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Cyclists and Back Pain

The following comes to us from faculty member Allison Ariail. Allison teaches several courses for the Institute, her next one being Rehabilitative Ultrasound Imaging in Baltimore, MD on June 12-14. There is still room, so sign up today!

Living in Colorado, I come across a lot of individuals who are avid runners, cyclists, or triathletes. Even with a higher level of fitness, these individuals will at times have back pain. What is going on in these physically fit, strong individuals? This is what Rostami et al.[1] set out to determine in their recent study. Using ultrasound imaging, they measured the thickness of the transversus abdominis, internal oblique, external oblique, and the cross sectional area of the multifidus while laying down as well as while mounted on a bicycle. They also measured the back strength, endurance, and flexibility of off-road cyclists with and without back pain. Fourteen professional competitive off-road cyclists with low back pain were compared to 24 control. Results showed a significantly thinner transversus abdominis, and cross sectional area of the multifidus muscle in the cyclists with back pain. There was no significant difference found in flexibility or isometric back strength between the two groups. However the cyclists with low back pain demonstrated decreased endurance in back dynamometry with 50% of their maximum isometric back strength.

The results of this study are consistent with other studies that examined less athletic individuals; thinner transverseus abdominis, and smaller multifidus muscles. This further reinforces the training of the local stabilizing muscles. What does this training method consist of? Learning to isolate each of the local stabilizing muscles; the transversus abdominis, the multifidus, and the pelvic floor muscles. Once a patient is able to isolate a contraction, challenge the muscles by holding a contraction while breathing normally, or holding the contraction while performing motor tasks such as Sahrmann’s exercises. Progress the patient so they are able to perform contractions in weight bearing positions and co-contractions of the muscles. Finally, progress the patient to maintaining co-contractions during functional activities and exercise activities. This will improve stability of the back and pelvis as well as decrease the pain experienced by the patient.

Even patients with higher levels of activity and physical fitness can benefit from a program such as this one. I have used this treatment protocol using ultrasound imaging to confirm and train the local stabilizing muscles on individuals who are both active as well as with individuals not able to participate in as much physical activity. Each and every patient has made gains, even patients who already had a higher level of activity and sports participation such as cyclists, runners, and triathletes. It is rewarding to see all patients make gains and improvements!

[1]Rostami M, Ansari M, Noormohammadpour P et al. Ultrasound assessment of trunk muscles and back flexibility, strength and endurance in off-road cyclists with and without back pain. J Back Musculoskelet Rehabil. 2014; Nov.

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Don’t burn out, Zen out. Meditation for you and your patients:

Patients and practitioners alike can benefit from meditation and mindfulness training for the rehabilitation setting. Nari Clemons joined us today to discuss her upcoming Meditation for Patients and Practitioners course taking place in New York.

We all live in a fast paced world. Our smart phones are letting us know to get back to people with email or texts, we have busy practices with full days, and many of us also have care-giving to do when we get home. Many practitioners see chronic pain patients, sometimes with abuse history or a history of many years of failed medical care. Our patients come to us stressed out and ready to unload, and this happens all day long.

We know our pelvic patients would do better to calm their system. We go home at night so drained sometimes. We would do better to regulate our system. But how? We are all so busy. In Meditation for Patients and Practitioners, we focus on the therapist as well as the patient.

Perhaps you have tried meditation for yourself or your patient. Perhaps you didn’t respond to imagining a waterfall or counting your breath, and you gave up. Perhaps your patient didn’t really take to it, or you can’t figure out how to fit it into your sessions. So many of us know that we are tired of our own low level anxiety, or that our patients would do better if we could get them to re-frame mentally. However, when it comes to implementing those changes, we often come up at a loss.

A randomized control study[1] of nurse leaders who work in understaffed environments were tested with a workplace meditation program. Stress scores were tested at baseline and one week after completing a 4 week program. What do you know? The participants had a decrease in distress scores and an increase in positive symptoms.

“But my day is too busy,” you think? In this course, we work on strategies to center yourself at the beginning of your day, the end of your day, or during your day with 1, 2, or 5 minute strategies. This way, even on your busiest days, you have a way to reel in your stress level and find your calm. For your patients, we offer around 10 different techniques.

When teaching PF1, PF2A and PF2B, we talk about the need to downtrain the nervous system to be effective with pelvic pain, constipation, and history of trauma. Yet, the question always arises about which technique to use with a patient. In the Meditation for Patients and Providers course we give you a working model of how to choose a technique for your patient depending on the time you have, the patient personality, and the situation you are working on resolving.

As one participant said after the last course, “Excellent course. No other course has so beautifully described such practical techniques that are just as important for the therapist’s mental health as they are for the patient’s”. Sound exciting? Join us at the Meditation for Patients and Practitioners course being offered July 19-20 in New York City.

[1]Bazarko, Dawn et al. “The Impact of an Innovative Mindfulness-Based Stress Reduction Program on the Health and Well-Being of Nurses Employed in a Corporate Setting." Journal of Workplace Behavioral Health 28.2 (2013): 107–133. PMC. Web. 2 June 2015.

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Hip or Pelvic Pain – The Chicken or the Egg?

The following is contributed by faculty member Ginger Garner, who teaches the Hib Labrum Injury course. You can read more about that course on the Herman & Wallace course page.

Hip labral injury (HLI) is a relatively new diagnosis in the last 10 years of orthopaedic and rehabilitative care. However, just because HLI is a new diagnosis doesn’t mean the injury is new. In fact, HLI is posited to be responsible for the premature aging and osteoarthritis of the hip joint and pelvis that leads to hip replacements. HLI is also a major source of hip pain, with groin pain being the most common subjective complaint.However, groin pain is not the only complaint that is associated with HLI. Pelvic pain commonly goes hand-in-hand with hip pain.

What does this mean for patients? If you have hip or pelvic pain you should be evaluated by an HLI specialist, which can be a PT, surgeon, or osteopath who has received additional training on managing HLI. It is critical that you see someone who specializes in HLI. If HLI or other hip or pelvic injury is suspected, it is important that you follow up with a physical therapist who has had advanced training in HLI rehab for the best chance of recovery.

I find the premenstrual cycle pain (usually 1-5 days before the cycle begins) is a common phenomenon with many women with HLI (operative and non-operative), which is an area that needs more attention in research. Some women say it feels like they have retorn their labrum, and as a result, they get fearful – which affects not just their physical functioning but their psychoemotional and social well-being.

They limit activity which can exacerbate faulty neuromuscular patterning and deconditioning and result in increased pain from faulty structural support. Their realm of social activity and self-efficacy can suffer, which is also not good for long-term well-being.

Additionally, sleep can be interrupted with HLI and pelvic pain, which can dysregulate the HPA (hypothalamic pituitary adrenal) Axis and cause further problems with issues like pain centralization, cortisol dysregulation, and digestion. A recent study correlated vulvodynia and FAI (femoracetabular impingement), a type of hip impingement commonly found with HLI. The study found that those women who received early surgical intervention received the most relief from vulvodynia, while those who had a longer duration of pain did not experience the same level of improvement.

The take-home message is that early intervention for HLI is absolutely critical for the best long-term prognosis, and that pelvic pain, which can include anything from vulvodynia, dyspareunia, interstitial cystitis, non-relaxing pelvic floor/myalgia, pudendal neuralgia or entrapment, athletic pubalgia, and/or continence issues, although a common occurrence with HLI, is not normal and should be addressed by a trained pelvic rehab professional.

Want more? Read my post about Hip Labrum Tear Risk: Why Early Care is Critical, is absolutely necessary for the best long-term prognosis.

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Do Male Therapists Belong in Pelvic Rehab: Part III

Physical therapist, educator, researcher, and clinical instructor Daniel Kirages, who was mentioned in Do Male Therapists Belong in Pelvic Rehab: Part I, shares his viewpoint from the perspective of his various roles.

“As a male, how did you get involved in pelvic rehab?” This is a question I have been asked countless times and the answer can be pretty simple, I usually say “It’s really not much different than any other musculoskeletal related issue. I’m just not afraid of working below the belt.” Working within the domain of neuro-musculo-skeletal physical therapy offers an endless supply of opportunities. Pelvic rehab is just one subcategory amongst many and this can be further subdivided into several categorizations as well – incontinence, voiding dysfunction, pain, etc. Despite a heavy dose of specialized knowledge necessary for these topics, ultimately we view the patient/client using a similar lens as any neuro-musculo-skeletal condition. This would include the need to examine and intervene for identified deficits in motor coordination, mobility, flexibility, strength, awareness and knowledge. Therefore, all PTs are primed to enter the world of pelvic rehab and they should consider “uploading the mental software” of pelvic specific knowledge by taking courses and finding a mentor to get started.

Being a male within what is typically considered a female related health domain never really bothered me. It just made me witness what a great opportunity it is and how I can be somewhat unique with my practice because there was and still is a need for more male PTs to be involved in pelvic rehab. Early on in my career I would see more females than I do now because our clinic needed the coverage and I wanted to use all aspects of the pelvic related knowledge I acquired. There was never an issue because the patients were willing to work with me; it was not a big deal to them because most of the time a male physician referred them to me in the first place. I would protect myself from any concerns by having a female aide or student be my chaperone in the room. This way a witness was present. It was not a burden on the clinic in any way, and actually the chaperones reported feeling very enlightened about what I do and I believe having a chaperone comforted the patient as well. The male patients I treat are so grateful and many express how they would be uncomfortable with a female therapist although they would go "if they had to". Of course, we as the practitioners know that the care offered by a PT of any gender will be therapeutic and professional, but the patient would not know until they had a positive experience. Some of my patients have avoided going to PT for their pelvic dysfunction until they discovered they can see a male PT. Unfortunate, but true.

The sheer number of people experiencing pelvic health related disorders speaks to the need for competent PTs to help them, but we have competition from urologic nurses, occupational therapists, Pilates instructors, personal trainers amongst others. However, we as PTs are most equipped to serve this population because of our educational backgrounds in manual therapy, exercise physiology, systems physiology and the priceless ability to take time to educate our patients. So the door is open for all of us to get involved and join the world of pelvic rehab which is why I try to make a push to incorporate pelvic rehab topics within entry-level DPT programs. We are making some gains in select programs, but without the PT board exam or the school credentialing agencies seeing value in pelvic rehab it will not change rapidly. The last several years there has been at least one male student applying each semester for a 16-week clinical affiliation with me for a hybrid ortho/male pelvic health experience. As long as there are more PTs offering this exposure to male students we will soon be populating the pelvic rehab world with a bit more testosterone, which can only be a good thing.

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Can Ultrasound Imaging allow you to treat more patients?

Today’s contribution to the Pelvic Rehab Report comes from Allison Ariail, the instructor for Herman & Wallace’s Rehabilitative Ultrasound Imaging courses. Join Allison and others this June 12-14 at Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics - Baltimore, MD!

Is an Ultrasound that provides images of the pelvic floor and other deep musculature a cool gadget to have in the office or something that is truly essential? That depends on who you are asking! If you know how to use Ultrasound imaging properly and market yourself and your practice accordingly, it can become a tool that is not only fun to have and handy to use clinically, but also essential to providing your most efficient and thorough care!

Using an ultrasound (US) machine allows you to view the deeper musculature to assess how the muscles are functioning. The most common muscles assessed with US imaging are the transverse abdominis, the multifidus, and the pelvic floor. The patient then can use what is seen on the US screen as biofeedback to retrain their strategy and timing of recruitment. The therapist can also assess the patient’s ability to activate and maintain a contraction in various positions and even during motor tasks as well. This type of biofeedback is not only useful for pelvic floor patients, but is also important for patients with back and sacroiliac joint pain. Research is showing that using this type of stabilization program is making a difference in athletes. Julie Hides has published two articles recently showing that this type of stabilization program has helped with low back pain in professional cricket players, as well as to decrease the rate of lower extremity injury in Australian professional football players. (1,2) (see my post on The Local Stabilizing Muscles and Lower Extremity Injury.

You may be saying to yourself that you can save a lot of money and just palpate the transverse abdominis (TA), and the multifidus. However I would ask you… are you really feeling a transverse abdominis contraction, or some of the internal obliques? I have had 2 patients referred to me from very capable therapists that I respect and look up to. They were referred to me due to a lack of progress in their treatment. The therapist was addressing a local stabilization program, but their back pain was not getting better. To their credit, the therapist was able to train both patients to perform a proper TA contraction in supine, however one patient was unable to hold a contraction beyond 1 second, and another one was not able to activate it in sitting, or standing. This would explain why they were not progressing with respect to their pain. After treating each patient for 1 or 2 visits using US imaging, and sending them back to their referring therapist, they made rapid progress. Both therapists were so convinced on the usefulness of US imaging that they both went out and bought a machine to use in their clinic. Additionally, you would be surprised how many physical therapists (I can’t count the number on two hands anymore) I have seen that think they are properly performing a TA contraction and want to see how they are doing on the US. However, once we used the US imaging to assess their TA contraction, they realized they were overcompensating with their internal obliques. This is with physical therapists who have more knowledge than the general public regarding the importance of these muscles and how to activate them!

If you are knowledgeable in using ultrasound imaging, you open your doors to a number of possible patients you may not be currently accessing as referrals. There are numerous women and men who would like to receive treatment for pelvic floor weakness issues, but do not want to have to disrobe each treatment. Using ultrasound imaging is a wonderful option for these patients. It also is a way to treat younger patients that you have not been able to treat in the past as well (I would recommend taking the Pediatric Incontinence and Pelvic Floor Dysfunction course prior to treating pediatric patients). By using ultrasound imaging you not only gain an edge over your competing clinics that specialize in pelvic floor therapy, but you can gain an edge for back patients and sacroiliac joint patients as well. For the reasons I stated above when discussing a stabilization program centered on the use of US imaging, you could become very busy with referrals from spine surgeons, and ortho docs. In my office we have six therapists trained in using ultrasound imaging and two ultrasound machines. One of our most limiting factors is not the lack of patients to use ultrasound on, but that we only have two US units available to use! We have several spine physicians that send all of their patients to us because they have seen the difference using ultrasound imaging and the stabilization program can make in patients’ lives. We are eagerly awaiting a third machine and know it will be immediately used and allow us to further grow our clinic.

Now you may be saying, “Yes this would be handy but the pricing makes it impossible!” I would say think outside of the box! Some machines are going down in price making them more affordable. Plus, the settings we as therapists use are pretty basic, so we do not need to purchase a unit with a lot of bells and whistles that makes it more expensive. However there are other ways to acquire a unit other than purchasing one brand new. You could look into the price of refurbished units or look to your referring physician groups that you have a good relationship with. You may be surprised to find out how much physician’s offices get for machines when they are upgrading; hardly anything! If you work for a hospital system you may be able get the old machine transferred to your department for no cost to you! Or if you work in a private practice, you could offer to match the little amount the office would get from the vendor when upgrading. I guarantee you it would not be as much as a new unit. You also might be able to share a unit with another department, office, or clinic. In the past, I have shared ultrasound units with a surgical department, and a gynecology office. I would use the ultrasound some days of the week, and they would other days of the week. It worked out well! There are a lot of possibilities of ways to acquire an ultrasound unit if you think outside of the box! It may take a little effort coordinating things in order to get an US unit, but with proper knowledge, proper marketing, and word of mouth your business will grow and you will not regret the decision to invest in your practice!

Join me to discuss more ideas of how to use US imaging to grow your practice in both clinical skill as well as business growth this June in Baltimore!

1. Hides, Stanton, Wilson et al. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scand J Med Sci Sports. 2010; 20: 834-842.
2. Hides JA, Stanton WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exec. 2014; 46(4): 762-8.

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Visceral Mobilization as a Component of Manual Therapy, Part 1

The following post was contributed by Herman & Wallace faculty member Ramona Horton. Ramona teaches three courses for the Institute; "Myofascial Release for Pelvic Dysfunction", "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 1: The Urologic System", and "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 2: The Reproductive System". Join her at Visceral Mobilization of the Urologic System - Madison, WI on June 5-7!

My physical therapy training and initial experience were in the US Army, so I had a strong bias toward utilization of manual therapy techniques based on a structural evaluation. When the birth of my 10 pound baby boy threw me head-long into the desire to become a pelvic dysfunction practitioner, I became plagued by the question: how do you treat the bowel and bladder, without treating the bowel and bladder? That, along with a mild obsession for the study of anatomy was the genesis of my desire to explore the technique of visceral mobilization.


The field of pelvic physical therapy has moved far beyond the rehabilitation of the pelvic floor muscles for the purpose of gaining continence, which was its origin. Now pelvic rehabilitation is a comprehensive specialty within the PT profession, treating a variety of populations and conditions (Haslam & Laycock 2015). Research has provided a greater understanding of the abdomino-pelvic canister as a functional and anatomical construct based on the somatic structures of the abdominal cavity and pelvic basin that work synergistically to support the midline of the body. The canister is bounded by the respiratory diaphragm and crura, along with the psoas muscle whose fascia intimately blends with the pelvic floor and the obturator internus and lastly the transversus abdominis muscle (Lee et al. 2008). The walls of this canister are occupied by and intimately connected to the visceral structures found within. These midline contents carry a significant mass within the body. In order for the canister to move, the viscera must be able to move as well, not only in relationship to one another, but with respect to their surrounding container. There are three primary mechanisms by which disruption of these sliding surfaces could contribute to pain and dysfunction: visceral referred pain, central sensitization and changes in local tissue dynamics.


Since the inception of physical therapy, manual manipulation of tissues has been a foundational practice within the profession. Manual therapy is a generic therapeutic category for hands-on treatment of a structural anomaly; it encompasses a variety of techniques which can be subdivided into either soft tissue based or joint based. Although the majority of manual therapy research has been on the musculoskeletal system, its effects are not exclusive to any particular region of the anatomy. The Orthopaedic Section of the American Physical Therapy Association (APTA) defines the technique of mobilization as "the act of imparting movement, actively or passively, to a joint or soft tissue" (Farrell & Jensen 1992). Visceral mobilization is a treatment approach focusing on mobilizing the fascial layer of the visceral system with respect to the somatic frame; it therefore falls under the classification of soft tissue based manual therapies. Soft tissue and or fascial based manual therapies have higher-levels of evidence to support their use for treating musculoskeletal pain and dysfunction (Ajimsha & Al-Mudahka 2014; Gay et al. 2013). Although many models have been proposed, the specific mechanisms behind the response of the musculoskeletal system to manual interventions are still not fully understood (Bialosky et al. 2009; Clark & Thomas 2012).


The previous model of manual therapy directly relieving local tissue provocation has given way to a recognition that the observed clinical improvement is not simply a result of the practitioner directly altering the structure beneath their hands through mechanical means. Rather this improvement is a combination of afferent input influencing the neurophysiologic output, changes in the endogenous cannabinoid system, and even a placebo responses simply because of touch (Bialosky et al. 2009; McParland 2008; Gay et al. 2014).


There is significant clinical evidence that issues of somatic pelvic pain, bowel, bladder and reproductive system dysfunction may be the result of visceral referred pain, central sensitization and restrictions in visceral tissue mobility which may further contribute to dysfunction within the canister of core muscles. The musculoskeletal framework is a mysterious, perplexing and complicated system. It is unique in that it offers us a variety of tissues and techniques from which to choose in order to help our patients from a manual therapy perspective. Science has acknowledged that the visceral structures and their connective tissue attachments indeed have an influence on the function of the somatic frame, the question is can we manually manipulate these structures and bring about an effect with a reasonable degree of specificity while producing a therapeutic outcome.
Part 2 of this report will discuss the evidence to support visceral mobilization.
Ajimsha M.S., Al-Mudahka N.R. & Al-Madzhar J.A. (2015) Effectiveness of myofascial release: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies 19, 102-112.
Clark B.C., Thomas, J.S., Walkowski S., Howell J.N. (2012) The biology of manual therapies. The Journal of the American Osteopathic Association 112 (9), 617-29.
Bialosky J., Bishop M. & Price D. (2009) The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy 14 (5), 531-538.
Gay C.W., Robinson M.E., George S.Z., Perlstein W.M. & Bishop M.D. (2014) Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain. Journal of Manipulative and Physiologic Therapeutics 37 (6), 614-627.
Haslam J. & Laycock J. (2015) How did we get here? The development of women’s health physiotherapy special interest groups in the UK. Journal of Pelvic Obstetric and Gynecological Physiotherapy 116 (Spring), 15-24.
Farrell J.P. & Jensen G.M. (1992) Manual therapy: a critical assessment of role in the profession of physical therapy. Physical Therapy 72, 843-852.
Lee D.G., Lee L.J. & McLaughlin L. (2008) Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies 12 (4), 333-348.
McPartland J M (2008) Expression of the endocannabinoid system in fibroblasts and myofascial tissues. Journal of Bodywork and Movement Therapies 12(2), 169-182.

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The Local Stabilizing Muscles and Lower Limb Injuries

Today's post on the Pelvic Rehab Report comes from faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison instructs the ultrasound imaging courses, the next of which will be Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics in Baltimore, MD on Jun 12, 2015 - Jun 14, 2015.

In the past several decades there has been quite a bit of research regarding stabilization of the low back and pelvic ring. We as therapists have changed our focus from working more of the global stabilization muscles to the local stabilizing muscles; the transverse abdominis, the lumbar multifidus, and the pelvic floor. Both research studies and clinical experience has shown us what a positive difference working on these muscles can makes for back pain and pelvic ring pain, as well as for the risk of injury in the back and pelvic ring. However, what does it do for risk of injury for the lower limb? In 2014, Hides and Stanton published a study looking at the effects of motor control training on lower extremity injury in Australian professional football players. A pre- and post-intervention trial was used during the playing season of the Australian football league as a panel design. Assessment included magnetic resonance imaging and measurements of the cross-sectional area of the multifidus, psoas, and quadratus lumborum, as well as the change in trunk cross-sectional area due to voluntary contraction of the transverse abdominis muscle. A motor control program included training of the multifidus, transversus abdominis, and the pelvic floor muscles using ultrasound imaging for feedback that then progressed into a functional rehabilitation program was used with some of the players. Injury data was collected throughout the study. Results showed that a smaller multifidus or quadratus lumborum was predictive of lower limb injury during the playing season. Additionally, the risk of sustaining a severe injury was lower for players who received the motor control intervention.

This is interesting and intriguing information. Yes, there are many factors that are involved in sustaining an injury during a sport. However, it would be a good idea to do a quick screen of the local stabilizing muscles before a playing season, whether it is a professional player or an adolescent player. Do adolescents really have issues with weakness in their local stabilizing muscles? Yes! Clinically I have seen adolescent players who display back pain and other issues related to weakness in their core muscles. Usually this occurs after they have gone through a growth spurt, but some of these adolescent athletes did not recover, even several years after the large growth spurt.

What a nice community service it would be to screen a local sports team for strength of the local stabilizing muscles in order to decrease injuries! It would also be nice to see additional research regarding this topic! To learn more about recent research and how to use ultrasound imaging to accurately assess and treat the local stabilizing muscles, join me at Johns Hopkins in Baltimore this June for the Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor course.



Hides JA, Stanton WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exec. 2014; 46(4): 762-8.

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Have you tried Ultrasound Imaging to Evaluate Prolapse?

Today's post is written by faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. You can join Allison in her Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics course, which takes place in Baltimore this year, June 12-14.

Since the mid 1990’s the POP-Q has been used to quantify, describe and stage pelvic organ prolapse. A series of 6 points are measured in the vagina in relation to the hymen. In a recent years, translabial ultrasound imaging has been used to look at the pelvic organs and the pelvic floor. A skilled practitioner can view pelvic floor muscle contractions, as well as Valsalva maneuvers and the effects each of these have on the pelvic organs. For example funneling of the urethral meatus, rotation of the urethra, opening of the retrovesical angle, and dropping of the bladder neck and uterus can be viewed using ultrasound imaging of the anterior compartment during Valsalva maneuvers. Pelvic organ descent seen on ultrasound imaging has been associated with symptoms of prolapse.

Until now the relationship between ultrasound and clinical findings has not been examined. A recent study by Dietz set out to see if there is an association between clinical prolapse findings and pelvic descent seen on ultrasound. Data was obtained on 825 women seeking treatment at a urogynecological center for symptoms of lower urinary tract or pelvic floor muscle dysfunction. Five coordinates of the POP-Q scale were measured and compared to ultrasound measures of descent. All data was blinded against other data obtained. Clinically, 78% of the women were found to have a POP-Q stage of 2 or greater. It was found that all coordinates were strongly associated with ultrasound measures of descent. The association was almost linear, particularly for the anterior compartment. This means that ultrasound measures can be used to quantify prolapse and be comparable to the POP-Q. Proposed cutoffs have been made for the bladder, uterus, and rectum in relation to the pubic symphysis.

It is exciting to see ultrasound use in the quantification and identification of more gynecological disorders. The use of translabial ultrasound imaging is growing and continuing to be researched. It is an exciting field to be a part of and I look forward to seeing where this research goes. I believe it will be used to help improve surgical procedures as well candidate selection for surgery. Join more for more discussion regarding translabial ultrasound imaging and learn how to view these images in Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor in Baltimore this June!

Dietz HP, Kamisan Atan I, Salita A. The association between ICS POPQ coordinates and translabial ultrasound findings: implications for the definition of ‘normal pelvic organ support’. Ultrasound Obstet Gynecol. 2015; April.

 

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Need an alternative to Kegels? Try this Heel Squeeze exercise

Today's post is written by faculty member Martina Hauptmann, who instructs the Pilates for Pelvic Dysfunction, Osteoporosis, and Peripartum course. Come learn how to apply Pilates in your practice this September 19-20 in Chicago, IL!

Treating the incompetent pelvic floor (urinary incontinence and pelvic organ prolapse) is a staple of therapists who have specialized in this complex area.

Ever since Dr. Arnold Kegel published his research “A Non-surgical Method of Increasing the Tone of the Sphincters and Their Supporting Structures” back in 1942 women have been strengthening their pelvic floor by conscious contraction of their perineum by either squeezing or lifting.

Another method to strengthen the pelvic floor is through the muscles that are extrinsic synergists to the pelvic floor musculature. The hip abductors, adductors, extensors and lateral rotators are extrinsically linked to the pelvic floor musculature. Except for one of the hip lateral rotators, the obturator internus, which by its anatomical attachments is actually an intrinsic synergist of the pelvic floor.

Pilates is an exercise method that seeks to increase a client’s strength, posture, control, and body awareness through precise exercises. The Heel Squeeze exercise is an excellent exercise to indirectly strengthen the pelvic floor via isometric contraction of the hip lateral rotators and hip extensors.

To perform the Heel Squeeze exercise, have the client lie prone with their legs hip distance apart, knees bent. The heels are touching and the toes pointing away from center. Draw the client’s awareness to their abdominals and have them slightly lift their stomach away from the mat. Instruct the client that she should continue with this contraction of her abdominals. Then as she exhales, the client squeezes her heels together and presses her pubic bone down into the mat. The client should hold this contraction for 5 seconds and do 8-12 repetitions.

 

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Grounding in Mountain Pose

Today on the Pelvic Rehab Report, we hear from Dustienne Miller. Dustienne wrote and teaches the Yoga for Pelvic Pain course, which is available in Cleveland, OH on July 18-19, and in Boston, MA on September 12-13.

"It feels like my pelvic floor just sighed."

Grounding in Mountain Pose

As musculoskeletal professionals, we have a sharp eye for postural dysfunction. We explain to our patients that the ribcage is sheared posteriorly to the plumb line and how gravity magnifies forces at specific structures. Some physical therapists perform the Vertical Compression Test (VCT) to allow the patient to feel the difference between their typical habitual posture and a more optimally aligned posture. This works well to “sell” your patients on why their newly aligned posture allows for more efficient weight transfer through the base of support. In addition to the VCT, I utilize Tadasana, or Mountain Pose as an additional kinesthetic approach to postural retraining.

Last week in the clinic, I was teaching my client postural awareness using Tadasana. I asked her to close her eyes, or lower her gaze if she was not comfortable closing her eyes. Working from the ground up, we started bringing awareness to her base of support. She noted that she was standing with her weight mostly in her heels. When I encouraged her to bring her weight forward, hinging from the talocrural joint, she had an “aha moment.” She said, “It feels like my pelvic floor just sighed.” She was unaware that her habitual posture was to stand with her weight mostly posterior to plumb line, thus encouraging her posterior pelvic floor to remain in an overactive state. Once she balanced her body from the ground up, she felt a major release in her holding patterns.

At our follow-up session, the client remarked that her postural awareness increased dramatically. She was surprised at how often her pelvic floor was in a habitual pattern of over-firing. Additionally, she reported increased awareness while practicing standing yoga postures during class. She feels more in control of her body after experiencing embodied optimal alignment and has had success with carrying over postural awareness outside of the clinic setting. Self-awareness and empowerment are two major goals of my physical therapy practice, and using yoga to achieve these goals makes my clinical practice even more enjoyable.

For more info on the Vertical Compression Test, click here. For detailed instruction on Tadasana, click here.

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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