were far less inclined to open up about their dysfunctions despite this assumed level of privacy. I had to ensure to schedule in times where one on one care with a closed door was possible. Another imperative factor was studying ahead of time. Being new to this care, I had to have a prescription from the MD or an intake form from the patient beforehand in order to research the night before.

I am still in the process of mastering this flow of practice. However I can happily report that as more and more patients catch wind of what I’m working on, their interest spurs. I can’t say they have all come in for a pelvic floor evaluation, especially the older generation, but they are certainly opening up a dialogue and asking some questions – which is all I can hope for.

That being said, I am even more confident in my ability to help the patients in question. Since returning from my first class, my greatest successes have been working with an elderly woman with severe uterine prolapse and a middle aged gentleman suffering from urinary incontinence s/p inguinal hernia repair. I can gladly report that their quality of life has greatly improved since beginning this care and I can only hope to guide them further in this process, with further success.

Reema has been a practicing Physical Therapist in Manhattan since 2011, specializing in orthopedics and vestibular rehabilitation. Reema is currently pursuing further training in order to become a certified Pelvic Rehabilitation Practitioner.

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Merging of Worlds - A Guest Post from Barbara Rabin

Today we are fortunate to hear from Barbara S. Rabin MSPT ATC PYTc, owner and practitioner at Holistic Physical Therapy in Gates Mills, OH. Barbara has more than 20 years of experience in orthopedic rehabilitation. Her perspective as an athletic trainer and orthopedic therapist highlights the many approaches practitioners can take when working with pelvic rehabilitation patients.

"We were reminded how all the muscles of the hip are intricately integrated into the pelvic floor and one can’t ignore the influence and interaction they have on each other."

My physical therapy career has been in the world of outpatient orthopedics and sports medicine. While in physical therapy graduate school I became a nationally certified athletic trainer, and most of my post graduate CEU’s have been in the orthopedic and sports medicine arena.

Stepping Outside the Comfort Zone

As an orthopedic PT, it was “safe” to study the pelvic girdle when I took Richard Jackson’s continuing education course in 1994 because it focused on muscles, ligaments, bones and nerves. However, I was leaving “safe territory” when I took Janet Hulme’s course, “Beyond Kegels: Evaluation and Treatment of Pelvic Muscle Dysfunction and Incontinence” in 1998. Long ago, back in gross anatomy lab in physical therapy school, we barely looked at the pelvic floor contents. Yes, we identified the digestive system but basically ignored all of the rest. Our mission was mostly to learn the muscles, ligaments, bones and nerves. After Janet Hulme’s course, I tried to offer incontinence rehabilitation at my place of employment at the time, but the idea was quickly dismissed. However, I am very glad to say that pelvic floor rehab is now commonly offered at most major hospitals and many clinics.

I continued my education of the pelvis and hip in several other courses and especially enjoyed one I attended last year called, "Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management" by the Herman & Wallace Pelvic Rehabilitation Institute and taught by Ginger Garner PT ATC PYT. We were reminded how all the muscles of the hip are intricately integrated into the pelvic floor and one can’t ignore the influence and interaction they have on each other.

I was intrigued and wanted to learn more about the pelvic floor. I got another opportunity when I most recently attended an intimidating course for an “orthopedic sports medicine physical therapist” called, “Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 1: The Urinary System” taught by Ramona Horton, MPT. I learned that externally mobilizing the bladder can often increase hip extension. Here was a combining of the fascial, pelvic floor, and orthopedic worlds!

Myofascial Release and Other Manual Therapy

I learned several manual therapy techniques in courses, and I took the best out of many but never specialized. As of late, I have been gladly drawn into the world of John F Barnes myofasical release. Studying and working with the fascia coincides with my holistic approach of rehabilitation, since the fascia is intricately woven throughout our body. The fascia was another thing we ignored in gross anatomy lab in physical therapy school. It was cut to move it out of the way so we could “get to the important stuff.” Even in that dead and embalmed state, the fascia was fascinating. It was strong and flexible at the same time. Now, with the advent of micro discography of the fascia by Dr. Jean-Claude Guimberteau (http://www.guimberteau-jc-md.com/en/biographie.php) we can view fascia in its live state and we can really see the phenomenal structure that it truly is.

Incorporating Yoga into Rehabilitation Practices

About eight years ago I took my first yoga class. I thought I was a conditioned athlete as a lifelong runner but I was humbled as I could not even balance on one leg for a minute. I noticed the physical and emotional benefits in myself and wanted to include yoga in the treatment of my patients. I had a patient who had physical issues from an eating disorder and needed supervision to exercise. I thought to myself that what she needed was not physical therapy but possibly meditation and relaxation. Even though I didn’t learn those techniques in PT school, I felt that I should be able to offer them to my patients. With one yoga class under my belt, in 2007, I entered into a 200 hour teacher training with Marni Task studying her combination of Jivamukti and Anusara yoga. I further continued my yoga training in 2011 with Ginger Garner PT, ATC, PYT of Professional Yoga Therapy Studies (http://proyogatherapy.org). Her school of medical yoga training, was just what I was looking for to merge my worlds of physical therapy and yoga.

Instead of looking at our patients as “pieces and parts,” referring to them as “the knee or the shoulder patient,” it is so important to see them as a whole. As an orthopedic PT I need to recognize that patients have not only a physical side of muscles, ligaments, bones and nerves, but other parts too that make them a whole person. Most likely I won’t specialize in pelvic pain or woman’s health but it is so important for me to be knowledgeable about this field to be the most effective therapist. In addition, it’s important to also go beyond the physical aspect and recognize patient’s psycho-emotional-social, spiritual, energetic, and intellectual aspects of their beings. Optimal health is achieved by recognizing and addressing all aspects of a patient.

And on that note, I’m going to continue merging all of my worlds of fascia, pelvic floor, orthopedics, and yoga, to address all the components of well-being, as I attend an upcoming course offered by Herman and Wallace called, Yoga for Pelvic Pain this month in Cleveland, Ohio.

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Sex After Gynecologic Cancer - Part I

The following comes to us from Herman & Wallace faculty member Michelle Lyons. Michelle travels the world spreading the word about pelvic rehabilitation and the powerful benefits it can have on a patient's everyday life. Michelle will be teaching her newest course, "Oncology and the Female Pelvic Floor: Female Reproductive and Gynecologic Cancers" in White Plains, NY this August 14 - 15. Join her to learn more about evaluating and treating oncology patients.

According to the Scientific Network of Female Sexual Health and Cancer, ‘Sexuality is an experience that really is at the intersection of mind, body and relationship, and cancer treatment can impact all three of those elements”. Dr Sharon Bober of Dana Farber says ‘Part of the problem is that doctors are so focused on saving a cancer patient's life that they forget to discuss issues of sexual health. My sense is that it's not about physicians or health care providers not caring about your sexual health or thinking that it's unimportant, but that cancer is the emergency, and everything else seems to fall by the wayside".

If you harness the power of Google to look up female sexual dysfunction after gynaecologic cancer, you may see phrases like ‘Possible sexual side effects…’ or ‘Cancer treatment can cause physical changes that make having sex more difficult’ or even ‘cancer treatments may make intercourse painful’. To call these descriptions ‘understatements’ does not really do them justice.

For many women post-gynaecological cancer, resuming sexual function can be a multi-faceted problem. Issues can range from dealing with Cancer Related Fatigue and nausea, vomiting or diarrhea to physical changes in the size and shape of the vaginal canal. Cancer treatments can also cause hormone imbalances and tissue damage. Add to this issues with post-surgical/radiation adhesions, a disruption to the ability to produce lubrication, challenges to the musculo-skeletal systems within the hips and the pelvis as well as the onset of medically induced menopause….well you get the picture.

In a 2009 paper, ‘Interventions for sexuality after pelvic radiation therapy and gynaecological cancer’, Katz talks about the fact that ‘…very little attention has been paid to the sexual difficulties women experience after radiation to the sexual organs. There are a limited number of interventions for the woman who has been treated for gynaecological cancer with radiation. These focus on the provision of information and some specific suggestions related to treating vaginal dryness, the need for vaginal dilatation after radiation therapy, and management of fatigue. In ‘A systematic review of sexual concerns reported by gynaecological cancer survivors’ (Abbot Anderson 2012), the author points out that common concerns in the physical dimension were dyspareunia, changes in the vagina, and decreased sexual activity.

In the psychological dimension, common concerns were decreased libido, alterations in body image, and anxiety related to sexual performance. And in the social dimension, common concerns were difficulty maintaining previous sexual roles, emotional distancing from the partner, and perceived change in the partner's level of sexual interest.

The good news is that you can return to a normal sex life after surviving gynaecological cancer – particularly with the help of a skilled pelvic rehab provider.

In part 2 of this blog series, I will look at specific interventions in sexual rehab for the gynaecological cancer survivor. Interested in learning more about pelvic rehab and oncology? Join me in White Plains in August!

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Why is yoga a helpful modality for healing chronic pelvic pain?

Today we hear from Herman & Wallace instructor Dustienne Miller CYT, PT, MS, WCS. Dustienne instructs the Yoga for Pelvic Pain course. Join her next month at Yoga for Pelvic Pain, Cleveland, OH on July 18 and 19!

We all know yoga can help chronic headaches, insomnia, anxiety, low back pain, and a myriad of other conditions. How can we apply the principles and benefits of yoga to the treatment of chronic pelvic pain?

Breathing
As rehab professionals who treat chronic pelvic pain, we know how critical it is for our clients to learn how to downtrain the nervous system. Breath awareness and training are a useful tool in reducing sympathetic nervous system override. Some clients may not have the awareness that they are holding their breath because of pain, or even anticipation of pain. Because of the direct mechanical relationship between the diaphragm and the pelvic floor, breath holding can lead to pelvic floor muscle holding. By building awareness, which is a learned skill, the client begins to notice and eventually control non-optimal breathing patterns.

Yoga offers several types of pranayama, or breathing techniques. Integrating breath with gentle movement has proven to be highly beneficial for men and women with chronic pelvic pain. Simple belly breathing lowers heart rate, blood pressure, and anxiety levels. For more detailed instructions on two pranayama, dirgha (3 part breath) and ujjayi (ocean-sounding breath), please click here.

Grounding
Grounding techniques decrease dissociation and anxiety. Two easy postures to practice in the clinic are Seated and Standing Mountain Pose (Tadasana). When practicing Seated Tadasana, encourage your patient to feel the ischial tuberosities heavy into the chair while imagining a string lifting up the spine and through the top of the head. When practicing Standing Tadasana, offer the imagery of a magnetic pull from the soles of the feet into the earth. For more detailed instruction on Tadasana, please click here.

Being Present
Negotiating medical system can leave clients with chronic pelvic pain feeling traumatized. Sadly, the percentage of men and women who have experienced additional traumas (ie: verbal abuse, sexual abuse) are quite high. Training the mind-body-spirit connection is helpful for the client to stay in the present moment rather than think about past painful experiences or anticipate future expectations of pain. Encourage the client to move at their pace and comfort level. Teach them gentle, loving acceptance of themselves and where they are in their healing journey. Clinicians must be mindful to avoid any potential trauma triggers (ie: teaching Supta Badha Konasana, butterfly/adductor stretch, in an open gym area). An excellent book to read to enhance your understanding of the delicacy of this subject is Overcoming Trauma through Yoga by Emerson and Hopper.

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Tweets from the sheets!

Calling all Pelvic Rehab tweeters! On June 24th, there will be a tweetchat hosted by 'Living Beyond Breast Cancer' to discuss and explore the effects of breast cancer on sexual health. Topics will include:
- How diagnosis and treatment side effects can affect intimacy and sexuality
- How to communicate with your cancer care team and partner
- Tips and suggestions for managing these side effects

Now, while I think it is brilliant that we are talking about sexuality during and after cancer, the panel has no input from pelvic rehab providers! We have so much to offer women in terms of sexual rehab in an oncology setting but if our colleagues and patients don't know about us.....

So some along and join the conversation on twitter on the 24th - don't forget to use the hashtag #LBBCchat. Hope to see you there to help raise the profile of pelvic rehab in the world of oncology.

Interested in learning more about sexual rehab after gynecologic cancer? Join me in White Plains NY this August!

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As a Pelvic Rehabilitation Practitioner, you are Uniquely Suited to Treat Breast Oncology Patients

Today we hear more from Susannah Haarmann, PT, WCS, CLT about how pelvic rehabilitation practitioners are suited to contribute to a breast oncology patient's medical team. Susannah will be sharing more insights and treatment tools at the Rehabilitation for the Breast Cancer Patient course taking place June 27-28 in Maywood, IL.

Most pelvic rehab practitioners are incredible problem solvers and independent thinkers. We understand that often our referrals from a physician occur after a battery of tests and ineffective medical interventions. We may agree to treat a patient only to find that the diagnosis is vague and the patient often feels lost and broken. So we take out our sleuth caps, ask as many subjective questions as it takes and see where our objective examination leads us. Afterwards we paint a picture of our findings, focus the patient on what is working, tell them where we are going to start and how we are going to build one brick at a time.

The same is true for rehabilitation and breast oncology. Most physicians don’t understand how our work as therapists can complement and alleviate the side effects of mainstream medical intervention, but when the pain medication no longer works, we are there. When the range of motion no longer exists to get the patient’s arm into a cradle for breast radiation, we are there. And when the patient walks in our door, we are there, quite often for a period of time that extends well beyond after treatments cease, because the potential side effects of breast cancer, if they occur, may take years or even decades to show up. The rehab practitioner understands how to prepare the patient, without fear, for what the road ahead may look like. The purpose of this education is to empower patients to serve as their own best advocates. Pelvic practitioners and breast oncology specialists are noted for their exceptional manual skills. We are also versed to pounding the pavement educating physicians, patients and other therapists alike about who we can serve and how we can be of service. We are definitely a unique breed of therapists.

The Rehabilitation for the Breast Cancer Patient course will add to the pelvic rehab practitioner's current knowledge allowing them to become a specialist. Consider the following:
A therapist understands the biomechanics of a shoulder joint and function, but do they understand how the effects of radiation, reconstruction procedures and impairments in the lymphatic system as a side effect of cancer treatment might prevent optimal upper extremity function?
A therapist may understand peripheral neuropathy and balance training or osteoporosis and aging, however, do they understand which chemotherapeutic and hormone therapies may cause these side effects and how the prognosis may differ depending upon which medical intervention was used?
A therapist may commonly treat back pain, but do they understand how a plan of care might be altered to accommodate for a patient who experienced a TRAM flap or latissimus dorsi reconstruction?
A therapist may be able to initiate a post-operative rotator cuff strengthening program for the upper extremity, but if the patient has a history of lymphedema, how do these parameters change?
A therapist may have advanced manual therapy skills, but how might one use these skills to identify and treat lymphatic cording or set safe parameters for working around radiated tissue to restore optimal function?
These are just a few of many examples of what constitutes a specialist in the field of breast oncology and each of these questions and more will be covered in detail in the course Rehabilitation for the Breast Cancer Patient.

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How Can a Pelvic Rehab Practitioner Contribute to a Breast Oncology Patient's Recovery?

Today we hear from Susannah Haarmann, the instructor for Rehabilitation for the Breast Cancer Patient. If you want to learn how to implement your pelvic rehab training with breast oncology patients, join Susannah in Maywood, IL on June 27th and 28th.

Effective pelvic rehab practitioners demonstrate many skills which are especially suitable to treat people with breast cancer, however, the first idea that comes to mind is that they understand what my friend refers to as, ‘the bikini principle.’ She remarked this week that I treat the ‘no no’ areas; the private places that we rarely share…with anyone. The reproductive regions of the pelvis and chest wall both consciously and subconsciously are associated with a plethora of personal psychological and social connotations. A pelvic health practitioner has a raised level of sensitivity to working with this patient population; there is no true protocol in this line of work, effective treatment will require a deeper level of listening and being present with the patient, and a person’s healing of the pelvic region is likely to go beyond the physiologic realm.

The biopsychosocial model of treatment is especially pertinent to the pelvic and breast oncology specialties. The breasts have great biological importance for sexual reproduction and nurturing offspring. Psychologically, breasts represent femininity for many women (and imagine how the story would change for a male with breast cancer.) Furthermore, different societies tend to create a host of rules and guidelines about what is ‘breast appropriate.’ The rehab practitioner understands that a person’s perceptions of their breasts are unlike any others and the same holds true for their cancer journey and goals with therapy.

The pelvic practitioner understands the importance of a straight face; if you have been in the field long enough something completely surprising is bound to occur, but in the day in the life of a pelvic rehab practitioner, no matter how shocking, we’ve seen it before, right? The breast oncology practitioner is going to visualize radiation burns that make their own chest wall hurt upon seeing it. Practitioners will encounter the most frustrating of severe functional deficits that could have been easily avoided had there been the opportunity for earlier intervention. The rehab practitioner providing breast oncologic care understands the story is complex, the road may be long, and although our role revolves around the body, the side effects of our treatment may have much greater reward beyond just physical function.

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Upcoming Continuing Education Courses

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (RESCHEDULED)

Jul 10, 2020 - Jul 12, 2020
Location: Virginia Hospital Center

Mobilization of Visceral Fascia: The Gastrointestinal System

Jul 10, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Short Form Remote Course

Athletes & Pelvic Rehabilitation - Remote Course

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Bowel Pathology and Function - Remote Course (SOLD OUT)

Jul 11, 2020 - Jul 12, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

Jul 12, 2020 - Jul 14, 2020
Location: Rutgers University - Doctoral Programs in Physical Therapy

Pregnancy Rehabilitation - Remote Course

Jul 16, 2020 - Jul 17, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

Jul 18, 2020 - Jul 19, 2020
Location: Intercore Physical Therapy

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

Jul 18, 2020 - Jul 19, 2020
Location: Manual Edge Physiotherapy

Postpartum Rehabilitation - Remote Course

Jul 18, 2020 - Jul 19, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

Jul 18, 2020 - Jul 19, 2020
Location: Husson University

Pelvic Floor Level 1 - Columbus, OH

Jul 18, 2020 - Jul 19, 2020
Location: Fitness Matters

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 21, 2020 - Jul 22, 2020
Location: Short Form Remote Course

Nutrition Perspectives for the Pelvic Rehab Therapist - Columbia, MO (Rescheduled)

Jul 24, 2020 - Jul 26, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Advocate Illinois Masonic Medical Center

Pelvic Floor Level 1 - Fayetteville, NC (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Methodist University School of Health Sciences

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jul 25, 2020 - Jul 26, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Glenwood Springs, CO (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Valley View Hospital

Pudendal Neuralgia and Nerve Entrapment - Maywood, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Loyola University Health System

Pelvic Floor Level 2B - Los Angeles, CA (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Mount Saint Mary’s University

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Jul 31, 2020 - Aug 1, 2020
Location: Short Form Remote Course

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

Jul 31, 2020 - Aug 2, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Restorative Yoga for Physical Therapists - Remote Course

Aug 1, 2020 - Aug 2, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Chicago, IL (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: Midwestern Regional Medical Center

Pelvic Floor Level 2A - Washington, DC (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: The George Washington University

Pelvic Floor Level 1 - New York City, NY (RESCHEDULED)

Aug 2, 2020 - Aug 3, 2020
Location: Touro College

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Aug 8, 2020 - Aug 9, 2020
Location: Shelby Baptist Medical Center