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Herman & Wallace Blog

Balloon-assisted Training in Dyssynergic Defecation

Dyssynergic defecation occurs when the pelvic floor muscles (PFM) are not coordinating in a manner that supports healthy bowel movements. Ideally, emptying of the bowels is accompanied by a lengthening, or bearing down of the PFM, and with dyssynergia, the muscles instead shorten. Because a portion of the levator ani muscles slings directly around the anorectal junction (where the rectum meets the anal canal when the muscles are tight, the "tube" where the fecal material has to pass through narrows, making it difficult to pass stool. If emptying the bowels is difficult, patients will often strain for prolonged periods of time, an unhealthy pattern for the abdominopelvic area, and constipation may occur due to the stool remaining in the colon for prolonged periods of time, where the water is reabsorbed from the stool, becoming harder and more difficult to pass.

Can patients with this condition be helped by pelvic rehabilitation providers? Absolutely, with correction of muscle use patterns, bowel re-training education, food and fluid recommendations, and pelvic muscle rehabilitation addressed at optimizing the muscle health. Much of the time, patients with this dysfunctional muscle use pattern present with tension and shortening in the pelvic floor muscles, although they may also present with muscle lengthening and weakness. Surface electromyography (sEMG a form of biofeedback, has also been utilized and the literature supports sEMG for bowel dysfunctions including dyssnergia.

Another technique used by pelvic rehabilitation providers for re-training dyssynergia (also known as non-relaxing puborectalis, or paroxysmal puborectalis, naming the muscle fibers that sling around the rectum) is the use of balloon-assisted training. In this technique, a small, soft balloon is inserted into the rectum and is attached to a large syringe that will inject either water or air into the balloon, causing the balloon to enlarge within the rectum. This training technique allows the patient to provide feedback about sensation of rectal filling including when the patient perceives urges to defecate. The patient can practice expelling the balloon, and in the event of a dyssynergic pattern of pelvic floor muscles, the balloon would not be expelled due to increased muscle tension and shortening of the anorectal area. In this manner, the patient is trained to bring awareness to the anorectal area, and to respond with healthy patterns of defecation.

One study that compared biofeedback training to balloon-assisted training found that biofeedback was more effective in training patients for reduction of constipation. 65 patients, 49 women and 16 men, were included and were diagnosed with constipation and dyssynergia. In the balloon training (n = 31 patients were trained to expel the balloon with increased abdominal pressure and relaxed PFM, whereas in the biofeedback group (n = 34 the patients were trained to relax the pelvic floor muscles while increasing abdominal pressure. The good news is that while the biofeedback group reported higher levels of success in emptying, both groups reported positive effects of their training, with improved amount of stool passed, decreased maneuvers required to empty the bowels, and decreased time needed to defecate.

If you would like to learnabout sEMG for bowel dysfunction, sign up for the Pelvic Floor series 2A continuing education course. We are sold out for the rest of the year for PF2A, and the next opportunity to take the course will be next March in Madison, Wisconsin, or May of 2015 in Seattle. If you want to learn how to use balloon-assisted re-training techniques, you still have an opportunity this year to get into a course. Faculty member Lila Abatte has developed the Bowel Pathology, Function, Dysfunction, the Pelvic Floor course that still has seats left for the November, Torrance, California course.

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Amy C. Sanderson - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy C. Sanderson, PT, OCS, PPRC.

Amy Sanderson

Describe your clinical practice.:

I am a co-owner of a private physical therapy practice in the Spokane, Washington area. We currently have 3 clinics and staff 14 providers overall. I have been an Orthopaedic Certified Specialist since 1996, and our clinic is primarily an orthopedic setting. We do, however, provide several specialties, including Pelvic Rehab, Vestibular Program, and Video Gait Analysis for athletes.

How did you get involved in the pelvic rehabilitation field?

I have been practicing since 1993 and began a Women’s Health program in 1994 at a previous place of employment. When I had interviewed for the position of a staff physical therapist for this clinic, I was asked if I would be interested in starting any new programs for the company. The manager had recommended that I develop a Women’s Health program. Truthfully, I had not heard of Women’s Health in the early 90’s, but I really wanted the job, so I said “absolutely!” I figured that I was a woman and I knew some things about health, so how hard could it be. Countless hours of continuing education and several years of marketing to the local physicians and community, we have now built our Pelvic Rehab program up to 3 physical therapists providing treatment to all of our clinics in the Spokane, Washington area.

What patient population do you find the most rewarding in treating and why?

I have enjoyed the patients who are experiencing sexual pain disorders for the past 15 years and have found this to be the most rewarding. Several times, I have been contacted after the birth of children to be told how grateful the couple has been to achieve such a life experience. Most recently, I received an email from a patient whom I had not seen in 3 years because she wanted to let me know that she and her husband were finally able to achieve intercourse after several years of counseling and my help with physical therapy. It is extremely gratifying to know that we can make a difference in peoples’ lives.

What motivated you to earn PRPC?

I have been practicing for greater than 20 years, including treating patients with all types of pelvic conditions, and after so many years, I wanted to challenge myself to see if truly what I was doing as a practitioner was effective, appropriate, and up to date. I decided that reviewing my education, seeking further education, and testing would be an effective way to do so. I felt that as I was preparing for this exam, I was able to realize that my treatment techniques are effective and appropriate. I am extremely grateful to the Herman & Wallace Pelvic Rehabilitation Institute for providing such great instructors to teach these skills.

Learn more about Amy C. Sanderson, PT, OCS, PPRC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

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Stress Management, Gender Differences, & the Physical Therapist's Role

This is a guest blog-post by Herman & Wallace faculty member Jennafer Vande Vegte, MSPT, BCIA-PMB, PRPC


Stress. We all have it. We all deal with it in one way or another. Sometimes stress comes and goes quickly while at other times it lasts and lasts. Research shows that at times, short bouts of stress can be good, even helpful. The surge of adrenalin and cortisol we get staying up past midnight to finish that assignment before it is due the next morning can power our brains to accomplish a task about which we procrastinated because it seemed burdensome or boring. We are very grateful for the extra burst of speed we feel in our legs as we run to catch our naughty three year old as they run off into a busy street. After these stressful events are over, our bodies recover but chronic stress can affect our bodies in negative ways and our bodies may need help finding a way to cope.

Research shows one main pathway that stress takes in the body is the Hypothalamus Pituitary Adrenal Axis or HPA axis for short. In the HPA axis there is a systematic release of chemical messengers that create a cascade of effects in our bodies. The HPA axis governs our response to stress and also affects our energy levels, digestion, sexual functioning, immune system and other body processes. We don't even need the research to tell us this because we have all experienced it firsthand.

Unfortunately when stress in any form does not go away, our bodies may not find the way back to homeostasis and chronic issues can develop. Research also points out that the function of our HPA axis could have been impaired during our development. Maternal stress can affect a developing baby in utero, and trauma or stress in infancy or early childhood can influence the function of our stress response into adulthood.

Interestingly, there are also gender differences in how stress influences behavior. In their article on the female response to stress, authors Taylor et al. describe the effects of oxytocin on the HPA axis. Oxytocin is released during nurturing behaviors and helps to decrease the activity in the HPA axis. The authors postulate that estrogen may be one reason women cope and respond to stress differently than men. Mothers comfort their babies when they cry and help sooth them. This action is beneficial to both mom and baby. Friends offer comfort with a listening ear, a hug, and emotional support. John Gray in his book Venus on Fire Mars on Ice also notes that oxytocin is released when we feel loved, appreciated and heard. As physical therapists working one-on-one with our patients we are also in a position to listen to and validate our patients which may aid in combating their stress response. Joining a support group may also be of benefit.

How do you respond to stress in your life? Dartmouth researchers found their students drink more caffeine, sleep less, and consume more alcohol. Exactly the WRONG responses when you look at the physiological effects on the HPA axis.. According to the article, "Leproult et al. found that plasma cortisol levels were elevated by up to 45 percent after sleep deprivation, an increase that has implications including immune compromise, cognitive impairment, and metabolic disruption." Caffeine and alcohol also increase cortisol release.

So how should we respond to stress? Relaxation and slow, deep, diaphragmatic breathing are two other huge tools that impact the down regulation of HPA axis activity. In Pelvic Floor Level 2B participants will encounter a host of relaxation techniques to teach patients. People respond differently to various relaxation strategies and it is important to be able to try several to try to get a good fit for your patient. It is truly imperative that our patients with chronic pain have some way to help themselves. Deep breathing, progressive relaxation, autogenics, biofeedback, guided imagery and visualization will be discussed and practiced in class. Yoga and Tai Chi and other types of exercises that link breath with movement and body awareness can also be very helpful for our patients with chronic pain.

The body of research of using mind body techniques to manage chronic pain is growing daily. As health care providers treating patients with IC/PBS, chronic pelvic pain, vulvodynia, IBS, chronic back pain, fibromyalgia and other pain syndromes it is imperative to have these strategies in our treatment tool boxes and educate our patients on the importance of addressing the central nervous system portion of how stress influences chronic pain.

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Can Mindfulness Help Struggling Middle Schoolers?


In an encouraging study sure to grab a lot of attention, researchers studying middle schoolers and the effect of mindfulness on suicidal thoughts have positive findings. We all know that middle school is a very challenging time, with students feeling pressure socially, academically, hormonally, and that family stressors can also be involved in this time of significant growth and change. If we think back to our time in middle school, we may recall some very challenging emotions, and a difficulty in seeing past our school environment and into our potential future. What if mindfulness training could provide an outlet for positive thoughts and a way to more effectively manage emotions?

In this study, highlighted in the research spotlight of the National Center for Complementary and Alternative Medicine, 100 sixth graders were randomized into an Asian history class with daily mindfulness practice and into an African history class with a matched activity unrelated to mindfulness or self-care. The mindfulness instruction included breath awareness and breath counting, body sensation, thoughts, and emotions labeling, and body sweeps. Silent meditation increased from 3 minutes to 12 minutes. Over the study period of 6 weeks, students were assessed for development of suicidal thoughts or self-harm behaviors.

While the researchers conclude that more studies with larger groups need to be done to validate the findings, the reports of this study are very encouraging. Keeping in mind that there are no equipment needs and little or no risk with the applied intervention, perhaps more schools will look to trainable skills in mindfulness to teach young people self-management skills. Mindfulness and meditation continue to receive significant attention in the research literature, and rightly so, as patients, providers, and family members may benefit from simple techniques that can be practiced and applied in a variety of ways.

If you would like to learn more about how to practice and to teach skills in mindfulness, sign up early for our new continuing education course called Mindfulness-based Biopsychosocial Approach to Chronic Pain. Instructor Carolyn McManus has been studying, practicing, and teaching mindfulness to patients and providers for many years. This course can be taken by any health provider, so invite your colleagues to join you at the course! If you are not yet familiar with her work or her patient resources, you may find her guided meditation and relaxation CD's a terrific tool to share or utilize yourself. You can listen to samples of the work on her website by clicking here.

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Is Place of Birthing a Choice?


One thing I have decided after working with women during and after pregnancy is this: babies come when they want, and how they want to arrive. A mother's best laid birth plans will hopefully have enough flexibility to allow her to feel successful even if, and especially if, her plans have to change. A fundamental question that has been asked, from the standpoint of a mother's beliefs is, do women really feel they have a choice to deliver at home versus in a hospital?

Researchers in the UK asked this question of a diverse sample of 41 women who were interviewed. Despite the fact that in the UK, a woman can birth at home with a midwife (and this is covered by the National Health System) home births are unusual, accounting for only 3% of all births. And while it may seem exciting to read that in the US, the number of home births has risen by more than 50% over a decade, the actual numbers include that less than 2% of births occur at home according to the Centers for Disease Control (CDC) data.

Back to the concept of choice, when women were interviewed about where they planned to give birth, perceptions rather than fact ruled the day. The concept of which environments were "safe" versus "risky" were a common theme, with women having differing explanations of why a hospital might be more safe than the home environment, or vice versa. The authors describe the issue that, when healthy mothers with low-risk pregnancies give birth in hospital environments, medical interventions including surgical birth are more likely to place. Women who would choose a home birth reported beliefs such as not being able to have a 'natural' birth in a hospital, fear of contracting illness or disease, or of wanting to be at home surrounded by loves ones. Women also reported that at home, more control over the environment and increased ability to relax would be available.

On the other hand, women who wanted to give birth within a hospital associated the medical environment with safety and reassurance, and expressed fear of feeling guilty if events did not turn out well with a home birth. Unfortunately, some women reported feeling "unfit" to give birth and chose the hospital as a place where both mother and the baby would be more safe. This, I believe, is a very sad statement about the disempowerment that women feel in relation to their own ability to feel healthy and strong in their own body, and to trust that the birth experience can progress well in a multitude of environments. Women interviewed in the study cited marketing and propaganda as contributing to a sense of not being healthy or fit enough to manage the birth outside of a hospital.

The authors point out that "…beliefs and assumptions about birth risk are deeply ingrained…" and that fear of the risks of birthing at home, well-founded or not, remain prevalent. So what is our role? Perhaps to share that healthy women who have uncomplicated pregnancies have choices, and that we believe in their ability to make positive, strong choices that their bodies are fit to perform. There are many birthing centers that are designed with home comforts, and that offer a "middle ground" between a hospital center and a home environment. Home births can be attended by well-trained midwives or other practitioners who are experienced in knowing when and how to access more interventional approaches if needed. This post is not about whether a woman should give birth at home or in a hospital- that issue is hotly debated by many forums currently and by experts in the topic. What we as pelvic rehabilitation providers can continue to offer is coaching, encouragement, and education that is empowering to a woman, so that when she makes a decision (in conjunction with her chosen providers) about how she would like the birth of her child to be achieved, she feels "fit" to birth in the environment she chooses.

If you agree that we have a role in providing a platform from which we educate and empower women to trust their bodies and their choices about birthing, then you will L.O.V.E taking a course with Ginger Garner, a very empowered (and empowering) woman who is a relentless advocate of these issues. In New York, in November, you can take Ginger's continuing education course Yoga as Medicine for Pregnancy. Watch for future Yoga as Medicine courses from Ginger to be updated on our schedule in the coming weeks. Can't make a live course right now? Check out Ginger's online courses with Medbridge, and take advantage of the Herman Wallace discount on our website!

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Jennafer Vande Vegte - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner and Herman & Wallace faculty member Jennafer Vande Vegte, MSPT, BCIA-PMB, PRPC


What role do you see pelvic health playing in general well-being?

Our understanding of the importance of pelvic health has increased dramatically in the past decade but I feel what we know is just the tip of the iceberg. I would love to see our society being even more proactive in utilizing our skills as pelvic floor therapists (for example evaluating every post partum mom, or having physical therapy before and after prostate or prolapse surgery part of standard protocols). Studies show that many pelvic floor dysfunctions don't become symptomatic until decades after trauma to the pelvic structures occurred (SUI/prolapse/FI for example). It would be wonderful to play a more proactive role in these disorders.

What do you find is the most useful resource for your practice?

This probably changes month to month but right now I am having a lot of fun with smart phone apps. My favorites are pranayama free and calm.com. I instruct my pain patients to start with 5-10 minutes of breathing and relaxation most days. It has been instrumental in counteracting the effects of stress on the body.

What patient population do you find most rewarding in treating and why?

I have to say I love to work with pelvic pain. I get excited by the challenge of putting the pieces of the puzzle together with a thorough evaluation and then determining the best treatment route. I feel it is a privilege to partner with patients to meet their specific goals. I especially enjoy working with patients with vaginismus. I have a special victory dance that is reserved for when they come in and excitedly announce that they had intercourse for the first time and it didn't hurt!

Describe your clinical practice:

I treat women, men and children with a wide range of pelvic floor/pelvic girdle dysfunctions including pelvic pain, elimination dysfunctions, problems during pregnancy and post partum, hip and lower back pain, pudendal neuralgia, IC/PBS, vulvodynia/provoked vestibulodynia and vaginismus.
I work for a large hospital system that is very supportive of pelvic health. Our PTs and physicians collaborate for the best possible outcomes for patients. I truly love what I do and who I get to do it with.

How did you get involved in the pelvic rehabilitation field?

Truthfully, it was never on my radar. My supervisor years ago suggested I go to a course and I thought she was nuts. A marathoner/tri-athlete at the time, I wanted to work with athletes. But when she persisted with the idea the following year, I took her up on her suggestion. Sitting in my first class (PF1) and listening to Holly Herman, I was HOOKED. I felt like a duck that has finally discovered water and I never looked back.

What/who inspired you to become involved in pelvic rehabilitation?

I suppose my supervisor at the time saw something in me that I did not see in myself, for which I am so grateful. But truly, I will never forget my experience with Holly at my first PF1 course. I can still picture myself (in the front row because I am "that" girl) laughing hysterically at her stories and soaking in her incredible wisdom, compassion, and wit. I also realized at the time that I would love to teach. Years later it has been a dream come true to be on faculty with Herman and Wallace.

What motivated you to earn PRPC?

It is the only certification that really tests the skill set that I have been developing over the past 13 years. I also saw how much work Herman and Wallace put into developing it. It was an honor to be a part of the first testing group. I am just thrilled that pelvic floor therapists can have specialty certification. It's been needed for a long time.

How have you developed as a therapist after earning your PRPC certification?

I have to say that the process of studying for the PRPC really helped me take my learning to a new level. I joined a study group with an AMAZING group of women who were so inspiring. We all worked together and pushed each other and we all passed. The experience helped get excited about pelvic floor physical therapy in a whole new way.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?

The wealth of information coming from amazing researchers like Ruth Sapsford, Diane Lee and Paul Hodges really shows how the pelvic floor is just one group of muscles in a whole motor system of musculature that needs to be assessed and addressed in the majority of our patients, not just those with elimination or pelvic pain disorders. Moreover I would also like to say to pelvic floor therapists: Jump in with both feet! It can be intimidating to treat men or bowel patients but often you are the only person who has at least one tool that can help these patients. Most often we learn the most when we are outside of our comfort zone.

What ways do you work to inspire your patients? Other therapists?

I love learning and that passion rubs off on my patients. I read a ton and get excited by new research and science tidbits. I always said that if I were not a PT I would have followed in my parents' footsteps and become a teacher. I enjoy mentoring other therapists and helping them grow. We have a large group of West Michigan PTs who get together periodically and also email each other. I am always blowing up their inboxes with things I find interesting. I really try to practice what I preach as well.

What is in store for you in the future?

My PRPC study group would like to get back together at some point and study for the WHS. I am thinking about Ginger Garner's Yoga Therapy Certification. But right now I am very content to enjoy my sweet daughters and husband and maintain a healthy balance between home and work life.

Learn more about Jennafer Vande Vegte, MSPT, BCIA-PMB, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

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Erica Vitek - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Erica Vitek MOT, OTR, BCB-PMD, PRPC


Describe your clinical practice:

I have two outpatient based practice locations. One is located right next to the Marquette campus in Milwaukee, Wisconsin at Aurora Sinai Medical Center. The second location that I offer pelvic rehabilitation is in a suburb of Milwaukee at the Aurora Women’s Pavilion, Franklin. I treat women and men and also have taken the Pediatric course with Herman and Wallace and am working on marketing that area of my practice. I also have a special interest in Parkinson disease. I am specially trained in amplitude based exercise for people with Parkinson disease and am a certified LSVT BIG provider and faculty member of LSVT global certifying clinicians in this treatment around the United States and internationally. The area of pelvic health fits in very nicely with this population as the research demonstrates approximately 60% of people affected by Parkinson disease experience urinary incontinence and 80% experience constipation.

What/who inspired you to become involved in pelvic rehabilitation?

I attended college at Concordia University in Wisconsin. A local occupational therapist who had been practicing pelvic floor therapy for some time came to one of our foundational courses to demonstrate different niche practice areas. The demonstration revolved around the use of biofeedback. I was so intrigued that I could demonstrate concrete information to patients for learning. However the primary reason of intrigue was being able to have such an enormous impact on a patient’s quality of life. Treating bladder and bowel issues, being my primary initial interest, has grown into an amazing pelvic rehabilitation practice encompassing all areas of pelvic health.

What motivated you to earn PRPC?

When I attended the Herman and Wallace Pelvic Floor Level 3 course, we were told there was a certification in the works. I was already in the process of perusing my board certification in biofeedback for pelvic muscle dysfunction, but was intrigued in the vast amounts of knowledge beyond that. I wanted to be able to demonstrate to my patients that I had put in the effort to go above and beyond to ensure I had the knowledge and resources to rehabilitate their very private and sensitive conditions. I feel that having the certification not only demonstrates my expertise in pelvic health but my dedication to patient’s well-being and healing.

What patient population do you find most rewarding in treating and why?

Daily, I observe impact being made in all patients that I see as is reported by all of my colleagues treating pelvic health issues. I truly feel compassion for these patients and love to share in their joy of improvement. Patients that are able to avoid surgery or recover from surgery with the help of pelvic floor therapy is extremely rewarding. Treating patients with Parkinson disease and pelvic floor dysfunction is also an important part of my practice and most rewarding for many reasons. The movement issues that these patients are dealing with, such as hand tremor resulting in difficulty with clothing adjustment for toileting, muscle stiffness/rigidity and balance issues resulting in difficulty getting up out of bed or chairs and ambulating to the bathroom safely, as well as slowness/bradykinesia delaying arrival to the bathroom can be life altering. These patients and their caregivers may become socially isolated. It may be hard enough to manage these conditions at home therefore going to others homes, out in public, or on vacation may become overwhelming or impossible. Pelvic rehabilitation can have a profound impact on independence, community participation, socialization, and personal relationships. Many times sexuality issues experienced by people with Parkinson disease had not yet been discussed, so what an opportunity for us as pelvic rehabilitation specialists to address this.

Learn more about Erica Vitek MOT, OTR, BCB-PMD, PRPC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

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Stress & Bowel Dysfunction

digestive system

A recent article describing the impact of psychological factors on bowel dysfunction describes several mechanisms by which this may occur. Issues cited that may influence the bowels include psychological stress, which can lead to nausea, vomiting, abdominal pain, and changes in bowel patterns or habits. Stress can also affect the hypothalamus-pituitary-adrenal axis, or HPA axis. This axis is a major part of the neuroendocrine system that, in addition to controlling stress reactions, regulates many body functions such as digestion and immunity. During stress, cortico-releasing factor (CRF) can also be released, and act directly on the bowels or via the central nervous system. The authors point out that CRF can also affect the microbiota composition within the gut.

Corticotrophin-releasing factor can affect gut motility, permeability, and inflammation. The way in which motility is affected can vary, from increased movement of bowel contents to more sluggish movement, depending "…on the type of CRF family receptor expressed on the target organ." Gut permeability can also be affected by CRF, leading to bowel hypersensitivity and other issues such as nutritional absorption dysfunction. Stress-associated inflammation is also of concern, with markers of inflammation being found in patients who have irritable bowel syndrome and other conditions. Dysbiosis, or microbial imbalance, can be caused by stress, leading to changes in bowel motility , inflammation, and permeability, according to the referenced article. Diet-induced dysbiosis, discussed in this article, can lead to inappropriate inflammation and to cellular damage and autoimmunity, making a person vulnerable to chronic disease of the gastrointestinal tract. Such disease conditions may include ulcerative colitis, Chrohn's disease, celiac disease, and diabetes. Probiotics, prebiotics, and alterations in dietary intake are current therapeutic approaches, with further research needed to determine what types of interventions are most helpful for specific conditions.

Pelvic rehabilitation providers, especially those who are newer to the field, quickly discover that trying to treat pelvic dysfunction without knowledge of bowel health is like trying to treat low back pain while ignoring the pelvis: to truly ease symptoms both may need to be addressed. Patients often present with a combination of issues in the domains of bowel, bladder, sexual health and pain, and being able to address all with expertise aids in effectiveness of care. If you are interested in learning more about bowel dysfunction, faculty member Lila Abbate teaches her continuing education course "Bowel Pathology and Function" in California in early November. There is also an opportunity to learn about how to ameliorate stress and its potentially negative affects on bowel health by attending the Mindfulness-Based Biopsychological Approach to the Treatment of Chronic Pain taking place in Seattle in November.

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Differential Diagnosis: A Big Deal

pelvic pain

According to the APTA's Guide to Physical Therapist Practice, physical therapists use a systematic process, also termed differential diagnosis, to place a patient into a diagnostic category. This diagnosis is aimed towards defining the dysfunctions that will be treated, and in determine the needs of the patient based on each individual's presentation. Rehabilitation professionals must also consider symptoms and clinical examination findings that point to a need for other health care providers' involvement. In pelvic rehabilitation, this becomes a challenging process. In an article in Canadian Family Physician, physicians Bordman & Jackson list conditions that can cause chronic pelvic pain, and these conditions cover a variety of body systems and conditions. For example, bladder, bowel, or gynecologic malignancies, endometriosis, pelvic congestion, interstitial cystitis, urethral syndrome, constipation, inflammatory or irritable bowel syndrome can all cause pelvic pain. Abdominal wall or pelvic floor muscle myofascial trigger points, coccyx pain, neuralgia, and even depression can be other sources for pain. Certainly, it is uncommon to find only one source of pain in our population of patients with chronic pelvic pain.

Within a multidisciplinary approach, which is more often the recommended approach to treating chronic pelvic pain, physical therapy will ideally work with other practitioners to develop the best course of care for the patient. In my professional experience mentoring students and therapists, once a pelvic rehabilitation provider has learned basic skills and has treated many patients, the therapist develops a keen interest in improving skills of differential screening. The ability to diagnose requires learning which keys unlock certain doors, whether from an organs systems standpoint or a musculoskeletal standpoint. The Institute offers several courses that focus on the ability of a therapist to test specific tissues and movement patterns to determine the most appropriate plan of care. Steve Dischiavi's Biomechanical Assessment of the Hip and Pelvis includes a sports medicine approach to evaluating and treating hips and pelvic dysfunction, which can often confound one another. Finding the Driver in Pelvic Pain is another popular course instructed by faculty member Elizabeth Hampton and the course emphasizes pelvic pain and the musculoskeletal co-morbidities that often accompany pelvic floor dysfunction. More dates are being scheduled for these 2 continuing education courses, sign up early to hold your spot!

You still have an opportunity to take Peter Philip's Differential Diagnostic of Chronic Pelvic Pain & Dysfunction this course takes place in Connecticut in mid-October. In this course, Peter emphasizes anatomical palpation, nervous system influence on pelvic pain, and biomechanical examination of nearby joints and tissues. Internal labs are included in this 2-day continuing education course. If you are interested in hosting any of these courses, contact the Institute today to get the process started!

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Does Chronic Pelvic Pain Affect Male Fertility?

Male chronic pelvic pain (CPP) is well-known to be associated with sexual health impairments including, but not limited to, pain limiting sexual activity, premature ejaculation, erectile dysfunction. In addition to potential interference in sexual activity due to pelvic pain associated alteration in libido and function, does CPP affect sperm health? According to a systematic review and meta-analysis published this year, semen parameters are impacted in men who present with chronic pelvic pain. 12 studies were utilized, including nearly 999 cases and 455 controls. Semen parameters studied included seminal plasma volume, sperm concentration, total sperm count, motility, vitality, and morphology. Men diagnosed in the studies with CPP or chronic pelvic pain syndrome (CPPS) met the NIH criteria for the condition.

The results of the analysis indicate that sperm concentration, percentage of progressively motile sperm, and morphologically normal sperm in patients with CPP/CPPS were significantly reduced when compared with controls. Semen volume was higher in the CPP pain group than in controls, and the results suggested no significant difference in sperm total motility, sperm vitality, and total sperm count. How do these factors affect fertility? The authors point out that semen parameters are "the mainstay of male fertility and reproductive health assessment" and and that the percentage of morphologically normal sperm is an indicator of male fertility potential. While the sperm concentration was identified to be lower in male patients who have CPP, the semen volume being elevated may affect these numbers. Sperm motility, being necessary for fertilization, would logically be a factor in potential impairment of fertility.

The authors discuss the possibility that an inflammatory response associated with chronic pelvic pain, or an autoimmune response against prostate specific antigens factor into the alterations in semen analysis observed in men who have chronic pelvic pain. While the issue of fertility and pelvic pain is controversial, and not entirely understand, we can hypothesize about local factors affecting pelvic and sexual health, as well as autonomic nervous system implications mediated by the chronic pain state. As science aids in the understanding of the mechanisms affecting semen parameters, pelvic rehabilitation professionals will continue to address the potential causes of the dysfunction: nervous system dysfunction such as anxiety, depression, hormonal regulation, and neuromuscular pain states that may affect local blood and lymph flow (and therefore affect cellular nutrition and removal of waste products of cellular metabolism). If you are interested in learning more about male anatomy, sexual dysfunction, pelvic pain, and incontinence, come to the Male Pelvic Floor Function, Dysfunction, & Treatment continuing education course in Tampa in October!

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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Chicago, IL (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Cancer Treatment Centers of America - Chicago, IL

Male Pelvic Floor - St. Paul, MN (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Regions Hospital

Pelvic Floor Level 1 - Boston, MA (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Marathon Physical Therapy

Chronic Pelvic Pain - Kansas City, MO (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Saint Luke\'s Health System

Pudendal Neuralgia and Nerve Entrapment - Philadelphia, PA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Core 3 Physical Therapy

Pelvic Floor Level 2B - Freehold, NJ (Rescheduled)

Apr 4, 2020 - Apr 6, 2020
Location: CentraState Medical Center

Sexual Interviewing for Pelvic Health Therapists - Seattle, WA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Evergreen Hospital Medical Center

Pelvic Floor Level 2A - Grand Rapids, MI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Mary Free Bed Rehabilitation Hospital

Pelvic Floor Level 1- Kansas City, MO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Centerpoint Medical Center

Oncology of the Pelvic Floor Level 1 - Grand Junction, CO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Urological Associates of Western Colorado

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Virginia Hospital Center

Pelvic Floor Level 2B - East Greenwich, RI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: New England Institute of Technology

Pilates for the Pelvic Floor - Livingston, NJ (Rescheduled)

Apr 18, 2020 - Apr 19, 2020
Location: Ambulatory Care Center- RWJ Barnabas Health

Genital Lymphedema

Apr 24, 2020

Pelvic Floor Level 1- Canton, OH (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Aultman Hospital

Pelvic Floor Level 1 - Rochester, NY (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Unity Health System

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Michigan Medicine

Lumbar Nerve Manual Assessment and Treatment - Madison, WI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: University of Wisconsin Hospital

Pelvic Floor Level 2A - Winfield, IL (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Trenton, NJ (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Robert Wood Johnson Medical Associates

Athletes & Pelvic Rehabilitation - Minneapolis, MN (Rescheduled)

Apr 25, 2020 - Apr 26, 2020
Location: Viverant

Sacral Nerve Manual Assessment and Treatment - Fairlawn, NJ

May 1, 2020 - May 3, 2020
Location: Bella Physical Therapy

Pelvic Floor Level 1 - Fayetteville, AR

May 1, 2020 - May 3, 2020
Location: Washington Regional Medical Center

Pelvic Floor Level 1 - Boise, ID

May 1, 2020 - May 3, 2020
Location: St Luke's Rehab Hospital

Pediatric Incontinence - Duluth, MN

May 1, 2020 - May 3, 2020
Location: Polinsky Medical Rehabilitation Center

Yoga for Pelvic Pain - Online Course

May 2, 2020 - May 3, 2020