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Foot Pain and Pelvic Pain….Is There a Connection and What Can You do About it?

Ramona C. Horton MPT, DPT received the prestigious Academy of Pelvic Health Elizabeth Noble Award for her contributions to the field of pelvic health in 2020. Ramona serves as the lead therapist for her clinic's pelvic dysfunction program in Medford, OR. Her practice focuses on the treatment of men, women, and children with urological, gynecological, and colorectal issues. Ramona has completed advanced studies in manual therapy with an emphasis on spinal manipulation, and visceral and fascial mobilization. She developed and instructs the visceral and fascial mobilization courses for Herman & Wallace. Her upcoming courses are Mobilization of Visceral Fascia: The Gastrointestinal System - Satellite Lab Course scheduled for June 25-27, 2021, and Mobilization of the Myofascial Layer: Pelvis and Lower Extremity Satellite Lab Course scheduled for July 9-11, 2021.

I recently treated a male patient who presented with anal pain following surgery and radiation for rectal cancer. Secondary to radiation fibrosis, he has a grossly rigid pelvic floor and minimal tolerance for intra-rectal manual therapy. In addition, he is a poorly controlled type-2 diabetic, with painful bilateral peripheral neuropathy.

How often do we think about asking patients who present with pelvic dysfunction about lower extremity pain? I am sure all reading this ask about gluteal, hip, or leg pain but do we excuse foot pain such as peripheral neuropathy or tarsal tunnel syndrome as an incidental finding? Do we consider this observation a direct cause, or effect, anatomic relationship, or compensation pattern?

The anatomic relationship to chronic urogenital pain and the feet is obvious when one considers the positioning on the motor homunculus as well as the sacral level dermatomal distribution at the spinal cord but how does the playout clinically? Jantos, Johns, Torres, & Baszak-Radomanska (2015) used data from 82 women with chronic urogenital pain to map the location of their symptoms and noted a prevalence of pain reported in the typical distribution of abdomen, pelvis, and buttock as well as the dorsum of the foot

Feet1Jantos, Johns, Torres, & Baszak-Radomanska (2015) Reprinted with permission

One could submit that the association between pelvic pain and foot pain is one of compensation, with patterns secondary to postural anomalies. Because the pelvic floor and hips are not functioning adequately, resulting in greater reliance on ankle strategies for balance and mobility.

Kaercher et al., (2011) explored the hypothesis that patients with chronic pelvic pain would display greater postural anomalies than controls. The researchers compared 32 women reporting chronic pelvic pain (CPP) to 30 healthy controls, utilizing baropedometry to measure the pressure distribution in each segment of the plantar surface. Baropedometry utilizes a force platform that is a technique to indicate postural abnormalities. Despite multiple observations in the literature about “pelvic pain protective patterns,” Kaercher et al., (2011) failed to find any difference in the postural behavior between the two groups.

In preparing for any number of presentations on myofascial manual therapy, including the articular and pannicular layer of the fascial system, I remember an article that utilized connective tissue manipulation to treat patients with diabetic foot ulcers. Joseph et al. (2016) compared standard treatment for diabetic foot ulcers to standard treatment plus connective tissue mobilization. After six weeks of treatment, the researchers observed accelerated healing of ulcers. Remarkably, they also observed a significant decrease in the wound bacterial colony count in the treatment group compared to controls. These researchers postulated that this improvement was secondary to the reflexive improvement in peripheral circulation that provides increased oxygen to the lower limbs.

A more recent controlled study by Xie et al. (2019) utilized instrument-assisted soft tissue mobilization in the form of Gua Sha Therapy for 119 patients with diabetic peripheral neuropathy. Not only did the subjective pain improve, but the results demonstrated a statistically significant improvement in objective measurements of the ankle-brachial index and vibration perception threshold.

This brings us full circle back to my patient with anal-foot pain that prompted me to write this article. I taught this patient self-care techniques that utilized connective tissue mobilization for his lower extremities. The goal was to decrease nociceptive input to the sacral segments, which in turn decreased the input from a bottom-up perspective. By doing this, I addressed the pannicular layer of the fascial system. This is the most highly innervated fascial layer, containing the greatest concentration of nociceptors.

For these techniques, I prefer fascial decompression (cupping) and Gua Sha over skin rolling because the intensity is easier to modulate and is tolerated easier by sensitive patients. This treatment provided two very interesting results. The patient reported a warming sensation in the treated leg. What was completely unexpected, was a visible change in the coloration of the treated extremity - that is evident in the photo below.

Feet2

At the end of our session both of the patient's lower extremities had been treated. The patient reported an improved sensation in his feet, as well as a significant decrease in his anal pain. He was so pleased by his tissues' reaction that he gave me permission to share this photo and write about his case to train other clinicians.

The connection between pelvic pain and foot pain is not clear-cut and has many causes other than diabetic peripheral neuropathy (DPN). Given the prevalence of diabetic peripheral neuropathy, I remind the reader that peripheral neuropathy as a condition is not painful. It is purely a lack of sensory input secondary to small vessel disease. Joseph et al. (2016) and Xie et al. (2019) concluded that a change in circulation was most likely the catalyst for the study findings. This theory is supported by the bench research of Nielsen, Knoblauch, Dobos, Michalsen, & Kaptchuk (2007) that demonstrated a 400% increase in microcirculation measured by laser doppler imaging following the application of Gua sha to surface tissues.

Did the patient experience a change in his pelvic pain secondary to the modulation of cross-talk at the dorsal horn and reflexive increased circulation to the pelvic floor? Or was it because he had better sensory input to his brain from his feet that allowed him to relax his pelvic floor muscles? The answer is unknowable and frankly not important.

What we do know, based on biology, is that nerves are little vampires. Without blood, they wither and die. The exact mechanisms of fascial-based manual therapies are not fully understood. However, I believe the medical community can agree that increased blood to peripheral tissues that are lacking blood is a good thing. This increased blood flow just might make a difference in the patient's experience.


Jantos, M., Johns, S., Torres, A., & Baszak-Radomanska, E. (2015). Mapping chronic urogenital pain in women: insights into mechanisms and management of pain based on the IMAP Part 2 ) Pelviperineology 34:28-36.

Joseph, L. H., Paungmali, A., Dixon, J., Holey, L., Naicker, A. S., & Htwe, O. (2016). Therapeutic effects of connective tissue manipulation on wound healing and bacterial colonization count among patients with diabetic foot ulcer. Journal of Bodywork and Movement Therapies 20:650-656

Kaercher, C. W., Genro, V. K., Souza, C. A., Alfonsin, M., Berton, G., & Cunha Filho, J. S. (2011). Baropodometry on women suffering from chronic pelvic pain-a cross-sectional study. BMC Women's Health11(1), 1-5.

Nielsen, A., Knoblauch, N. T., Dobos, G. J., Michalsen, A., & Kaptchuk, T. J. (2007). The effect of Gua Sha treatment on the microcirculation of surface tissue: a pilot study in healthy subjects. Explore3(5), 456-466.

Xie, X., Lu, L., Zhou, X., Zhong, C., Ge, G., Huang, H., ... & Zeng, Y. (2019). Effect of Gua Sha therapy on patients with diabetic peripheral neuropathy: A randomized controlled trial. Complementary Therapies in Clinical Practice35, 348-352.

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Pain is in the Brain

Sullivan photo

This blog contains excerpts from an interview with Tara Sullivan, PT, DPT, PRPC, WCS, IF. Tara started in the healthcare field as a massage therapist, practicing over ten years including three years of teaching massage and anatomy and physiology. Tara has specialized exclusively in Pelvic Floor Dysfunction treating bowel, bladder, sexual dysfunctions, and pelvic pain since 2012. 

Acute pain can indicate specific injury to the body. Chronic pain is very different. With Chronic Pelvic Pain (CPP) the initial injury has healed, but the pain continues because of changes in the nervous system, muscles, and tissues. Recognizing that the nervous system influences pain perception, especially in the chronic pelvic pain population, is the first step in treating these patients, but is it enough? Tara Sullivan and Alyson Lowrey are presenting a new remote course on chronic pelvic pain called Pain Science for the Chronic Pelvic Pain Population scheduled for July 17-18, 2021.

The medical definition of pain is an unpleasant feeling that is conveyed to the brain by sensory neurons. Pain is a universal experience that serves to alert the brain to potential damage to the body. It performs the function of triggering avoidance to preserve itself from harm. Oddly, the strength and unpleasantness of pain is not directly related to the nature or extent of the damage. 

When the pain signal remains active in the nervous system for longer than six months and persists after the triggering event has healed, then it is cataloged as chronic pain. There is another layer when experiencing chronic pain known as central sensitization. This is an increased responsiveness of the nervous system that results in hypersensitivity and an increased pain response outside the area of injury. Pain itself can produce systematic and chemical brain changes resulting in more pain from fewer stimuli.

The course, Pain Science for the Chronic Pelvic Pain Population, offers tools to recognize when sensitization may be playing a role and provides the framework needed to apply pain science to the chronic pelvic pain population. In this course, you will gain an understanding and expand your knowledge on how pain science specifically presents in patients suffering from endometriosis, interstitial cystitis, primary dysmenorrhea, pelvic floor muscle overactivity, vulvodynia/vestibulodynia, vaginismus, and prostatitis. 

Case studies and specific intervention techniques, including how to explain pain to a patient, are discussed so participants leave with the confidence to address the missing link in treating your patient’s chronic pelvic pain. We will also discuss how common rehab interventions such as manual therapy, dry needling, biofeedback, graded exposure, and therapeutic exercise assist in downregulating the nervous system.

On July 17-18th, 2021, Alyson Lowrey and Tara Sullivan team up to give you their combined experience of orthopedic and pelvic health in treating this population in the course Pain Science for the Chronic Pelvic Pain Population.

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Pudendal Neuralgia Treatment

pamela downey

This blog contains excerpts from an interview with Pamela A. Downey, PT, DPT, WCS, BCB-PMD, PRPC, Pamela is a Board Certified Clinical Specialist in Women’s Health Physical Therapy and Board Certified in Biofeedback for Pelvic Muscle Dysfunction. She is the owner of Partnership in Therapy, private practice in Coral Gables, Florida. Dr. Downey's treatment focuses are pelvic floor dysfunction, urogynecological and colorectal issues, spine dysfunction, osteoporosis, and complaints associated with pregnancy and postpartum. Her mission is to educate and integrate healthy lifestyles for patients on the road to wellness.

Physical therapists often require special training to treat pudendal neuralgia. Pamela A. Downey is partnering with H&W to teach the Pudendal Neuralgia and Nerve Entrapment Remote Course, scheduled for June 19-20, 2021. This course teaches pudendal neuralgia diagnostic skills for practitioners to have an improved impact in treating patients with pudendal nerve/pelvic floor muscle dysfunctions.

Pudendal neuralgia is also known as Alcock’s syndrome, pudendal canal syndrome, or cyclist syndrome. This condition is caused by tension, compression, or entrapment of the pudendal nerve, and leads to pelvic pain, sexual dysfunction, difficulty with urination and defecation, among other issues.

Pudendal neuralgia is often unrecognized by physicians, including gynecologists, urologists, and neurologists. Dr. Downey observes that “Organizing your clinical decision-making process is key in determining the source of seated pain. Pudendal neuralgia can be a chicken and egg clinical phenomenon. My success comes from relying on a solid anatomy background in helping solve the pudendal puzzle.”

Successful treatments can include connective tissue mobilization, neural mobilization, and a home exercise program. Poor movement patterns can contribute to the symptoms of pudendal neuralgia. Physical therapy evaluation in these cases can include movement assessment and a gentle internal assessment of the patient's pelvic muscles. This provides information about the muscles’ ability to contract and relax. Exercises recommended to relax the pudendal nerve and provide temporary relief include cobra pose, side-lying hip abduction and extension, and wide-leg bridges. 

Dr. Downey shares that she loves teaching the Pudendal Neuralgia and Nerve Entrapment Remote Course. “We teach the participants, in real-time, how to use evidence-based criteria to see if pudendal neuralgia makes sense as the driving diagnosis. Then we develop this confidence by careful dissection of case studies of real patients treated out over multiple visits, just like you do in the clinic." 

Hone your decision-making process and gain confidence in the Pudendal Neuralgia and Nerve Entrapment Remote Course to treat pelvic pain with Pamela Downey on June 19-20, 2021.

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Interview with Allyson Shrikhande on Physiatry

Allyson Shrikhande

Working with Physiatry for Pelvic Pain is a new remote course created by Dr. Allyson Shrikhande, scheduled for Jun 27, 2021. This course overviews the synergistic nature of pelvic physiatry with pelvic floor physical therapy, in hopes of promoting collaboration for the care of male and female chronic pelvic pain patients.

Dr. Allyson Shrikhande is a board-certified Physical Medicine and Rehabilitation specialist and is the Chair of the Medical Education Committee for the International Pelvic Pain Society. Allyson has published peer-reviewed articles on the treatment of muscle pain in academic journals and works closely with renowned pelvic pain gynecologists and urologists. Taking a team approach, she works with specialists in pelvic floor physical therapy, kinetics and movement, as well as acupuncturists, nutritionists, cognitive-behavioral therapists, and functional medicine physicians.

The following is our interview with Allyson Shrikhande on physiatry.

Q: What is a physiatrist?

A: A physiatrist is an MD or DO with a specialty in Physical Medicine and Rehabilitation. This non-operative medical discipline involves focusing on the neuromusculoskeletal system to help patients recover their functional well-being and quality of life. We describe physiatry as an extension of physical therapy because a physiatrist diagnoses, manages, and treats pain from injury, illness, or medical conditions, incorporating other methods in concert with physical therapy to rehabilitate the body. Physiatrists are trained not solely in one organ system – rather, they take a holistic, full-body approach that accounts for the interplay of different organ systems, both with each other and with the neuromuscular and myofascial systems. 

Q: What does a physiatrist do? 

A: Physiatrists work with physical therapy to rehabilitate the neuromuscular system. A core underlying theme in physiatry is the concept of Neuroplasticity. This is the understanding that the nervous system has the ability to form and reorganize synaptic connections, especially in response to experience or learning following injury. 

Q: What do physiatrists treat? 

A: Because physiatrists focus on the interconnected systems of the entire body, they treat a wide range of injuries and disorders. Physiatrists commonly work with patients who have pelvic, back or neck pain who are recovering from issues such as sports injuries, neuromuscular disorders, arthritis, or injuries to the brain or spinal cord.

Q: Why would I see a physiatrist? 

A: At Pelvic Rehabilitation Medicine, our Pelvic Physiatrists diagnose and treat the structures of the pelvis – the muscles, nerves, and joints. One of our physiatrists can provide non-operative options to medically manage and treat pelvic pain and pelvic floor muscle dysfunction. We treat an array of symptoms under the umbrella of pelvic pain which includes pain with intercourse, urinary urgency/frequency or pain with urination, constipation or painful bowel movements, and pain affecting the coccyx, groin, pelvis, lower back, and lower abdomen.

Q: As a pelvic floor physical therapist, what can I learn from a physiatrist?

A: The relationship between physiatry and physical therapy is vital to the collaborative approach that our pelvic pain patients require. Physiatrists perform a full neuromuscular exam (including an internal pelvic floor exam) and can order imaging, prescribe oral medications, suppositories, and topical medications for some patients. Our physiatrists can also perform safe outpatient ultrasound-guided procedures to treat underlying neuromuscular dysfunction, all in combination with continued pelvic floor PT when appropriate. 

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Organic Food vs. Conventional: Is There Any Difference?

640px-USDA_organic_seal.svg The question about organic vs. conventional might just be the most important one deserving a thoughtful discussion to unravel the complexities around the topic of food.

Megan Pribyl, PT, CMPT is a practicing physical therapist at the Olathe Medical Center in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic rehabilitation. Megan’s longstanding passion for both nutritional sciences and manual therapy has culminated in the creation of her remote course, Nutrition Perspectives for the Pelvic Rehab Therapist, designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to continually update this course with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation.

 

As a course developer and instructor for the Herman & Wallace Pelvic Rehab Institute, it is a privilege to continue sharing my passion for nutrition and pelvic rehabilitation with professionals nationwide. Interest in the topic continues to grow, and many pelvic rehab providers have identified nutrition as the “missing link” in their clinical practice. Nutrition Perspectives for the Pelvic Rehab Therapist has helped hundreds of pelvic rehab professionals integrate nutrition-related information into their clinical practice since 2015.

In the realm of nutrition, few questions provoke discussion with the same fervor as our title question: Organic Food vs. Conventional: Is There Any Difference? This question deserves a multi-dimensional answer - not unlike many topics in nutrition - including accessibility concerns, ethical factors for farmers, socio-economic factors, and our unique agricultural construct here in the United States. But the question about organic vs. conventional might just be the most important one deserving a thoughtful discussion to unravel the complexities around the topic of food.

You see, the answer to this question has profound implications for us. As we expand our ability to identify potential root contributors to conditions commonly encountered in pelvic rehabilitation, we must factor in nutrition. At first glance, it might be a stretch to see how one might link organic foods and potential effects on conditions such as constipation, inflammatory bowel diseases, IBS, PBS, and endometriosis for example. However, looking at food in a functional way, we acknowledge there may be under-appreciated qualitative differences between foods grown organically or produced conventionally.

Take, for example, the recent article by Kesse-Guyot et.al., 2020. which discusses the prospective association between organic food consumption and the risk of type 2 diabetes. In this study of over 30,000 participants, those with the highest quintile of organic food consumption compared to those with the lowest quintile had a 35% lower risk of having type 2 diabetes. The conclusion made by the authors was that organic food consumption was inversely associated with the risk of type 2 diabetes.

Said a different way, the study described a phenomenon where, for example, you might eat an organic bowl of oatmeal for breakfast and I might eat the same serving size conventional bowl of oatmeal for breakfast. If we extrapolate the comparison over our entire dietary intake pattern, you would have a 35% lower risk for developing type 2 diabetes compared to me…..despite you and I “eating the same foods”. How can this be possible? And might this begin to explain the sheer exasperation and frustration that can evolve in persons trying to make positive dietary changes - only to find they have no notable effect? How many times do you hear someone say “I am trying to eat healthily but it doesn’t seem to make a difference”.

Keeping in the context of type 2 diabetes, it is very well established that reductions in the richness and diversity of healthy microbes inhabiting the large intestine (gut dysbiosis) are correlative to metabolic syndrome. In those with type 2 diabetes, microbiomes showed a decrease in anti-inflammatory, probiotic, and other [beneficial] bacteria that could be pathogenic. (Das et al, 2021) Appreciating the differences between organic vs conventional - it is also well established that organic foods do carry less residue of herbicides and pesticides. These residues - which are found in higher concentration in conventionally produced foods - have been implicated in the same reduction in richness and diversity of microorganisms in the gut - which is contributory to dysbiosis. (Rueda-Ruzafa et all, 2019) Therefore it now seems not just plausible - but probable that there is a distinguishable difference between organic and conventional diets - to a degree at which all health care providers would do well to take notice.

In a report on the history of organic agriculture, author George Kuepper points out that:

Pioneers of the organic movement believed that healthy food produced healthy people and that healthy people were the basis for a healthy society.

And if organic foods can be a part of that, our patients deserve to know that these scientifically documented differences exist.

As our awareness of the connection between nutrition and health grows, so does the need to follow the science to share evidence-based and evidence-informed information. It is now more important than ever to have a working knowledge of nutrition basics as a pelvic rehabilitation professional. Plan to join us at one of our upcoming remote offerings of “Nutrition Perspectives for the Pelvic Rehab Therapist”: June 19-20 where we will explore this and many additional - and fascinating facets of the nutrition discussion.


Das, T., Jayasudha, R., Chakravarthy, S., Prashanthi, G. S., Bhargava, A., Tyagi, M., . . . Shivaji, S. (2021). Alterations in the gut bacterial microbiome in people with type 2 diabetes mellitus and diabetic retinopathy. Sci Rep, 11(1), 2738. doi:10.1038/s41598-021-82538-0

Kesse-Guyot, E., Rebouillat, P., Payrastre, L., Alles, B., Fezeu, L. K., Druesne-Pecollo, N., . . . Baudry, J. (2020). Prospective association between organic food consumption and the risk of type 2 diabetes: findings from the NutriNet-Sante cohort study. Int J Behav Nutr Phys Act, 17(1), 136. doi:10.1186/s12966-020-01038-y

Kuepper, George. (2010) A Brief Overview of the History and Philosophy of Organic Agriculture. Kerr Center for Sustainable Agriculture. http://kerrcenter.com/wp-content/uploads/2014/08/organic-philosophy-report.pdf Accessed May 14, 2021.

Rueda-Ruzafa, L., Cruz, F., Roman, P., & Cardona, D. (2019). Gut microbiota and neurological effects of glyphosate. Neurotoxicology, 75, 1-8. doi:10.1016/j.neuro.2019.08.006

Images:
Par, Cecilia for Unsplash.
USDA organic seal.svg. Public Domain.
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Osteoporosis Management

Image-from-iOS-16 PRPC - Chiropractor's Viewpoint

Deb Gulbrandson, PT, DPT has been a physical therapist for over 42 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. Dr. Gulbrandson frequently presents community talks on topics related to Osteoporosis and safe ways to develop Core Strength. She is a member of the APTA Geriatric and Private Practice Sections, a Certified Osteoporosis Exercise Specialist using the Meeks Method, and is a CEEAA (Certified Exercise Expert for the Aging Adult) through the Geriatric Section of the APTA.

Hello, my name is Deb Gulbrandson. May is National Osteoporosis Month, and my colleague, Frank Ciuba, and I are creators of the upcoming remote course Osteoporosis Management on June 12-13, 2021.

Did you know that approximately half of all women and a quarter of all men will break a bone due to osteoporosis? Equally disheartening, every year about one-third of adults in the US age 65 and older will fall. Many of these falls will result in broken bones.

Frank and I developed the Osteoporosis Management course to bring treatment protocols to practitioners in an organized and easily implementable format. This course is based on the Meeks Method created by Sara Meeks, PT, MS, GCS, with whom Frank and I taught for several years. With Sara’s blessing, we have branched out to add information on sleep hygiene, exercise dosing, and basic nutrition for a person with low bone mass. Knowing how to recognize signs, screen for osteoporosis, and design an effective and safe program can be life-changing for these patients.

In all likelihood, you are working with osteoporosis patients right now whether you know it or not. Osteoporosis affects all ages and stages of life including young and middle-aged men and women. Often we see patients with orthopedic or neurologic diagnoses who also have osteoporosis- known or unknown. Being able to address patients’ comorbidities helps ensure safety and quality of life. Many of the techniques we use can apply across several patient demographics. After all, who doesn’t benefit from postural alignment, back extensor/glute strengthening, and balance activities?

Working with this population has been extremely rewarding, because similar to pelvic health patients, these patients have been told there’s nothing you can do about it. They are incredibly grateful to find out that there IS something you can do about osteoporosis. They enthusiastically take an active role in their rehabilitation.

In addition, as a private practice owner for over 30 years, I’ve found osteoporosis to be a great business opportunity. An incredible niche practice, bringing in patients who have actively sought out my clinic with their self-referrals or by word of mouth.

We hope that you will join us this June 12-13 for our course Osteoporosis Management for an opportunity to experience posture, power, visual cueing, strengthening, and balance activities along with osteoporosis screening, evaluation, and evidence-based practice.

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Early Postpartum Rehab - When to Start

In this blog, instructor Heather Rader, PT, DPT, PRPC, BCB-PMD, discusses the concerns and fears therapists have when treating mothers recovering from childbirth and how her upcoming course can prepare therapists to confidently treat patients within hours to weeks after childbirth.

 

When is it OK for a new mom to start therapy?

When a new pelvic therapist asks me this question at courses, my answer begins by shifting the focus towards the birth itself. Childbirth is a mechanism of injury, not a “special population.” The real question then is when is it OK to start therapy after perineal or abdominal tissue trauma? When your clinical reasoning begins from this point of view, it removes biases you may have about childbirth and instills confidence in your skills as a trained clinician. Every therapist learns acute care skills - how to treat wounds, how to mobilize post-op patients, and how to screen for medical complications. Simply put, dear clinician, you know more than you think you do.

On average, 3.75 million women give birth in the US per year (1.) 100% will have some level of injury because of it. Those injuries will be perineal, abdominal, or both. There will be muscle strains and ligamentous sprains. There will be soft tissue bruising and swelling.

There are risks of immobility and re-injury without proper patient education. There might be stitches or staples in the abdominal or vulvar skin. There will be pain issues, mobility issues, safety issues, and definitely body mechanics and ergonomic issues. Given these obvious musculoskeletal and mobility impairments, I ask you to ponder this - what profession is better prepared to assess the acute and sub-acute needs of a new mother than rehab professionals?

Let’s imagine the same question posed to an acute care therapist about newly injured trauma patients.

Every lecture on the history of rehabilitation highlights the early days when bed rest was thought to be therapeutic.

Through research and clinical observations, we know immobility was, in some cases, deadly. Nowadays, it is considered standard of care to begin mobilization as early as medically possible, even in the ICU. And so should it be with new mothers. When should a person who was in an accident start rehab? What information would our therapist need to determine when to start and what early intervention is medically appropriate?

  • Is the patient medically stable?
  • Are the injured tissues structurally stable?
  • Have any problems developed as a result of being immobilized in the hospital?
  • Are there other co-morbidities to complicate the recovery?
  • How is the patient’s mental status after the trauma?
  • What social support is in place to assist with short-term and long-term needs?
  • Can the patient function independently? Need home health? Benefit from outpatient therapy?

The clinical decision-making and critical thinking necessary to manage the care of an acute care patient is not much different than that of a pelvic therapist managing the recovery of a new or “acute” mother. More and more hospitals and birthing centers are incorporating acute care therapy within hours of birth. There are anatomical and physiological differences because of the effects of pregnancy itself that the clinician must learn, however. While the patient is recovering from childbirth, the body is returning to its pre-pregnancy state. Having a better understanding of the late pregnancy, birth, and the peripartum state has on healing can assist the motivated clinician in adding maternal-based therapy to their skill set.

The course Peripartum Advanced Topics covers medical screening, early exercise, patient education, hospital-based programming, and treatment strategies, as well as early outpatient care and fitness transition planning, such as returning to running.

If you are contemplating expanding your outpatient practice to see patients early in the “4th Trimester” or even earlier in the acute setting after the 4th stage of labor (recovery), consider signing up for the course.


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Pain during sex? It might be Dyspareunia.

Mia Fine, MS, LMFT, CST, CIIP has written and instructing her remote course, Sexual Interviewing for Pelvic Health Therapists, with H&W on June 5-6, 2021. Mia (they/she) is a student of Queer Theory, Intersectionality, and Social Justice, and offers holistic, anti-oppressive, and trauma-informed therapy. This is a course intended for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns.

Let’s talk terms: Dyspareunia and Vaginismus

  • Vaginismus: involuntary contraction of vaginal muscles preventing insertion/penetration
  • Dyspareunia: pain felt during penetration

Symptoms (not limited to): pain - painful penetration, painful orgasms, painful periods, painful pelvic exams, inability to use tampons/cups, urinary or bowel hesitancy, feeling “too tight”

Causes (not limited to): stress, relationship concerns, mood concerns (anxiety, depression), insufficient arousal/desire/interest, trauma, side effects of meds, negative attitudes towards sex, and other pelvic pain concerns such as a tilted uterus.

The deal is, when it comes to dyspareunia and vaginismus there’s a cycle that can be difficult to break. The cycle is: you feel pain, then you feel broken (shame about feeling pain), then anxiety that pain will happen again, then you tighten your pelvic floor, and the cycle repeats. It becomes a self-fulfilling prophecy.

Often unwanted sexual pain goes unaddressed. Why? Because we are not taught about the interactions between feelings, relationships, and our body. We are not taught that sex should not be painful; that pain is (likely) our body giving us information that something is going on (Hello crappy sex education and the stigma of sexual health and body awareness!). It’s not uncommon that most people who experience sexual pain often feel they are broken.

You are not broken

How to heal from unwanted sexual pain? There’s a trifecta! Effective healing comes from working with a sex-positive medical provider, sex therapist, and pelvic floor PT. We will all collaborate!

Sex is not supposed to be painful. You are not broken.

Mia ️

#therapy #sextherapy #wellness #health #awareness #mentalhealth #bodyawareness

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The Sacroiliac Joint - A New Management Paradigm

Steve Dischiavi holds credentials as a licensed physical therapist and a certified athletic trainer. He also has a manual therapy certification from the Ola Grimsby Institute and is board certified by the American Physical Therapy Association as a Sports Clinical Specialist (SCS).

 

The blog you’re about to read is targeted at clinicians just like myself. I was taught in PT school to evaluate the sacroiliac joint (SIJ) via a movement-based analysis. I even went on for a certification in manual therapy nearly 2 decades ago, and again was taught the movement-based approach. Well, as the song goes… “times they are a changin”….

So… if you’re a clinician who will diagnosis the SIJ as being “unstable” from movement-based testing, using tests that evaluate the positional movement of the PSIS… then you need to begin to question the approach you’re taking.

There is a contemporary conversation taking place within the field of physical therapy. If you’re like me and learned to evaluate the sacroiliac joint (SIJ) through movement-based testing, you need to be involved in this evolving conversation.

A great place to start is with a “Perspective” article published in Physical Therapy in 2019. It is titled “Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area” written by Thorvaldur Palsson, et.al.1

The narrative dives into several areas pertaining to the treatment of this mysterious region of the body. It gives the reader a thoughtful and contemplative view of the contemporary conversation surrounding the evaluation and treatment of the SIJ.

The target audience should be the clinicians who continue to evaluate the SIJ solely on movement based analysis, attempting to diagnosis the SIJ with terms related to movement dysfunction. We have all heard terms like “upslip, downslip, or sacral torsions”. The narrative addresses why this is not the best approach to diagnosing the SIJ.

The article also touches on the concepts of “pain science” and how assessing how the SIJ “moves” tells the clinician very little about why the tissues about the SIJ might be sensitized. The article scratches the surface about the patient’s pain experience and how harmful terms such as “instability” and how the SIJ “goes out” are ways that can perpetuate and even heighten the pain experience for your patients.

The Perspective article gives the reader a great introduction as to why you might consider altering your approach to the SIJ. I’ll leave you with a quote directly from the article:
“If clinical decisions are based on a construct that lacks plausibility and clinical tests lacking in validity and reliability, the entire management paradigm must be questioned.”
The next question you might be asking yourself… ok, how do I learn a new management paradigm? A great start would be to take the 4-hour introductory webinar, Sacroiliac Joint Current Concepts - Remote Course - June 26, 2021, offered by Herman and Wallace… learn the evidence-based approach to the SIJ with Steve Dischiavi, PT, DPT, MPT, SCS, ATC, COMT who has been working closely on the hip and pelvis for over 20 years!

I hope to see you at the webinar!

1. Palsson TS, Gibson W, Darlow B, et al. Changing the Narrative in Diagnosis and Management of Pain in the Sacroiliac Joint Area. Phys Ther. 2019;99(11):1511-1519.

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Inviting softness into the rib cage

Dustienne Miller is the creator of the two-day course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life. 

 

I’m one of the small business owners who has survived this difficult time. Day after day I would mask up, put on the filtration systems, and be filled with gratitude that I could still safely do my work in the world. Despite being vigilant on sleep, eating lots of veggies from the local farm, exercising, and staying well hydrated I still carry a deep covering of stress and tension.

We have been holding our breath literally and figuratively with collective humanity for the past year. I realized when I had an acute flare of lumbopelvic pain that I had to melt away layer by layer of holding tension in both my back and ribs and go deeper into my breathwork and meditation practice.

I share this to acknowledge that as health care providers we are caring for more than just the physical concerns of our patients. We are honored to witness their grief, which could be from any type of trauma (physical, medical, etc). We are chosen to be their trusted source of advice which often goes beyond the rehab lens. We also need to notice when we as clinicians (and humans experiencing a global pandemic) experience burnout.

We teach our patients how breathing patterns inform our digestion, our spine, our emotional state, our pelvic floor, etc. It’s one of the most powerful tools we have to inform our system that we are safe. Despite this knowledge, we will often find ourselves holding our breath or breathing in non-optimal ways without even realizing it. When we don’t want to feel something we don’t breathe. When we are afraid we hold our breath. We might even find our ribs stay tight even when we feel relaxed.

Let’s pause to notice and soften.

Notice your body without “fixing” your posture. Where is your ribcage in relationship to your pelvic floor? What does it feel like when you breathe in? What does it feel like when you breathe out?

If you are sitting, slouch down. How does breathing feel in this position? Now imagine your head is getting magnetically pulled up towards the ceiling and sit in a more lengthened position. Take a breath with a taller spine. Does it feel different?

Now try this with your eyes closed: imagine the intercostal space widens with each inhale - then softens during each exhale. Do you have a habit of holding your ribs open with tension? Picture your shoulders softening, as if the tension from the upper traps was melting away. The jaw softens, the tongue softens, the center of the forehead softens.

Now take another long, conscious breath. What do you notice?

As practitioners, we give so much to our patients. It serves us to stay grounded in our bodies and as relaxed as we can be while we work. It’s a tall order and hard to remember but it might help decrease fatigue, exhaustion, physical pain, and burnout. Let’s all try and keep our breaths long, jaws soft, and pelvic floors pliable. I hope this pause was useful for you!

Dustienne Miller can be found teaching her course Yoga for Pelvic Pain online for 2021 on the following dates:
May 15-16, July 31-Aug 1, and Sept 25-26

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Upcoming Continuing Education Courses

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jun 19, 2021 - Jun 20, 2021
Location: Replacement Remote Course

Pudendal Neuralgia and Nerve Entrapment - Remote Course

Jun 19, 2021 - Jun 20, 2021
Location: Replacement Remote Course

Mobilization of Visceral Fascia: The Gastrointestinal System - Self-Hosted

Jun 25, 2021 - Jun 27, 2021
Location: Self-Hosted Course

Mobilization of Visceral Fascia: The Gastrointestinal System - Medford, OR Satellite Lab Course

Jun 25, 2021 - Jun 27, 2021
Location: Asante Rogue Valley Medical Center

Mobilization of Visceral Fascia: The Gastrointestinal System - Chicago IL Satellite Location

Jun 25, 2021 - Jun 27, 2021
Location: Athletico Physical Therapy

Mobilization of Visceral Fascia: The Gastrointestinal System - Athens, GA Satellite Location

Jun 25, 2021 - Jun 27, 2021
Location: Thrive Integrated Medicine

Pelvic Floor Capstone - Satellite Lab Course

Jun 26, 2021 - Jun 27, 2021
Location: Replacement Remote Course

Pelvic Floor Level 2A - Self-Hosted

Jun 26, 2021 - Jun 27, 2021
Location: Self-Hosted Course

Pelvic Floor Capstone - Garden City, NY Satellite Location (CANCELLED)

Jun 26, 2021 - Jun 27, 2021
Location: Metro Physical & Aquatic Therapy

Pelvic Floor Capstone - Mequon, WI Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Health In Balance Physical Therapy

Pelvic Floor Capstone - Self-Hosted (SOLD OUT)

Jun 26, 2021 - Jun 27, 2021
Location: Self-Hosted Course

Pelvic Floor Capstone - Torrance, CA Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Women's Advantage Inc

Pelvic Floor Level 2A - Charlotte, NC Satellite Location (SOLD OUT)

Jun 26, 2021 - Jun 27, 2021
Location: Ivy Rehab Physical Therapy

Pregnancy Rehabilitation - Remote (SOLD OUT) Course

Jun 26, 2021 - Jun 27, 2021
Location: Replacement Remote Course

Pelvic Floor Capstone - Bozeman, MT Satellite Location (SOLD OUT)

Jun 26, 2021 - Jun 27, 2021
Location: Great Northern Physical Therapy

Pelvic Floor Level 2A - Virginia Beach, VA Satellite Location (SOLD OUT)

Jun 26, 2021 - Jun 27, 2021
Location: Southeastern Physical Therapy

Pelvic Floor Capstone - Decatur,GA Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Emory Healthcare

Pelvic Floor Capstone - Chamblee, GA Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Revelle Physical Therapy Atlanta

Pelvic Floor Level 2A - Belle Chasse, LA Satellite Location (CANCELLED)

Jun 26, 2021 - Jun 27, 2021
Location: Rehab Access Belle Chasse

Pelvic Floor Level 2A - Hebron, NE Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Thayer County Health Services

Pelvic Floor Level 2A - Chicago, IL Satellite Location

Jun 26, 2021 - Jun 27, 2021
Location: Advocate Condell Medical Center

Sacroiliac Joint Current Concepts - Remote Course (SOLD OUT)

Jun 26, 2021
Location: Short Form Remote Course

Coccydynia and Painful Sitting - Remote Course

Jun 27, 2021
Location: Short Form Remote Course