(646) 355-8777

Herman & Wallace Blog

Why you should learn about Pudendal Neuralgia

Herman & Wallace are pleased to announce a new course! Pudendal Neuralgia and Nerve Entrapment will be presented by Michelle Lyons in Freehold, NJ on June 17/18, 2017. We chatted with Michelle about this new course to hear her thoughts and get an overview of the contents

There are a number of courses which I teach for Herman & Wallace including Pelvic Floor Level 2A, my Male Oncology and Female Oncology and the The Athlete and the Pelvic Floor courses. They all have sections on pudendal dysfunction and it’s an area that participants always want more information on. There’s no other nerve that elicits the same interest, discussion and confusion! Nobody really talks about iliohypogastric or ulnar neuralgia with the same intensity as pudendal neuralgia, and no other nerve dysfunction provokes the same amount of controversy and mystery.

When I was approached about developing this course for the Institute, I jumped at the opportunity. For those who don’t know me, I really like to bring an integrative approach to my work, both clinically and educationally. I have experience and training in nutrition, coaching, yoga, Pilates and mindfulness as a therapeutic intervention and I think these fit really well alongside traditional pelvic rehab approaches. Manual therapy and bespoke exercise prescription will always be the bedrock of my approach, but sometimes our patients, especially those with chronic pain, need some extra support. I’m also a bit of an anatomy nerd, so the chance to delve deep into pelvic neuroanatomy and neurodynamics was too much to resist!

I think this is a Golden Age in pelvic health – there are so many great learning opportunities and resources available to us to help serve our patients better. Another area that I find fascinating to explore is the huge leap we have made in understanding neuroscience and the role of pain education when it comes to chronic pelvic pain. I’m a big fan of the work done by Moseley and Butler in Australia, and I love how authors like Hilton, Vandyken and Louw have transferred that to the world of pelvic pain in their book "Why Pelvic Pain Hurts". The language that we use is very important when discussing how the brain responds to chronic pain and the changes that occur with central sensitization. We never want our patients to feel as if we think their pain is ‘all in their heads’ but at the same time, we need to be able to incorporate strategies such as motor imagery and graded exposure and to demonstrate to our patients that"…it is important to acknowledge that chronic pain need not involve any structural pathology" (Aronoff 2016).

Those are some of the discussions we’ll be having in Freehold, NJ next June – I hope you’ll come and join the conversation!


"What Do We Know About the Pathophysiology of Chronic Pain? Implications for Treatment Considerations" Aronoff, GM Med Clin North Am. 2016 Jan;100(1):31-42
"Why Pelvic Pain Hurts: Neuroscience Education for Patients with Pelvic Pain" Hilton, Vandyken, Louw, International Spine and Pain Institute (May 28, 2014)

Continue reading

Pelvic Health for Athletes

When I bring up the topic of pelvic floor dysfunction in athletes, stress urinary incontinence (SUI) is usually the first aspect of pelvic health that springs to mind – and rightly so, as professional sport is one of the risk factors for stress urinary incontinence Poswiata et al 2014. The majority of studies show that the average prevalence of urinary incontinence across all sports is 50%, with SUI being the most common lower urinary tract symptom. Athletes are constantly subject to repeated sudden & considerable rises in intra-abdominal pressure: e.g. heel striking, jumping, landing, dismounting and racquet loading.

What’s less often discussed is the topic of gastrointestinal dysfunction in athletes. Anal incontinence in athletes is not well documented, although a study from Vitton et al in 2011 found a higher prevalence than in age matched controls (conversely a study by Bo & Braekken in 2007 found no incidence). More recently, Nygaard reported earlier this year (2016) that young women participating in high-intensity activity are more likely to report anal incontinence than less active women.

A presentation by Colleen Fitzgerald, MD at the American Urogynecologic Society meeting in 2014 highlighted the multifaceted nature of pelvic floor dysfunction in female athletes, specifically in this case, triathletes. The study found that one in three female triathletes suffers from a pelvic floor disorder such as urinary incontinence, bowel incontinence and pelvic organ prolapse. One in four had one component of the "female athlete triad", a condition characterized by decreased energy, menstrual irregularities and abnormal bone density from excessive exercise and inadequate nutrition. Researchers surveyed 311 women for this study with a median age range of 35 – 44. These women were involved with triathlete groups and most (82 percent) were training for a triathlon at the time of the survey. On average, survey participants ran 3.7 days a week, biked 2.9 days a week and swam 2.4 days a week.

Of those who reported pelvic floor disorder symptoms, 16% had urgency urinary incontinence, 37.4% had stress urinary incontinence, 28% had bowel incontinence and 5% had pelvic organ prolapse. Training mileage and intensity were not associated with pelvic floor disorder symptoms. 22% of those surveyed screened positive for disordered eating, 24% had menstrual irregularities and 29% demonstrated abnormal bone strength. With direct access becoming a reality for many of us, we must acknowledge the need for specific questioning when it comes to pelvic health issues, as well as the ability to recognise signs and symptoms of the female athlete triad in our patients.

Want to learn more about pelvic health for athletes? Join me in beautiful Arlington this November 5-6 at The Athlete and the Pelvic Floor!


J Hum Kinet. 2014 Dec 9; 44: 91–96 Published online 2014 Dec 30. doi:10.2478/hukin-2014-0114 PMCID: PMC4327384. Prevalence of Stress Urinary Incontinence in Elite Female Endurance Athlete Anna Poświata, Teresa Socha and Józef Opara1
J Womens Health (Larchmt). 2011 May;20(5):757-63. doi: 10.1089/jwh.2010.2454. Epub 2011 Apr 18. Impact of high-level sport practice on anal incontinence in a healthy young female population. Vitton V, Baumstarck-Barrau K, Brardjanian S, Caballe I, Bouvier M, Grimaud JC.
Am J Obstet Gynecol. 2016 Feb;214(2):164-71. doi: 10.1016/j.ajog.2015.08.067. Epub 2015 Sep 6. Physical activity and the pelvic floor. Nygaard IE, Shaw JM.

Continue reading

Reaching deeper when treating chronic pelvic pain

Our understanding of treating pelvic pain keeps growing as a profession. We have so many manual therapies such as visceral manipulation, strain counter strain, and positional release adding dimension to our treatment strategies for shortened and painful tissues. Pharmacologic interventions such as botox, valium, and antidepressants are becoming more popular and researched in the literature. We are beginning to work more collaboratively with vulvar dermatologists, urogynecologists, OB’s, family practitioners, urologists, and pain specialists.

Pelvic rehab providers are in a unique position of being able to offer more time with each patient and to see our patients for several visits. Frequently we are the ones being told stories about how a particular condition is really affecting our patient’s life and the emotional struggles around that. We are often the one who gets a clear picture of our patient’s emotional and mental disposition. A rehab provider may realize that a patient seems to exhibit mental patterns in their treatment. It can be anxiety from how the condition is changing their life, difficulty relaxing into a treatment, poor or shallow breathing patterns, frequently telling themselves they will never get better, or being able to perceive their body only as a source of pain or suffering, losing the subtlety of the other sensations within the body. Yet, aside from contacting a physician, who may offer a medication with side effects, or referring to a counselor or psychologist, our options and training may be limited. Patients may be resistant to seeing a mental health counselor, and we have to be careful to stay in our scope.

Research is showing us that meditation as an intervention can be very helpful in addressing these chronic pain issues.

In a study in the Journal of Reproductive Medicine, 22 women with chronic pelvic pain were enrolled in an 8 week mindfulness meditation course. Twelve out of 22 enrolled subjects completed the program and had significant improvement in daily maximum pain scores, physical function, mental health, and social function. The mindfulness scores improved significantly in all measures (p < 0.01).

The questions have arisen, if meditation alters opiod pathways, how can it be administered safely with prescription medications. However in a 2016 study in the journal of neuroscience, it was concluded that meditation-based pain relief does not require endogenous opioids.” Therefore, the treatment of chronic pain may be more effective with meditation due to a lack of cross-tolerance with opiate-based medications.” “The risks of chronic therapy are significant and may outweigh any potential benefits”, according the the journal of American Family Medicine. Meditation training can be a tool to help our patients manage their pain without risk of long term opiod use.

In the two day course, Meditation for Patients and Providers, participants will learn several different meditation and mindfulness techniques they can use for patients with different dispositions, and to tailor the most appropriate approach to specific patients. The aim of the course is to be able to work meditation into a treatment and a home program that is best suited for your patient. The course also covers self care, preventing provider burn out and ways to be more mentally quiet as a provider seeking to give optimal care with appropriate boundaries.


Fox, S. D., Flynn, E., & Allen, R. H. (2010). Mindfulness meditation for women with chronic pelvic pain: a pilot study. The Journal of reproductive medicine, 56(3-4), 158-162.
LEMBKE, A., HUMPHREYS, K., & NEWMARK, J. (2016). Weighing the Risks and Benefits of Chronic Opioid Therapy. American Family Physician,93(12).
Zeidan, F., Adler-Neal, A. L., Wells, R. E., Stagnaro, E., May, L. M., Eisenach, J. C., ... & Coghill, R. C. (2016). Mindfulness-Meditation-Based Pain Relief Is Not Mediated by Endogenous Opioids. The Journal of Neuroscience, 36(11), 3391-3397.

Continue reading

Pelvic Floor Capstone Course is Ready for Liftoff!

More than a year ago, after working on updating the pelvic floor series courses PF1, 2A and 2B, the Institute turned our attention to the final course in our popular series, PF3. To determine what content our participants wanted to learn about in the last continuing education course of the series, we asked that exact question. From a large survey of therapists who had taken all or most of the courses in the pelvic core series, we collected detailed data from therapists about what was needed to round out their comprehensive training. The results of that survey guided hundreds (and hundreds!) of hours of work completed by a team of instructors. This month, in the beautiful city of Denver, the three instructors who created the Capstone course will share their wisdom, clinical experiences, as well as their thoughtfully-designed lectures and labs. You will have an opportunity to learn in depth about topics covered in the prior courses in the series. 

Such topics include lifespan issues and health issues common to different ages, conditions of polycystic ovarian syndrome, endometriosis, infertility, pelvic organ prolapse and surgeries, pelvic fascial anatomy, pharmacology and nutrition. Lab components are detailed and comprehensive for working with specific common implications from conditions in pelvic dysfunction or surgery. This course focuses on the female pelvis, including diving into the complexities of female pelvic health issues. The instructors have all worked in the field for many years, are experienced in working with complex patient presentations, and all excel at manual therapies. I asked each of them to briefly share thoughts about the Capstone course that they each dedicated the last year in developing; following you can read their thoughts.

Nari Clemons

"I'm excited for every therapist who will take this course, as it is made to help you approach your practice at a whole new level.  We are eager to help your hands work dynamically with more intelligence and how to tackle complex restrictions in the pelvis and abdomen that go far beyond releasing muscles.  Additionally, the practitioners will raise their capacity of recognizing and helping the patient manage complex conditions, such as endometriosis, PCOS, fibroids, and IBS." 

Allison Ariail

"One of the best things about the Capstone course is that it provides the participants tools to treat more complicated patients. Topics such as endocrinology, oncology, vulvar dermatology, and surgical procedures are addressed, which will complete the picture for some of those patients that are hard to treat due to the complexity of their case. This knowledge, along with more advanced manual treatment techniques, will add to the skill set of the participants to improve their treatment outcomes. I am excited for the participants to combine their current clinical skills along with some new knowledge and techniques to be able to treat the whole person when working with complex and challenging patients." 

Jennifer van de Vegte

"Designing and creating Capstone with Nari and Allison was an incredible experience. My own knowledge and clinical expertise grew profoundly while researching and writing this material. Capstone is designed to really take the experienced pelvic health therapist to the next level of understanding and treating more complex patients. I can't wait to see the impact this material has on participants and their patients."

There is still time to register for the few remaining seats in Denver this weekend!

Continue reading

Pelvic Pain and Dysfunction; a Differential Diagnosis Manual by Peter Philip

Dr. Peter Philip, a faculty member with the Herman & Wallace Institute, has published a new book! "Pelvic Pain and Dysfunction: A Differential Diagnosis Manual" is available now through Thieme Medical Publishers. We caught up with Dr. Philip to learn a bit more about his project.
Peter is also the author and instructor of two courses offered through Herman & Wallace. Sacroiliac Joint Evaluation and Treatment is an opportunity to learn an exercise and stabilization approach to pelvic girdle, sacroiliac joint, and pelvic ring dysfunction. This course is available twice in 2016; May 21-22 in Austin, TX and later on November 6-7 in Bayshore, NY. Peter's other course, Differential Diagnostics of Chronic Pelvic Pain: Interconnections of the Spine, Neurology and the Hips, expands the practitioner's diagnostic toolkit for complicated chronic pelvic pain patients. This course is available on August 19-21 in Nashville, TN. Don't miss out!


H&W: Thanks for doing this interview, Peter! What's new?
Dr. Philip: After years of research, and writing, my textbook has been published and is ready for the public.


H&W: That's great! What can you tell us about the book?
Dr. Philip: It's called Pelvic Pain and Dysfunction; a Differential Diagnosis Manual, and it has been published by Thieme. Thieme is based out of Stuttgart Germany and is the world’s largest distributor of medical textbooks and journals! The purpose of the book is to answer the questions that so many clinicians have as it relates to their patient’s pain, such as:

  • Why are there muscle spasms?
  • How can the pain seemingly spread from one organ to the next? Or even from one system to another?
  • How can I effectively and efficiently evaluate my patients who suffer with pelvic, bladder, bowel, or visceral pain and dysfunction?
  • And so much more

The textbook also outlines a revolutionary strategy that immediately provides the patient with a reduction in their pain, and often immediate resolution of tight “spasms” or “trigger points”. The mysteries of how and why our patients' pain changes and progresses are outlined in a clear, linear fashion that integrates into a practitioner's current practice. The purpose of the textbook is to provide a means of understanding where pain originates and how to isolate it to a specific region. Once isolated, the book instructs how to treat that region effectively.


H&W: you mean to tell me that you’ve created a method which allows a suffering patient to experience “immediate relief”?
Dr. Philip: Yes! And it's actually quite simple once you understand the anatomy, and the integration of the central nervous system, the peripheral nervous system, psychology, viscera, muscles, tendons, ligaments, and nerves.


H&W: Who is this textbook written for?
Dr. Philip: the textbook is written for all my colleagues who treat patients with pelvic pain. Medical Doctors and Doctors of Science in both the United States and Germany have reviewed the material and found the information, concepts and strategies to be useful.


H&W: how did you put this all together?
Dr. Philip: I realized years ago that the field of pelvic health did not take into consideration the multiple facets that may be involved in a patient’s pain. Many strategies employed simply address restrictions in tissue mobility by “stretching” or “massaging” without taking into consideration the reason these structures are limited in mobility, or have spasms. Knowing why a structure is limited in its mobility or is spastic will allow the clinician to immediately address the suffering patient's needs and promote healing, even if the patient has been suffering for decades.


H&W: but how did you come up with this process?

Dr. Philip: my background is in non-surgical orthopedic medicine. Having three degrees in orthopedic physical therapy, and a certification by the International Academy of Orthopedic Medicine, I applied the differential diagnostic concepts of orthopedic medicine to the pelvic pain population with great success! Using the principles found within this textbook the clinician will have the opportunity to address the exact tissue at fault, provide a near immediate resolution of their pain, and provide a means for the patient to completely regain their wellness and move forward in their life.


H&W: I can see why you are so excited. Is this textbook available yet?
Dr. Philip: yes it is. It can be found at http://www.thieme.com/books-main/obstetrics-and-gynecology/product/3517-pelvic-pain-and-dysfunction. I put in a lot of effort to keep the book comfortably priced at $99.00! I know how tight cash can be for students and the working professional, so keeping it affordable was paramount to me.


H&W: What a fantastic project. Thank you so very much for taking the time to share it with us!


Dr. Philip: It's been a pleasure. Thank you to the Herman and Wallace Institute for allowing me to introduce my textbook and to teach these concepts and strategies.

Continue reading

What's New this March?

There's a lot going on in the world of pelvic rehab, and continuing education is no exception! This March, Herman & Wallace is hosting NINE courses around the country. It's a lot to keep up with, so we thought you might appreciate a brief overview of what's coming up next!

Where's this pain coming from?

Pelvic pain can have many sources, and Elizabeth Hampton wants to help you quickly get to the source. Finding the Driver in Pelvic Pain empowers you to play detective in order to help even the most complex patients. Don't miss out on Finding the Driver in Pelvic Pain in San Diego, CA on March 4-6, 2016

What goes in eventually comes out

How important is a good diet? For most of us eating healthy is important, and for many pelvic rehab patients it is a necessity. That's why Megan Pribyl wrote her "Nutrition Perspectives for the Pelvic Rehab Therapist" course. This beginner level course is intended to expand the your knowledge of the metabolic underpinnings for local to systemically complex disorders. Don't miss out on Nutrition Perspectives for the Pelvic Rehab Therapist - Kansas City, MO - March 5-6, 2016!

There's fascia everywhere!

Fascial mobilization is a rising star in pelvic rehab treatment techniques, and Ramona Horton is excited to share it with you! "Mobilization of the Myofascial Layer: Pelvis and Lower Extremity" is the best opportunity you'll get to learn about the evaluation and treatment of myofascia for pelvic dysfunction. Check it out on our continuing education course page. Ramona will be teaching these techniques in Santa Barbara, CA on March 11-13.

Giving birth hurts

Sometimes the newborn is the one to get all the attention, but what about the new mother? Be sure that you can help postpartum women with symptoms like postural dysfunction, pelvic girdle dysfunction, diastasis recti abdominis and more by attending Care of the Postpartum Patient in Seattle, WA this March 12-13, taught by the wonderful Holly Tanner!

Vulvar pain is easy to have and hard to lose

12% of women in the US have vulvar pain for 3 or more months at some stage in their life. It takes a multidisciplinary approach to address all the causes and co-morbidities, and that is exactly what you'll get at Dee Hartmann's Vulvodynia: Assessment and Treatment in Houston, TX on March 12-13, 2016. Dee aims to address the vicious cycle of pain, visceral and sexual dysfunction, and the general hit to quality of life that patients with vulvodynia suffer from.

The challenge of SI joint pain

The sacroiliac joint, pelvic girdle, and pelvic ring sure can take a beating, and Peter Philip knows how to keep you moving. Through exercise and stabilization, the pelvic rehab practitioner can quickly treat pain in the lumbopelvic-hip complex. Learn all about the direct and indirect anatomy that influences the sacroiliac joint, and then get ready to find and treat the source of pain and dysfunction in Sacroiliac Joint Treatment in Minneapolis, MN on March 19-20, 2016.

Taxes and Menopause

The menopause transition is not something many people look forward to. For some women it goes more smoothly than others, and it's the less fortunate ones who need access to a well-trained pelvic care professional. Michelle Lyons is flying in from Ireland to help you to become that pro! Be it vaginal atrophy, sexual health dysfunction, pelvic organ prolapse, or any other of the myriad possible symptoms of menopause, you'll be equipped to handle them all after attending Menopause: A Rehabilitation Approach in Atlanta, GA on March 19-20, 2016.

Continue reading

Today Marks 10 Years Since the Founding of Herman & Wallace

Today, September 28th, marks the ten year anniversary of the founding of Herman & Wallace! The Institute was founded on this day in 2005 by Holly Herman, PT, DPT, MS, OCS, WCS, BCB-PMD, PRPC and Kathe Wallace, PT, BCB-PMD with a mission of providing the very best evidence-based continuing education related to pelvic floor and pelvic girdle dysfunction in men and women throughout the life cycle.

By Joey Gannon from Pittsburgh, PA (Candles) [CC BY-SA 2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia CommonsSince our founding, it’s been our privilege to spread this mission through an ever-increasing number of course offerings, products, resources and certification so that therapists can meet their goals and patients can access trained practitioners who can address their needs.

To celebrate with us, use the discount code HappyBirthday for $10 off your next downloadable Herman & Wallace product!

In the past ten years, we’ve significantly expanded our course offerings. Currently-offered courses cover pediatrics and geriatrics, sexual health, yoga and Pilates, oncology, meditation and mindfulness, and a number of other topics instructed by some of the foremost experts in the field, with whom we are thrilled to work and provide a platform to spread their knowledge. In addition to our flagship Pelvic Floor series courses which were the first offered by the Institute, H&W now offers 46 live courses and 14 online courses on topics related to pelvic floor dysfunction, as well as related women’s health, men’s health and orthopedic topics.

We have also had the opportunity to take this mission abroad and have offered pelvic floor courses in Saudi Arabia, United Arab Emirates, Chile, Brazil, the UK and Europe. In 2013, H&W launched the first-ever certification recognizing expertise in treating pelvic floor dysfunction in men and women throughout the life cycle, the Pelvic Rehabilitation Practitioner Certification. Since then, 84 practitioners have sat for and passed this exam and earned PRPC as a designation of their competence in evaluating and treating pelvic rehab patients. This coming year and beyond, we are looking forward to continuing with our mission of providing the very best education and resources for pelvic rehab therapists. We are continuing to expand our offerings of intermediate and advanced- level Pelvic Floor coursework for experienced therapists, as well as an increasing number of scheduled events for our introductory courses so that more practitioners can begin learning the skills needed to serve this growing patient population.

Over these years, the best part is hearing from therapists that our mission is changing lives for practitioners and for patients. This recent email we received from a course participant is the best birthday gift we received!:
“I always gain so much from your courses and they are the first ones I look to each year for simply excellent use of my education dollars and to further my knowledge of Women’s/Men’s/Children’s Pelvic Health. Kuddo’s to you, sincerely, for really making a difference in the lives of so many – that you, as therapists, work with directly, AND that you “work with” through each therapist that you train. What a huge ripple effect for making the difference in the lives of many…..and on such personal issues. And I give due credit to you with each patient I see for the training I have and am still receiving! Thank-you!!!!”

Continue reading

It's About More than the Pelvic Floor (Why We Offer New Courses)

The Herman & Wallace Pelvic Rehabilitation Institute was founded nearly a decade ago by physical therapists and educators Kathe Wallace and Holly Herman. The Institute has served as a platform for foundational to advanced pelvic rehabilitation coursework that covers a wide variety of topics. Included in some of the newer coursework is content directed at more general orthopedics or women’s health topics, such as:

Occasionally, as we have continued to expand our offerings at the Institute, participants have expressed concern that a few of the courses are “not pelvic floor” related. We wanted to take a moment to share our perspective regarding that concern:

1. Most pelvic rehabilitation providers are not exclusively working with patients who have pelvic floor dysfunction.
When we completed a survey of job task analysis among pelvic rehabilitation therapists, we learned that many therapists are not working with patients who have pelvic dysfunction 100% of their time, and that general musculoskeletal care makes up a large part of many pelvic rehab therapists’ caseload. Unfortunately, many patients aren’t often dealing with only one dysfunction, so our patients who present with urinary incontinence may also have foot pain, or headaches, for example.

2. Many pelvic rehabilitation providers also describe themselves as orthopedic therapists.
The majority of therapists who responded to our job analysis survey (and those who attend our courses) work in either an outpatient facility or a hospital-based outpatient facility. In fact, many of the respondents are board-certified in orthopedics. Outpatient facilities typically require that a therapist can work with any part of the body, in addition to the pelvis.

3. General orthopedic rehabilitation is closely related to pelvic rehabilitation.
There are an overwhelming number of ways that a patient’s comorbid conditions can be related to the pelvic floor. For example, a patient with foot pain may unload the involved side, placing increased strain on the hip, pelvis, and low back on the opposite side. Another patient who has poor balance may decrease their degrees of freedom by holding the trunk and pelvic muscles tense in order to compensate for a balance difficulty. A patient who has migraines may have to spend a significant amount of time lying flat when she has migraines, potentially leading to discomfort in other joints.

4. We have not decreased the amount of pelvic courses we offer in exchange for general, orthopedic courses. On the contrary, the Institute has continued to add more focused pelvic rehabilitation courses such as Post-Prostatectomy Patient Rehabilitation, Assessing and Treating Women with Vulvodynia, and Geriatric Pelvic Floor Rehab.

In short, we have chosen to offer some coursework that is not solely focused on the pelvis, because these courses can provide benefits to the therapists and to the patients they serve. The Institute is always interested in participant feedback, and is willing to try out new courses to gauge interest level and satisfaction with new courses. As always, you will be provided with the best in pelvic rehabilitation education, and have opportunities to take courses from instructors who offer additional skills and expertise. If you have any questions, or suggestions about course content, please let us know by filling out the Contact Us form on the website. And if you have an idea for a new course you’d like to teach that adds to our existing offerings, we’d love to hear from you- please fill out this form if you have a new course idea.

Continue reading

Is Your Clinic Following AUA Guidelines for Painful Bladder Syndrome?

If you area clinic owner, are in a management or leadership position, one of your jobs is making sure your therapists are using best practices. This can be a challenge when best practices are continually being researched and discussed, and when systematic reviews continue to tell us that pelvic rehabilitation research lacks homogeneity and enough high-level evidence to make convincing arguments about interventions. In the absence of this, we can still integrate recommendations from clinical practice guidelines and from best practice statements. The American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) is participating in the APTA's initiative to develop clinical practice guidelines. For current guidelines, check out their page here. To see which guidelines are in development at the APTA, click here.

The American Urological Association (AUA) has also developed practice guidelines, including the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/PBS). Within this guideline, the first line treatments are listed as general relaxation/stress management, pain management, patient education, and self-care/behavioral modification. Second-line treatments include "appropriate manual physical therapy techniques", oral medications, bladder medications (administered inside the bladder), and pain management. What is very interesting about this guideline is that the authors define what types of manual therapy approaches are appropriate, and these include techniques that resolve muscle tenderness, lengthen shortened muscles, release painful scars or other connective tissue restrictions. The guidelines also define who should be working with patients who have IC/PBS and pelvic muscle tenderness: "appropriately trained clinicians". Very importantly, the authors state that pelvic floor strengthening exercises should be avoided.

How can these guidelines be used to assess best practices? Find out if your therapists who work with patients who have IC/PBS are indeed instructing in relaxation strategies, using pain education and pain management techniques (for pain-brain education specific to pelvic pain, check out the book "Why Pelvic Pain Hurts". Find out if your therapist is instructing in pelvic muscle strengthening as a first-line of treatment, since this would not be in line with the AUA guidelines. (Having said this, teaching pelvic muscle strengthening can be very appropriate when done with consideration of pelvic muscle pain.) Lastly, ask your therapist if she feels that her skill set and training is sufficient to treat the condition. Even in our comprehensive pelvic floor series, there is so much to learn at the initial course that IC/PBS is not discussed in great detail until PF2B. Maybe a little more knowledge and training would help your therapist feel that she is providing the "appropriate manual physical therapy techniques" recommended in the guidelines.

To find out when the next intermediate or advanced course in the series is happening, or to find other specialty courses, check our course listings to see if there is a course happening near you!

Continue reading

Chronic Pelvic Pain and Evil Triplets

Many diagnoses that live under the umbrella of "chronic pelvic pain" have similar symptoms, confounding the differential diagnosis and development of a treatment pathway. Dr. Charles Butrick, in an article published in 2007, suggested that gynecologists "…be alert to…interstitial cystitis in patients who present with chronic pelvic pain typical of endometriosis." The concurrent conditions of bladder pain syndrome (BPS) and endometriosis have been described as "evil twins syndrome" in the realm of chronic pelvic pain. Bladder pain syndrome. also known as Interstitial Cystitis (IC), is a condition commonly associated with pelvic pain, bladder pressure, and urinary dysfunction such as urgency and frequency. Endometriosis can also cause or contribute to pelvic pain, and a variety of pelvic dysfunctions including bowel, bladder, or sexual dysfunction.

A study published in the International Journal of Surgery reported on the prevalence of these two conditions. Utilizing a systematic review approach, the authors located articles reporting on the prevalence of bladder pain syndrome and endometriosis in women with chronic pelvic pain. Nine observational studies were included, and the range of endometriosis diagnosis ranged from 11%-97%, with a mean prevalence of 61%. The prevalence of endometriosis ranged from 28%-93% with a mean prevalence of 70%. The large variation in these rates were explained as potentially being due to the variations in study quality and sample selection. (The authors point out that the highest rates of prevalence for BPS and endometriosis were noted in the patient groups recruited from specialist clinics and from lists of patients from operating lists.) The study concludes that in women who present with chronic pelvic pain (CPP), screening for bladder pain syndrome is important so that appropriate treatment can be directed to all issues.

If another chronic pelvic pain condition, pudendal neuralgia, is added to the diagnoses of endometriosis and painful bladder syndrome, "evil triplet syndrome" can be experienced by a patient. The various symptoms of each of these conditions can add to the total level of pain and dysfunction experienced by a woman with chronic pelvic pain. Having the tools to evaluate and treat symptomatology and address the chronic aspect of tissue, joint, neural, myofascial, and the processing of pain is a skill that most pelvic rehabilitation therapists continue to work on throughout their careers. Michelle Lyons, faculty member from Ireland, brings her "Special Topics in Women's Health" course to Chicago in a couple of weeks. Within the course, Michelle will be discussing each of these conditions from the standpoint of a multidisciplinary approach, and with the role of the pelvic rehabilitation provider in mind. She will also be sharing up-to-date and practical information about infertility and hysterectomy. If you are interested in joining Michelle and colleagues in Chicago, you still have time to sign up! And if you would like to host Michelle's course in your facility, give us a call or send us a note!

Continue reading
Tags:

Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Newark, NJ (Rescheduled)

Jul 12, 2020 - Jul 14, 2020
Location: Rutgers University - Doctoral Programs in Physical Therapy

Pregnancy Rehabilitation - Remote Course

Jul 16, 2020 - Jul 17, 2020
Location: Replacement Remote Course

Postpartum Rehabilitation - Foothill Ranch, CA (RESCHEDULED)

Jul 18, 2020 - Jul 19, 2020
Location: Intercore Physical Therapy

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

Jul 18, 2020 - Jul 19, 2020
Location: Manual Edge Physiotherapy

Postpartum Rehabilitation - Remote Course (SOLD OUT)

Jul 18, 2020 - Jul 19, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1- Bangor, ME (Rescheduled)

Jul 18, 2020 - Jul 19, 2020
Location: Husson University

Pelvic Floor Level 1 - Columbus, OH

Jul 18, 2020 - Jul 19, 2020
Location: Fitness Matters

Pelvic Floor Level 1 Part 1 - Remote Course (SOLD OUT)

Jul 21, 2020 - Jul 22, 2020
Location: Short Form Remote Course

Nutrition Perspectives for the Pelvic Rehab Therapist - Columbia, MO (Rescheduled)

Jul 24, 2020 - Jul 26, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Chicago, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Advocate Illinois Masonic Medical Center

Pelvic Floor Level 1 - Fayetteville, NC (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Methodist University School of Health Sciences

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Jul 25, 2020 - Jul 26, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Glenwood Springs, CO (SOLD OUT)

Jul 25, 2020 - Jul 26, 2020
Location: Valley View Hospital

Pudendal Neuralgia and Nerve Entrapment - Maywood, IL (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Loyola University Health System

Pelvic Floor Level 2B - Los Angeles, CA (RESCHEDULED)

Jul 25, 2020 - Jul 26, 2020
Location: Mount Saint Mary’s University

Manual Therapy for the Abdominal Wall - Remote Course

Jul 31, 2020
Location: Short Form Remote Course

Parkinson Disease and Pelvic Rehabilitation - Remote Course

Jul 31, 2020 - Aug 1, 2020
Location: Short Form Remote Course

Neurologic Conditions and Pelvic Floor Rehab - Washington, DC

Jul 31, 2020 - Aug 2, 2020
Location: George Washington University Hospital Outpatient Rehabilitation Center

Restorative Yoga for Physical Therapists - Remote Course

Aug 1, 2020 - Aug 2, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Chicago, IL (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: Midwestern Regional Medical Center

Pelvic Floor Level 2A - Washington, DC (SOLD OUT)

Aug 1, 2020 - Aug 2, 2020
Location: The George Washington University

Pelvic Floor Level 1 - New York City, NY (RESCHEDULED)

Aug 2, 2020 - Aug 3, 2020
Location: Touro College

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

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

Pediatric Functional Gastrointestinal Disorders - Pullman, WA (RESCHEDULED)

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

Pregnancy Rehabilitation - Remote Course

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

Pediatric Functional Gastrointestinal Disorders - Remote Course

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