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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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Do Male Therapists Belong in Pelvic Rehab: Part III

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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Sex After Gynecologic Cancer - Part I

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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