Aparna Rajagopal, PT, Mhs, PRPC, and Leeann Taptich, PT, DPT are the authors and instructors of the Breathing and the Diaphragm remote course. Aparna and Leeann bring a wealth of experience to this course. 

Aparna: About 10-plus years ago I had a patient who had a large para esophageal hernia which had been surgically repaired. She had been referred to therapy because of general debility and weakness and she couldn't do endurance-based things like gardening or walking for long periods of time. She was in her mid-sixties. She had seen 2 or 3 therapists and they couldn’t figure things out. She had the same complaint that she couldn’t breathe and every time she said she couldn’t breathe the therapist would obviously refer her back to the doctor who would run cardiac tests, and all kinds of other tests and say she was cleared from a medical standpoint and then send her back to therapy. So in this process, the patient came to me and one of the first things she said was that she had difficulty taking in a breath of air -that she felt like she couldn’t expand - not that she couldn’t breathe.

Based on that complaint, I started my assessment. I started looking at the thoracic spine and found that she actually couldn’t expand from the rib cage at all because of her surgery to fix her large para esophageal hernia. One of the things we know about para esophageal hernias is also that it can be associated with increased intraabdominal pressure - related to things like chronic severe constipation, chronic cough, etc. She got better. She healed, and I realized that this was something that patients needed. In the process of treating her, my interest in breathing and the diaphragm developed.

Leeann: I started at Henry Ford Health Systems, where Aparna and I currently work together, about 7 years ago. Around that time, Aparna did a one-hour lecture on dysfunctional breathing and breathing to help us understand the mechanics of the pelvic floor and the abdominals, and the diaphragm. I’ve always looked for my missing link in my treatment, specifically in my lumbar/low back pain patients. The lecture was a lightbulb moment for me, and it made sense to me. What I used to focus on at that time was Transverse Abdominis engagement and it didn't always work for all patients.

I call Aparna my missing link. So, it started off with the one-hour lecture that she delivered. Then we collaborated and worked on developing a four-hour course on the same topic that ended up with eight hours worth of content because of how much great research there was available about the topic. Gradually the four-hour class transitioned into what we have now -  a full weekend course. It’s a great mash-up of ortho and pelvic floor approaches for both of us and has really helped both of us treat our patients better from both a pelvic standpoint and an orthopedic standpoint.

Aparna: We work together. We are able to treat patients jointly, bringing in the diaphragm/breathing aspect,  incorporating the sports and manual training that Leeann has and the pelvic knowledge that I have. We are able to tie everything together and treat our patients in a very holistic way.

Leeann: My big thing is that we try to incorporate more of the regional interdependence model. When patients come in with symptoms in an area, we look above, below, and beyond to see how the whole system is functioning together. We like to see how the body moves as a whole instead of focusing on just one part of it. That’s where most of our treatment is derived from and how we work together.

Breathing and the Diaphragm - Remote Course

Course Dates:
November 19-20
January 21-22, 2023

Price: $450
Experience Level: Beginner
Contact Hours: 14

Description: This remote course is designed to expand the participant's knowledge of the diaphragm and breathing mechanics. Through multiple lectures and detailed labs, participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi-component system that works together. Optimal function of the diaphragm and breathing patterns are key to a healthy pelvic floor, a normal functioning core, and postural stability. Evidence-based methods to assess the diaphragm and breathing mechanics are presented along with easy-to-apply practical intervention strategies.

This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. The assessment concepts and treatment techniques can easily be integrated into a therapist's current evaluation and intervention strategies.

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with site fellow faculty member Tina Anderson, MS PT.

Urinary incontinence (UI) is defined as ‘any complaint of involuntary leakage or urine’ that has several different subtypes based on when this leakage occurs¹.  UI is a common and relevant condition that has a profound influence on well-being and quality of life of many patients worldwide.  Millions of men and women throughout the world are affected.  According to our body of evidence, UI can affect anywhere between 5-70% of the female population^2-4 and 11-32% of the male population^5,6, contributing to decreased participation in preferred daily, work and recreational activities alongside an immense economic burden for some of those affected.^1-7These symptoms have not only been shown to have a significant impact on a person’s quality of life, but also on their mental health status.⁷

While UI is both common and very bothersome, it is also very treatable. I would love nothing more than to see our society and healthcare continuum recognize that UI is something that is ABNORMAL versus the typical categorization that it is a normal part of the aging, postpartum or postoperative experience.

Common, not normal.  Common, but treatable.
UI can be treated with lifestyle and behavioral interventions, bladder training, electrical stimulation, pelvic floor muscle training (PFMT) with or without biofeedback, physical therapy, neuromodulation, periurethral injections and, in some cases, surgical intervention. ^5,8

Understanding the continence mechanism
In a well-functioning pelvic floor, the connective tissue of the ligaments and fascia act together with the pelvic floor musculature to counteract the impact of any increase in intra-abdominal pressure and ground reaction forces, helping to maintain our continence.^8-10 This is an automatic function, requiring no need to think about voluntary contraction of the pelvic floor musculature. ⁸ When this mechanism is not working adequately, which can undoubtedly be multifactorial, urinary incontinence may occur.

The external urethral sphincter mechanism is a complex system of striated muscle which includes fiber blends from the urogenital triangle musculature and the anterior muscle bundle of the levator ani. ¹¹ The good news here is that we, as rehabilitative clinicians, have many different tissue targets for treatment of UI.

Dry Needling and UI
Dry needling (DN) encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions. DN is both effective and efficient in modulating the central and peripheral nervous systems as well as the somatic tissues, including the pelvic floor.

There is a growing body of evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice as it relates to UI.^12-17 With the external urethral sphincter and associated tissues being a main player in our urinary continence mechanism, it provides a road map on how we can utilize DN to treat UI. This boils down to two things: (1) tissue specificity and (2) utilization of electrical stimulation. DN provides us with an avenue to directly influence a specific tissue as we are able to use an indwelling needle electrode placed strategically into a muscular or perineural tissue target. Using that tactically placed indwelling electrode we can then precisely deliver electrical stimulation, essentially speaking the language of the neuromotor system, making this technique one of the most effective tools we have as rehabilitative clinicians to treat UI.

Ultimately, we are able to stimulate the pudendal nerve alongside the targeted tissues. This can help to improve electric activation, proprioception and coordination in pelvic floor contraction during situations that contribute to UI.^18,19,22 Additionally, the pudendal nerve is an efferent nerve for the external urethral sphincter, so this treatment is capable of increasing the pressure of urethral closure, improving UI. Another important factor is that electrical stimulation has been shown to increase blood flow to the urethra and pelvic floor musculature, lending towards improvements in neuromuscular connections, muscle fiber function and genital atrophy, all leading to improvements in the mechanism of urethral closure. ^19-22

The power of the tissue reset that DN provides has changed clinical outcomes for the better. It has, and will continue to, positively impact and change the lives of many patients through facilitating a more balanced homeostatic baseline within the tissues, healthier motor recruitment patterns and optimal neuromuscular utility to re-establish function.  Want to add this tool to your clinical practice? Check out our Dry Needling course offerings with Herman & Wallace!

 References:

1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26
2. Milson I and Gyhagen M. The prevalence of urinary incontinence. Climacteric. 2019;22(3):217-222
3. Carryer, J, Weststrate, J, Yeung, P et al. Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand. Research In nursing & Health. 2017;40(6):555–563
4. Damian, J, Pastor-Barriuso, R, Garcia Lopez, FJ et al. Urinary incontinence and mortality among older adults residing in care homes. Journal of Advanced Nursing. 2017;73(3):688–699
5. Gacci M, Sakalis VI, Karavitakis M et al. European Association of Urology guidelines on male urinary incontinence. European Urology. 2022;82:387-398
6. Cao C, Zhang C, Sriskandarajah C et al. Trends and racial disparities in the prevalence of urinary incontinence among men in the USA, 2001-2020. European Urology Focus. 2022; https://doi.org/10.1016/j.euf.2022.04.015
7. Krhut J, Gartner M, Mokris J et al. Effect of severity of urinary incontinence on quality of life in women. Neurourol Urodyn. 2018;37:1925–1930
8. Bo K. Physiotherapy management of urinary incontinence in females. Journal of Physiotherapy. 2020;
9. Ashton-Miller J, DeLancey JOL. Functional anatomy of the female pelvic floor. In: Bø K, Berghmans B, Van Kampen M, Mørkved S, eds. Evidence based physical therapy for the pelvic floor. Bridging science and clinical practice. Chapter 3. Edinburgh: Elsevier; 2015:19–34
10. DeLancey JOL, Low LK, Miller JM et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol. 2008;199:610.e1–610.e5
11. Suriyut J, Muro S, Baramee P et al. Various significant connections of the male pelvic floor muscles with special reference to the anal and urethral sphincter muscles. Anatomincal Science Internatiional. 2020;95:305-312
12. Feng X, Lv J, Li M et al. Short-term efficacy and mechanism of electric pudendal nerve stimulation versus pelvic floor muscle training plus transanal electrical stimulation in treating post-radical prostatectomy urinary incontinence. Oncology. 2022;160:168-175
13. Wang S, Zhang S. Simultaneous perineal ultrasound and vaginal pressure measurement prove the action of electrical pudendal nerve stimulation in treating female stress incontinence. BJU Int. 2012;110:1338–1343
14. Wang S, Lv J, Feng X, Wang G, Lv T. Efficacy of electrical pudendal nerve stimulation in treating female stress incontinence. Urology. 2016;91:64–69
15. Wang S, Lv J, Feng X, Lv T. Efficacy of electrical pudendal nerve stimulation versus transvaginal electrical stimulation in treating female idiopathic urgency urinary incontinence. J Urology. 2017;197:1496–1501
16. Wang S, Zhang S, Zhao L. Long-term efficacy of electric pudendal nerve stimulation for urgency-frequency syndrome in women. International Urogynecology Journal. 2014;25:397-402.
17. Li T, Feng X, Lv J et al. Short-term clinical efficacy of electric pudendal nerve stimulation of neurogenic lower urinary tract disease: a pilot research. Urology. 2018;112:69-73
18. Monga AK, Tracey MR, Subbaroyan J. A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction. Int Urogynecol J. 2002;23:993–1005
19. Chai TC, Steers WD. Neurophysiology of micturition and continence in women. Int Urogynecol Urol. 1997;8:85–97
20. Spruijt J, Vierhout M, Verstraeten R, et al. Vaginal electrical stimulation of the pelvic floor: a randomized feasibility study in urinary incontinent elderly women. Acta Obstet Gynecol Scand. 2003;82:1043–8
21. Balcom AH, Wiatrak M, Biefeld T et al. Initial experience with home therapeutic electrical stimulation for continence in myelomenin-gocele population. J Urol. 1997;158:1272–6
22. Correia GN, Pereira VS, Hirakawa HS et al. Effects of surface and intravaginal electrical stimulation in the treatment of women with stress urinary incontinence: randomized controlled trial. Euro J of Ob & Gyn and Reproductive Bio. 2014;173:113-118

Dry Needling and Pelvic Health - Live Course

Course Dates:
Worcester, MA - November 12-13, 2022
Katy, TX - January 21-22, 2023
Birmingham, AL - September 16-17, 2023

Price: $995
Experience Level: Beginner
Contact Hours: 26

Description: This is the foundational dry needling course in our three course pelvic health series. Practitioners will learn an innovative approach to treating clients with pelvic floor and neuromusculoskeletal dysfunction commonly associated with lumbopelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This foundational dry needling course will instruct participants in the application of dry needling to female pelvic floor musculature and associated neuroanatomical structures including the lumbosacral spine, abdomen, pelvis, and hip joint complex. This course will provide a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation - Live Course

Course Dates:
Salt Lake City, UT - November 5-6, 2022

Price: $995
Experience Level: Advanced
Contact Hours: 26

Description: Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation is a lab intensive, hybrid course designed with the pelvic health practitioner in mind. This course is an innovative approach to treating clients with pelvic floor dysfunction commonly associated with pelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This advanced dry needling course will instruct participants in the application of dry needling to female and male pelvic floor musculature and associated neuroanatomical structures including the thoracolumbar spine, trunk, abdomen, pelvis and hip joint complex. This course will also discuss and integrate the concept of and techniques associated with neuromodulation. Additionally, there will be a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Dawn Sandalcidi, PT, RCMT, BCB-PMD can be found online at https://kidsbowelbladder.com/. Dawn is a long time instructor with Herman & Wallace and has generously shared her recent blog with The Pelvic Rehab Report. "Stool Withholding And Core Activation" can be found in its original post on her website here: https://kidsbowelbladder.com/stool-withholding-and-core-activation/.

What do they have in common?
About 9-12% of children suffer from functional constipation, which is the vicious cycle of retained stool causing rectal distention and subsequent loss of sensation and urge to defecate, which results in further stool retention. The exact physiologic causes for functional constipation are not completely understood.

We know the bowel absorbs water constantly. The longer stool sits in the rectum, the harder it becomes. For some children, this leads to very large stools that are uncomfortable or difficult to eliminate. In turn, these children may practice something called stool withholding (which may be the reason stool was sitting in the rectum too long in the first place).

There are many other reasons a child may withhold their stools beside the standard issues that functional constipation presents. Some other reasons for stool withholding include:

• Inability to generate intraabdominal pressure
• Availability, likes, and dislikes of the toilet
• Fear of having a bowel movement
• Perineal sensation issues
• Psychological concerns
• Pain with defecation
• Dietary contribution
• Illness or infection
• Medications
• And more

No matter how or why a child began withholding stools, it’s vital to treat the problem as soon as possible. When withholding and constipation go untreated, they can cause lifelong issues. In this article, we will explore the relationship between constipation and core control, specifically the child’s ability to generate intraabdominal pressure.

What are the Symptoms a Child May have When Practicing Stool Withholding?
Normally, when enough stool enters the rectum and it’s time for a bowel movement, the rectum will send messages to the brain to make you aware that it’s time to have a poop. Ideally, when you receive this message and become aware of your body’s need to defecate, you find a toilet and do so.

When a child regularly withholds stools, the stool may become retained in the rectum and cause rectal distention and a subsequent loss of sensation. Because the rectum isn’t able to sense its fullness, the messages are never sent to the brain, and the sense of urge to poop disappears.

Although children who withhold stools may not have the urge to poop, they can have other physical symptoms if their stool withholding causes stool retention.

Physical symptoms of stool retention include:

• Abdominal pain
• Offensive body odor
• Stools that clog the toilet
• Decreased appetite
• Urinary incontinence or frequency
• And more

Children who withhold stools do not always have retention, however, and sometimes will simply withhold stools due to their environment (such as being at school during the day), and poop as soon as they get home.

How Might Core Strength Relate to Stool Withholding?
I treated a 6-year-old child once who had a bowel movement every single day, but only after he fell asleep in his parents' arms. His parents hadn’t been able to transition him out of diapers because of this. His bowel movements were so predictable that his parents would wait for him to poop, then clean him up and put him back to bed.

This child was also autistic and did have issues with low tone. I discovered during examination of the child that he had a difficult time voluntarily contracting his core muscles. Rotational and balance activities were difficult for him to perform as well due to his lack of core control.

You may be wondering what the core has to do with constipation, or stool withholding specifically. For starters, you need adequate core strength in order to sit upright on the toilet. Without proper core control, children may develop poor toileting postures which can lead to difficulty with defecation.

Correct toileting posture involves first being able to have enough hip extension, back extension, and side-to-side control to balance in a seated position on the toilet seat. Seats of differing heights add to the complexity of good toileting posture.

Proper Body Position for Toileting
Ideally, your feet should be supported, not dangling (which is a common occurrence for our children using adult-sized toilets). Forearms should be resting on the thighs, and the hips should be bent to at least 90 degrees of flexion. The spine should be in a neutral position (no posterior pelvic tilt).

This position allows for the pelvic floor muscles to relax appropriately, and for the core muscles to activate enough in order to produce appropriate intraabdominal pressure.

Without appropriate intraabdominal pressure generation, it will be difficult for a child to push out their poop. This is precisely what we discovered with my patient who was withholding until she got into bed. When in her parents' arms she was flexed, it was easier for her to generate enough intraabdominal pressure to poop, and so she did!

Knowing the reason for his withholding allowed us to target treatment planning where he needed it the most.

How to Address Core Strength in Children who Withhold Stools
Once you’ve determined that core activation is a root issue, you’ll need to address it in order to see any change with your patient’s bowel habits. Parents are usually at their wit’s end and are looking to you for answers. Your physical exam is your best tool in identifying root causes of stool withholding.

Many children attending physical and/or occupational therapy do suffer from low tone. As we’ve learned, this can compound constipation issues and even lead to stool withholding.

With the child above, we worked on core activation exercises first in supine, then in prone on an incline, and gradually added challenge to his exercises until she was able to generate enough intraabdominal pressure to poop on the toilet independently.

Even if your patient does not suffer from low tone, core activation and training may still be indicated. Some children have difficulty with coordinating or timing appropriate muscle contraction and relaxation. Be sure to evaluate the core when treating patients who suffer from constipation and stool withholding.

These children may have difficulty crossing midline as well. Age-appropriate exercises to engage the core while also incorporating diagonal and midline-crossing motions will be beneficial for those patients.

Additionally, you’ll want to assess the rib cage. Oftentimes I find children who have difficulty with core control also have a wider rib angle and hence need upper abdominal engagement exercises.

Lastly, many of the children you’ll treat will need help with rotation. This is a common finding during examination and without addressing rotation, you’ll see much slower progress.

Treating Stool Withholding and Core Issues is Possible
So many children with constipation will not receive appropriate treatment during childhood and their problems will persist into adulthood. It’s our job as pediatric therapists to identify children in need of help. Many children with bowel and bladder problems will be seen in your clinics for other issues, and unfortunately never even bring up the bowel or bladder concerns.

I put together a list of 5 Screening Questions you can ask your patients to determine whether they might be suffering from bowel or bladder issues and not even know it. This is a quick and easy way to identify patients in need of pediatric pelvic floor therapy.

It’s a great idea to get in touch with your local pediatric pelvic floor specialist to be able to easily refer these patients. You can also become a pediatric pelvic floor therapist yourself by taking my online courses! I believe this patient population is severely underserved and have made it easier than ever to learn how to best support these children.

My courses are held live in various locations around the world throughout the year, but I also offer online options for you to be able to work at your own pace from the comfort of home. Inside my online courses, there is space in every module to leave comments or ask questions and they go directly to me.

Sign Up For the Pediatric Functional Gastrointestinal Disorders Remote Course.

I’ve also created a group online where those who have taken my courses can collaborate, receive my mentorship, and discuss any issues that come up along their pediatric pelvic floor therapy journey. The group is called KBB Professional Village.

Learn More about KBB Professional Village.

Pediatric Functional Gastrointestinal Disorders

Course Dates:
November 12-13, 2022
May 20-21, 2023
November 4-5, 2023

Price: $600
Experience Level: Intermediate
Contact Hours: 15

Description:  This two-day, remote course is offered on Zoom and is the next step for therapists who focus on the pediatric pelvic floor patient population. It is designed to expand your knowledge of the development of normal bowel patterns in children, introduce the new Rome IV criteria (Zeevenhoovenet al. 2017), and review the anatomy and physiology of the GI system with emphasis on Pediatric Functional Gastrointestinal Disorders (FGID).

This course will delve into the most common types of functional constipation and the tests and measures used to assess it. Special emphasis on constipation with the coexistence of fecal incontinence (Nurko, Scott. 2011) and the psychological effects of these disorders will also be presented. Additionally, participants who have not yet been trained will learn external and internal anorectal PFM evaluation of the pediatric perineum. Indications for rectal balloon training and determining the appropriate patient will be instructed with lab. Functional defecatory positions for breathing and PFM relaxation, manual therapy techniques of the abdominal wall and viscera will be taught. 

Kelley Kukis, DPT, PRPC sat down with The Pelvic Rehab Report this week to discuss herself and how she came to TA for Herman & Wallace.

Who are you? Describe your clinical practice.
I’m Kelley Kukis, DPT, PRPC, and I’m a pelvic PT at East Sacramento Physical Therapy, or East Sac PT as we are referred to locally. East Sac PT has been a pelvic health clinic for over 30 years, and early on the owners, Risa and Jim MacDonald had to educate other medical providers about what pelvic PT was and how it would help their patients. Now the clinic treats adult and pediatric patients of all genders with pelvic dysfunction as well as adult patients with orthopedic conditions.

I also organize the Sacramento Pelvic and Sexual Health Professionals Network (Sac PuSHPiN), which is a network of PTs, MDs, mental health therapists, sex educators, and more, who meet quarterly and share ideas about pelvic and sexual health.

In addition to being a lead TA for Herman & Wallace, I do some guest teaching at my alma mater, California State University, Sacramento (CSUS).

What has your educational journey as a pelvic rehab therapist looked like? Where did you start?
Some of my earliest jobs were movement related. I taught swim lessons, yoga classes, and dance classes in high school and college. I earned a teaching credential and had a  career as an elementary teacher for a few years. Unfortunately, I entered teaching in the midst of a difficult economy. As a newer teacher, I was laid off every year due to uncertain education budgets and had to reapply each fall, which became very stressful after 5 years.

I decided to go back to school to be a school PT because as a teacher, I was familiar with rehab in a school setting, but I was pretty naive about what getting into and completing PT school meant. Because I didn’t have a kinesiology degree, I had to take a few years of prerequisite classes while I worked as a dance instructor and professional dancer. I got into the PT program at CSUS and was exposed to the wide variety of settings available for PTs to practice in. When I did a clinical rotation at East Sac PT, I fell in love with pelvic health and never looked back. I took Pelvic Floor 1 as a student in preparation for my clinical rotation, and I completed the rest of the pelvic series after graduation. I earned my PRPC the following year.

How did you get involved in the pelvic rehabilitation field?
One thing that drew me to pelvic rehabilitation was the amount of time we get to spend really getting to know patients. Patients will often tell us things they haven’t told other medical providers, and I love helping patients solve mysteries about their bodies and make new connections. I also love that the little things we do can make a big difference. I gave a constipated patient an abdominal massage, and she returned and called me a “poop doula”.

What patient population do you find most rewarding in treating and why?
I love treating dyspareunia because it’s often something that people have lived with for a long time and thought was either normal or untreatable. I also love working with the LGBTQIA+ community because as a queer person I know that finding queer-competent healthcare providers is more difficult than it should be.

If you could get a message out to physical therapists about pelvic rehab what would it be?
Ask every patient specific questions about their pelvic health. Often patients won’t tell you that they are having incontinence or pelvic pain unless you ask them specifically. These are things that should be screened for at every PT evaluation. PTs also need to get really comfortable asking these questions because if you as the PT are nervous or embarrassed, your patient won’t be honest with you.

What lesson have you learned in a course, from an instructor, or from a colleague or mentor that has stayed with you?
I’ve learned so much from my mentor Risa MacDonald, but one of the most useful things I observed from her is the phrase “you’re right”. She starts nearly every bit of patient education with it, and it’s magic. If you start out telling a patient something they’re right about, they’ll listen to almost anything you have to say after that.

What do you find is the most useful resource for your practice?
I love podcasts. I listen to them while I’m getting ready for work or while I’m working around the house on the weekends. There are so many, but some of the podcasts in my rotation right now are At Your Cervix, Decolonizing Fitness, Foreplay Radio, Pain Science and Sensibility, The Nutrition Diva, The Penis Project, and Tough to Treat. One of my all-time favorite podcasts is Ologies, which is not a pelvic health-specific podcast but which does have some pelvic health-themed episodes, such as “Phallology”, which is what got me hooked.

What is in store for you in the future as a clinician?
I am loving the journey of continuing to learn about different aspects of pelvic health. I’d love to work more in PT education, and I have plans to own a clinic at some point in the future.

What books or articles have impacted you as a clinician?
I’ve just registered for Diane Lee’s ISM series, so I’m working my way back through The Pelvic Girdle and The Thorax right now. Both are such a dense wealth of information that give me new perspectives each time I go through them. I aspire to understand anatomy at as deep a level as Diane Lee.

What has been your favorite Herman & Wallace Course and why?
Megan Pribyl’s Nutrition Perspectives course dramatically changed both the way I eat and the way I talk to patients about nutrition. I recommend it to people every time I TA. I also learned so much in Lila Abbate’s Pudendal Neuralgia course.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
I started fermenting things and sprouting grains after taking Megan Pribyl’s course. I’ve also fashioned several pelvic models out of pipe cleaners after taking Jen Vande Vegte’s courses.

What do you love about assisting at courses?
I love meeting other PTs and learning things from them. Our field has so many passionate and talented PTs with so many interesting ideas. It’s also really fun to see how other clinics are set up and run. And even when I’ve TA’ed a course several times, it’s always valuable to hear the material with a new instructor and practice it with a different set of PTs. I learn so many new things each time.

What is your message to course participants who are just starting their journey?
Assume nothing! Even with the most open mind, patients will make you realize the assumptions and biases you’re bringing into the treatment room. Just when you get comfortable, a patient will throw you an absolute curve ball. This is what makes our specialty interesting though!

Pauline Lucas, PT, DPT, WCS, NBC-HWC, PYT, CMMI is the is the author and instructor of the Mindfulness and Meditation for Pelvic Health course. Pauline works as an integrative physical therapist, specializing in pelvic health, at the Mayo Clinic in Arizona. As faculty member at the Mayo Clinic Alix School of Medicine she is director of the Health Coaching course and teaches Introduction to Lifestyle Medicine. Additionally, she is the creator and instructor of a successful meditation program for Mayo Clinic employees and patients. Pauline is a frequent presenter for local, regional, and national medical conferences on topics related to mindfulness, women’s health, and integrative medicine. She presented twice at CSM, both on the therapeutic use of yoga for chronic pain as well as the use of mindfulness and meditation in rehabilitation. She is the owner of Phoenix Yoga and Meditation, www.phoenixyogaandmeditation.com

In 2014, JAMA published the findings of a systematic review on the use of mindfulness meditation programs for stress-related outcomes like anxiety, depression, and pain, in diverse groups of adults.¹ The evidence suggested that mindfulness meditation programs could help reduce anxiety, depression, and pain in some clinical populations. The authors, therefore, concluded that clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress.

As pelvic health providers, we frequently work with patients dealing with significant psychological stress, both the result of their condition, but often also a contributor to their symptoms. What is our role in addressing those stressors? And how do we manage our own well-being when providing care for patients with high-stress levels and sometimes strong emotions?

Colleagues sometimes ask me when I use mindfulness during my workday. My answer is that I aim to use mindful awareness all day; when I wash my hands, when I greet my patient, as I listen to their story, when holding space for a patient with strong emotions, when touching during an exam or treatment, and while staying present for myself at the same time.

The science is clear: when we as healthcare providers practice mindfulness, both we and our patients benefit. A mindful therapist helps the patient feel safe and heard, which improves the therapeutic relationship; one of the factors determining a positive or negative treatment outcome.² Of course we need to have good clinical skills, but the therapist’s mindful presence is like “the secret sauce” that enhances everything else they provide in their interactions.

There are many studies on the effects of mindfulness training on mental health providers. Outcomes such as increased compassion, better counseling skills, less stress, and better quality of life, likely apply to pelvic health rehabilitation professionals as well. ³

These days we can easily learn the basics of mindfulness through various Apps, online classes, books, and podcasts. But with mindfulness has many aspects, and even some contra-indications, learning to create a personal practice and skillfully navigate the integration of mindfulness practices in patient care requires more in-depth training with a qualified instructor.

Would you like to learn about the origins of and the science behind mindfulness, create a personal mindfulness and meditation practice, explain mindfulness to your patients (without ever using the word mindfulness), what techniques to choose, and when to limit or avoid mindfulness practices with your patient? Join me for Mindfulness and Meditation for Pelvic Health on October 22-23.

References:

1. Goyal M, Singh S, Sibinga EMS, et al. Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(3):357–368. doi:10.1001/jamainternmed.2013.13018
2. Brito, G. Rethinking Mindfulness in the Therapeutic Relationship. Mindfulness5, 351–359 (2014). https://doi.org/10.1007/s12671-012-0186-2(accessed August,31, 2022)
3. https://www.apa.org/monitor/2012/07-08/ce-corner (accessed August,31, 2022)

Course Dates:
October 22-23, 2022

Price: $360
Experience Level: All
Contact Hours: 12

Description:  This 2-day virtual course is geared toward the pelvic rehabilitation professional to enhance both their personal and professional life satisfaction and serve their patients in a more mindful way. You will learn how chronic stress impacts health and well-being and the latest research on the benefits of mindfulness training for both patients and healthcare providers. You will personally experience various mindfulness practices such as body scan, breath awareness techniques, mindful movement, and meditation, so you can experience the power and benefits first-hand. We will explore how to apply mindful awareness in clinical practice to improve your patients’ experience and treatment outcomes, in addition to making your day more peaceful and productive as you enhance your ability to stay focused and become less reactive to triggering situations. You will return to your clinic with the ability to explain mindful awareness and its benefits to your patients and introduce mindfulness into your patient care. You will be able to begin or deepen your own mindfulness practice and apply practical mindfulness skills to a busy workday and personal life to promote your own happiness and well-being.

Today The Pelvic Rehab Report is featuring two short interviews with instructor teams Alyson Lowrey & Tara Sulivan who teach Pain Science for the Chronic Pelvic Pain Population, and Sandra Gallagher & Caitlin Smigelski who teach Transgender Patients: Pelvic Health and Orthopedic Considerations.

The Pain Science for the Chronic Pelvic Pain Population instructors Alyson N Lowrey, PT, DPT, OCS &Tara Sullivan, PT, DPT, PRPC, WCS, IF answered the following two questions:

What Is Pain?
All pain occurs in the brain. Whether it is from acute tissue injury, nerve injury, or chronic pain, all pain has to be interpreted by the brain. How do you explain to a patient that their pain may not be from tissue damage, but from their brain interpreting something as painful that shouldn’t? While their pain may be in their brain, it is NOT in their head!

Pelvic pain is complicated because of a phenomenon called pelvic organ cross-talk. Your brain has a really hard time determining which pelvic organ or muscle is having pain or sensations, so signals can get crossed. Patients can present with uterine pain that can cause bowel or bladder pain and vice versa. We commonly see this with endometriosis and interstitial cystitis. Another example is the prostate and bladder. Prostatitis may present as an overactive bladder. This makes our jobs more difficult because we have to be able to determine the true source of a patient’s pain and understand that their pain may not be coming from an obvious source.

What is pain neuroscience education (PNE) and how can it be used?
Pain neuroscience education (PNE) is the explanation of the neurophysiological changes in the central nervous system to patients that have chronic pain. It is explaining pain, sensitization, and all the factors that can be contributing to their pain and abnormal sensations.

PNE typically decreases the threat value of pain, diminishes catastrophic thinking about pain, and facilitates a more active coping strategy. In the Pain Science for the Chronic Pelvic Pain Population, you will leave with the tools to combine pain science education with current interventions for a more effective treatment.

The Transgender Patients: Pelvic Health and Orthopedic Consideration instructors Sandra Gallagher, PT, DPT, WCS & Caitlin Smigelski, PT, DPT answered the following two questions:

What made you want to create this course?
We created this course on rehabilitation in gender-affirming care in 2018 because, at that time, nothing like it existed. We had learned so much from working with patients preparing for surgery and knew we need more information. Through attending conferences, we had opportunities to talk with experts in the field including surgeons, endocrinologists, primary care physicians, and social workers. Combined with researching additional topics, we made the course we wish we could have taken: a course that bridges physical rehabilitation considerations with medical and surgical information on transgender care.

Today, many brief courses and videos about gender-affirming care exist. You can now find courses and videos that address trauma-informed care, language aspects of gender-affirming care, and physicians and surgeons speaking on their procedures. We think this is great and encourage people to continue to seek out these learning opportunities! Our goal is to expand on the perspective of the rehab professional by offering a course that has both depth and breadth.

Our course has evolved to a hybrid format with pre-recorded self-paced lectures and live webinar content. We know that some participants are well versed in LGBTQ topics and are trained in providing trauma-informed care. For other participants, our course may be the first time they are exploring topics like sex, gender, sexuality, trauma-informed care, and gender-affirming language. The content in the pre-recorded lectures allows participants to work at their own pace, whether it is review or brand new information and allows everyone to have a similar foundation when we meet for the live portion.

What is your message to practitioners about gender-affirming care?
Our message to participants who are just starting their journey on gender-affirming care is to remember that gender is not genitals and that undergoing gender-affirming procedures is not strictly about sexual activity options. Sometimes people get so focused on the genital surgery or changes, that they forget the person. Every patient's path will be a bit different and there is more to gender-affirming care than peri-operative rehab.

Keep learning! Engage with professional organizations like WPATH, watch videos featuring gender diverse individuals, practice language with coworkers, and attend grand rounds. Many university hospitals now have virtual rounds that are available live or as recordings. There is so much information available if you search for it!

Pain Science for the Chronic Pelvic Pain Population

Course Date: October 8-9, 2022
Price:$400
Experience Level: Beginner
Contact Hours: 12

Description: This course is designed to expand the participant's knowledge, experience, and treatment in understanding and applying pain science to the chronic pelvic pain population including endometriosis, interstitial cystitis, irritable bowel syndrome, vaginismus, vestibulodynia, primary dysmenorrhea, and prostatitis. This course provides a thorough introduction to pain science concepts including classifications of pain mechanisms, peripheral pain generators, peripheral sensitization, and central sensitization in listed chronic pelvic pain conditions; as well as treatment strategies including therapeutic pain neuroscience education, therapeutic alliance, and the current rehab interventions' influence on central sensitization.

Lecture topics include the history of pain, pain physiology, central and peripheral sensitization, sensitization in chronic pelvic pain conditions, therapeutic alliance, pain science and trauma-informed care, therapeutic pain neuroscience education, the influence of rehab interventions on the CNS, and specific case examples for sensitization in CPP.

Transgender Patients: Pelvic Health and Orthopedic Considerations

Course Date: October 8,2022
Price: $500
Experience Level: Beginner
Contact Hours: 17

Description:  This course is appropriate for any physical rehabilitation professional, regardless of their specialty area, who has an interest in better serving people who are gender diverse. There is specific content aimed at teaching pelvic health therapists how to expand their skills for working with people of all gender identities. There will be particular education regarding gender-affirming genital surgeries as well as discussion of other gender-affirming surgeries and medical interventions that people transitioning might choose.

Often times therapists think of genital surgeries and sexual function when contemplating work with transgender people. However, therapists have far more to offer transgender patients. For providing optimal care, knowledge of the intricacies of gender transition is essential. We provide that overview in this course. Topics covered include:

• Societal influence on gender transition including interactions with health care providers
• Recognizing difference between sex, sexuality, and gender
• Understand the complexities of the legal system for the person transitioning gender
• Tips and tools for a trauma-informed intake and examination
• Health effects of hormones for gender transition as related to differential diagnosis in rehabilitation
• Supporting healing after gender-affirming surgery
• Operative procedures for face and chest
• Operative procedures for masculinizing and feminizing genital surgery
• Pre-operative evaluation, treatment, and education issues
• Post-operative evaluation, treatment, education, and follow-up for genital surgeries
• Outcome measures with rehab focus for people undergoing gender-affirming surgeries
• Fertility and pregnancy in gender diverse people.

Rachna Mehta, PT, DPT, CIMT, OCS, PRPC is the author and instructor of the Acupressure for Optimal Pelvic Health course. Rachna brings a wealth of experience to her physical therapy practice and has a personal interest in various eastern holistic healing traditions.

One of the main reasons I got into Acupressure was because of my complex orthopedic patients. People who were struggling with chronic pelvic pain, and a lot of my patients were doing complementary and alternative medicine ( CAM ) modalities like Acupuncture and Yoga. That got me interested, because as they were going along with those programs in addition to therapy, the question they always asked was what could they do themselves.

I started looking into Acupressure and found that there was such a big knowledge base, but the information was very scattered. If I found a study that talked about Acupressure points, I wouldn’t know where they were located, what they were good for, where I could use them, or how I could integrate them into my practice. I started to piece the information together and that was the conception of this course Acupressure for Optimal Pelvic Health.

Acupressure for Optimal Pelvic Health  is a two-day course with about an hour and a half of pre-recorded lectures that go over the history of Acupuncture (because Acupressure draws from that), Traditional Chinese Medicine (TCM) concepts, getting our basics down, and terminology. We talk about the meridian channels, Ying and Yang, and where the meridians and Acupoints are located on the body. Next we delve into the scientific and evidence-based perspectives by taking a look at all of the evidence for Acupuncture and Acupressure.

From there we go into how to read the chart and what are the abbreviations. We have 12 main meridians that we look at and out of those there are 4 that we focus more on for pelvic health. Those are the Bladder, the Kidney, the Stomach, and the Spleen meridians - those have the most points that we focus on. There are also other important points all over the body that help and stimulate the nervous system and tap into the peripheral nervous system, the Qi, and improve the physiological functioning of the organs.

Lectures also talk about the fascial and connective tissue networks, and how Acupoints are located along fascial planes. We discuss the connections of the fascia with the peripheral nervous system and how Acupoints have high electrical conductivity on the surface of the skin (there are instruments that can measure this). Next, we tackle the question of how Acupoints tap into the central nervous system and how there are internal connections to the different organs that can help to heal and promote physiological wellbeing. Acupressure can treat conditions like anxiety, incontinence, constipation, dysmenorrhea and a host of pelvic health conditions. Acupressure is good for so many different things.

On day two of class, we dive into Yin yoga. Yin yoga is a very beautiful form of yoga. It’s a quiet, meditative form of yoga, and it connects the Acupressure points by putting the body in specific poses that stress those tension lines along the meridians. It is a mindful way of putting the body in specific positions and supporting the body with props. It is also a meditative state in which we stay in each pose for about  3 to 5 minutes, and we become still. The main principles of Yin Yoga are that we arrive in a pose, become still and stay for time. We get into a pose and basically, we are meeting our body where it is. It’s also a lot of acceptance and mindfulness. Stillness is something that a lot of people have a hard time doing, be it physical or stillness of the mind.

The beauty of us using Acupressure is that we are musculoskeletal specialists and we are so hands on with all of our patients. If we know exactly where the points are, we can work on those points as we are working on other things such as stretching a muscle, doing range of motion, or just working on fascia. There are a lot of things that we can do for our pelvic health patients in particular, but this is applicable to even our orthopedic patients.

Acupressure is truly a mind-body practice that can be taught to patients in their journey towards self-care, holistic healing and wellness.

Acupressure for Optimal Pelvic Health

Course Dates:
October 15-16, 2022
February 4-5, 2023
June 3-4, 2023
October 14-15, 2023

Price: $450
Experience Level: Beginner
Contact Hours: 12.5

Description: This is a two-day course that offers an evidence-based perspective on the application of Acupressure for evaluating and treating a host of pelvic health conditions including bowel, bladder, and pelvic pain issues. The course explores a brief history of Acupressure, its roots in Acupuncture and Traditional Chinese Medicine (TCM), and presents current evidence that supports the use of complementary and alternative medicine as an adjunct to western medicine. TCM concepts of Meridian theory and energy channels are presented with scientific evidence of Acupoints transmitting energy through interstitial connective tissue with potentially powerful integrative applications through multiple systems.

Lectures will present evidence on the use of potent Acupressure points and combinations of points for treating a variety of pelvic health conditions including chronic pelvic pain, dysmenorrhea, constipation, digestive disturbances, and urinary dysfunctions to name a few. Key acupoints for decreasing anxiety, and stress and bringing the body back to a state of physiological balance are integrated throughout the course. Participants will be instructed through live lectures and demonstrations on the anatomic location and mapping of acupressure points along five major meridians including the spleen, stomach, kidney, urinary bladder, and gall bladder meridians. Key associated points in the pericardium, large intestine, small intestine, lung and liver meridians as well as the governing and conception vessels will also be introduced. The course offers a brief introduction to Yin yoga and explores Yin poses within each meridian to channelize energy through neurodynamic pathways to promote healing across multiple systems. Participants will learn how to create home programs and exercise sequences and will be able to integrate acupressure and Yin yoga into their orthopedic and pelvic health interventions.

Holly Tanner is the Director of Education at Herman & Wallace and has curated and instructs the Male Pelvic Floor course. Male Pelvic Floor was first taught in 2008 and has since been expanded to include 22 contact hours. This current content includes 7 pre-recorded lectures and 2 full days of live lectures and labs, allowing more time for hands-on skills in examination and treatment. The schedule covers bladder, prostate, sexual health, and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease.

Post-orgasmic illness syndrome (POIS) is a condition that encompasses a cluster of clinical symptoms. The literature most often reports this presentation in men as a response that occurs shortly after ejaculation and that lasts a period of days or even a week or longer. Symptoms may include transient, flu-like symptoms including, but not limited to headache, sore throat, general myalgia, exhaustion, and cognition that is impacted during the reaction. Understandably, people who experience post-orgasm illness often limit sexual encounters, demonstrate avoidance of sexual function, experience interference in relationships with partners, and report lost time from work and other activities. The diagnosis may be primary (occurring from first ejaculation experience) or secondary (acquired later in life.)

Despite the recognition that clinical presentation can be highly variable, diagnostic criteria have been described by Waldinger and colleagues in 2011 (Part 1) and are based on their study of 45 Dutch Caucasian men with POIS.

Preliminary diagnostic criteria for post-orgasmic illness syndrome include 1 or more of the following:

• Flu-like symptoms, fatigue, muscle weakness, feeling feverish, sweating, mood disturbances or irritation, memory and concentration difficulties, nasal congestion, watery nose, and/or itchy eyes.
• Symptoms occur immediately after or within hours after ejaculation
• Symptoms occur almost always, or in more than 90% of ejaculation events
• Symptoms last for 2-7 days
• Symptoms disappear spontaneously

There are various theories postulating the reason for developing POIS including the autoimmune-allergy hypothesis, cytokine and neuroendocrine disruption, and endogenous m-opioid receptors (orgasm uses large quantities of endogenous opioids). One of the primary reasons that immune reaction to a patient’s own semen has been a strong theory is because sexual activities without ejaculation often do not produce the reaction. Hyposensitization with autologous semen has proven beneficial as a desensitization therapy. (Waldinger et al., 2011, Part 2) Other treatments that may be used include antihistamines, SSRIs, benzodiazepines, and NSAIDs. Comorbidities of POIS reported by Natale and colleagues (2020) include erectile dysfunction, allergies, chronic pelvic pain, autoimmune conditions, and depression and anxiety.

From the standpoint of pelvic rehabilitation, there is much to offer to alleviate symptoms and promote function in patients who have POIS. Genitopelvic pain during or after ejaculation, urinary hesitancy, and difficulty with bowel movements can accompany the syndrome - all complaints that warrant evaluation typical of any patient who has abdominopelvic dysfunction. In the men who have presented to me with this diagnosis, a period of sexual dysfunction including premature ejaculation was described prior to developing POIS. One patient, in particular, described a period of a decade or more of suppressing sexual desires, including masturbation, due to beliefs in his community. When he did masturbate for the first time, he developed post-orgasm illness immediately. I have also observed a tendency to report hypersensitivity to touch, with any palpation to the lower abdomen or groin area causing significant discomfort, and even spontaneous erection or orgasm that was difficult for the patient to manage. In the few cases I have seen, abdominal and pelvic muscle dysfunction was present, and patients responded favorably to manual therapy, education, breathing, and self-management with the use of thermal therapies and self-treatment for soft tissues. It is likely that a combination of medical management, as well as rehabilitation efforts, will provide the best recovery, as anyone who develops fear of an activity usually benefits from learning how to prepare for said activity by addressing concerns prior to, during, and after the activity. Addressing the nervous system response to ejaculation can be part of the rehabilitation process, and a referral to a mental health professional may also prove beneficial in managing the anxiety that often accompanies post-orgasm illness syndrome.

References:

1. Abdessater, M., Elias, S., Mikhael, E., Alhammadi, A., & Beley, S. (2019). Post orgasmic illness syndrome: what do we know till now?. Basic and Clinical Andrology, 29(1), 1-6.
2. Le, T. V., Nguyen, H. M. T., & Hellstrom, W. J. (2018). Postorgasmic Illness Syndrome: What do we know so far?. Journal of Rare Diseases Research & Treatment, 3(2).
3. Nguyen, H. M. T., Bala, A., Gabrielson, A. T., & Hellstrom, W. J. (2018). Post-orgasmic illness syndrome: a review. Sexual Medicine Reviews, 6(1), 11-15.
4. Waldinger, M. D., Meinardi, M. M., Zwinderman, A. H., & Schweitzer, D. H. (2011). Postorgasmic illness syndrome (POIS) in 45 Dutch Caucasian males: clinical characteristics and evidence for an immunogenic pathogenesis (part 1). The journal of sexual medicine, 8(4), 1164-1170.
5. Waldinger MD, Meinardi MM, Schweitzer DH. Hyposensitization therapy with autologous semen in two Dutch caucasian males: beneficial effects in Postorgasmic illness syndrome (POIS; part 2). J Sex Med. 2011a;8(4):1171–6
6. Waldinger, M. D., & Schweitzer, D. H. (2002). Postorgasmic illness syndrome: two cases. Journal of Sex &Marital Therapy, 28(3), 251-255.

Price: $695                                            Experience Level: Beginner-Intermediate                                            Contact Hours: 22

Description:  
The course introduces valuable concepts in pelvic health including urinary and prostate function, chronic pelvic pain, and sexual health. For therapists who have taken Pelvic Floor Function, Dysfunction, and Treatment Level 2A, the Men’s Pelvic Health Course expands on the men’s pelvic health topics introduced in Pelvic Floor Level 2A. This continuing education course is also created at an introductory level, covering topics such as internal rectal pelvic muscle examination, so that a therapist who has not taken prior pelvic floor muscle function coursework can attend. It is expected that participants will only register for satellites in which they are within driving distance, and adhere to all state and local COVID guidelines, including wearing a mask at all times during the course.

Urinary dysfunction such as post-prostatectomy incontinence, benign prostatic hypertrophy, urinary retention, and post-micturition dribble are discussed in this class. Because urinary incontinence is a potential consequence following prostate surgery, risk factors, pre-surgical rehabilitation, and post-surgical intervention strategies following prostatectomy are instructed. The medical aspects of prostate cancer testing are also clearly described, including prostate-specific antigen (PSA) testing, Gleason scores, and any recent updates in recommended medical screening.

Although most men diagnosed with prostatitis do not have a true infection, prostatitis remains a common diagnosis within chronic pelvic pain. The Men’s Pelvic Health course explains typical presentations of prostatitis-like pain, evaluation techniques, and evidence-informed intervention techniques. Other pelvic diagnoses are covered, such as Peyronie's Disease, testicular and scrotal pain, penile pain, and pelvic floor muscle-related conditions. Men who experience pelvic muscle dysfunction including pain or weakness are at risk for sexual dysfunction. Participants will be able to describe the relationships between pelvic muscle function and men’s sexual health, including the evidence that demonstrates pelvic muscle rehabilitation's positive impact on erectile function. This continuing education course includes lectures and labs, including external and internal muscle mapping and neuro-myofascial treatment techniques.

Next Course Date: October 22-23, 2022

Satellites:

• Self-Hosted
• Virginia Beach, VA
• Downer's Grove, IL
• Baltimore, MD
• New York City, NY
• Omaha, NE
• Leesburg, FL
• Smyrna, TN

Bethany Blake, PT, DPT, PRPC sat down with The Pelvic Rehab Report this week to discuss herself and how she came to TA for Herman & Wallace.

Who are you? Describe your clinical practice.
I’m Bethany Blake. I co-own Arkansas Pelvic Health and use social media (@thebladderbaddies previously @thekegelchronicles) to educate about pelvic health.

At Arkansas Pelvic Health we believe everyone should be able to live their life confidently, without pelvic pain or leakage. We believe pelvic therapy should be a standard, not a luxury, and we are on a mission to change this, one pelvis at a time. That's why we started this business, to raise the standard of care in women's health.

As a patient at Arkansas Pelvic Health, you will be paired one-on-one with a Doctor of Physical Therapy, never a tech or computer. You will never be rushed, and your pain and symptoms will be validated. We’re tired of doing things like they've always been done, and we’re tired of women's pain being ignored. We practice evidence-based, patient-centered, compassionate care to get you lasting relief from your pelvic symptoms and get you back to living your life!

What has your educational journey as a pelvic rehab therapist looked like? Where did you start?
I really jumped all in. I took Pelvic Floor Level 1, Pelvic Floor Level 2A, and Pelvic Floor Level 2B all within a month of each other. Very shortly after that, I took a visceral class with Ramona Horton and started teaching courses. I love learning and refuse to settle with not knowing something.

How did you get involved in the pelvic rehabilitation field?
I started my career as an outpatient orthopedic therapist. I picked this site as a clinical rotation because of one therapist in particular, Amanda Brooks-Ritchie. I liked the training that she had and the certifications she was working toward. I had a lot of pregnant and postpartum patients there and worked with a team of pelvic health therapists. Anytime treatment didn’t involve actual vaginal exams, they got “kicked out” to ortho…me. I learned a lot about pelvic health during that time and eventually decided to jump on board the pelvic health ship. I love zooming in and out of the pelvis and bringing the orthopedic background into pelvic health. Soon after I took the courses, I got my PRPC. I realized when studying for that certification, I wanted to merge my orthopedics and pelvic floor, which looked different from how I was practicing at my then-current job. I reached out to a classmate, colleague, and friend, Beth Anne Travis, who had previously approached me about starting a clinic, and told her I was ready to go!

What patient population do you find most rewarding in treating and why?
I love treating pain patients - pelvic pain in general, interstitial cystitis, pudendal neuralgia, and pain with intercourse. It is so rewarding to give people a part of their life back that they hate and to help their bodies work for them instead of against them.

If you could get a message out to physical therapists about pelvic rehab what would it be?
If you suspect pelvic floor issues with your patient, don’t try to manage them yourself.  You are potentially doing more harm than good by blindly issuing Kegels and TA contractions. If you aren’t sure, call your friendly neighborhood pelvic PT, and they would be very happy to help you with your patient. I also love the Cozean pelvic floor screening tool.

What lesson have you learned in a course, from an instructor, or from a colleague or mentor that has stayed with you?
Pelvic floor issues are complex. The evaluation is an ongoing process. You won’t know everything for everyone, but you know how to research, you have colleagues you can talk to, and don’t stop trying. Pain is absolutely not part of being a woman.

What do you find is the most useful resource for your practice?
My colleagues. We have a weekly hour where we chat about cases, practice new techniques, and review. It is the best time of the week.

What is in store for you in the future as a clinician?
Arkansas Pelvic Health is growing and expanding. I see opportunities for growth in space and location. I will continue patient care (it’s my favorite part) and also educating the public on social media and through different PT schools.

What books or articles have impacted you as a clinician?
The Interstitial Cystitis Solution
Come As You Are
Headache in the Pelvis
The Body Keeps the Score
Netter’s Anatomy
and many articles!

What has been your favorite Herman & Wallace Course and why?
Pelvic Floor Level 2B is my all-time favorite because I love treating pain conditions. I also really enjoyed the Nutrition Perspectives for the Pelvic Rehab Therapist course.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Progress is not linear!

What do you love about assisting at courses?
I love teaching people about the pelvis, knowing that they will go out and help so many people. I love the updated evidence at the courses, reconnecting with colleagues, and meeting new ones.

What is your message to course participants who are just starting their journey?
Sometimes the load is heavy, but you get stronger, and colleagues help carry it! This is the most rewarding job you will ever have. It is an honor that people let you help them with a vulnerable issue, don’t take it lightly.

This week The Pelvic Rehab Report sat down with faculty member Ken McGee, PT, DPT. Ken (they/he) is a queer transmasculine pelvic health physical therapist based in Seattle whose mission is to bring greater awareness to the pelvic health needs of the LGBTQIA2S community. Their practice, B3 Physical Therapy, centers on transgender and perinatal rehabilitation. Ken also provides peer bodyfeeding support and doula care, and can be found on Instagram at @b3ptcob3ptco.

You can join Ken in their remote course, Perinatal Mental Health: The Role of the Pelvic Rehab Therapist, scheduled for October 22, 2022.

Who are you? Describe your clinical practice.
Experiencing inadequate care for my own pelvic health conditions as a teenager motivated me to become a pelvic health physical therapist. Being a member of the queer community further drove me to offer trauma-informed care and develop better access to care through home visits. Currently, I split my time between providing gender-affirming physical therapy and serving as a birth doula.

What lesson have you learned (in a course, from an instructor, or from a colleague or mentor) that has stayed with you?
Very few clients will remember detailed biomechanical explanations or every exercise you teach them. However, each client will remember how you treated them and how you made them feel. Asking clients about their preferences for care and following up go a long way in establishing rapport.

What do you find is the most useful resource for your practice?
One of my favorite resources is Decolonizing Fitness. It is an educational platform by Ilya Parker, PTA, (he/they). It provides a catalog of exercises and trainings for people looking to improve their care of gender-diverse people and People of Global Majority.

What books or articles have impacted you as a clinician?
The healthcare field regularly puts people in boxes to determine care. For example, many providers might determine care based on whether someone is a transgender woman or man. However, gender is actually someone’s individual experience rather than a category. Kate Bornstein’s My New Gender Workbook is a good starting point for understanding gender as uniquely one’s own, rather than part of a treatment algorithm.

What made you want to create this course, Perinatal Mental Health?
I wanted to create this course because, as a parent and physical therapist, I see both the challenges that the perinatal period presents, as well as the ways that rehabilitation providers can support mental health. In developing the content, I drew upon my background as a volunteer for a perinatal mental health warm line.

What need does your course fill in the field of pelvic rehabilitation?
Pelvic rehabilitation providers regularly interact with people who have mental health challenges. However, there are very few courses that specifically address the needs of the pelvic health providers serving folks in the perinatal period. This course looks at perinatal mental health from the perspective of pelvic rehabilitation providers, while offering specific actions providers can take to support their clients.

Who, what demographic, would benefit from your course?
Rehabilitation providers of any experience level would benefit from taking this course. Providers who are new parents or considering becoming pregnant may also find the content personally enriching. While the research discussed in this course focused on the perinatal period, much of it can be extrapolated to other populations.

What is your message to course participants who are just starting their journey?
For people just starting in pelvic rehabilitation, I would recommend focusing on patient education. For me, I find that the greatest amount of client improvement comes through reviewing the basics. It’s okay to still be developing skills in manual therapy.

Perinatal Mental Health: The Role of the Pelvic Rehab Therapist

Price: $150

Contact Hours: 5.75

Course Date: October 22, 2022

Description: This one-day remote course covers mental health considerations in pregnancy and postpartum and is targeted to the pelvic rehab clinician treating patients in the peripartum period. Topics include common mental health concerns in the postpartum period including depression, anxiety, OCD, and PTSD, as well as the connectedness between mental health and physical dysfunction. The course will introduce useful screening tools and how to connect patients to resources and diagnosing professionals. Labs will include partnered breakout sessions to practice listening and dialogue skills. The course also includes a review of coping techniques to support mental health and physical symptoms.