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.

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.

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.

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!

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.

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.

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.

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!