A faculty spotlight on Erica Vitek and her upcoming remote course at Herman & Wallace.

Pelvic rehab and neurorehab have traditionally lived in separate clinical silos. Pelvic clinicians manage incontinence, prolapse, and pelvic pain from a primarily musculoskeletal frame. Neuro clinicians work on gait, ADL, and cognition. The patient sitting across from you with multiple sclerosis, spinal cord injury, or Parkinson disease lives at the intersection, and their pelvic floor symptoms are often the ones quietly eroding their quality of life.

Erica Vitek, MOT, OTR, BCB-PMD, PRPC, has spent her career at that intersection. Her two-day remote course at Herman & Wallace, Neurologic Conditions and Pelvic Floor Rehabilitation, returns on June 27 and 28, 2026, and it is the rare course that gives pelvic rehab clinicians a neuroanatomy-forward framework for these patients.

How common is pelvic floor dysfunction in neurologic disease?

Far more common than referral patterns would suggest. In the North American Research Committee on Multiple Sclerosis (NARCOMS) survey of 9,397 patients, moderate-to-severe pelvic floor symptoms were reported by roughly one in three respondents, including 41% with bladder symptoms, 30% with bowel symptoms, and 42% with sexual dysfunction (Browne et al., 2015). Lower urinary tract symptoms in Parkinson disease run between 27 and 80% across studies, driven by dopaminergic degeneration in pathways that govern autonomic and pelvic floor function (Cheng et al., 2023). Spinal cord injury reliably produces neurogenic bladder and bowel patterns that depend on the level and completeness of the lesion.

The clinical gap is wider than the prevalence gap. Most patients with these conditions have never been offered pelvic rehabilitation, and many of the clinicians treating their gait and balance issues have never been trained to evaluate the pelvic floor in a neurologic context.

One in three people with MS reports moderate-to-severe pelvic floor symptoms. Most have never been offered pelvic rehabilitation.

What changes in the nervous system affect the pelvic floor?

The pelvic floor is governed by an unusually long and vulnerable neural chain that runs from cortical micturition centers down through the pontine micturition center, spinal cord, sacral plexus, and pudendal and pelvic nerves. Damage anywhere along that chain produces a different clinical picture. Cortical and subcortical lesions, demyelinating disease, and dopaminergic degeneration each disrupt different aspects of storage, voiding, and pelvic floor coordination.

That is why an orthopedic-style pelvic assessment, on its own, will miss the diagnosis in these populations. A neurogenic bladder is not a tight pelvic floor. A sphincter dyssynergia is not a coordination problem in the conventional sense. The course gives clinicians the neuroanatomy and pathophysiology they need to read the picture correctly before deciding on intervention.

What conditions does this course cover?

The course goes in depth on three conditions and offers a generalizable framework for others:

• Multiple sclerosis. Demyelination across the central nervous system produces a wide range of bladder, bowel, and sexual health patterns. Up to 80% of women with MS experience bladder and sexual dysfunction within ten years of diagnosis.
• Spinal cord injury. Lesion level and completeness determine whether the clinical picture skews toward upper motor neuron, lower motor neuron, or mixed bladder and bowel patterns. The course covers assessment and management for each.
• Parkinson disease. Dopaminergic degeneration drives lower urinary tract symptoms in 27 to 80% of patients, with orthostatic hypotension and constipation often appearing years before the motor diagnosis is made.
• General neurologic considerations. A foundation participants can extend to stroke, traumatic brain injury, and other neurologic populations they may encounter.

What will you learn in this course?

The course runs over two days on Zoom and is built for clinicians with prior pelvic floor coursework or treatment experience. Participants leave with:

• A working knowledge of neuroanatomy and pathophysiology of the central and peripheral nervous system as it relates to pelvic structures
• Assessment frameworks for neurogenic bladder, neurogenic bowel, and neurogenic sexual health considerations
• Pelvic floor external evaluation considerations adapted to neurologic populations
• Treatment planning and intervention strategies for MS, SCI, and Parkinson disease
• Applications of biofeedback and TENS in the neurologic population
• An Ask the Experts Q&A session for problem-solving complex neurologic patient cases

References

Browne, C., Salmon, N., & Kehoe, M. (2015). Pelvic floor disorders and multiple sclerosis: Are patients satisfied with their care? International Journal of MS Care, 17(1), 6 to 12.

Cheng, B., Chen, Z., Yang, K., & colleagues. (2023). Lower urinary tract symptoms in Parkinson disease: Prevalence, mechanisms, and management. Frontiers in Aging Neuroscience.

Tornic, J., & Panicker, J. N. (2018). The management of lower urinary tract dysfunction in multiple sclerosis. Current Neurology and Neuroscience Reports, 18(8), 54.

Parkinson's Foundation. (n.d.). Autonomic dysfunction and orthostatic hypotension in Parkinson disease. Parkinson's Foundation Clinical Resources.

The Voice and the Pelvic Floor: Why Three Diaphragms Belong in Your Assessment

A faculty spotlight on Dr. Ginger Garner and her upcoming remote course at Herman & Wallace.

The respiratory diaphragm and the pelvic floor have been clinical neighbors in pelvic rehab for decades. The vocal diaphragm, sitting at the top of the same fascial highway, has been largely missing from the conversation. Dr. Ginger Garner, PT, DPT, ATC-Ret, is changing that with her Voice to Pelvic Floor (V2PF) Method, and her short-format remote course at Herman & Wallace returns on Saturday, June 27, 2026.

What is the Voice to Pelvic Floor Method?

The Voice to Pelvic Floor approach is a systems-based, trauma-informed framework for evaluating and treating three connected diaphragms: the vocal and oropharyngeal complex, the respiratory diaphragm, and the pelvic diaphragm. These structures share fascial connections, neuromuscular pathways, and pressure regulation responsibilities. Vocalization, continence, and core stability all depend on how those three systems coordinate.

Dr. Garner developed V2PF to give pelvic health clinicians a more comprehensive lens, particularly for complex cases involving trauma, hormonal transitions, hypermobility, and persistent pain that has not responded to standard pelvic interventions.

The respiratory diaphragm has been part of pelvic rehab for decades. The voice has been missing from the same conversation.

Why should pelvic health clinicians assess the voice?

The voice is a clinical biomarker for pressure regulation. Hormonal shifts, particularly the estrogen decline of perimenopause and menopause, alter vocal endurance, pitch range, and tissue hydration in patterns that mirror changes in pelvic tissue elasticity and continence. Trauma also leaves footprints on the voice, with research linking psychogenic voice disorders to traumatic stress histories (Baker, 2003). When voice is missing from the assessment, those signals get missed too.

Polyvagal pathways and the emotional motor system connect vocalization to the same autonomic and somatic networks that govern pelvic organ function (Holstege, 2016). For patients carrying trauma histories, pressure pain conditions, or stress-driven voiding patterns, the voice is often the clearest window into the system you are already trying to treat.

What will you learn in this course?

The Voice and the Pelvic Floor is a short-format remote course delivered through Zoom, with didactic content followed by interactive lab activities. Participants leave with:

• The anatomy and physiology of the three diaphragms and the fascial and neuromuscular links between them
• A four-pronged V2PF assessment covering respiratory mechanics, core and pelvic floor, orofacial and vocal function, and psychosocial determinants
• Evidence-based vocal techniques you can apply as clinical interventions for pelvic floor and core dysfunction
• A trauma-informed, polyvagal-informed framework for sensitive cases, including survivors of intimate partner violence, sexual trauma, and birth trauma

References

Baker, J. (2003). Psychogenic voice disorders and traumatic stress experience: A discussion paper with two case reports. Journal of Voice, 17(3), 308 to 318.

Garner, G. (2024). The voice and the pelvic floor. The Pelvic Rehab Report, Herman & Wallace Pelvic Rehabilitation Institute.

Holstege, G. (2016). How the emotional motor system controls the pelvic organs. Sexual Medicine Reviews, 4(4), 303 to 328.

Holstege, G., & Subramanian, H. H. (2016). Two different motor systems are needed to generate human speech. Journal of Comparative Neurology, 524(8), 1558 to 1577.

Endometriosis is one of the most common and most misunderstood conditions in pelvic health. It can drive chronic pelvic pain, painful periods, bowel and bladder symptoms, fatigue, and pain with intimacy, and on average it takes years for a patient to receive an accurate diagnosis. For the clinicians who treat them, the question is rarely whether to help, but how to help more completely.

Medical management, surgery, and pelvic rehabilitation are all important parts of care. Alongside them, a growing body of attention is turning toward the daily habits that shape how a person living with endometriosis actually feels day to day.

Why Lifestyle Matters in Endometriosis

Endometriosis is an inflammatory condition, and many of the factors that influence inflammation, pain sensitivity, and overall wellbeing are tied to lifestyle. Nutrition, movement, sleep, stress regulation, and nervous system care all interact with how symptoms are experienced. None of these replace medical treatment, but used thoughtfully and individualized to each patient, they can become meaningful supports within a comprehensive plan of care.

For clinicians, the opportunity is to move beyond treating symptoms in isolation and instead help patients understand the levers they can influence themselves, building agency and self-efficacy along the way.

What This Free Webinar Covers

In this session, Allison will walk clinicians through the lifestyle factors most relevant to patients living with endometriosis and how to introduce them in a way that is practical, evidence-informed, and patient-centered. Whether you specialize in pelvic health or simply want to support these patients more effectively, you will leave with strategies you can share right away. Bring your questions for the live discussion.

Last month I was invited to give a talk at the Michigan APTA Student Conclave, and I gave myself a challenge before I walked into that lecture hall.

Pelvic health is my jam. Talk to me about it at a dinner party, at a conference, on a podcast, and I will not stop. But education has changed since I was in school. My version of learning was lecture, test, repeat. My college daughters describe classrooms that look almost nothing like that, and frankly, theirs sound more interesting. So I did not want to lecture these students. I wanted to give them an experience with their own pelvic floors. Could I pull that off in a way that was both fun and meaningful? That was the assignment I gave myself.

The talk was called “Explore Your Floor: What You May Not Have Learned in School About the Land Down Under.”

Walking Into the Room

The first thing that struck me was the diversity. Pelvic health desperately needs practitioners of every gender and orientation to meet the needs of the patients who depend on us, and seeing that room felt like a real preview of where the profession is heading.

I told the group up front what I wanted the next hour to feel like: safe, inclusive, humble, educational, fun, and a little inspiring. Because we need more people in this field. Participation was voluntary throughout. Questions were welcome.

A Tour of the Layers

We started with a tour of the layers of the pelvic floor. Students stood up and used their bodies to act out the individual muscles and feel their unique functions. From there, we moved into biofeedback work where each student could discover the range of motion of their own pelvic floor.

Breath, Pressure, and the Body’s Truth

Next came pressure regulation. I wanted them to experience the relationship between breath, abdominal wall tension, and pelvic floor function, so we did it with a balloon. Everyone blew one up and we watched several different patterns emerge in how people accomplished that simple task. The lesson was right there in the room.

For the last physical activity, everyone stood up and tried to push each other over under three conditions: relaxed bodies, holding breath and bracing, exhaling and bracing. Most students felt most stable holding their breath. That gave us a really meaningful conversation about internal pressure and the way it finds its path to the places of least resistance. Hernia. Prolapse. Diastasis. Disc herniation. The body always tells the truth about where the load is going.

The Detective Work of Pelvic Health

The rest of our hour explored the relationships between the pelvic floor and the visceral, musculoskeletal, endocrine, and nervous systems, and how a pelvic floor physical therapist uses those relationships to shape the rehab experience for every patient.

I talked about the role and responsibility of the pelvic health specialist and shared snippets from real case studies. Two patients can show up with the same complaint, whether stress urinary incontinence, constipation, or pelvic pain, and have completely different reasons behind it. Our job is to be detectives. The presentation is never the diagnosis. The patient is.

I had a blast. The mission felt accomplished. And the students seemed to have a great time learning.

A Message That Stayed With Me

A few days later, a student sent me a note that I have not stopped thinking about:

“I am one of the many male students inspired by your pelvic floor presentation at the APTA Student Conclave. After walking out of your conference, I felt a responsibility to advocate for pelvic floor health for everyone. I find pelvic floor therapy truly fascinating.”

I could not agree more.

If you are a student reading this, or a clinician on the fence about pursuing pelvic health, I want you to know that this field needs you. All of you. Every background, every identity, every clinical curiosity. There has never been a better time to bring your full self to this work.

Experience It for Yourself: Free Live Webinar

Curious what it feels like to truly explore your floor? Jenna is bringing this same session to a free live webinar open to clinicians and students everywhere. Come ready to participate, bring your questions, and discover what you may not have learned in school about the land down under.

Pelvic health symptoms rarely exist in isolation. A patient may present with urinary urgency, pelvic pain, constipation, or prolapse symptoms, but beneath the surface there is often another layer: fear, stress, bracing, hypervigilance, and a nervous system that has been living in high alert for far too long.

As pelvic rehabilitation providers, we are trained to assess muscles, fascia, posture, breathing, pressure management, and functional movement. Yet many of our patients also need tools that help them feel safe in their bodies again. This is where acupressure becomes a valuable part of integrative pelvic health care.

Acupressure is a noninvasive, self-applied technique rooted in Traditional Chinese Medicine that uses manual pressure on specific points of the body. In pelvic rehabilitation, it may be used as an adjunct to support nervous system regulation, symptom self-management, and whole-person care — serving as a practical bridge between the body, the breath, and the nervous system.

Why Mental Health Belongs in the Conversation

The relationship between pelvic health and mental health is bidirectional. Stress and anxiety can increase pain sensitivity, alter breathing patterns, contribute to pelvic floor overactivity, and worsen symptom perception. Pelvic symptoms, in turn, can increase fear, distress, and loss of control. This is especially relevant in conditions such as chronic pelvic pain, urinary urgency, dysmenorrhea, constipation, and prolapse-related symptoms.

Integrative physical therapy offers a framework for this complexity, blending conventional rehabilitation with complementary strategies while emphasizing therapeutic presence, patient empowerment, and the interconnection of mind, body, and function.

Published Case Report: Rectal Prolapse

In a newly published case report in the Journal of Women's & Pelvic Health Physical Therapy, Rachna Mehta and co-author Becky Parr, PT, DPT, DHSc, OCS describe an integrative plan of care for a 71-year-old woman with chronic rectal prolapse, rectal pain, urinary urgency, and low back pain.

The patient's treatment plan combined pelvic floor muscle training, manual therapy, mindfulness-based interventions, bowel and bladder education, and acupressure. Two acupressure points were taught for post-bowel-movement symptom management, paired with the phrase: relax, release, let go.

Acupressure Points Used

The Role of the Clinician

Pelvic rehabilitation clinicians are uniquely positioned to care for patients whose symptoms are influenced by stress, fear, trauma, anxiety, sleep disruption, and nervous system dysregulation. Treatment strategies can include breathing and downregulation techniques, identification of pelvic floor guarding patterns, acupressure as a self-management tool, and integration of mindfulness into pelvic floor coordination.

Acupressure provides an accessible, noninvasive adjunct to support whole-person healing. When integrated with breathwork, pelvic floor muscle training, patient education, and compassionate clinical reasoning, it helps patients improve body awareness, enhance self-regulation, and develop greater confidence in symptom management.

Thirty-eight years ago, in 1988, I gave birth to my first son.

I was 24 years old and had been a practicing physical therapist for about three years. Like many young clinicians, I thought I understood the human body fairly well. Then I went through childbirth myself.

After 23 hours of labor and four hours of pushing, my son was delivered by cesarean section at 4:33 a.m. He weighed 9 pounds, 15 ounces and measured 23¾ inches long. A very large baby for a young mother.

The labor had been long and exhausting. A spinal anesthesia attempt was unsuccessful, so general anesthesia was ultimately used. Years later, I would discover I had a spondylolisthesis at L4-5, finally giving context to why the spinal could not be completed.

After delivery, I became profoundly swollen. My legs, feet, ankles, really my entire body, retained fluid. The clothes I had packed to wear home from the hospital no longer fit, even though they had fit me at about four months pregnant. The swelling was so severe that when I stood, my toes barely touched the floor.

What confused me most was the scale.

I had just delivered a nearly 10-pound baby after a prolonged labor and major surgery, yet I had only lost 10 pounds total.

As a physical therapist, I remember thinking: What do I do to help myself?

But there were no answers.

I had learned how to rehabilitate orthopedic injuries and neurological conditions. I understood anatomy and movement. Yet education regarding postpartum recovery was not available. There had been endless discussion about caring for the newborn, but almost none about caring for the mother.

No one talked about pelvic floor recovery, abdominal healing, swelling, scar mobility, bladder function, prolapse, breathing mechanics, or the physical and emotional recovery after birth.

At that time, women were largely expected to recover quietly and independently.

That experience stayed with me.

My second birth experience became another turning point in my life. I had a VBAC (Vaginal Birth After Cesarean), and that experience deepened my passion for childbirth and women’s health even further. I became increasingly interested not only in rehabilitation after birth, but in empowering women during pregnancy and labor as well.

In 1993, I became a Lamaze Certified Childbirth Educator (LCCE). I wanted women to feel more informed, supported, and confident than I had felt during my own first birth experience. Teaching childbirth classes allowed me to connect with women in a completely different way, not just as a clinician, but as a mother who understood the uncertainty, fear, excitement, and physical demands of pregnancy and birth.

As the years went on, I continued searching for answers that traditional physical therapy education had never provided. I joined the OB/GYN Section of the American Physical Therapy Association, founded by Elizabeth Noble, one of the true pioneers in women’s health physical therapy. Through that community, I found mentors, colleagues, and a growing specialty that finally gave language to what so many women were experiencing.

I studied with Elizabeth Noble herself and later learned from Holly Herman and Kathe Wallace, whose teaching helped shape the future of pelvic rehabilitation in the United States. At the time, pelvic health physical therapy was still a very small world. Many of us were learning piece by piece, course by course, often driven by our own experiences as women and clinicians.

One of my earliest urinary incontinence courses was with Dr. Jo Laycock, a physiotherapist from England who was internationally recognized for her work in pelvic floor rehabilitation. I remember many nurses attending alongside physical therapists, which reflected how new and interdisciplinary this field still was.

Over the years, my education continued to evolve alongside my patients’ needs and my own life experiences.

As women came to me with pelvic pain, incontinence, pregnancy-related issues, chronic pain, and later perimenopause and menopause concerns, I kept learning so I could better support them.

I pursued advanced training in pelvic health physical therapy, therapeutic pain management, yoga therapy, women’s health coaching, and eventually earned my transitional Doctorate in Physical Therapy. More recently, I completed certification programs focused on perimenopause and menopause care, areas that are finally receiving the attention they deserve.

None of this happened because I had a perfectly planned career path.

It happened because women kept showing up with questions that deserved better answers.

And because I understood, personally and professionally, what it felt like to navigate recovery and womanhood without enough support.

Along the way, I also became involved in teaching. I served as a teaching assistant for Herman & Wallace pelvic rehabilitation courses for many years, mentoring clinicians entering the field of pelvic health. In 2023, I became a Lead Teaching Assistant, something that felt especially meaningful considering how much this specialty has grown since I first entered it.

Looking back now, I realize I was not only searching for answers for my patients. I was also searching for answers for my younger self.

The specialty of pelvic health physical therapy barely existed when I gave birth in 1988. There were few mentors, limited research, and almost no standard postpartum rehabilitation education for physical therapists or physicians. Much of what we now consider essential postpartum care simply was not discussed.

Over the decades, I have had the privilege of participating in the growth of this specialty.

I witnessed pelvic health physical therapy evolve from a marginalized area of practice into a recognized and evidence-based field. I saw conversations about urinary incontinence, pelvic pain, prolapse, sexual health, pregnancy, postpartum recovery, and now perimenopause and menopause slowly move from whispered concerns into legitimate healthcare discussions.

Most importantly, I saw women finally begin to receive care that acknowledged their own recovery mattered too.

For me, pelvic health physical therapy has never been just a professional specialty.

It has always been deeply personal.

From Home Care to Pelvic Health: A Journey Guided by Faith, Mentorship, and Resilience

Sometimes the most meaningful career paths aren’t the ones we plan. For Herman & Wallace faculty member Carole High Gross, PT, MS, DPT, PRPC, the road to becoming a leader in pelvic health rehabilitation was shaped by unexpected challenges, pivotal relationships, and a willingness to trust the journey even when the destination wasn’t yet visible.

We recently sat down with Carole to talk about her career, her calling, and the work that drives her. What unfolded was one of the most compelling stories of resilience and purpose we’ve heard.

A Career Built on Breadth

Carole’s career in physical therapy spans more than three decades. After earning her Master of Science in Physical Therapy from Thomas Jefferson University in 1992, she worked across nearly every clinical setting imaginable: pediatrics, aquatics, outpatient orthopedics, inpatient rehab, contract work, and home care, which she loved most. She built a deep clinical foundation long before pelvic health was on her radar.

Then life intervened.

Carole was diagnosed with breast cancer, followed by a rare chronic leukemia called hairy cell leukemia. She also lives with CIDP, a neurological condition that significantly impacted her mobility. At one point, she was using a walker, a wheelchair, and a scooter for community outings. Clinical work, at least the way she’d always done it, was no longer an option.

But Carole’s response was characteristically forward-looking: her brain was still working, so she went back for her doctorate.

Getting Back Into the Swing of Things

When Carole enrolled in her Doctor of Physical Therapy program at Arcadia University, the same institution where she’d started her undergraduate education years earlier (she lovingly calls them her “bookend university”), the transition wasn’t easy. She recalls sitting on her bed, textbooks in hand, wondering why she was putting herself through it.

But she found a way to reframe the challenge. She hadn’t forgotten how to learn. She’d simply had a very long summer. That simple mindset shift became a guiding mantra. Every time Carole faces a challenge in her health, her career, or her education, she reminds herself that she’s just getting back into the swing of things.

Walking Through the Door

As Carole neared the end of her DPT, she knew she couldn’t return to home care. She felt pulled toward something but didn’t know what it was. She describes it as trusting a GPS where someone else can see the full route, but she can only see the next turn on the screen.

Then, in a matter of days, a series of small, seemingly random events changed the trajectory of her career.

A friend convinced her to stop by a retirement party. There, she bumped into Kathy Sumner, a PT she’d worked with 20 years earlier. Kathy invited Carole to visit a pelvic health clinic she ran with Janet Drake Whalen, who Carole now works alongside as a Lead Teaching Assistant at Herman & Wallace.

When Carole walked through the clinic door, the feeling was immediate and unmistakable. She was home.

Kathy and Janet became Carole’s mentors. Weekends of hands-on training. Patients brought in for teaching opportunities. Encouragement to pursue coursework. The small-room private practice setting turned out to be the perfect environment for someone navigating mobility challenges, a place where Carole could not only survive, but thrive.

The timing was ideal. Her DPT program required a semester-long research project on a topic of interest, and Carole channeled everything into developing her Belly After Baby program for postpartum women, with Kathy and Janet guiding her every step of the way.

Eating Disorders and Pelvic Health: A Critical Connection

Today, Carole is a Pelvic Clinical Rehabilitation Specialist at Jefferson Health Lehigh Valley in Pennsylvania, where she treats patients of all genders with pelvic, bowel, bladder, and abdominal concerns. She holds her Pelvic Rehabilitation Practitioner Certification (PRPC) and serves as both an instructor and Lead Teaching Assistant at Herman & Wallace.

Her course, Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional, fills a critical gap in pelvic health education. Individuals with eating disorders frequently present with the exact symptoms pelvic rehab professionals treat every day: constipation, bloating, abdominal pain, pelvic organ prolapse, urinary dysfunction, and pelvic pain. Yet the connection between eating disorders and pelvic health is often overlooked.

As Carole explains, pelvic health providers aren’t going to diagnose or treat eating disorders, but they absolutely can and should be asking the right questions. They can observe, support, refer, and provide manual and educational tools that make a real difference in someone’s recovery journey. Sometimes, a pelvic health clinician is the first provider to notice the signs and gently guide someone toward help.

The course has received outstanding reviews, with clinicians praising its depth and Carole’s ability to connect the bigger picture, the multidisciplinary web of providers that supports individuals with eating disorders, with the specific, actionable skills pelvic health professionals can bring to the table.

Research at the International Level

Beyond Herman & Wallace, Carole serves on the Pelvic Workgroup of the International Consortium on the Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders, facilitated by the Ehlers-Danlos Society. In 2024, the workgroup published a landmark paper in PLOS ONE, a multidisciplinary, multinational effort co-creating evidence-based clinical guidelines for the management of pregnancy, birth, and postpartum recovery in individuals with hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorders (HSD).

The workgroup is currently finalizing a paper focused on pelvic health concerns in individuals with hEDS and HSD, with additional publications expected through 2026 and into 2027, including updates to diagnostic criteria and guidance across multiple clinical domains.

Carole is passionate about the screening role pelvic health professionals can play for hypermobility. As she describes it, asking just a few simple questions about a history of joint subluxations, dislocations, or being “super bendy” can start to connect dots that no one else has connected. Many individuals with hypermobility present with pelvic dysfunction, GI issues, chronic pain, skin changes, and temperature sensitivities. Pelvic health clinicians may be the first to notice that these seemingly unrelated issues share a common thread.

A Philosophy of Mentorship

One theme that runs through every chapter of Carole’s story is mentorship. She was mentored into pelvic health by Kathy and Janet. She was encouraged to take that first Pelvic Floor Level 1 course by people who believed in her when she wasn’t sure she believed in herself. And now, she pays it forward: mentoring new clinicians, serving as boots on the ground at satellite courses, and fostering the collaborative, family-like learning environment that she believes is the heart of what Herman & Wallace does best.

Her advice to clinicians who feel overwhelmed by the breadth of pelvic health education?

“Keep your focus on the step you’re on. Don’t look up at the full staircase. There’s no timeline. One course, one skill, one patient at a time, and before you know it, you’ll have built something incredible underneath you.”

About Carole

Carole High Gross, PT, MS, DPT, PRPC (she/her) earned her Doctorate of Physical Therapy from Arcadia University in 2015 and her Master of Science in Physical Therapy from Thomas Jefferson University in 1992. She works as a Pelvic Clinical Rehabilitation Specialist at Jefferson Health Lehigh Valley and serves as a Lead Teaching Assistant and instructor at Herman & Wallace, where she created and teaches Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole is a member of the Pelvic Workgroup of the Ehlers-Danlos International Consortium and has a special interest in working with individuals living with eating disorders and hypermobility throughout the pregnancy and postpartum journey. She is a dedicated mentor for growing pelvic professionals and focuses on team building and program development.

Learn From Carole

Ready to explore the intersection of eating disorders and pelvic health rehabilitation? Carole’s course is designed to expand your clinical lens, build your confidence in screening and observation, and equip you with practical tools to support individuals with eating disorders on their recovery journey.

Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional

Remote Course | October 4–5, 2025 | Live via Zoom

Your patients deserve comprehensive care, and you deserve the knowledge to deliver it. Register today at hermanwallace.com. Spots are limited.

Low back pain is one of the most common reasons patients walk into a physical therapy clinic. It is also one of the most under-treated when clinicians focus only on the lumbar spine. For a growing body of patients, the lumbar spine is the symptom. The pelvic floor is the source.

If you are an orthopedic, sports, or general outpatient clinician treating low back pain and feel your patients are not making the progress you would expect, the pelvic floor may be the missing piece. Herman & Wallace is offering two free live webinars this May with senior faculty member and Director of Education Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. The first session unpacks the clinical connection between the pelvic floor and low back pain. The second is an open Ask Me Anything session for clinicians considering the Pelvic Rehabilitation Practitioner Certification (PRPC).

What does the pelvic floor have to do with low back pain?

The pelvic floor does not work in isolation. It works as part of the deep stabilization system of the trunk, alongside the transverse abdominis, the lumbar multifidus, and the diaphragm. These muscles co-contract to create intra-abdominal pressure and provide segmental stability through the lumbar spine and pelvic ring.

When one piece of that system is dysfunctional, the others compensate. A pelvic floor that is overactive, underactive, or poorly coordinated can drive instability at the sacroiliac joint, alter lumbopelvic control, and present clinically as nonspecific low back pain. Research has consistently demonstrated that women with chronic low back pain have measurable differences in pelvic floor activation and timing compared to controls. The same patterns have been identified in men with persistent lumbar pain and a history of pelvic pain or urinary symptoms.

For clinicians without pelvic floor training, this connection can be easy to miss. Patients rarely volunteer urinary, bowel, or sexual health symptoms. They come in describing back pain. They may have already failed two or three previous courses of physical therapy that focused exclusively on the lumbar spine and core.

Free Webinar 1: The Pelvic Floor and Low Back Pain

In this live session, Allison will walk clinicians through the clinical and anatomical connections between the pelvic floor and low back pain, share the symptom patterns that suggest pelvic floor involvement, and outline what assessment and referral pathways can look like in everyday practice. This webinar is designed for clinicians who do not specialize in pelvic health but who want to recognize when the pelvic floor is part of the picture.

Date: Wednesday, May 20, 2026   |   Time: 1:00 PM ET / 11:00 AM MT
Cost: Free   |   Presenter: Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC
Register: Register for Webinar

Free Webinar 2: PRPC Ask Me Anything

For clinicians who already work in pelvic health and are ready to formalize their expertise, the Pelvic Rehabilitation Practitioner Certification (PRPC) is the credential that signals advanced clinical mastery. The second webinar in this series is a live open Ask Me Anything session where Allison answers your questions about the certification, the exam, eligibility, and how to prepare.

Date: Wednesday, May 27, 2026   |   Time: 1:00 PM ET / 11:00 AM MT
Cost: Free   |   Presenter: Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC
Register: Register for Webinar

What is the PRPC, and why earn it through Herman & Wallace?

The Pelvic Rehabilitation Practitioner Certification is a board certification developed by Herman & Wallace that recognizes clinicians who have demonstrated advanced clinical knowledge across the full scope of pelvic rehabilitation. The exam covers male and female pelvic health, pediatric and geriatric considerations, oncology, pregnancy and postpartum care, bowel and bladder dysfunction, sexual health, and chronic pelvic pain.

Unlike credentials limited to one population or one diagnostic area, the PRPC reflects breadth across the lifespan and across the full pelvic health caseload. Clinicians who hold the PRPC use it to communicate their expertise to referring providers, patients, employers, and the broader rehabilitation community.

Herman & Wallace is the institute that developed and administers the PRPC, and the only place to learn directly from the faculty who write and teach the foundational coursework. Allison Ariail is one of those faculty members, having served as senior faculty and Director of Education at Herman & Wallace for many years.

To learn more about the PRPC requirements, eligibility, and exam content, visit hermanwallace.com/prpc.

Why these two webinars belong on your calendar

Whether you are an orthopedic clinician who wants to recognize when the pelvic floor is contributing to your low back pain caseload, or a pelvic health specialist who wants to formalize your expertise with a board certification, these two free webinars deliver high-value clinical content from one of the most respected voices in pelvic rehabilitation.

Register for one or both. Bring your clinical questions. Both sessions are free and live.

Electrostimulation is a conservative treatment of improving bladder function. This can be performed parasacrally, intravaginally or by stimulation of the tibial nerve (Wang and Liu, 2022, Jacomo et al, 2020, Bhide et al 2019, Padilha et al., 2020).

Tibial Nerve Stimulation (TNS) is performed to assist patients to improve bowel and bladder function such as fecal incontinence, constipation, overactive bladder (OAB), painful bladder syndrome, pediatric voiding dysfunction, neurogenic bladder, urinary urgency (UU), and enuresis. Today we are going to explore tibial nerve stimulation for overactive bladder symptoms.

A 2025 systematic review and meta-analysis reviewed transcutaneous tibial nerve stimulation with OAB. All the studies reviewed revealed improvements in urinary symptoms through improved quality of life and OAB functional outcome scores or improvements with 3-day voiding diary measures such as urinary incontinence, urgency, frequency and nocturia (Vaca-Benavides et al., 2025).

How does TNS work for OAB?

Although research is still determining exact pathways, TNS is thought to work through retrograde neuromodulation of the sacral nerve plexus (L4-S3) via transmission of electrical signals from the ankle (distally) along the path of the posterior tibial nerve (more proximally) to the spinal cord, which is believed to suppress excessive or abnormal afferent signaling at the detrusor muscle, thereby inhibiting involuntary spasms and/or contractions (Shang et al., 2026, Vaca-Benavides et al., 2025, Sapouna, 2024).

TNS likely modulates neural pathways by stimulating peripheral somatic afferent nerves which to calm the bladder and inhibit the micturition reflex (Al-Danakh et al., 2022). Utilizing TNS long-term may reprocess the signals received by the bladder by inducing neural plastic changes over a longer period with repeated nerve stimulation (Kovacevic and Yoo, 2015). Repeated TNS sessions may also potentially assist with reorganization of the central nervous system’s sensory processing relieving detrusor overactivity (Sapouna, 2024).

Animal models also suggest a reduction of mast cells, which may reduce sensitivity and inflammation (Gaviev et al., 2013, Sapouna, 2024). In addition, stimulation in the animal models have reduced the expression of C-fos in the spinal cord, which is a marker of neuronal metabolic activity, which may lead to a downregulation in neuronal pathways (Sapouna, 2024).

What are different types of Tibial Nerve Stimulation (TNS)?

Shang et al, describe 3 main types of TNS utilized clinically.

The first type is Percutaneous Tibial Nerve Stimulation (PTNS), involves delivering low-voltage stimulation through the insertion of a needle-shaped electrode approximately 3-4cm above the medial malleolus.

The second type, Transcutaneous Tibial Nerve Stimulation (TTNS), is something we are more familiar with. This involves placing non-invasive use of electrode pads on the skin and utilizing a TENS unit to provide stimulation on the route of the posterior tibial nerve.

The third type is Implantable Tibial Nerve Stimulation (ITNS / iTNM), which involves surgically implanting electrodes near the tibial nerve for chronic stimulation with special units.

How can I learn to use TTNS?

To learn more about TTNS, as well as other forms of neuromodulation, take Modalities and Pelvic Function: The Pelvic Health Toolkit. In this course you learn how to integrate into your treatments numerous types of modalities including neuromodulation, biofeedback, estim, release tools, tools for sexual health, and modalities for urinary and fecal incontinence. Participants are introduced to many examples of modalities with hands on labs to practice the application of these tools. Join us June 27 and 28 in Milwaukee, Wisconsin for Modalities and Pelvic Function to learn more about frequently used modalities in pelvic health.

https://www.hermanwallace.com/continuing-education-courses/modalities-and-pelvic-function

References

Al-Danakh, A., Safi, M., Alradhi, M., Almoiliqy, M., Chen, Q., Al-Nusaif, M., Yang, X., Al-Dherasi, A., Zhu, X., & Yang, D. (2022). Posterior Tibial Nerve Stimulation for Overactive Bladder: Mechanism, Classification, and Management Outlines. Parkinson’s disease, 2022, 2700227. https://doi.org/10.1155/2022/270022

Barroso, U., Jr, & Lordêlo, P. (2011). Electrical nerve stimulation for overactive bladder in children. Nature reviews. Urology, 8(7), 402–407. https://doi.org/10.1038/nrurol.2011.68

Bhide, A. A., Tailor, V., Fernando, R., Khullar, V., & Digesu, G. A. (2020). Posterior tibial nerve stimulation for overactive bladder-techniques and efficacy. International urogynecology journal, 31(5), 865–870. https://doi.org/10.1007/s00192-019-04186-3

Cava, R., & Orlin, Y. (2022). Home-based transcutaneous tibial nerve stimulation for overactive bladder syndrome: a randomized, controlled study. International urology and nephrology, 54(8), 1825–1835. https://doi.org/10.1007/s11255-022-03235-z

Gaziev, G., Topazio, L., Iacovelli, V., Asimakopoulos, A., Di Santo, A., De Nunzio, C., & Finazzi-Agrò, E. (2013). Percutaneous Tibial Nerve Stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: a systematic review. BMC urology, 13, 61. https://doi.org/10.1186/1471-2490-13-61

Jacomo, R. H., Alves, A. T., Lucio, A., Garcia, P. A., Lorena, D. C. R., & de Sousa, J. B. (2020). Transcutaneous tibial nerve stimulation versus parasacral stimulation in the treatment of overactive bladder in elderly people: a triple-blinded randomized controlled trial. Clinics (Sao Paulo, Brazil), 75, e1477. https://doi.org/10.6061/clinics/2020/e1477

Kovacevic, M., & Yoo, P. B. (2015). Reflex neuromodulation of bladder function elicited by posterior tibial nerve stimulation in anesthetized rats. American journal of physiology. Renal physiology, 308(4), F320–F329. https://doi.org/10.1152/ajprenal.00212.2014

Padilha, J. F., Avila, M. A., Seidel, E. J., & Driusso, P. (2020). Different electrode positioning for transcutaneous electrical nerve stimulation in the treatment of urgency in women: a study protocol for a randomized controlled clinical trial. Trials, 21(1), 166. https://doi.org/10.1186/s13063-020-4096-7

Sapouna, V., Zikopoulos, A., Thanopoulou, S., Zachariou, D., Giannakis, I., Kaltsas, A., Sopheap, B., Sofikitis, N., & Zachariou, A. (2024). Posterior Tibial Nerve Stimulation for the Treatment of Detrusor Overactivity in Multiple Sclerosis Patients: A Narrative Review. Journal of personalized medicine, 14(4), 355. https://doi.org/10.3390/jpm14040355

Shang, D., Deng, H., Li, C., Wang, Z., Jin, L., & Li, X. (2026). Tibial nerve stimulation for overactive bladder: a literature review of stimulation parameters. Translational andrology and urology, 15(2), 67. https://doi.org/10.21037/tau-2025-aw-774

Vaca-Benavides, D. A., Ju, W., Gonzalez, C., Aitken, P., Appukuttan Nair Syamala Amma, A. K., Mitra, S., & Shenkin, S. D. (2025). The importance of electrical parameters on transcutaneous tibial nerve stimulation for overactive bladder syndrome: a systematic review and meta-analysis. Age and ageing, 54(7), afaf203.

Wang, Z. H., & Liu, Z. H. (2022). Treatment for overactive bladder: A meta-analysis of tibial versus parasacral neuromodulation. Medicine, 101(41), e31165. https://doi.org/10.1097/MD.0000000000031165

Candido, T. A., Ribeiro, B. M., de Araújo, C. R. C., Pinto, R. M. C., Resende, A. P. M., & Pereira-Baldon, V. S. (2020). Effects of tibial and parasacral nerve electrostimulation techniques on women with poststroke overactive bladder: study protocol for a randomized controlled trial. Trials, 21(1), 936. https://doi.org/10.1186/s13063-020-04856-4

There are faculty members who teach courses, and then there are faculty members who help define the standard of education in an entire specialty. Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC, is the latter. A Senior Faculty member at Herman & Wallace since 2006, Dr. Downey has spent nearly two decades shaping how clinicians learn to assess and treat pelvic floor dysfunction, and she shows no signs of slowing down.

We are proud to spotlight one of the longest-serving and most accomplished educators in our institute.

A Clinician and Educator Since 1991

Dr. Downey has been a physical therapist for more than 30 years. She is a Board-Certified Specialist in Pelvic Health Physical Therapy (WCS), Board-Certified in Biofeedback for Pelvic Muscle Dysfunction (BCB-PMD), and a Certified Pelvic Rehabilitation Practitioner (PRPC). She brings more than 25 years of focused experience treating individuals with pelvic pain, including neuralgias of the lumbosacral plexus, voiding and sexual dysfunction, pregnancy-related and postpartum musculoskeletal dysfunction, diastasis recti, sacroiliac joint pain, and dyspareunia.

She is the owner of Partnership in Therapy, a private practice in Coral Gables, Florida, where she provides personalized one-on-one care to patients of all genders, from adolescents to octogenarians. Her mission is to educate and integrate healthy lifestyles for patients on the road to wellness.

From Sarah Lawrence to the University of Miami

Dr. Downey earned her Bachelor of Arts from Sarah Lawrence College and her Master of Science and Doctorate in Physical Therapy from the University of Miami Miller School of Medicine. She currently serves as an Adjunct Professor in the Physical Therapy Program at both the University of Miami Miller School of Medicine and Nova Southeastern University in Fort Lauderdale, Florida.

Her academic career runs alongside her clinical and continuing education work. She is actively involved in the Academy of Pelvic Health of the American Physical Therapy Association, where she has served as Coordinator of Research Submissions for annual meetings and as a manuscript reviewer for the Journal of Women’s Health.

Pilates as a Clinical Tool

One of the hallmarks of Dr. Downey’s practice is her integration of Pilates therapeutic movement into pelvic health rehabilitation. A certified Polestar Pilates Educator since 2000, she has spent more than two decades using Pilates and therapeutic exercise interventions specifically designed for patients with prenatal and postnatal conditions, pelvic floor muscle dysfunction, and lumbo-pelvic pain.

Her Herman & Wallace course, Pilates Therapeutic Exercise for Pelvic Health, introduces clinicians to the Pilates Method with an emphasis on clinical application and patient empowerment. The course covers the original 34 mat exercises and select Reformer activities, giving clinicians tools to move patients beyond passive treatment and into active, neuromuscular integration. For Dr. Downey, the philosophy is simple: patients who understand and feel how their muscles work become active participants in their own healing.

A Published Author and International Speaker

Dr. Downey has lectured nationally and internationally at professional conferences and has authored multiple published research articles. She is the author of a book chapter on chronic pelvic pain in the medical text Women’s Health in Physical Therapy, contributing to the academic body of knowledge that informs how clinicians approach complex pelvic pain cases.

Her expertise is sought beyond the continuing education classroom. Most recently, Dr. Downey was invited to present at a virtual pop-up session co-hosted by the International Pelvic Pain Society (IPPS) and the APTA Academy of Pelvic Health. Her presentation, “What About Ken? Sexual Dysfunction and Pain in Younger Men,” addressed the musculoskeletal side of sexual pain and dysfunction in younger males and the positive outcomes that can be achieved through collaborative, multidisciplinary care. It is a topic that remains underrepresented in pelvic health education, and Dr. Downey’s willingness to bring it to the forefront reflects her commitment to advancing the field for all patient populations.

Senior Faculty at Herman & Wallace

Dr. Downey has been teaching with Herman & Wallace since 2006, making her one of the institute’s longest-serving faculty members. She teaches across the Pelvic Floor Series as well as her own Pilates course, bringing a combination of clinical depth, movement expertise, and patient-centered philosophy to every course she leads.

Her role as Senior Faculty reflects not just longevity, but the sustained impact she has had on the quality and direction of pelvic health education at Herman & Wallace. Clinicians who train under Dr. Downey consistently describe her as thorough, passionate, and deeply invested in helping them translate what they learn in the classroom into meaningful results for their patients.

About Dr. Downey

Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC (she/her) is a Board-Certified Specialist in Pelvic Health Physical Therapy, Board-Certified in Biofeedback for Pelvic Muscle Dysfunction, and a Certified Pelvic Rehabilitation Practitioner. She is the owner of Partnership in Therapy in Coral Gables, Florida, and an Adjunct Professor at the University of Miami Miller School of Medicine and Nova Southeastern University. A Polestar Pilates Educator since 2000, she has more than 25 years of experience treating pelvic pain, voiding and sexual dysfunction, and pregnancy-related musculoskeletal conditions. She has been Senior Faculty at Herman & Wallace since 2006 and is the author of a book chapter on chronic pelvic pain in Women’s Health in Physical Therapy.

Learn From Dr. Downey

Whether you are looking to build your foundation in pelvic health or integrate Pilates into your clinical practice, Dr. Downey’s courses offer the depth, clinical precision, and hands-on learning that define the Herman & Wallace experience.

May 30-31, 2026: Pilates Therapeutic Exercise for Pelvic Health 

Pelvic Floor Series (Levels 1, 2A, and 2B)

Multiple dates and locations available | Satellite, In-Person, and Self-Hosted formats

Your patients deserve comprehensive care, and you deserve the knowledge to deliver it. View upcoming course dates and register at hermanwallace.com. Courses fill quickly, so register early to secure your spot.