When we think of sports rehab, we typically envision athletes returning to the court after an ankle sprain or knee injury. But what if the same principles of rigorous assessment, load transfer optimization, movement education, and functional stability could apply to one of the body’s most critical yet under‑appreciated joints: the sacroiliac joint (SIJ)?

For clinicians working in pelvic health, embracing a sports‑rehab mindset can transform how we evaluate and treat SIJ dysfunction and pain, and recent research supports this crossover approach. Now might just be the ideal time to integrate these strategies into your practice.

Why Sports Rehab Principles Matter for SIJ/Pelvic Health

• High prevalence of SIJ issues in athletic populations: A 2024 systematic review found that among athletes, average prevalence of SIJP or SIJD was ~10.7%, with rates much higher (32–36%) in those presenting with low back or pelvic pain. (Mirdamadi et al, 2025)
• SIJ dysfunction often coexists with lower extremity injuries: In a 2023 study of basketball players, those with SIJ pain or dysfunction reported significantly more lower-limb and pelvic‑girdle injuries, both acute and overuse, than their peers without SIJ complaints. (Abdollahi et al, 2023)
• Biomechanics and load transfer matter: The SIJ plays a key role in transmitting loads between the spine and lower extremities. Disruption in force transmission, whether from muscular imbalance, altered movement patterns, or pelvic instability, may contribute not just to SIJ pain, but to secondary injuries elsewhere. (Prather, 2000; Abdollahi et al, 2023)

These findings align closely with core sports‑rehab principles: assessing mechanical and neuromuscular impairments, correct faulty movement or load patterns, and restore stability and function before returning to high‑demand activity.

Translating Sports‑Rehab Strategies into Pelvic Health Practice
Here are some of the evidence-based crossover strategies that pelvic rehab clinicians can begin using:

• Comprehensive Functional Assessment: Rather than isolating the SIJ, consider the entire kinetic chain. For instance, when evaluating an athlete (or active individual) with lower extremity complaints, include SIJ screening - given its association with lower‑limb injuries. (Abdollahi et al, 2023)
• Dynamic & Stabilization Exercises: Inspired by sports rehab protocols, incorporating exercises that challenge stability, proprioception, and dynamic load transfer can be effective. A case study combining Swiss‑ball training, mobilization with movement, and taping demonstrated promising results in an athlete with concurrent SIJD and ankle sprain. (Shedge et al, 2024)
• Manual Therapy + Movement Integration: While manual therapy alone has mixed evidence, a recent meta‑analysis found that SIJ manual therapy did not significantly reduce pain vs. non-manual interventions but did improve disability moderately. Combining manual therapy with functional movement and exercise tends to align with best-practice sports rehab philosophy. (Trager at al, 2024)
• Holistic, Movement‑Based Rehab Over “Fixing” Passive Structures: Rather than focusing solely on static “joint alignment” or joint‑centric correction, prioritize restoring functional movement, load capacity, and neuromuscular control - all principles that athletic trainers and sports PTs rely on routinely.

Why This Matters - For Both Clinicians and Clients
Adapting a sports‑rehab informed paradigm for SIJ/pelvic health offers several advantages:

• Broader applicability: Whether your client is a weekend runner, a postpartum individual, or a competitive athlete, a functional, movement‑based SIJ rehabilitation model supports real‑world demands.
• Better injury prevention and reduced recurrence: By addressing underlying load‑transfer dysfunction and neuromuscular control, not just symptoms, you may reduce the risk of future pelvic or lower‑extremity injuries.
• Improved patient buy-in: Clients often resonate with language around “stability,” “function,” and “return to activity.” Familiar terms from sports rehab, which can increase compliance and perceived relevance.

Connect the Dots Between Sports Rehab & Pelvic Rehab - Take the 4‑Hour Course
If you’re ready to bridge the gap between sports rehab and pelvic health, I invite you to join the upcoming four‑hour remote course, Sacroiliac Joint Current Concepts, taught by experienced former NHL physical therapist and athletic trainer Steve Dischiavi, PT, PhD, DPT, MPT, SCS, ATC, COMT.

📅 Date: January 25, 2026
📚 You’ll receive:

• A full, easy‑to-follow SIJ exam sequence - optimized for a pelvic‑health context.
• Treatment strategies aligned with current evidence and sports rehab biomechanics.
• Practical tools you can integrate into your clinical practice immediately (Monday morning!)

Transform your approach and help clients move, perform, and heal better. Register today to reserve your spot.

References

1. Mirdamadi N, Khadembashiri MM, Moghadam N, Kordi R. Prevalence and Risk Factors of Sacroiliac Joint Pain in Athletes: A Systematic Review and Proportional Meta-Analysis. Clin J Sport Med. 2025 Mar 26;35(4):514-525. doi: 10.1097/JSM.0000000000001341. PMID: 40135982.
2. Abdollahi, S., Sheikhhoseini, R., Rahimi, M. et al. The sacroiliac dysfunction and pain is associated with history of lower extremity sport related injuries. BMC Sports Sci Med Rehabil 15, 36 (2023). https://doi.org/10.1186/s13102-023-00648-w
3. Prather H. Pelvis and sacral dysfunction in sports and exercise. Phys Med Rehabil Clin N Am. 2000 Nov;11(4):805-36, viii. PMID: 11092020.
4. Shedge SS, Ramteke SU, Samal S. Integrated Rehabilitation Approach Utilizing Swiss Ball Training, Mulligan Taping, and Mobilization With Movement for Simultaneous Management of Sacroiliac Joint Dysfunction and Lateral Ankle Sprain in a Badminton Athlete: A Case Study. Cureus. 2024 Mar 26;16(3):e56942. doi: 10.7759/cureus.56942. PMID: 38665699; PMCID: PMC11044192.
5. Trager RJ, Baumann AN, Rogers H, Tidd J, Orellana K, Preston G, Baldwin K. Efficacy of manual therapy for sacroiliac joint pain syndrome: a systematic review and meta-analysis of randomized controlled trials. J Man Manip Ther. 2024 Dec;32(6):561-572. doi: 10.1080/10669817.2024.2316420. Epub 2024 Feb 14. PMID: 38353102; PMCID: PMC11578406.

Pelvic floor rehabilitation is often associated with urinary continence or pelvic support, but recent research highlights its broader role, including significant impacts on respiratory health. Studies now suggest that combining pelvic floor muscle (PFM) training with pulmonary rehabilitation can enhance lung function, particularly in elderly patients recovering from orthopedic surgery.

Pelvic Floor Muscle Training and Pulmonary Function
A 2025 randomized controlled trial investigated the effects of combining pelvic floor muscle training with pulmonary rehabilitation in elderly patients following surgery for intertrochanteric femur fractures (Ji et al., 2025). Fifty patients were randomly assigned to either pulmonary rehabilitation alone or pulmonary rehabilitation combined with PFM training. After four weeks, both groups showed improvements in forced vital capacity (FVC), peak expiratory flow (PEF), and the FEV1/FVC ratio, with the combined intervention group demonstrating significantly greater gains. Diaphragm excursion and thickening fraction were also improved, suggesting a synergistic relationship between the diaphragm and pelvic floor muscles that enhances respiratory mechanics.

Supporting Evidence
Additional studies support the connection between PFM function and respiratory performance. A recent study using sensor-based diaphragm exercises combined with PFM training in women with stress urinary incontinence demonstrated improvements in both pelvic floor function and respiratory parameters (Yakıt Yeşilyurt et al., 2025). Similarly, pelvic floor electrical stimulation has been shown to enhance diaphragm excursion and rib-cage movement during tidal and forceful breathing and coughing (Hwang et al., 2021). Foundational work also demonstrated that co-activation of abdominal and pelvic floor muscles contributes to improved expiratory function and intra-abdominal pressure regulation (Sapsford et al., 2001). Together, these studies highlight the physiological link between the pelvic floor, diaphragm, and respiratory system.

Why This Matters
For elderly patients recovering from hip fractures, optimizing lung function is critical to reducing postoperative complications such as pneumonia and supporting overall recovery. Integrating PFM training with pulmonary rehabilitation provides a novel and underutilized approach to enhance respiratory efficiency and accelerate functional recovery. Moreover, these findings expand the role of pelvic floor rehabilitation beyond traditional urogenital outcomes, emphasizing its value in multidisciplinary rehabilitation programs.

Takeaway
The pelvic floor contributes significantly to respiratory mechanics. Combining pelvic floor muscle training with pulmonary rehabilitation can improve lung function in elderly post-surgical patients and may support broader recovery goals. As research evolves, pelvic floor specialists have the potential to play a key role in integrated rehabilitation approaches.

Practical Next Step: Elevate your clinical expertise by enrolling in Breathing and the Diaphragm, scheduled for December 6. This course covers diaphragm anatomy, breathing mechanics, and how the diaphragm, abdominals, and pelvic floor interact to regulate intra‑abdominal pressure, support core stability, and influence posture. Lab sessions include assessment and treatment of dysfunctional breathing patterns, ribcage and thoracic-spine restrictions, and practical strategies for clinical integration. While broadly applicable to pelvic pain, incontinence, prolapse, and core/abdominal issues, these techniques can be adapted for elderly post-hip-fracture patients to optimize lung function and recovery.

References

• Yakıt Yeşilyurt S, Şahiner Pıçak G, Başol Göksülük M, Balıkoğlu M, Özengin N. Investigating the Effectiveness of Pelvic Floor Muscle Training, Including Sensor-Based Diaphragm Exercises in Women With Stress Urinary Incontinence: A Randomized Controlled Study. Arch Phys Med Rehabil. 2025 Jul 11:S0003-9993(25)00796-8. doi: 10.1016/j.apmr.2025.06.019. Epub ahead of print. PMID: 40653184. https://pubmed.ncbi.nlm.nih.gov/40653184/
• Ji D, Fu Y, Wu L, Tian C, Jin S. Effect of pelvic floor muscle combined with pulmonary rehabilitation training on lung function in elderly patients after surgery for intertrochanteric fractures of the femur: a randomized controlled trial. Eur J Med Res. 2025 May 14;30(1):381. doi: 10.1186/s40001-025-02610-7. PMID: 40369675; PMCID: PMC12076919. https://pubmed.ncbi.nlm.nih.gov/40369675/
• Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial. Medicine (Baltimore). 2021 Jan 8;100(1):e24158. doi: 10.1097/MD.0000000000024158. PMID: 33429797; PMCID: PMC7793445. https://pubmed.ncbi.nlm.nih.gov/33429797/
• Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neurourol Urodyn. 2001;20(1):31-42. doi: 10.1002/1520-6777(2001)20:1<31::aid-nau5>3.0.co;2-p. PMID: 11135380. https://pubmed.ncbi.nlm.nih.gov/11135380/

As the holiday season approaches, Thanksgiving reminds us to pause and reflect on what we are grateful for in our personal lives and in our professional practice. For pelvic health practitioners, one of the greatest sources of gratitude is the opportunity to guide patients toward meaningful progress in their rehabilitation journeys.

Recognizing Small Wins Makes a Big Difference
Pelvic rehabilitation is often a journey of incremental improvements. While some changes may be subtle, each step forward is a win. Whether it’s a patient regaining core strength, experiencing reduced pain, improving bladder or bowel control, or building confidence in their body, these victories deserve recognition.

Celebrating small milestones can empower patients, reinforcing that their effort and consistency are yielding real results. Acknowledging progress, even the tiniest, can make a difference in adherence, motivation, and long-term outcomes.

Ways to Celebrate Patient Progress

• Track measurable improvements: Use objective measures like strength, endurance, or symptom diaries to show patients how far they’ve come.
• Highlight functional achievements: Celebrate when a patient reaches a daily-life goal, like returning to exercise, sitting comfortably, or managing symptoms during work or travel.
• Share success stories (with permission): Patient testimonials can motivate others and reinforce a culture of positivity and gratitude in your clinic.
• Verbal acknowledgment: Never underestimate the power of simply saying, “You’ve made great progress!”

Simple Pelvic Floor-Friendly Tips for the Holidays
The holiday season often brings long hours of cooking, hosting, or traveling. Activities that can challenge posture, core stability, and pelvic floor engagement. Here are some short, actionable tips patients can use to stay mindful of their pelvic health:

1. Engage the core while standing: While chopping vegetables or stirring a pot, gently draw the belly button toward the spine and lift the pelvic floor to maintain activation.
2. Shift weight regularly: Avoid standing in one position for too long. Step side to side or gently march in place while waiting for the oven timer.
3. Practice deep breathing: Encourage diaphragmatic breathing while seated or standing to release tension and coordinate with the pelvic floor.
4. Take micro-breaks: Every 30–60 minutes, sit or stand with good posture, roll the shoulders, and gently lengthen the spine.
5. Travel-friendly stretches: While on the road or sitting for long periods, gently lift and lower the pelvic floor or do seated pelvic tilts to maintain mobility.

These simple practices can help patients maintain pelvic floor awareness, reduce tension, and feel more comfortable throughout the holiday festivities.

Fostering Gratitude in Your Practice
Showing gratitude to your patients strengthens the therapeutic relationship. A simple thank-you note, a personalized follow-up, or acknowledging their dedication in session can help them feel seen and appreciated. Gratitude flows both ways: as you recognize patients’ efforts, you’re also reminded why you chose this profession - the opportunity to make a meaningful impact in people’s lives.

Looking Ahead with Appreciation
Thanksgiving is a perfect time to reflect on the wins from the past year, both big and small. Take a moment to appreciate the resilience of your patients and the progress you’ve helped facilitate. As we guide patients toward healthier, more empowered lives, celebrating these victories reminds us of the profound value of pelvic rehabilitation work.

Pelvic rehabilitation is a constantly evolving specialty, and your ability to offer high-quality care grows when you have access to a diverse set of tools. Modalities play a significant role in strengthening clinical precision, improving neuromuscular learning, enhancing patient engagement, and expanding treatment possibilities. When you integrate evidence-based modalities into your practice, you elevate the effectiveness and individualization of your patient care.

Here are the top five reasons modalities matter in pelvic rehabilitation, along with examples of tools that can support your work

1. Modalities Improve Your Clinical Precision

Pelvic health presentations often involve complex relationships between muscle tone, coordination, pain, biomechanics, breathing patterns, and emotional factors. Modalities help you see these interactions more clearly and treat them more effectively.

Tools that support clinical precision include:

• Surface EMG biofeedback for assessing activation, resting tone, and timing.
• Real Time Ultrasound Imaging (RUSI) for observing deep core mechanics, pelvic floor movement, and breathing synergy.
• Myofascial tools that help you identify tissue restrictions and monitor tissue response.
• Postural support belts and braces clarify how external stabilization influences symptoms.

With these tools, you gain insights that strengthen your clinical decisions and give patients a clearer understanding of what is happening in their bodies.

2. Modalities Support Both Uptraining and Down Training

Pelvic rehabilitation patients often need help with improving activation, reducing overactivity, coordinating movement, or building endurance. Modalities help you guide the nervous system in the direction that best supports each patient’s goals.

Examples include:

• Surface EMG biofeedback for awareness, facilitation, and relaxation.
• Electrical stimulation to support neuromuscular firing for those with inhibition or weakness.
• Real Time Ultrasound Imaging to help patients visualize diaphragmatic motion and pelvic floor excursion.
• Myofascial tools such as soft tissue instruments to reduce guarding and improve mobility.
• Breath training accessories like visual feedback tools that support better coordination.

Using modalities for both uptraining and down training gives patients more ways to understand and feel the changes you are guiding them toward.

3. Modalities Enhance Patient Understanding and Self-Efficacy

Education and behavior change are central to pelvic rehabilitation. Many patients struggle to conceptualize pelvic floor movement, pressure systems, or muscle relaxation. Modalities make these invisible processes visible and actionable.

Tools that promote self-efficacy include:

• Biofeedback displays that show contraction and relaxation in real time.
• Real-time ultrasound images that reveal how the pelvic floor, transversus abdominis, and diaphragm work together.
• Myofascial release tools that patients can use safely at home.
• Lubricants, dilators, and pelvic wands that support sexual wellness, tissue tolerance, and desensitization.
• Pelvic support belts that help patients feel stable and confident during daily activities.

When patients understand what they are doing and feel empowered by their progress, they become stronger partners in their own recovery.

4. Modalities Expand What Is Possible in Your Treatment Sessions

You already rely on your hands, your knowledge, and your clinical reasoning. Modalities add another layer that allows you to address diverse needs in more targeted ways.

Examples include:

• Myofascial tools for reducing soft tissue restrictions and improving movement.
• Electrical stimulation for supporting continence or reducing pelvic pain.
• Light therapy devices that can help with tissue healing.
• RUSI for assessing pressure management and facilitating motor learning.
• Belts, braces, and supports that can help reduce pain and improve load transfer during movement.
• Lubricants and moisturizers support tissue comfort and sexual function.

Your treatment sessions become more versatile, adaptable, and responsive to the patient in front of you.

5. Modalities Improve Outcomes Across Many Pelvic Health Conditions

The evidence for modality use continues to grow. When you broaden your clinical toolkit, you are better equipped to support patients with varied needs.

Modalities can enhance care for:

• Stress and urge incontinence
• Pelvic pain and overactive pelvic floor conditions
• Bowel dysfunction and dyssynergia
• Dyspareunia and sexual dysfunction
• Postpartum recovery
• Post-prostatectomy rehabilitation
• Vulvodynia and vestibulodynia
• Coordination impairments and breathing dysfunction
• Lumbopelvic instability and load transfer issues

From myofascial support tools to electrical stimulation to imaging and external supports, modalities allow you to tailor interventions with greater specificity and effectiveness.

Build Your Skills with a Hands-On Course Focused on Modalities
If you want clear guidance, supported practice time, and evidence-based instruction on using modalities safely and effectively, Modalities and Pelvic Function was designed for you.

The course combines pre-course video lectures with two days of hands-on lab and dedicated instruction. You will learn how to select and apply modalities, interpret findings, support neuromuscular learning, and integrate tools such as biofeedback, electrical stimulation, myofascial instruments, RUSI, and patient support devices.

Join the Upcoming Boston Course
Venue: Current Medical Technologies
Address: 14 Kendrick Road, Unit 1, Wareham, MA 02571
Dates: January 24 through 25, 2026
Elevate your pelvic rehabilitation practice. Register now to reserve your seat.

Male pelvic cancer survivors, including those treated for prostate, bladder, penile, and testicular cancers, face a range of ongoing functional challenges that affect quality of life. Treatments such as radical prostatectomy, radiation therapy, chemotherapy, and reconstructive surgery can lead to urinary incontinence, erectile dysfunction, bowel irregularity, pelvic pain, and changes in body image or hormonal balance. These effects often overlap and require an integrated rehabilitation approach.

Prostate cancer survivors frequently report urinary leakage, urgency, and reduced bladder control. Bladder cancer patients, particularly those who undergo urinary diversion or neobladder reconstruction, may struggle with altered storage and emptying patterns. Colorectal cancer survivors treated with low anterior resection often develop low anterior resection syndrome, which is characterized by stool clustering, urgency, and incontinence (Jones et al., 2024; Kim & Oh, 2023). Penile and testicular cancer survivors may experience sexual dysfunction and hormonal disruptions that influence pelvic floor function and psychosocial well-being. Across these diagnoses, common contributors to dysfunction include pelvic floor muscle weakness or discoordination, neural disruption, scar tissue and fibrosis, and the cumulative impact of cancer treatment on mobility, confidence, and daily function.

The Role of Pelvic Floor Rehabilitation
Pelvic floor rehabilitation is an essential component of survivorship care. Randomized trials and systematic reviews consistently support structured pelvic floor muscle training to improve urinary continence after prostatectomy (Fernández et al., 2015; Chen et al., 2023; Gerlegiz et al., 2025). Supervised PFMT produces better outcomes than unsupervised exercise, particularly when initiated before surgery or early postoperatively. Confirming accurate pelvic floor activation through biofeedback or palpation is critical for optimizing treatment success (Gerlegiz et al., 2025).

For men treated with pelvic radiation, long-term changes in muscle structure and neural control can contribute to urinary or bowel dysfunction and pelvic pain. Morphological and functional assessments using MRI, surface electromyography, and palpation have demonstrated reduced pelvic floor muscle endurance and altered activation patterns years after treatment (Ribeiro et al., 2021). These findings highlight the importance of ongoing rehabilitation to restore motor control, manage fibrosis, and reduce symptom burden.

Colorectal cancer survivors with low anterior resection syndrome benefit from targeted pelvic floor rehabilitation. Structured programs including pelvic floor muscle training, coordination exercises, and biofeedback have demonstrated improvements in bowel function, urgency, and quality of life (Jones et al., 2024; Kim & Oh, 2023). Programs delivered over multiple sessions, with patient adherence to home exercises, provide the most consistent benefit.

Sexual health is another domain where pelvic rehabilitation is important. Pelvic floor muscle training can improve erectile function, particularly when initiated preoperatively or in high-volume programs (Milios et al., 2020; Wong et al., 2020). Pelvic therapists can also address pelvic pain, scar sensitivity, and coordination deficits that contribute to sexual discomfort. Multidisciplinary collaboration with urology, sexual medicine, and mental health professionals provides comprehensive support for survivors navigating intimacy and relationship challenges.

Practical Rehabilitation Strategies
Evidence-based rehabilitation for male pelvic cancer survivors should include the following components:

Assessment and activation  - Confirm voluntary pelvic floor contraction using digital palpation, biofeedback, or ultrasound. Accurate assessment allows for individualized exercise prescription and objective tracking of progress (Gerlegiz et al., 2025; Ribeiro et al., 2021).

Structured exercise prescription - High-volume pelvic floor muscle training incorporating both slow- and fast-twitch fibers is recommended. Supervised sessions ensure correct technique, increase adherence, and improve outcomes (Fernández et al., 2015; Chen et al., 2023).

Biofeedback and adjunct modalities - Biofeedback supports motor learning and awareness. Electrical stimulation may be used selectively in patients unable to contract muscles effectively (Fernández et al., 2015).

Bowel retraining and coordination exercises - Strategies such as urge suppression, stool consistency management, scheduled toileting, and coordination exercises improve function in patients with low anterior resection syndrome (Jones et al., 2024; Kim & Oh, 2023).

Manual therapy and scar management - Hands-on techniques address fibrosis, scarring, restricted mobility, and pain. Scar desensitization and soft tissue mobilization support improved muscle recruitment and pelvic comfort.

Sexual rehabilitation integration - Pelvic floor muscle training can complement medical penile rehabilitation, graded exposure, and sensory retraining to improve sexual function and comfort (Milios et al., 2020; Wong et al., 2020).

Psychosocial support - Addressing body image, anxiety, and intimacy concerns is essential. Counseling referrals and supportive communication improve adherence and quality of life.

Prehabilitation and telehealth - Preoperative pelvic floor training can improve postoperative outcomes (Chen et al., 2023). Telehealth facilitates remote guidance, adherence monitoring, and access to specialized pelvic rehabilitation services.

Takeaway
Functional impairments after male pelvic cancer treatment are common, but rehabilitation can significantly improve urinary continence, bowel control, sexual function, pain, and overall quality of life. Evidence strongly supports structured, supervised pelvic floor muscle training for urinary incontinence after prostatectomy, with growing support for bowel and sexual rehabilitation in this population. Early, individualized, and evidence-based intervention is key to maximizing recovery.

Clinicians seeking to deepen their skills in treating male pelvic and colorectal cancer survivors are encouraged to register for the Oncology of the Pelvic Floor Level 2A: Male Pelvic and Colorectal Cancers course on December 6–7. This two-day training provides hands-on learning, case-based discussions, and practical strategies for evidence-based assessment and intervention.

References

1. Fernández RA, García-Hermoso A, Solera-Martínez M, Correa MT, Morales AF, Martínez-Vizcaíno V. Improvement of continence rate with pelvic floor muscle training post-prostatectomy: a meta-analysis of randomized controlled trials. Urol Int. 2015;94(2):125-32. doi: 10.1159/000368618. PMID: 25427689.
2. Ribeiro AM, Nammur LG, Mateus-Vasconcelos ECL, Ferreira CHJ, Muglia VF, de Oliveira HF. Pelvic floor muscles after prostate radiation therapy: morpho-functional assessment by magnetic resonance imaging, surface electromyography and digital anal palpation. Int Braz J Urol. 2021 Jan-Feb;47(1):120-130. doi: 10.1590/S1677-5538.IBJU.2019.0765. PMID: 33047917; PMCID: PMC7712707.
3. Milios JE, Ackland TR, Green DJ. Pelvic Floor Muscle Training and Erectile Dysfunction in Radical Prostatectomy: A Randomized Controlled Trial Investigating a Non-Invasive Addition to Penile Rehabilitation. Sex Med. 2020 Sep;8(3):414-421. doi: 10.1016/j.esxm.2020.03.005. Epub 2020 May 14. PMID: 32418881; PMCID: PMC7471070.
4. Chen, Yi-Hsuan1; Juan, Yung-Shun1,2,3,4; Wei, Wei-Chi1; Geng, Jiun-Hung5; Chueh, Kuang-Shun1,4; Lee, Hsiang-Ying1,2,3,4,*. Effects of Early Pelvic Floor Muscle Training on Early Recovery of Urinary Incontinence after Prostate Surgery. Urological Science 34(1):p 39-45, Jan–Mar 2023. | DOI: 10.4103/UROS.UROS_59_22
5. Wong C, Louie DR, Beach C. A Systematic Review of Pelvic Floor Muscle Training for Erectile Dysfunction After Prostatectomy and Recommendations to Guide Further Research. J Sex Med. 2020 Apr;17(4):737-748. doi: 10.1016/j.jsxm.2020.01.008. Epub 2020 Feb 3. PMID: 32029399.
6. Jones S, Edie A, Troop E, Hill JS, Thompson JA. The Effect of Pelvic Floor Rehabilitation on Low Anterior Resection Syndrome After Colorectal Cancer Treatment. J Adv Pract Oncol. 2024 May 22:1-12. doi: 10.6004/jadpro.2024.15.8.4. Epub ahead of print. PMID: 39802528; PMCID: PMC11715399.
7. Kim YM, Oh EG. Effectiveness of Pelvic Floor Muscle Training for Patients Following Low Anterior Resection: A Systematic Review and Meta-analysis. J Wound Ostomy Continence Nurs. 2023 Mar-Apr 01;50(2):142-150. doi: 10.1097/WON.0000000000000958. PMID: 36867038.
8. Gerlegiz ENA, Öztürk D, Gürşen C, Akbayrak T, Özgül S. Structured and supervised pelvic floor muscle training following confirmed contraction in post-prostatectomy urinary incontinence: a systematic review of randomized controlled trials. J Cancer Surviv. 2025 Aug 28. doi: 10.1007/s11764-025-01882-6. Epub ahead of print. PMID: 40877548.

Pelvic rehabilitation practitioners often focus on mechanical concerns such as diastasis recti, pelvic floor weakness, and altered load transfer. However, one foundational element that deserves equal attention in the postpartum period is the ongoing effect of hormonal shifts on connective tissues and joints.

Even after delivery, hormones such as relaxin, estrogen, and progesterone continue to influence tissue behavior, joint mobility, and the body's response to rehabilitation. Understanding how these hormones affect ligament laxity, collagen turnover, and neuromuscular control helps clinicians design safer and more effective recovery programs.

Hormonal Changes in Pregnancy and Early Postpartum
Relaxin is produced by the corpus luteum and placenta, and rises significantly during pregnancy. It is known for its role in “relaxing” muscles and ligaments, especially in the pelvis, to facilitate childbirth. Estrogen and progesterone also rise and modulate connective-tissue metabolism and receptor expression in ligaments.

A recent review highlights that pregnancy-associated hormonal fluctuations (relaxin, estrogen, progesterone) contribute to increased joint laxity (Yalçınkaya et al., 2025). These hormonal effects do not cease abruptly at delivery; they taper variably and may persist for months postpartum, meaning joint and tissue behavior remains altered during rehab.

Hormones Affect Connective Tissue and Joint Mechanics
At the cellular level, relaxin increases the activity of matrix metalloproteinases (MMPs) such as MMP-1, -9, and -13, which degrade collagen and weaken ligament/tendon architecture (Parker et al., 2-22). Estrogen and progesterone increase expression of relaxin receptors in ligaments, amplifying these effects (Yalçınkaya et al., 2025).

In animal and human tendon studies, both relaxin and estrogen have been shown to reduce tendon stiffness and increase compliance, which can reduce load tolerance (Danos et al., 2023). The net mechanical effect is increased joint mobility (or perceived laxity), reduced passive stability, and a greater need for neuromuscular control to compensate.

Clinically, this manifests as more “loose-feeling” joints, increased cushioning of movement, greater reliance on muscular control for stability, and potentially slower progress of load-transfer training. A prospective cohort during pregnancy found associations between estrogen changes and increased low-back/pelvic-girdle pain and disability (Daneau et al., 2025). Although postpartum longitudinal data are sparse, the same mechanisms are likely to persist into the early postpartum period and influence rehab.

Implications for postpartum rehabilitation of joints

1. Assessment and monitoring: Include joint laxity screening (e.g., Beighton score or joint-specific tests) and ask the client about subjective joint “giveness” or instability. Recognize that normal endpoints may be slower to return.
2. Loading progression: Because connective tissues are in a transiently weakened state, adopt more conservative load progressions. Emphasize neuromuscular control (motor control, stability) before heavy mechanical loading. Use subsets such as closed-chain, low-velocity, high-control activities.
3. Tailored timeline: Do not assume pre-pregnancy tissue behavior has returned simply because the organ-based recovery period has ended. A busy schedule, hormonal fluctuations (including lactation, menses return) may continue to modulate tissue mechanics.
4. Patient education: Explain that “it’s not just about the tummy and pelvic floor” but that “your ligaments and joints are still adjusting.” This can help set realistic expectations and foster adherence to graded rehab.
5. Coordination with other practitioners: Ensure communication with obstetric, primary-care, and sports-medicine colleagues about longer-term musculoskeletal implications of hormonal and biomechanical changes. As one review concluded, many women are at elevated risk for persistent joint instability and possible long-term sequelae such as early osteoarthritis (Yalçınkaya et al.., 2025).

Case example
A 34-year-old primipara at 10 weeks postpartum presents with “clicking” in the pubic symphysis region when lifting her 9-month-old toddler and reports a sense of “unstable hips” when stepping sideways. On assessment, she has a Beighton score of 5/9 (with bilateral thumb-to-forearm and elbow hyperextension). She also reports previous hip discomfort in adolescence.

Given her history and findings, you design a graduated program: phase 1 focused on pelvic-floor activation + hip stability in non-weight-bearing by week 12; phase 2 at week 16, introducing unilateral step-downs with low amplitude; phase 3 at week 20, adding higher load functional tasks (carrying child + step).

You monitor joint symptoms, ensure neuromuscular control precedes full load, and educate her regarding ligamentous recovery timeline (~6-12 months). You explain that although the baby is 9 months old, her connective tissues may still be adjusting to hormone-mediated changes.

Conclusion
Hormonal recovery is a critical but sometimes overlooked element of postpartum rehabilitation. The lingering influence of relaxin, estrogen, and progesterone shapes how connective tissues behave and respond to loading. By integrating hormonal awareness into clinical decision-making, pelvic health practitioners can enhance precision, promote safety, and improve long-term functional outcomes. Recovery after childbirth is not limited to muscle or fascia; it is a systemic process involving hormones, tissues, and time.

For clinicians interested in expanding their postpartum rehabilitation skills, consider registering for the upcoming Postpartum Rehabilitation Remote Course scheduled for December 13-14. This course covers acute postpartum management, mental health screening, and musculoskeletal considerations. Participants will learn to modify examinations and interventions for the relevant stages of postpartum recovery. In addition to abdominal wall considerations, typical spine and extremity dysfunctions will be addressed. The course includes instruction on postpartum exercise and return to fitness, with labs covering external perineal screening as well as techniques for the abdominal wall, spine, and ribs, and upper and lower quarter dysfunction.

References

1. Yalçınkaya, B., Sezgin, E. A., Saçıntı, K. G., & Özçakar, L. (2025). Neuromusculoskeletal disorders in pregnancy revisited. Journal of Joint Diseases and Related Surgery, 36(3), 741-750.
2. Parker, E. A., Meyer, A. M., Goetz, J. E., Willey, M. C., & Westermann, R. W. (2022). Do Relaxin Levels Impact Hip Injury Incidence in Women? A Scoping Review. Frontiers in Endocrinology, 13, 827512. https://doi.org/10.3389/fendo.2022.827512
3. Danos, N., Patrick, M., Barretto, J., Bilotta, F., & Lee, M. (2023). Effects of pregnancy and lactation on muscle-tendon morphology. Journal of Anatomy, 243(5), 860-869. https://doi.org/10.1111/joa.13916
4. Daneau, C., Nougarou, F., Abboud, J., Ruchat, M., & Descarreaux, M. (2025). Changes in pregnancy-related hormones, neuromechanical adaptations and clinical pain status throughout pregnancy: A prospective cohort study. PLOS ONE, 20(2), e0314158. https://doi.org/10.1371/journal.pone.0314158

In a recent article entitled “Physiotherapy Approaches in Individuals with Functional Defecation Disorders: Literature Review,” published in the Journal of Health Sciences in August of 2025, the use of surface EMG biofeedback (sEMG) was recommended as a first-step treatment for functional defecation disorders. It was concluded that biofeedback applications were superior to standard treatment and effective in improving patients’ quality of life. Both the American Neurogastroenterology and Motility Society and the American College of Gastroenterology recommend biofeedback as first-line therapy for dyssynergic defecation.

Surface electromyography (sEMG) biofeedback has emerged as one of the most effective conservative interventions for treating dyssynergic defecation, also known as pelvic floor dyssynergia. This condition is characterized by the paradoxical contraction or inadequate relaxation of the pelvic floor muscles and external anal sphincter during attempted defecation, resulting in functional outlet obstruction and chronic constipation. Dyssynergia affects many of our clients with chronic constipation and is a prevalent referral diagnosis in pelvic floor rehabilitation. For pelvic health therapists, sEMG biofeedback provides a valuable therapeutic tool that directly retrains neuromuscular coordination, corrects maladaptive defecation mechanics, and improves patient outcomes without the risks associated with pharmacologic or surgical interventions.

How Surface EMG Biofeedback Works
Biofeedback therapy addresses the underlying pathophysiology of dyssynergia by helping patients learn to modulate pelvic floor muscle activity during simulated defecation. Surface EMG biofeedback uses external perianal or intrarectal sensors to record muscle activation patterns, visually displaying motor unit firing in real time on a monitor. When patients attempt defecation, those with dyssynergia often engage in compensatory or dysfunctional mechanics such as breath-holding, strain maneuver without pelvic floor relaxation, or tightening of the external anal sphincter and puborectalis muscle. Biofeedback enables patients to see these abnormalities and receive immediate coaching to correct them. This learning model aligns with the principles of motor relearning and neuroplasticity and is particularly effective for reeducating muscles involved in autonomic and habitual reflex responses, including those of the pelvic floor.

A key benefit of surface EMG biofeedback is its ability to correct maladaptive motor patterns rather than merely provide symptomatic relief. Unlike laxatives, which simply soften stool or increase motility, biofeedback teaches coordinated defecation by training patients to relax the anal sphincter, lengthen the pelvic floor, and generate appropriate intra-abdominal pressure. Many patients demonstrate dyssynergic patterns such as Type I dyssynergia, where the pelvic floor contracts during attempted evacuation, or Type III, where inadequate abdominal force is generated. Biofeedback helps individualize treatment, as therapists can use EMG data to identify specific coordination deficits and modify training accordingly. In addition, EMG signals provide objective progress markers, reinforcing patient engagement and compliance.

Another important clinical advantage of biofeedback is that it is non-invasive, safe, and well-tolerated across patient populations. It is appropriate for adults, older adults, and even motivated pediatric patients. Side effects are minimal, especially with surface EMG sensors that eliminate the need for internal probes when preferred clinically. This makes EMG biofeedback a valuable option for patients who may not tolerate rectal balloon training or invasive anorectal procedures due to pain, anxiety, or trauma history.

Integrating Biofeedback into Pelvic Rehabilitation
Biofeedback therapy integrates well within holistic pelvic rehabilitation programs. Treatment typically includes coordination training, diaphragmatic breathing, colonic massage instruction, toileting posture education, bowel mechanics retraining, and behavioral strategies to restore normal recto-anal sensory reflexes. Surface EMG enhances the effectiveness of behavioral training by improving patients’ proprioceptive awareness of their pelvic floor, a region in which neuromuscular awareness is typically poor. Additionally, EMG biofeedback can incorporate downtraining techniques to reduce high resting pelvic floor tone.

Despite its proven benefits, access to biofeedback therapy can be inconsistent due to limited awareness among healthcare providers and insufficient training opportunities for therapists. However, pelvic health therapists are uniquely positioned to deliver this intervention effectively due to their expertise in neuromuscular reeducation, movement analysis, and behavioral coaching. Incorporating sEMG biofeedback into a pelvic rehabilitation practice not only aligns with evidence-based care but also enhances clinical credibility and expands therapeutic capabilities, especially for patients with chronic functional bowel disorders.

Surface EMG biofeedback offers substantial therapeutic benefits for the treatment of pelvic floor dyssynergia. It is superior to standard medical therapy, targets the root cause of dyssynergia through neuromuscular retraining, promotes long-term bowel function normalization, and empowers patients to take an active role in their recovery. With growing clinical validation and patient demand for non-pharmacologic treatments, sEMG biofeedback should be considered an essential component of pelvic floor therapy practice. For pelvic health therapists seeking to deliver advanced, evidence-based care, biofeedback represents a powerful and effective intervention with lasting results.

Excessive pelvic floor activity during attempts at bowel evacuation creates a mechanical barrier to evacuation and demonstrates dyssynergia (incoordination). When a patient “bears down” the abdominals (blue) should increase, and the pelvic floor (green) should relax.

Correct pattern: Pelvic floor muscles relax and abdominal muscles contract to increase intra-abdominal pressure for proper bowel movement coordination.

Conclusion
A long history of scientific evidence supports the use of sEMG biofeedback for managing incontinence or pain symptoms. As a noninvasive, cost-effective, and powerful treatment modality, healthcare providers should consider this tool when managing pelvic floor dysfunction. Providers should be adequately educated in this valuable modality to make the most of the skills and knowledge gained through this intervention. For more information regarding courses and certification, please visit www.pelvicfloorbiofeedback.com.

Biofeedback for Pelvic Muscle Dysfunction is available in satellite and self-hosted formats.
Biofeedback for Pelvic Muscle Dysfunction, scheduled for December 13, 2025, is led by board-certified Instructors Jane Kaufman and Tiffany Lee, who introduce participants to the use of biofeedback in the treatment of bladder, bowel, and pelvic floor disorders. In this course, participants learn about surface EMG biofeedback by using the equipment on themselves to experience dynamic muscle assessment in supine, sitting, and standing positions. This dynamic course also includes behavioral strategies to relearn proper muscle control and improve pelvic floor function.

If you attend this course at a scheduled hosted location (NOT self-hosted), then the equipment will be supplied by our biofeedback vendor, Current Medical Technologies. Satellite Locations for December 13th are:

• New Bern, NC
• Goodyear, AZ

• A 2-channel sEMG biofeedback hand-held unit with software on a laptop or computer is required. The instructors will teach biofeedback with the Prometheus Telesis software. Participants can use MR-20, MR-25, EMYO, CTS 1500, or CTS 2000.
• The participants who are self-hosting will need a vaginal or rectal sensor and abdominal leads. Alternatively, participants can use external perianal electrodes.
• To use the disposable external electrodes, participants will need a Pathway Velcro adapter (PG-3660), 1 Pathway External Adapter (PG-7100), and Vermed sEMG disposable lead wire set (VM-A10057-S).
• Another option for external electrodes are the Pre-gelled sEMG Biofeedback Electrodes (DE-301) with a 24-inch external lead wire set (PG-5328).

References:

1. Büyüktaş, N., & Bakar, Y. (2025). Physiotherapy Approaches in Individuals with Functional Defecation Disorders: Literature Review. Fenerbahçe University Journal of Health Sciences, 5(2), 281-291.
2. Kaufman, J., Stanton, K., & Lee, T. E. (2021). Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Biofeedback, 49(3), 71-76.
3. Rao, S. S., Benninga, M. A., Bharucha, A. E., Chiarioni, G., Di Lorenzo, C., & Whitehead, W. E. (2015). ANMS‐ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders.Neurogastroenterology & Motility, 27(5), 594-609.
4. Shelly, Beth & Kaufman, Jane (2023). Foundations of Pelvic Floor Muscle Assessment Using Surface Electromyography. APTA Academy of Pelvic Health Physical Therapy.

AUTHOR BIO
Tiffany Lee, OTR, OTD, MA, BCB-PMD, PRPC

Tiffany Lee holds a BS in OT from UTMB Galveston (1996), an MA in Health Services Management, and a post-professional OTD from Texas Tech University Health Sciences Center. In 2004, she received her board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance. She is a Herman and Wallace Pelvic Rehab Institute faculty member and teaches biofeedback courses. She has been treating pelvic health patients for 25 out of her 30-year career. Her private practice in San Marcos, Texas, is exclusively dedicated to treating urinary and fecal incontinence and pelvic floor disorders. Her continuing education company, Biofeedback Training & Incontinence Solutions, offers clinical consultation and training workshops. She also enjoys mentoring healthcare professionals working toward their BCIA certification.

Depending on where you live, you may have recently entered Daylight Savings Time, a time to “fall back” one hour. In the weeks leading up to this change, you might have noticed yourself staying up later or lingering in bed longer on dark mornings. Without conscious effort, your circadian rhythm gradually adjusted to the seasonal shift.

Recent research highlights that light profoundly influences human health, affecting metabolism, sleep, mood, and cellular function. Exposure to natural sunlight helps regulate circadian rhythms, initiates vitamin D synthesis, impacts mental health, enhances energy levels and cognitive performance, and influences appetite and metabolism.

Light and Circadian Rhythms
In 2017, the Nobel Prize was awarded to Jeffrey C. Hall, Michael Rosbash, and Michael W. Young for their discoveries of molecular mechanisms that control circadian rhythms. Circadian rhythms are driven by an internal biological clock that anticipates day/night cycles to optimize physiology and behavior (Nobelforsamlingen, 2017). Each mitochondrion, present in every cell, contains molecular timekeeping machinery that strongly influences body rhythms.

Research now shows that light stimulates these tiny clocks, programming circadian rhythm and activating mitochondria (Jiang et al., 2025; Trajano et al., 2025; Mezhnina et al., 2022). Because light directly nourishes mitochondria, the body’s powerhouses and timekeepers, it can be considered an essential nutrient.

By analogy, plants require light to thrive. While human physiology differs, light similarly drives cellular and molecular pathways. Insufficient natural light can impair mitochondrial function, affecting sleep, energy production, reproduction, and brain function (Trajano et al., 2025; Singh et al., 2025; Song et al., 2022).

Recent Research Linking Light to Health
Recent research highlights that light profoundly influences human health, affecting metabolism, sleep, mood, and cellular function. Exposure to natural sunlight initiates vitamin D synthesis, which is essential for bone health, immune regulation, and calcium absorption. Inadequate vitamin D production due to insufficient sunlight exposure can lead to conditions such as rickets and osteoporosis (Uçar & Holick, 2025).

In addition, light exposure has a significant impact on mental health. Sunlight increases serotonin levels, which improve mood and emotional well-being. A lack of light exposure, particularly in winter months, is associated with Seasonal Affective Disorder (SAD) and other depressive symptoms (Sanes et al, 2022).

Research also connects light to energy levels and cognitive performance. Exposure to bright, natural light during the morning and midday enhances concentration and productivity throughout the day (Islay et al., 2024).

Finally, studies show that light influences appetite regulation and metabolism. The timing and intensity of light exposure can affect glucose metabolism, insulin sensitivity, and energy expenditure, linking disrupted light patterns to obesity and metabolic disorders (Ishihara et al., 2024).

Taken together, these findings support the concept that light functions as a vital nutrient, nourishing both body and mind through its wide-ranging physiological effects.

Light exposure is as essential as nutrition – and perhaps looking at it from this perspective, we can learn ways to optimize our light diets.

Light in Modern Life
Our modern lifestyles can create imbalances in both nutrition and light exposure. While we carefully monitor food intake, we rarely consider how artificial lighting (LEDs, screens, and indoor lighting) affects our health. Excessive artificial blue light can disrupt circadian rhythms, mitochondrial function, and cellular health, in a manner comparable to processed foods that damage DNA (McNish et al., 2025; Trajano et al., 2025; Singh et al., 2025).

Morning sunlight acts as a “timestamp” for the circadian rhythm, regulating sleep and other physiological processes. Conversely, blue light exposure in the evening can suppress melatonin, affecting sleep quality (Ishizawa et al., 2021). Intentional daytime light exposure helps maintain natural rhythms, recharge mitochondria, and support overall health.

Practical Tips
Ask yourself: have you had your daily dose of natural light today? Morning exposure is ideal. Even a few minutes outside or near a bright window can help meet daily light requirements. If screen time is unavoidable in the evening, using blue-blocking glasses may reduce disruption to your sleep cycle (Ishizawa et al., 2021).

The Course
In Nutrition Perspectives in Pelvic Rehab, we go beyond nutrition basics. We delve into a systems approach to nourishment and introduce factors beyond foods that nourish our body, mind, and soul. We learn about our interconnected nature. And we are reminded that we are not nourished by food alone. Life requires light and is as essential as other nutrients for our health and well-being.

Please join us as we explore the many intriguing connections between nourishment, our cells, our systems, and our health and how we can better serve our pelvic health clients from this standpoint.

Nutrition Perspectives will be offered December 6-7, 2025, and quarterly in 2026.

References:

1. Cohen T, Medini H, Mordechai C, Eran A, Mishmar D. Human mitochondrial RNA modifications associate with tissue-specific changes in gene expression, and are affected by sunlight and UV exposure. Eur J Hum Genet. 2022 Dec;30(12):1363-1372. doi: 10.1038/s41431-022-01072-3. Epub 2022 Mar 4. PMID: 35246665; PMCID: PMC9712611.
2. Ishizawa M, Uchiumi T, Takahata M, Yamaki M, Sato T. Effects of pre-bedtime blue-light exposure on ratio of deep sleep in healthy young men. Sleep Med. 2021 Aug; 84:303-307. doi: 10.1016/j.sleep.2021.05.046. Epub 2021 Jun 8. PMID: 34217920.
3. Jiang Z, Wu S, Zhou S, Zheng H, Bai Y, Zhang Y, Yao M. Photobiomodulation mediates endoplasmic reticulum-mitochondria contact and ameliorates lipotoxicity in MASLD via Mfn2 upregulation. J Photochem Photobiol B. 2025 Sep; 270:113209. doi: 10.1016/j.jphotobiol.2025.113209. Epub 2025 Jul 2. PMID: 40633245.
4. McNish H, Mathapathi MS, Figlak K, Damodaran A, Birch-Machin MA. The Effect of Blue Light on Mitochondria in Human Dermal Fibroblasts and the Potential Aging Implications. FASEB J. 2025 Jun 15;39(11):e70675. doi: 10.1096/fj.202500746R. PMID: 40421626; PMCID: PMC12107506.
5. Mezhnina V, Ebeigbe OP, Poe A, Kondratov RV. Circadian Control of Mitochondria in Reactive Oxygen Species Homeostasis. Antioxid Redox Signal. 2022 Oct;37(10-12):647-663. doi: 10.1089/ars.2021.0274. Epub 2022 Feb 18. PMID: 35072523; PMCID: PMC9587791.
6. Nobelforsamlingen. Scientific Background Discoveries of Molecular Mechanisms Controlling the Circadian Rhythm. https://www.nobelprize.org/prizes/medicine/2017/advanced-information/  Accessed November 2, 2025.
7. Singh J, Kumar D, Kaur J, Singh A. The rhythm of decline: Circadian disruption in neurodegeneration. J Food Drug Anal. 2025 Sep 18;33(3):224-240. doi: 10.38212/2224-6614.3553. PMID: 41066745; PMCID: PMC12510711.
8. Song Y, Yang J, Law AD, Hendrix DA, Kretzschmar D, Robinson M, Giebultowicz JM. Age-dependent effects of blue light exposure on lifespan, neurodegeneration, and mitochondria physiology in Drosophila melanogaster. NPJ Aging. 2022 Jul 27;8(1):11. doi: 10.1038/s41514-022-00092-z. PMID: 35927421; PMCID: PMC9329351.
9. Trajano LADSN, Siqueira PB, Rodrigues MMS, Pires BRB, da Fonseca AS, Mencalha AL. Does photobiomodulation alter mitochondrial dynamics? Photochem Photobiol. 2025 Jan-Feb;101(1):21-37. doi: 10.1111/php.13963. Epub 2024 May 22. PMID: 38774941.
10. Uçar, N., & Holick, M. F. (2025). Illuminating the Connection: Cutaneous Vitamin D3 Synthesis and Its Role in Skin Cancer Prevention. Nutrients, 17(3). https://doi.org/10.3390/nu17030386
11. Sanes, J. R., et al. (2022). Researchers discover brain pathway that helps to explain light’s effect on mood. Proceedings of the National Academy of Sciences. (via Brown University). https://www.brown.edu/news/2022-07-06/light-mood
12. Campbell Islay, Sharifpour Roya, Aizpurua Jose Fermin Balda, Beckers Elise, Paparella Ilenia, Berger Alexandre, Koshmanova Ekaterina, Mortazavi Nasrin, Read John, Zubkov Mikhail, Talwar Puneet, Collette Fabienne, Sherif Siya, Phillips Christophe, Lamalle Laurent, Vandewalle Gilles (2024) Regional response to light illuminance across the human hypothalamus eLife 13:RP96576. https://doi.org/10.7554/eLife.96576.1
13. Ishihara, A., Courville, A. B., & Chen, K. Y. (2023). The Complex Effects of Light on Metabolism in Humans. Nutrients, 15(6), 1391. https://doi.org/10.3390/nu15061391

AUTHOR BIO
Megan Pribyl, PT, CMPT, CMPT/DN, PCES

Megan Pribyl (she/her) is a mastery-level physical therapist at the University of Kansas Health System in Olathe, KS, specializing in orthopedic care for a diverse outpatient population, including pelvic health, pregnancy, and postpartum rehabilitation. Her approach emphasizes the integration of health, wellness, and evidence-based practice.

Megan began her career in physical therapy in 2000 after earning her Master of Science in Physical Therapy from the University of Colorado Health Sciences Center. She also holds dual bachelor’s degrees in Nutrition and Exercise Sciences (B.S. Foods & Nutrition; B.S. Kinesiology) from Kansas State University. She later earned her Certified Manual Physical Therapist (CMPT) credential through the North American Institute of Orthopedic Manual Therapy and became certified in dry needling in 2019. Since 2015, Megan has served as a faculty member at the Herman & Wallace Pelvic Rehab Institute, where she enjoys both teaching and developing course content.

Her passion for nutrition and manual therapy inspired her to create Nutrition Perspectives for the Pelvic Rehab Therapist, a course designed to deepen understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. Megan combines traditional and contemporary approaches to provide clinicians with practical, immediately applicable tools to enhance patient care. Her teaching encourages a deeper appreciation for the complexity of clinical presentations in orthopedic manual therapy and pelvic rehabilitation.

Rectal sensation testing is a fundamental component in the evaluation of anorectal function, particularly in patients with constipation, fecal incontinence, and other defecatory disorders. For pelvic rehabilitation practitioners, a thorough understanding of rectal sensory thresholds and the appropriate use of rectal balloon catheters is essential for accurate assessment and effective intervention.

What Is Rectal Sensation Testing?
Rectal sensation testing assesses a patient’s ability to perceive rectal distension at incremental volumes. This procedure is typically performed using a rectal balloon catheter during anorectal manometry or as a stand-alone test. The method allows for quantification of rectal sensory function and compliance, both of which are key elements in normal defecation mechanics.

The key sensory thresholds measured include:

• First Sensation: The initial perception of rectal filling.
• Desire to Defecate: The volume at which the patient feels the urge to evacuate.
• Maximum Tolerable Volume (MTV): The largest volume the patient can tolerate without discomfort.

These parameters provide insight into the sensitivity and distensibility of the rectal wall, guiding clinicians in differentiating between various types of anorectal dysfunction.

Normative Values and Clinical Significance
Recent studies have provided reference values for rectal sensory thresholds in healthy populations. For example, Grando et al. (2024) reported a mean maximum tolerable volume of approximately 150 mL with a standard deviation of 30 mL in healthy subjects. Deviations from these norms may indicate abnormal sensory processing. Elevated thresholds can be indicative of rectal hyposensitivity, commonly associated with functional constipation, whereas reduced thresholds may reflect rectal hypersensitivity, which is often observed in patients with fecal incontinence (Jiang et al., 2023).

Understanding these normative values enables clinicians to identify sensory alterations contributing to disordered defecation and to develop targeted rehabilitation plans.

Clinical Application of Rectal Balloon Catheters
Rectal balloon catheters serve as both diagnostic and therapeutic instruments in pelvic rehabilitation. In the diagnostic context, they facilitate precise measurement of rectal sensory thresholds and compliance. Therapeutically, balloon catheters are used in rectal balloon retraining or sensory biofeedback programs, which aim to improve rectal awareness, enhance coordination of pelvic floor musculature, and promote normalization of rectal compliance.

Incorporating rectal balloon techniques into practice allows clinicians to:

• Differentiate Disorders: Identifying whether symptoms are due to hyposensitivity or hypersensitivity.
• Personalize Interventions: Designing biofeedback or neuromodulation therapies based on individual sensory profiles.
• Monitor Progress: Tracking changes in sensory thresholds over time to assess treatment efficacy.

Advancing Clinical Competency
To further develop competence in this area, practitioners are encouraged to participate in the upcoming course, Anorectal Balloon Catheters: Introduction and Practical Application, scheduled for December 7, 2025. This course provides comprehensive instruction in the use of rectal balloon catheters for assessment and treatment, including practical demonstrations and case-based learning.

Expanding proficiency in rectal sensation testing and rectal balloon catheter application enhances the clinician’s ability to evaluate anorectal function accurately, design individualized rehabilitation programs, and optimize patient outcomes.

References

1. Grando, L. M., Halfvarson, J., & van Nieuwenhoven, M. (2024). Rectal Sensory and Compliance Testing: A Method Comparison Study between High-Resolution Anorectal Manometry and Barostat Investigations. Diagnostics, 14(4), 351. https://doi.org/10.3390/diagnostics14040351
2. Jiang, Y., et al. (2023). Clinical significance and related factors of rectal sensory thresholds in patients with functional defecation disorders. Frontiers in Medicine. https://doi.org/10.3389/fmed.2023.1119617
3. Xiao, C. F., et al. (2024). Influence of the examination position and distension medium on rectal sensory testing in patients with functional constipation. Diagnostics. https://doi.org/10.3390/diagnostics14040351

Jessica: “Hey girlfriend, TMI, but my period’s about to start.”
Rachel: “Do you need anything? I have pads and tampons.”
Jessica: “No, I’m good - just tired, and my bra and jeans are tight.”
Rachel: “You didn’t wear your period clothes?”
Jessica” “Wait! You have period clothes?”

Jessica: “Hey, does your libido go up when you’re about to start?”
Rachel: “No. It’s just about zero.”
Jessica: “Girl…mine…through the roof! And I get anxious, like something bad is going to happen.”
Rachel: “Do you track those in your period app, so you know when they’re coming?”
Jessica: “No, they track me. I see some cute guy and suddenly remember…oh yeah…it’s time.”

Sound familiar? Some people, like Rachel, plan ahead for their cycle, while others, like Jessica, notice symptoms only when they appear. Neither approach is right or wrong, but it can be really helpful to be aware (Menstrual Mindfulness) of period-related symptoms (Menstrual Molimina) to prepare for what’s coming next (Cycle Syncing).

The Terminology
Menstrual Molimina is an older term that doesn’t get used that much nowadays. But I think it’s really useful. Symptoms of Menstrual Molimina occur due to fluctuations of hormones in different parts of your Menstrual Cycle. Please understand, these are NOT symptoms that are debilitating or prevent you from doing the things you need to do in life. They are subtle reminders of where you are in your cycle. Some of the most common ones are water retention leading to tight fitting clothes and feeling heavier, changes in mood such as feeling sad (like maybe before a period starts) or happy (like maybe before ovulation), changes in anxiety (often before a period starts), changes in libido (usually higher before ovulation but can be higher at other times too), constipation (often before a period starts), or feeling like you’re in a groove (often just after ovulation).

Menstrual Mindfulness is the practice of being aware of internal body cues and signals and emotional states, such as the symptoms experienced as part of Menstrual Molimina. Because the Menstrual Cycle is repetitive and predictable, it offers an opportunity to become more connected to your body and more grounded in your experience. It also provides an opportunity to prepare for more challenging parts of your Menstrual Cycle and take advantage of the parts of your Menstrual Cycle that help you do the things you need to do in life.

Cycle Syncing has become a buzzword online. Let me start by saying what Cycle Syncing is NOT, for the purposes of what we discuss in this class. Cycle Syncing is NOT women living together aligning their Menstrual Cycles. I am not saying that this does or does not happen (that is a whole other discussion). But this proposed phenomenon is NOT what we discuss in this class.

Furthermore, the Cycle Syncing we discuss in this class is NEVER about telling a woman that she should not do something that she wants to do (or needs to do) depending on what day of the month it is. We all know that women can do anything they want, and EXCEL at anything they want, on ANY day of the month. And life usually doesn’t ask us if we’re ready to do a particular activity…it just requires that we do it.

The Course
Dr. Amy Meehan and I invite you to register for Menstruation and Pelvic Health on December 6. In this class we use the term Cycle Syncing to describe the practice of using Menstrual Mindfulness (of Menstrual Molimina and of more serious Menstrual Symptoms) to create awareness of each body’s challenges and the opportunities. We talk about how to track and create an actionable plan to decrease negative symptoms and work with natural opportunities to create a better overall Menstrual Experience.

Dr. Amy Meehan and I hope you will join us to discuss these topics and many more with the goal of putting ourselves as providers in a position to improve patient outcomes for the people who come to us for health care:

Part 1: Cultural Aspects of the Menstrual Experience – We’ll examine historical and cultural influences on how menstruation is discussed in the U.S. and explore ways to break down remaining barriers.
Part 2: Menstrual Structures and Processes – We’ll review the anatomy, hormones, and physiology of the menstrual cycle, including how the HPO axis regulates this process. Understanding these foundations helps clinicians connect symptoms to underlying mechanisms.
Part 3: Menstrual Symptoms and Disorders – We’ll discuss common menstrual concerns such as dysmenorrhea, bloating, heavy bleeding, and mood changes and address conditions like PMS, PMDD, endometriosis, adenomyosis, and PCOS.
Part 4: Adjunctive Menstrual Interventions – We’ll cover evidence-based, non-surgical, non-hormonal, and non-prescription strategies like heat therapy, exercise, nutrition, and TENS to improve the menstrual experience.
Part 5: Flow Management – We’ll explore menstrual products, both disposable and reusable, to help patients manage flow with confidence and comfort. We’ll learn how to create a Flow Management Plan using a variety of disposable and reusable menstrual products:

External options: liners and pads, intra-labial pads, period underwear, period activewear, period swimwear, and period overnight wear
Internal options: tampons (navigating absorbency level, expanded shape, and how often to change, with and without applicators), tampon insertion devices, cups and discs (size, shape, firmness, emptying on the toilet, cleaning, ‘sterilizing’), and sea sponges (not recommended for use, but interesting to see), potential interactions between cups and discs with IUDs and uterine prolapse.

By understanding Menstrual Molimina, practicing Menstrual Mindfulness, and applying Cycle Syncing thoughtfully, practitioners can help patients create more positive and empowered menstrual experiences - on any day of the month.

AUTHOR BIO
Niko Gaffga, MD, FAAFP, MPH

Dr. Niko Gaffga, MD, FAAFP, MPH (he/him) is a family medicine physician working in the primary care outpatient setting in the Atlanta area. He graduated in 2005 from the Family Medicine Residency program at the University of Arizona, where he received training in pediatric medicine, adult medicine, women’s health, and delivered more than 100 babies. Over the years, he has developed an interest in and expertise in women’s health, designing innovative strategies to deliver high-quality healthcare to women. He has worked in the Prevention of Mother-to-Child Transmission of HIV in Africa and has become a strong proponent of improving the Menstrual Experience.

The idea for this course was born many years ago when he realized the limitations many clinicians, including himself, have in providing effective Menstrual Health to our patients. Although he has never experienced a Menstrual Cycle himself, he has dedicated his career to listening to the words and experiences of his patients. He uses his knowledge as a generalist physician to identify effective Menstrual Solutions from diverse areas of medicine. He believes that improving the Menstrual Experience is fundamental to helping women and men who menstruate participate in the activities they wish to participate in. It also makes society a richer place to receive the benefit of their contributions. He developed this course to share the knowledge and experience he has developed over the years. He wants to be a spark for participants to re-envision the Menstrual Cycle and improve their own Menstrual Experience and that of their patients.