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Optimizing Your Front Desk for Pelvic Rehab

Although awareness of pelvic rehabilitation is growing, patients who are referred for pelvic rehabilitation usually have more questions than the average patient about attending therapy. This can mean that you as a provider are burdened with a lot of phone calls or emails that go something like this: can I come to the clinic if I’m on my period? what are you going to do? are you familiar with my condition? how long will it take to get better? Consider how often these questions occur with patients who have knee pain, or headaches, and you may find that pelvic rehab is perceived by patients as quite unique from other types of rehab. How can you avoid trying to find time in your busy clinical schedule to tackle these additional communications? You can start by educating your front desk to handle patient care questions related to pelvic rehab, such as the following frequently asked questions:

  • Do I need a referral from a doctor?
  • What will we do on my first visit?
  • What is biofeedback?
  • What is ____________ (proctalgia fugax, interstitial cystitis), etc?
  • I have my period, should I reschedule?
  • Do you do internal work?
  • Will my insurance cover this?

It is likely that the patient will ask to speak directly with the therapist, so you can first encourage your support personnel to politely inquire if there is something he or she could help in answering. Create a list of conditions along with a brief description of its definition, and a few examples of skills that a pelvic rehab provider has to offer. Your support staff can also offer to mail a brochure or flyer that you create which answers some of the frequently asked questions. Providing an “FAQ” section on your website that can be referred to may also decrease some of the stress of trying to play phone tag. Make no mistake that if you DO have the time to follow-up with a patient who has a question, you may create a connection that is really important for that patient in regards to scheduling an appointment. On the other hand, if you don’t have time set aside in your day for such calls or emails, you risk having the patient not get her questions answered. A form (on your site or as a written resource) might have some of the commonly asked questions written out, and you could use the ones below as an example to get you started.

Do I need a referral from a doctor?

Most patients can attend a physical therapy visit without having a prescription or written referral from a doctor or other referring provider. Insurance companies, however, may insist that you have a referral in order for you or your therapist to receive payment. Even if you do not need a referral from a medical provider, your therapist may require that you have seen a medical provider for your condition. Many conditions involving the pelvis can be medical in nature and require checking for more serious conditions before coming to the clinic. It is also helpful to have a medical provider with whom your therapist can coordinate care and discuss your health as a team.

What will we do on my first visit?

First, we will talk about what concerns or symptoms you have. Your therapist will also look over any forms you filled out to learn more about your history. The exam will be discussed with you so that you can have any questions answered. Your therapy exam may include general movement like bending forward and backward, seeing how you move your body, and specific tests of your joints, muscles, and nerves. For pelvic rehabilitation, an assessment of your pelvic muscles internally (through the rectum or vaginal canal) may be valuable.

Will we use biofeedback? (What is biofeedback?)

Your therapist may use surface EMG (electromyography), a form of biofeedback. This may involve placing some sticky sensors on your body so you and your therapist can get a better idea of how you are coordinating muscle activity in the abdomen or pelvis. Biofeedback means that you will be able to get information about how your muscles are working, and in therapy this is often displayed as graphs or bars on a screen. An internal sensor for the vaginal or rectal canal may also be used.

(For those menstruating) Should I reschedule if I have my period?

It is usually not necessary to reschedule if you are on your cycle, so you are welcome to keep your appointment.

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Effectiveness of Exercise for Managing Osteoporosis in Women Postmenopause

Commonly in physical therapy we treat patients with osteopenia or osteoporosis, however, they are usually in our office for another diagnosis such as back, hip, or pelvic pain as the primary complaint and we learn about the osteoporosis from health history review. Physical therapy is an opportunity to provide them with not just relief from their primary complaint, but a chance to learn from a professional how to move in a more healthy way and learn the right ways to exercises to make a regular routine that can help them to protect their body and even slow or stop bone mineral density loss. This is important as the primary concern for a patient with the diagnosis of osteoporosis is risk of fracture (especially of the hip or spine) due to minimal trauma because of low bone mineral density. So let’s make sure we are giving patients comprehensive exercise programs that address their primary complaint, however be comprehensive and include exercise modes that may reduce fractures and may improve bone mineral density.

An interesting article by Palombaro et al1 in 2013 from Physical Therapy discusses a Cochrane review by Howe et al2 and applies the findings from this review to an example patient similar to the participants reviewed in the study. The goal of the article is to link evidence in the literature with how we practice as PT’s. The topic explored in the systematic review by Howe et al was exercise for the management of osteoporosis in women postmenopause and which exercise approaches reduce the loss of bone mineral density or reduce chance of fractures in women who are healthy postmenopause. The systematic review2 included 43 randomized controlled studies of postmenopausal women age 45-70 where the intervention groups included exercises that improved aerobic capacity or improved aerobic capacity and muscle strength and had a comparison group completing “usual activity: or placebo intervention. The duration of exercise lasted from 6 months to 2 years in the various studies. The results of the review demonstrated decreased bone loss (of the spine or hips) in groups who performed any type of exercise compared to the control groups. The review also performed additional sub group analysis to take into account the various types of exercise programs in the studies and found favorable effect for all types of exercises completed (dynamic, low force, high force, weight bearing, or non-weight bearing) all had favorable effect on bone density. The take home message from this systematic review is that exercise programs combining various forms of exercises lasting 6 months to 2 years resulted in reduced risk for fracture, and a slightly beneficial effect on bone mineral density of the spine, trochanter, and neck of the femur in postmenopausal women with osteoporosis.

At the end of this article1 the authors give a case of an active, postmenopausal female patient with history of osteopenia without a fracture seeking PT for an unrelated complaint. The authors took the findings from this review and showed the relevance of the findings, applying it to the patient and the outcome of care for this patient when giving her an exercise program. We can implement findings from this review simply to the common question posed by our patients… “what exercises should I be doing to help with my osteoporosis?”

Exercises for a patient with osteoporosis should be forms of exercises that may improve bone density by loading bones (weight bearing exercise) and by increasing muscle mass (strengthening resistive exercise) to produce mechanical load and stress to the bone. Also as we age we tend to experience changes with not just a reduction of bone mineral density, but also a reduction of muscle mass. Additionally complicating the natural progression of aging are balance and gait changes leading to impaired physical performance. We should be giving our patients a comprehensive exercise program including safe weight bearing exercises and a strengthening program. Common examples of weight bearing exercises include regular walking, jogging, jumping, dancing, and racquet sports. Common examples of strengthening activities would include use of resistive exercises for upper and lower body with bands, free weights or resistive equipment. All of these classifications of exercise were considered as beneficial in the review.

To learn more about helping postmenopausal patients, consider joining Michelle Lyons, PT, MISCP for "Menopause Rehabilitation and Symptom Management". This course will be taking place March 19, 2016 - March 20, 2016 in Atlanta, GA. Another great resource to consider is "Geriatric Pelvic Floor Rehab: Modifying Treatments for Seniors and Older Patients" with Heather S. Rader, PT, DPT, BCB-PMD, taking place January 16-17, 2016 in Tampa, FL.


1 Palombaro, K. M., Black, J. D., Buchbinder, R., & Jette, D. U. (2013). Effectiveness of exercise for managing osteoporosis in women postmenopause. Physical Therapy, 93(8), 1021-1025.
2 Howe, T. E., Shea, B., Dawson, L. J., Downie, F., Murray, A., Ross, C., ... & Creed, G. (2011). Exercise for preventing and treating osteoporosis in postmenopausal women (Review).

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How to Discuss Vulvar Pain: an Update to Terminology

Earlier this year, 3 prominent societies representing pelvic health met to discuss and update terminology for vulvar pain. The result is the “2015 Consensus Terminology and Classification of Persistent Vulvar Pain.” A complete list of the updated terminology can be accessed on the website of the International Pelvic Pain Society. The updated document takes into account the additions of the terms Primary versus Secondary Vulvodynia, intermittent versus persistent pain, and considers research-based interventions for the suspected etiologies of pain. Some of the other updates are highlighted below.

  • Replace the term “unprovoked” with “spontaneous”
  • Use the term “vulvar” rather than “vulvodynia” in the title of the terminology
  • Vulvar pain definition removes the word “burning” from description

Vulvar pain can have a known cause, and the categories within vulvar pain caused by a specific disorder are: infectious, inflammatory, neoplastic, neurologic, trauma, iatrogenic, and hormonal deficiencies. Vulvodynia, defined as vulvar pain at least 3 months in duration, and without a clear identifiable cause, is described as having “potential associated factors.” There are also descriptor terms such as localized, provoked, or mixed, and terms such as intermittent, persistent, constant, immediate or delayed.

The terminology document recognizes that a patient may have a specific condition or diagnosis, and also be diagnosed with vulvodynia. As this consensus document is designed to replace the ISSVD terminology from the 2003 publication, becoming familiar with the updates is valuable for pelvic rehabilitation providers. The evaluation and treatment of vulvar pain is introduced in the Insitute’s Pelvic Floor Level 1 continuing education course, and further developed in the Level 2B course. For an immersion in the topic of vulvar pain, check out the Institute’s course on Vulvodynia: Assessment and Treatment instructed by Dee Hartmann. Your next opportunity to take the course is this March in Houston.

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Can Pelvic Floor Training Be Learned Through Internet or Postal Training?

Can patients benefit from a non-face-to-face treatment program for stress urinary incontinence? A recent study addressing this question was published in the British Journal of Urology International. This randomized, controlled trial utilized online recruitment of 250 community-dwelling women ages 18-70 years. Criteria was stress urinary incontinence (SUI) at least 1x/week, diagnosis based on self-assessment questionnaires, 2 days of bladder diaries, as well as a telephone interview with a urotherapist. The Outcomes tools included the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF), the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), the Patient Global Impression of Improvement, health-specific quality of life (EQ-VAS), use if incontinence aids, and satisfaction with treatment.

The participants were randomized into 2 pelvic floor muscle training groups: an “internet-based” group (n=124) and a group who were sent information in the mail (n=126). The internet-based program contained information about pelvic muscle contractions (8 escalating levels of training), behavioral training related to lifestyle changes. The internet group received email support from the urotherapist, and the postal group did not. Pelvic floor muscle training was instructed at at least 8 contractions 3 times/day. After the 3 month training period, the internet-based treatment group was advised to continue pelvic floor muscle training 2-3 times/week, whereas the mail training group were not given any advice about continued training frequency. Follow-up data was collected at 4 months post-intervention, at 1 year and 2 years. At 2 years follow-up, 38% of the participants were lost from the study.

Within both groups, the authors report that the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) showed “highly significant improvements” after 1 and 2 years compared to baseline data. Much of the improvement occurred within the first 4 months of the study “…and then persisted throughout the follow-up period.” When comparing the internet group to the mail-only group, the perception of improvement following treatment was higher. Approximately 2/3 of the women in both groups reported satisfaction with the treatment even at the 2 year follow-up. The authors conclude that the internet or mail-based exercise programs may “…have the potential to increase access to care and the quality of care given to women with SUI [stress urinary incontinence] in a sustainable way.” Additionally, not all patients will improve significantly unless they have one-on-one intervention, leaving plenty of patients who do need our direct care.

If you would like to learn more about exercise prescription for urinary incontinence, consider attending one of Herman & Wallace's many continuing education courses.

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Self-mobilization of Hip Joint: A Step in the Right Direction

After pushing a double stroller for a 3 mile run to the park yesterday, I had a flare up of hip pain that made me doubt my ability to get my kids back home. While they were playing, a hanging ladder caught my eye and sent my manual therapy wheels spinning. I carefully slipped my leg over one of the rungs, angled my body just right, and leaned away to distract my hip. I noticed a toddler staring at me, so I politely told her, “I’m just mobilizing my hip joint, sweetie, but you can go ahead and climb now!” My relief was almost immediate, and I realized my patients need to know how to help themselves, too! We all know how to prescribe home exercises for patients regarding stretching and strengthening, but once a therapist is competent performing joint mobilizations, the need for this arthokinematic movement is often found to be essential prior to the osteokinematic movement of stretching. The hip joint in particular is affected by pathologies of the lumbar spine, the sacroiliac joint, and the pelvic floor. When the hip joint is not moving around the proper physiological axis, then the knee can be negatively impacted as well as the areas just mentioned.

Therapists need to discern whether a patient is appropriate for self-hip mobilization instruction, as a “motor moron” probably would not be a good candidate to whom you would explain how to perform mobilizations at home. When you realize a patient “gets it,” then you can suggest the techniques to that patient. Reiman and Matheson (2013) presented a paper regarding suggestions for self-mobilization of the hip joint. They demonstrate an inferior-posterior hip glide with a towel, weight, and a step with or without muscle reeducation in hip flexion; an inferior and lateral glide with hip flexion movement; a hip posterior glide with or without movement; a hip lateral glide with or without muscle reeducation; a hip anterior glide with or without muscle reeducation; and, a long axis distraction mobilization. The authors conclude the efficacy of their protocol and techniques are not completely backed up by evidence yet and recommend they be implemented as an adjunct to evidence based practice, not a primary treatment approach.

Regarding the efficacy of hip mobilization in the clinic by a skilled clinician, a study by Makofsky et al, (2007) discusses the effect of inferior hip joint mobilization on hip abductor force. This study leaves little doubt that mobilizing the hip can facilitate contraction of the gluteus medius. A 17.35% increase in hip abduction torque was noted immediately after the inferior Grade IV hip mobilization; whereas, the control group without mobilization experienced a 3.68% decrease in hip abduction torque. We generally see patients much less often than our services are needed, so being able to teach patients how to mobilize on their own to supplement our work could be extremely effective in the long run.

I have the extreme fortune of being married to a manual therapist, so I do not always have to find crafty ways to mobilize my own joints, but my recent experience was encouraging to know it is more than possible to help myself. My hip pain had caused some patellofemoral symptoms because my gluteal muscles were inhibited. Performing a self-distraction close to my hip joint helped kick in the muscles required for greater stability of my knee. I cruised home with the kids without a hitch. We should all be ready to educate our patients to take potentially embarrassing measures to help themselves as well.


Reiman, M. P., & Matheson, J. W. (2013). RESTRICTED HIP MOBILITY: CLINICAL SUGGESTIONS FOR SELF‐MOBILIZATION AND MUSCLE RE‐EDUCATION. International Journal of Sports Physical Therapy, 8(5), 729–740.

Makofsky, H., Panicker, S., Abbruzzese, J., Aridas, C., Camp, M., Drakes, J., … Sileo, R. (2007). Immediate Effect of Grade IV Inferior Hip Joint Mobilization on Hip Abductor Torque: A Pilot Study. The Journal of Manual & Manipulative Therapy, 15(2), 103–110.

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Nutritional Support for Inflammatory Bowel Disease

Inflammatory bowel diseases such as ulcerative colitis and Crohn’s disease (CD), according to Lan et al., are characterized by chronic inflammation in intestinal mucosa. There is little information available based on human studies that links nutritional support with inflammatory bowel disease. The authors of this article analyzed the available information about supplements that appear beneficial in healing the gut mucosa. 

The intestinal epithelium acts as a selective barrier, and inflammatory bowel disease can disrupt this important barrier, affecting absorption, mucus production, and enteroendocrine secretion. Intestinal wound healing, according to the linked article, is “dependent on the precise balance of several processes including migration, proliferation, differentiation, and apoptosis of the epithelial cells.” Although there are few human clinical studies (more are animal and cell model studies) there is evidence that both macronutrient and micronutrient deficiencies may exist in patients who have inflammatory bowel disease. Patients may have malnutrition of proteins, of minerals and vitamins. Following are some points from the article:

  • Arginine, glutamine, and glutamate are noted as amino acids that contribute to mucosal healing in animal studies, as well as threonine, methionine, proline, serine, and cysteine. 
  • Short-chain fatty acids, which are the result of metabolized dietary fiber (grains, legumes, fruits and vegetables), and resistant starch (beans, potatoes, brown rice) are a major source of energy for epithelial cells in the colon
  • Vitamin A deficiency is common in patients with newly diagnosed IBD
  • Vitamin D may decrease intestinal fibrosis, and reduce risk of Crohn’s relapse
  • Vitamin C and Zinc may both help heal epithelial wounds in the colon
  • During the remission phase, some foods may be poorly tolerated, such as dairy
  • During an active flare of IBD, a patient may require enteral nutrition 

The authors conclude that the exact mechanisms by which the various dietary compounds contribute to bowel healing is still unknown. Furthermore, the ability to make clear dietary recommendations is limited by the lack of clinical studies. At a minimum, this information can alert the pelvic rehab provider to discuss the potential benefits of nutrition on bowel health with patients. Many of us are quite comfortable giving advice about drinking appropriate amounts and types of fluid, or eating more whole and less processed foods. We can take our nutritional education a step further by encouraging a patient to discuss healing supplements with a provider and/or nutritionist to best support the healing bowel. If you are interested in learning more about nutrition and pelvic health, you might love our newer course Nutrition Perspectives for the Pelvic Rehab Therapist Kansas City in March of next year with instructor Megan Pribyl.


Lan, A., Blachier, F., Benamouzig, R., Beaumont, M., Barrat, C., Coelho, D., & Tomé, D. (2015). "Mucosal healing in inflammatory bowel diseases: is there a place for nutritional supplementation?" Inflammatory bowel diseases, 21(1), 198-207.

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Prednisone for Postpartum Perineal Pain

Postpartum perineal injuries can cause pain and dysfunction for a short or an extended period of time. Pelvic rehab providers are in a position to educate women about the immediate and long-term management of perineal pain. A 2015 study by Manfre et al. assessed the response of cortisone cream application to the perineum in the immediate postpartum period. The study was a randomized controlled trial involving 27 subjects with each subject serving as her own control. Three different treatments were given over a 12 hour period: corticosteroid, placebo, and no treatment. (The hydrocortisone cream was at 1% in an alcohol-based cream, the placebo was a non-medicated acetyl alcohol-based cream.) The cream was applied by an investigator who placed the cream on a Witch Hazel pad. The participants and the researchers were blinded to the type of cream applied, and the applications were randomized and took place within the first 12.5 hours after birth. Perineal pain levels were assessed immediately before cream application, and at 30 and 60 minutes after application. Using a visual analog scale (VAS), the symptom of pain was assessed and compared to baseline. In the study, the authors report that in the immediate postpartum period, women in their institution were often prescribed medication ranging from ibuprofen to hydrocodone. Topical medications, ice packs, heat packs are also mentioned as available treatments. Other pain medications or cold packs were available during the study; no other topical creams were utilized.

Results indicated that the participants responded positively to both creams with significantly more pain reduction than the no treatment group. The authors propose that both creams provided a soothing effect by providing moisture to the tissues, creating a protective barrier, and preventing friction and irritation. Because the placebo emollient cream was not significantly more expensive than the hydrocortisone cream, the article suggests using hydrocortisone on the postpartum perineum due to the medication’s potential beneficial anti-inflammatory effects. Also of note was that ice packs were used by less than half of the women in the study, and when ice was used, it was only during the first four hours after birth. One reason for the low frequency use of ice was thought to be the difficulty in maintaining ice application on the perineum.Manfre 2015

Because the pelvic rehab provider is in an optimal role as educator for pain reduction strategies, this study provides some interesting information to share with other birth providers and with patients. Learn more about postpartum patient care at Care of the Postpartum Patient, available in Seattle this March.


Manfre, M., Adams, D., Callahan, G., Gould, P., Lang, S., McCubbins, H., ... & Chulay, M. (2015). Hydrocortisone Cream to Reduce Perineal Pain after Vaginal Birth: A Randomized Controlled Trial. MCN: The American Journal of Maternal/Child Nursing, 40(5), 306-312.

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Home Exercises for Diastasis of the Rectus Abdominis Muscle

Diastasis of the Rectus Abdominis Muscle (DRAM) is the separation of the two rectus abdominis muscles along the linea alba and is very common during and after pregnancy as the rectus abdominis and linea alba stretches and thins. Patients with DRAM are often sent to seek non-surgical management for DRAM from a physical therapist (PT). Typically these patients are either at the end of their pregnancy or adjusting to round the clock care of an infant. They can be sleep deprived, and have a full schedule of doctor’s appointments, having difficulty finding childcare, making attending PT somewhat challenging. Furthermore, they may have difficulty finding the time for a home exercise program (HEP). As PT’s we often struggle with making sure to give the patient exercises that will accomplish the goal of improving DRAM, however, making sure the HEP is not so extensive or time consuming that it becomes unmanageable. Is something as easy as abdominal bracing with exercise effective for reducing DRAM in post-partum women? A recent study published in 2015 in the International Journal of Physiotherapy and Research explores just this topic(Acharry).

Why is Diastasis of the Rectus Abdominis Muscle (DRAM) important?

Women with DRAM tend to have a higher degree of abdominal and pelvic region pain(Parker). Also women with DRAM may be more likely to have support related pelvic floor problem such stress urinary incontinence, fecal incontinence, or pelvic organ prolapse. The linea alba and rectus abdominis play an integral role in maintaining the anterior support of the trunk, these structures work together with pelvic girdle, posterior trunk muscles, and hips in maintaining stability when we shift weight (or transfer load) such as with standing, squatting, walking, carrying, and lifting. Therefore postural stability may be impaired with these daily tasks. Lastly, the abdominal muscles and fascia protect and support our organs so women with DRAM may have compromised support and protection of visceral structures.

Is DRAM common?

Pregnancy is the most common cause of DRAM and studies widely range from 50-100% of women experiencing DRAM at end stage pregnancy. Natural reduction and greatest recovery of DRAM usually occurs between day 1 and week 8 after delivery. Various ways exist to diagnose DRAM. The gold standard for diagnosis is computed tomography but is sometimes considered impractical due to expense. Clinically a separation of 2.0-2.7cm or “two finger widths” of horizontal separation at the umbilicus or 4.5cm above or below while performing a hooklying (supine with knees bent) abdominal curl up is considered pathological separation.

What can be done for DRAM?

Current guidelines for conservative treatment of DRAM are sparse with little established recommendations. The earlier referenced recent cross sectional study(Acharry) explores efficacy of abdominal bracing as a treatment for reduction of DRAM in post-partum females. The study included 30 females that were one month post-partum or more who had vaginal delivery with or without episiotomy. The average distance of the diastasis was measured before and after treatment using the finger width technique. The treatment included teaching the subject four abdominal exercises, and the subjects were encouraged to complete abdominal bracing while carrying out daily activities. The four exercises included 1) static abdominal bracing exercise, lying supine with arms crossed over the diastasis for support and then pulling abdominals inwards with an isometric contraction of abdominal muscles. 2) Head lift with bracing, in hooklying with arms crossed over diastasis, exhale, lift head and use hands (or a towel/sheet) to approximate diastasis towards midline. 3) Head lift and pelvic tilt with bracing, is the same as previous exercise only adding a posterior pelvic tilt. 4) Pelvic clock exercise with bracing, visualize a clock on the lower abdominals and complete gentle movements from 12-6 o’clock, 3-9 o’clock, 12-3-6-9-12 o’clock, in a clockwise fashion and then reverse the pattern in a counter clockwise pattern. All exercises were performed twice daily, with a repetition of 5-6 days per week, for 2 weeks duration. After completing the program for two weeks the distance of the diastasis was re-measured and the average DRAM distance decreased from 3.5 to 2.5 finger widths which was considered significant. The results of this study show abdominal exercise with bracing is effective for reducing DRAM in early post partal females.

As PT’s who treat DRAM we should encourage our patients to use abdominal exercises with bracing as well as encourage our patients to use abdominal bracing with their daily tasks such as standing, lifting, weight shifting, and carrying. A home exercise program such as the one in this study proved to be effective for reducing DRAM and included only four exercises making this a manageable home exercise program for our post-partum patients.

Herman & Wallace offers a full series of peripartum courses called the "Pregnancy Series". To learn more about diastasis of the rectus abdominis muscle, join Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI at Care of the Postpartum Patient in Seattle, WA this March 12-13, 2016!


Acharry, N., & Kutty, R. K. (2015). ABDOMINAL EXERCISE WITH BRACING, A THERAPEUTIC EFFICACY IN REDUCING DIASTASIS-RECTI AMONG POSTPARTAL FEMALES. Int J Physiother Res, 3(2), 999-05.

Parker, M. A., Millar, L. A., & Dugan, S. A. (2009). Diastasis Rectus Abdominis and Lumbo‐Pelvic Pain and Dysfunction‐Are They Related?. Journal of Women’s Health Physical Therapy, 33(2), 15-22.

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Pelvic Floor Muscle Training for Sexual Dysfunction in Women with Multiple Sclerosis

Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups; 20 women completed the study. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.

  sEMG biofeedback Sham NMES Intravaginal NMES TTNS
Group 1 (n=6) X X    
Group 2 (n=7) X   X  
Group 3 (n=7) X     X

 

The following factors made up the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, and a 4 month history of stable symptoms. All of the participants were sexually active and were found to be able to contract pelvic floor muscles correctly. Group 1 patients were treated with “sham” electrical stimulation using surface electrodes placed over the sacrum at a pulse width of 50 ms and a frequency of 2 Hz. Patients in Group 2 used an internal (vaginal) electrode at 200 ms at 10 Hz. Group 3 were given transcutaneous tibial nerve stimulation at 200 ms and 10 Hz. All groups followed these treatments with pelvic floor muscle exercises using a vaginal sensor and biofeedback.

The authors concluded that pelvic floor muscle training alone or in combination with intravaginal neuromuscular electrostimulation or transcutaneous tibial nerve stimulation is effective in treating sexual dysfunction in women who have MS. Improvements were noted in these groups in sexual arousal, vaginal lubrication, satisfaction, and in the Female Sexual Function Index. While the numbers in the respective intervention groups is not large enough to determine the best option for patients who have multiple sclerosis, the research reminds us that neurostimulation in conjunction with pelvic muscle training may be very valuable.

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What does Vitamin D have to do with the Pelvic Floor?

As pelvic rehab practitioners, it is common for our patients to ask us dietary questions pertaining to their unique pelvic floor symptoms. We often counsel on fluid consumption, bladder irritants, and fiber intake. At times, we even give our patients a bladder or bowel diary to better monitor nutritional status and habits. However, how often do we ask about vitamin D status? It is common knowledge that vitamin D deficiency contributes to osteoporosis, fractures, and muscle pain and weakness, but what is the role of vitamin D in overall health of the female pelvic floor. Is vitamin D supplementation something we as health care providers need to at least discuss? An article published in the International Urogynecology Journal (Parker-Autry) explores this topic. This interesting paper reviews current knowledge regarding vitamin D nutritional status, the importance of vitamin D in muscle function, and how vitamin D deficiency may play a role in the function of the female pelvic floor.

How may vitamin D play a role in the function of the pelvic floor?

Vitamin D affects skeletal muscle strength and function, and insufficiency is associated with notable muscle weakness. Vitamin D has been shown to increase skeletal muscle efficiency at adequate levels. The levator ani muscles and coccygeus pelvic floor muscles are skeletal muscle that are crucial supporting structures to the pelvic floor. Pelvic floor musculature weakness can contribute to pelvic floor disorders such as urinary or fecal incontinence and pelvic organ prolapse. Pelvic floor muscle training for strengthening, endurance, and coordination, are first line treatment for both stress and urge urinary incontinence, fecal incontinence, pelvic organ prolapse, and overactive bladder syndrome. The pelvic floor muscles are thought to be affected by vitamin D nutrition status. Additionally, as women age, they are more prone to vitamin D deficiency and pelvic floor disorders.

This article reviews several studies, including small case and observational, that show an association between insufficient vitamin D and pelvic floor disorder symptoms and severity of symptoms. The recommendation from this review is that more studies of high quality evidence are needed to fully understand and demonstrate this relationship between vitamin D deficiency and pelvic floor disorders. However, the authors feel that vitamin D supplementation may be a helpful adjunct to treatment by helping to optimize our physiological response to pelvic floor muscle training and improving the overall quality of life for women suffering from pelvic floor disorders.

How much vitamin D?

The Institute of Medicine has only made recommendations for dietary allowance for vitamin D and calcium for bone health. There is no consensus for adequate vitamin D levels for a condition specific goal (other than bone health), and the levels of vitamin D varied throughout the reviewed studies. It has been shown that very high levels of vitamin D are tolerated well, so supplementation of vitamin D seems to be very safe in low and very high doses.

Food for thought?

As pelvic rehabilitation providers, it is our job to assess the whole person, however, we are not dieticians. As physical therapists we are musculoskeletal specialists and vitamin D affects muscle function. What our patients put in their bodies (wholesome nutritious food vs nutrient lacking artificial food) affects the quality of the cells they produce and tissues that are made, which can influence their healing. When reviewing health history, maybe consider discussing vitamin D status and possible supplementation with the patient, or with the patients’ primary care provider or naturopathic doctor. This team approach may provide more comprehensive health care, hopefully yielding more successful outcomes.

Parker-Autry, C. Y., Burgio, K. L., & Richter, H. E. (2012). Vitamin D status: a review with implications for the pelvic floor. International urogynecology journal, 23(11), 1517-1526.

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Upcoming Continuing Education Courses

Bowel Pathology and Function - Remote Course

Aug 7, 2020 - Aug 8, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Aug 8, 2020 - Aug 9, 2020
Location: Shelby Baptist Medical Center

Trauma Awareness for the Pelvic Therapist - Remote Course (Rescheduled)

Aug 8, 2020 - Aug 9, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Boston, MA (RESCHEDULED)

Aug 8, 2020 - Aug 9, 2020
Location: Marathon Physical Therapy

Colon System & Physiology - Remote Course

Aug 12, 2020
Location: Short Form Remote Course

Pediatric Functional Gastrointestinal Disorders - Pullman, WA (RESCHEDULED)

Aug 14, 2020 - Aug 16, 2020
Location: Pullman Regional Hospital

Pregnancy Rehabilitation - Remote Course (SOLD OUT)

Aug 15, 2020 - Aug 16, 2020
Location: Replacement Remote Course

Pediatric Functional Gastrointestinal Disorders - Remote Course (SOLD OUT)

Aug 15, 2020 - Aug 16, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Jonesboro, AR (Rescheduled)

Aug 15, 2020 - Aug 16, 2020
Location: Arkansas State University

Pelvic Floor Level 1 - Colorado Springs, CO (SOLD OUT)

Aug 15, 2020 - Aug 16, 2020
Location: Colorado Sport and Spine

Pelvic Floor Level 2A - Bangor, ME (RESCHEDULED)

Aug 15, 2020 - Aug 16, 2020
Location: Husson University

Mobilization of Visceral Fascia: The Reproductive System - Remote Course

Aug 21, 2020 - Aug 23, 2020
Location: Replacement Remote Course

Mobilization of Visceral Fascia: The Reproductive System of Men and Women - Salt Lake City, UT (Rescheduled)

Aug 21, 2020 - Aug 23, 2020
Location: Rocky Mountain University of Health Professions

Pelvic Floor Level 2A - Minneapolis, MN (Rescheduled)

Aug 22, 2020 - Aug 23, 2020
Location: Allina Hospitals and Clinics

Pelvic Floor Level 1 - Albany, NY (RESCHEDULED)

Aug 22, 2020 - Aug 23, 2020
Location: The Sage Colleges

Pelvic Floor Level 1 - Alexandria, VA (SOLD OUT)

Aug 22, 2020 - Aug 23, 2020
Location: Inova Physical Therapy Center

Pelvic Floor Level 2A - Remote Course

Aug 22, 2020 - Aug 23, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Coon Rapids, MN

Aug 22, 2020 - Aug 23, 2020
Location: Mercy Hospital

Pelvic Floor Level 2B - Houston, TX (Rescheduled)

Aug 22, 2020 - Aug 23, 2020
Location: Texas Children’s Hospital

Breastfeeding Conditions - Princeton, NJ (RESCHEDULED)

Aug 22, 2020 - Aug 23, 2020
Location: Princeton Healthcare System

Pelvic Floor Level 2B - Manchester, NH

Aug 22, 2020 - Aug 23, 2020
Location: Franklin Pierce University

Pelvic Floor Level 1 Part 1 - Remote Course

Aug 27, 2020 - Aug 28, 2020
Location: Short Form Remote Course

Pelvic Floor Level 1 - Remote Course (SOLD OUT)

Aug 28, 2020 - Aug 30, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Charlotte NC Satellite Course

Aug 28, 2020 - Aug 30, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Garden City Satellite Course (SOLD OUT)

Aug 28, 2020 - Aug 30, 2020
Location: Metro Physical & Aquatic Therapy

Pelvic Floor Level 1 - Zion, IL Satellite Course

Aug 28, 2020 - Aug 30, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Aug 29, 2020 - Aug 30, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Maywood, IL (Rescheduled)

Aug 29, 2020 - Aug 30, 2020
Location: Loyola University Health System