In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Marika Zandstra PT, PRPC
What motivated you to earn PRPC?
I was motivated to earn my PRPC because I wanted to promote the field of pelvic rehabilitation as well as my own practice. I believe that certification examinations give credibility to the quality of treatment that patients are already receiving and I wanted to be a part of improving the awareness as to the type and quality of treatment that pelvic specialists provide. I felt the PRPC was more focused specifically on pelvic conditions and therefore, more applicable to my current practice.
What advice would you give to physical therapists interested in earning PRPC?
Continue to utilize your skills on a daily basis and focus on the foundation of why you are providing those skills. Identify on all the different systems involved in providing pelvic rehabilitation and understand their pathways. It helped me to remember the anatomy, physiology and treatment techniques by linking them to my real patient cases. This helped me remember the what, where and why when answering questions on the exam.
What role do you see pelvic health playing in general well-being?
I feel that we, as pelvic practitioners, we tend to focus more on the patient as a whole. In pelvic therapy, we are dealing with so many systems that a patient’s general well-being can be greatly improved by our care, education and treatment. Pelvic practitioners are often the ones providing referrals and guidance to patients for other providers that will address other aspects of their general overall heath, in order to promote healing in the pelvic conditions that we are treating. I believe pelvic rehabilitation is a “whole person” therapy that addresses specific conditions as well as a person’s well-being as a whole.
How did you get involved in the pelvic rehabilitation field?
I kind of fell into treating patients with pelvic conditions initially. I had been working as an outpatient, orthopedic therapist for several years when my clinic received a referral to treat a patient with incontinence. Having worked with a therapist in the past, who treated incontinence, I was familiar with some basic strengthening exercises and the patient improved. After that, I became more curious about the field and started attending continuing education whenever I could. I was motivated to continue with pelvic rehabilitation because I felt that there was a real need offer services to patients dealing with such delicate problems that often had such an enormous impact on their lives. The more I learned about pelvic conditions and treatment, the more I wanted to learn. It has been a very rewarding career path.
Learn more about Marika Zandstra PT, 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.
What structures may be implicated in posterior hip pain in the athlete? This question is addressed in a comprehensive article that can be accessed here. Complaints of posterior hip pain are increasingly common, and the differential diagnosis can include a variety of conditions and structures. The differential diagnosis of posterior hip pain may include hip extensor or hip rotator muscle strain, femoroacetabular impingement, proximal hamstring rupture, piriformis syndrome, and referral from the lumbar spine or sacroiliac joint, and systemic conditions such as cancer or infection, according to the article. To this list, could we add sciatic and other nerves in the buttock and pelvic floor, ischial injuries or ischial bursa irritation? With lists that include both systemic dysfunction and a variety of potential neuromusculoskeletal causes of posterior hip pain, the therapist must have a comprehensive ability to apply clinical reasoning, expert interview, and solid clinical examination and evaluation skills.
Posterior hip pain is only one type of hip pain, and one complaint within the world of pelvic pain. How does the therapist keep sharp tools for diagnosing musculoskeletal conditions, other connective tissue dysfunctions, as well as screen for disease conditions and other dysfunctions that can mimic hip or pelvic pain? Herman & Wallace has increased our offerings of courses towards differential diagnosis of hip and pelvic pain, including Biomechanical Assessment of the Hip & Pelvis, taught recently by Steve Dischiavi. (Stay tuned for Steve's upcoming course schedule!)
Another continuing education course that offers excellent opportunity to fine tune your skills in Differential Diagnosis of Pelvic Pain is coming up in October in Connecticut. The course is instructed by Peter Philip, who completed his Doctor of Science degree on the topic of Differential Diagnostics of Pelvic Pain. In addition to learning detailed anatomy and palpation skills, the participant can take away from the course a better understanding of embryology, the somatic and autonomic nervous system, and pelvic conditions that may be caused by or influenced by pelvic pain. The course will include both internal and external pelvic muscle examination techniques. With seven labs scheduled in this continuing education course, the participant will have abundant opportunities to practice instructed skills.
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Christina McManigal, PT, DPT, PRPC
How did you get involved in the pelvic rehabilitation field?
Initially, I had an interest in women’s health because I grew up around a family full of laughter and women who crossed their legs a lot. I thought, ‘This isn’t right, there must be something that can be done about this’. I also experienced pelvic pain myself due to excessive running, and became more and more intrigued about how to address these problems without surgery or medications. The answers doctors or Dr. Google (the internet) always had were frightening – cancer, cysts, surgery must be needed... None of that resonated with me, so I pursued a clinical rotation in women’s health and was very fortunate to connect with Heather Jeffcoat PT, DPT. She inspired me to further pursue women’s health and specifically pregnancy/postpartum and pelvic pain education. Heather was pregnant at the time of being my CI which was great learning experience. She also taught me what a positive impact physical therapy can have on a women’s health and well being, their intimate relationships and comfort during and after pregnancy.
What/who inspired you to become involved in pelvic rehabilitation?
I equally love working with post partum moms as well as any woman with pelvic pain. The pelvis is such a taboo subject to most women, and many women don’t even understand that there are muscles in the pelvis, much like the rest of the body. When I am able to educate them in simple, understandable terms, to help them realize that their pain is not a mythical, mysterious or threatening issue it’s as if her entire body can sigh with relief. When a woman realizes that her pain is just muscles, it’s not cancer, it’s not something wrong with her reproductive system, it’s not going to last forever – then real progress can be made and many times a woman’s life can take a dramatic turn for the better. The oppressive worry and self criticism, and often times depression that can be associated with pelvic pain slowly begins to melt away when a woman is empowered by knowledge and self awareness.
What patient population do you find most rewarding in treating and why?
One of the most rewarding experiences I have had is helping a patient experience intercourse with her husband after 17 years of abstinence. I can’t say how grateful I am that this woman trusted me and let me guide her healing process. With diligent effort on her part, inclusion and support from her husband, and education from me, we were able to reconnect them in that intimate and innate way that is so significant to many relationships. I truly enjoy treating women with pelvic pain, especially post partum. It’s so rewarding to be the person in their lives cheering them on, and focusing on the mom. I believe helping moms heal and be well helps the whole family. Addressing pelvic pain and helping women re-connect with their new bodies is a joy.
What motivated you to earn PRPC?
I chose to pursue the PRPC in an effort to promote the practice of women’s health physical therapy. All too often I have women, or even physicians, tell me they did not know what a physical therapist could do for incontinence, pelvic pain or pregnancy related issues. Our work is so important, so vital to the wellbeing of women in our communities, and I felt that having a certification in this area would be another tool for getting that word out here in the Columbia Gorge. I am also thrilled to be part of this national team of women who are on a mission to reach out and connect with others to advocate for our profession and women as a whole. As I said before, so many issues women face with their health, and physical changes we go through as moms and aging women are simply not talked about enough. There’s a lot of fear associated with any change in our bodies. Education is power, and when women start to learn more about their bodies we will become a healthier nation.
Learn more about Christina McManigal, PT, DPT, 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.
This post was written by H&W instructor Ginger Garner, MPT, ATC, PYT. Ginger will be instructing the course that she wrote on "Yoga as Medicine for Pregnancy" in New York this November.
The power of language is inarguable. The spoken word affects how we see, perceive, and interpret the world around us. Language can also influence our actions and behavior, especially toward people around us.
The power of language in health care is not only important, but critical in prenatal health. The language a provider uses can help or harm a mother’s confidence and even her beliefs about birth.
Action to recognize and respond to the importance of language in general health care began with People First Language (PFL) movement. PFL advocates for mindful use of language that identifies the person first, rather than identifying the person based on their disability. Advocacy groups first started the movement for children’s sake. Mother’s who had given birth to children with Down’s syndrome wanted their children to be recognized as people first, rather than by their disability.
An example of People First Language would be, “Beth is a child who has Down’s syndrome,” instead of “Beth is a Down’s (syndrome) child.”
The second statement can be dehumanizing, whether intentional or subconscious. The effects of being identified as a disability, rather than as a human being, are far reaching on psycho-emotional and physical health, and can project a negative connotation on the individual. Read more on People First Language
However, have you noticed that no such language is used for prenatal care?
The shameful statistics on American childbirth and mortality rates for mothers and babies is no secret, internationally. However, many US mothers may not realize that their likelihood of receiving poor prenatal care is so high. In fact, it is dangerously high. Read my post: American Childbirth: A Human Rights Failure?
However everyone, including health care providers who provide prenatal care, can have a powerful impact on improving childbirth in America.
How? Through language.
Yoga as Medicine for Childbirth & Postpartum courses I teach for Herman & Wallace Pelvic Rehabilitation Institute, language is a powerful part of the empowerment process for women. It is an integral part of the biopsychosocial model available to 21st century healthcare providers who use yoga in prenatal and postpartum care. Yoga can improve postpartum physical therapy care and help moms who want to have a natural childbirth. Yoga is also a powerful prenatal mind-body fitness aid as well and works to decrease pain across the journey of pregnancy and into postpartum. Read this post on Why Every Expectant Mom Needs Yoga.
Yoga is a mind-body practice that places paramount importance on language. In fact, yoga uses an entirely different language than biomedical prenatal or postpartum care. Yoga focuses on empowerment through language and action.
Prenatal care using women-centered language looks very different than the historically patriarchal driven vernacular that is still being used today. These statements describe the same situation, but have profoundly different effects on a woman and her confidence and ability to give birth. Consider these common scenarios from a perspective on The Power of Birth Language.
Which scenario would you rather give birth in:
“My doctor/midwife is going to let me use a birthing tub.”
VERSUS “My doctor/midwife supports my plan to give birth in water.”
“My doctor/midwife delivered my baby.”
VERSUS “I gave birth to my baby (in the are of ______).
The first scenario in each example takes power from the mother and negates her participation and involvement in pregnancy and birth. The first scenarios also place her in a dominator relationship under the authority and order of the health care provider.
The second scenario in each example recognizes that mothers should be full partners in their own healthcare, not subordinates without a voice. The second scenario also recognizes that birth should be women-centered, not healthcare provider-centric.
Woman-centered language can usher in a powerful shift in prenatal care, helping tip the scales toward the positive for birth reform in America. Adopting the mindfulness of an ancient system, like yoga, can likewise enrich and expedite the process of reclaiming the full power of birth.
To learn more about Ginger's Women-centered continuing education for health care providers seeking integrated care when working with women during pregnancy or postpartum, visit Yoga as Medicine for Childbirth & Postpartum and join her for Yoga as Medicine for Pregnancy
According to the American Cancer Society, approximately 233,000 new cases of prostate cancer will be diagnosed this year, and nearly 30,000 men will die from the disease. The diagnosis and treatment of prostate cancer in the United States has experienced significant shifts in the past few years, making management of cancer survivors challenging. One of the big changes in prostate cancer screening took place in 2011; the US Preventive Services Task Force recommended against routine prostate specific antigen, or PSA testing due to the level of potential harm such as psychological distress and complications from the biopsy. You can read a prior post about that here. New guidelines for providing care to prostate cancer survivors have been published by the American Cancer Society so that providers can better identify and manage the side effects and complications of the disease and recognize appropriate monitoring and screening of survivors.
In patients younger than 65 years of age, radical prostatectomy surgery is the most common intervention for prostate cancer. Long-term side effects of radical prostatectomy commonly include, according to the guidelines, urinary and sexual dysfunction. Urinary incontinence or retention can occur following prostatectomy, and sexual issues can range from erectile dysfunction to changes in orgasm and even penile length. Other common treatments, such as radiation and androgen deprivation therapy, are also related to urinary, sexual, and bowel dysfunction, as well as a long list of "other" effects.
These guidelines were developed using evidence as well as expert recommendations. Topics covered include obesity, physical activity, nutrition, smoking cessation, and surveillance. BMI as a baseline measure is recommended as a screening tool because elevated BMI is associated with poorer health outcomes. Increased physical activity can be related to higher quality of life and general benefits in cardiorespiratory health and physical function. Exercise recommendations are for 150 minutes/week of moderate intensity exercise or 75 minutes/week of vigorous intensity physical exercise. Nutrition suggestions include eating a diet that is rich in vegetables, fruits, and whole grains. Because smoking after prostate cancer increases the risk of recurrence, therapists should discuss the benefits of smoking cessation.
All of the above issues concern pelvic rehabilitation providers; patient concerns about sexual heath, urinary and bowel health, and subsequent pain in the abdomen or pelvis following treatment for prostate cancer are all conditions that can be positively influenced in the clinic. All of the lifestyle and wellness recommendations are ones that can be reinforced in pelvic rehabilitation, and patients can be referred for more specialized education when needed. To learn more about the care of men following prostate cancer, come to Male Pelvic Floor Function, Dysfunction, & Treatmentcontinuing education course in October in Tampa. Also, stay tuned for an announcement about our new Rehabilitation of the Post-Prostatectomy Course coming in 2015! (Send us an email if you are interested in hosting the new continuing education course that will focus on post-prostatectomy (and related issues) recovery!)
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Jasmine Sia DPT, PRPC
Describe your clinical practice:
I’ve worked at Kirk Center for Healthy living in Lockport, Illinois for the last 3 and half years. We see both men and women with pelvic floor dysfunction, GI problems, and orthopedic condition. It is a small privately owned facility where we have two sites; Lockport and Oak Lawn. We see patients on an hourly basis and we get to work with them one on one. All of us here are manually based therapists and we incorporate independence and best practice. We incorporate manual techniques predominately using visceral manipulation and would like to be proficient in vascular, manual articular, and neural work.
How did you get involved in the pelvic rehabilitation field?
I had interests in gynecology/obstetrics before going to PT school. And while at PT school I had an opportunity to go on an internship where they had pelvic floor therapists. At Loyola, I learned a lot about pelvic floor issues. It was so fascinating and exciting.
What/who inspired you to become involved in pelvic rehabilitation?
On my first job as an orthopedic therapist, I was seeing more and more pelvic floor muscle complaints and dysfunction on the patients I was seeing for lower back, neck, LE diagnoses. I was the first one to screen them for dysfunction with their pelvic organs even though they were seeing me for a hip pain. Patients always tell me that they don’t offer the information because they think it was normal to have the problems. As I was seeing more and more of that, I felt that I wasn’t treating the patient as a whole and just treating them by parts. I thought to myself that an individual is like a puzzle where it is made out of difficult and complicated parts/pieces. And with my training and ongoing aspiration that I can help them.
What patient population do you find most rewarding in treating and why?
Every patient whether they have s/p hysterectomy, endometriosis, infertility, or GERD. The patients are very grateful to have just someone to actually listen to them about their problems and that the symptoms they are feeling are just not all in their heads. They have seen so many people with their problems that they finally found someone who could possibly understand and help them get better. Even if they only get better 70% they are still very thankful.
Learn more about Jasmine Sia DPT, 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.
Concepts in "core" strengthening have been discussed ubiquitously, and clearly there is value in being accurate with a clinical treatment strategy, both for reasons of avoiding worsening of a dysfunctional movement or condition, and for engaging the patient in an appropriate rehabilitation activity. Because each patient presents with a unique clinical challenge, we do not (and may never) have reliable clinical protocols for trunk and pelvic rehabilitation. Rather, reliance upon excellent clinical reasoning skills combined with examination and evaluation, then intervention skills will remain paramount in providing valuable therapeutic approaches.
Even (and especially) for the therapist who is not interested in learning how to assess the pelvic floor muscles internally for purposes of diagnosis and treatment, how can an "external" approach to patient care be optimized to understand how the pelvic floor plays a role in core rehabilitation, and when does the patient need to be examined by a therapist who can provide internal examination and treatment if deemed necessary? There are many valuable continuing education pathways to address these questions, including courses offered by the Herman & Wallace Institute that instruct in concepts focusing on neuromotor coordination and learning based in clinical research.
One article that helps us understand how the trunk can be affected by the pelvic floor was completed in 2002 by Critchley and describes how, in the quadruped position, activation of the pelvic floor muscles increased thickness in the transversus abdominis muscles. Subjects were instructed in a low abdominal hallowing maneuver while the transversus abdominis, obliquus internus, and obliquus externus muscle thickness was measured by ultrasound. While no significant changes were noted in obliques muscle thickness, transversus abdominis average measures increases from 49.71% to 65.81% when pelvic floor muscle contraction was added to the abdominal hollowing. Clinical research such as this helps us to understand how verbal cues and concurrent muscle activation may affect exercise prescription.
A collection of clinical research concepts such as the article by Critchley is valuable in connecting points of function and dysfunction for patients with trunk and pelvic conditions- a large part of many clinicians' caseloads. The Pelvic Floor Pelvic Girdle continuing education course instructs in foundational research concepts that tie together the orthopedic connections to the pelvic floor including lumbopelvic stability and mobility therapeutic exercises. Common conditions such as coccyx pain and other pelvic floor dysfunctions are instructed along with pelvic floor screening, use of surface EMG biofeedback, and risk factors for pelvic dysfunction. If you would like to pull together concepts in lumbopelvic stability with your current internal pelvic muscle skills, OR if you would like to attend this course to learn external approaches, you can sign up for the class that takes place in late September in Atlanta.
In a recent study examining demographic and obstetric factors on sleep experience of 202 postpartum mothers, researchers report that better sleep quality correlated negatively with increased time spent on household work, and correlated positively with a satisfactory childbirth experience. Let's get right to the take home points: how are we addressing postpartum birth experiences in the clinic, and how can we best educate new mothers in self-care? You will find many posts in the Herman Wallace blog about peripartum issues, and you can access the link here.
The authors recommend that healthcare providers "…should improve current protocols to help women better confront and manage childbirth-related pain, discomfort, and fear." Do you have current resources with which you can discuss these issues (and a referral to an appropriate provider) when needed? In our postpartum
course, we highlight the challenges a new mother faces due to the commonly-experienced fatigue in the postpartum period. According to Kurth et al., exhaustion impairs concentration, increases fear of harming the infant, and can trigger depressive symptoms. Issues of lack of support, not napping, overdoing activities,, worrying about the baby, and evenworrying about knowing you should be sleepingcan worsen fatigue in a new mother. (Runquist et al., 2007)
Back to what we can do for the patient: investigate local resources. This may include knowing what education is happening in local childbirth classes (and providing some training when possible respectfully inquiring of new mothers how they are doing with sleep and demands of running a household (and business or work life and finding out what support/resources the new mother has but is not accessing. Patients are often hesitant to ask for help, or may feel guilty in hiring someone to help clean for the first few months, feeling that she "should" be able to handle the chores and tasks. Educating women about results of the research and about potential improvements in quality of life can help the entire family.
If you are interested in learning more about Care of the Postpartum Patient, sign up today for our next continuing education course taking place next month in the Chicago area. (Don't you have a friend to visit in Chicago?) If you can't attend the Postpartum course, how about the Pregnancy and Postpartum Special Topics course taking place in October in Houston? Check the website as we add more Peripartum course series events, including Care of the Pregnant Patient, for 2015!
In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Marci Marshall, PT, PRPC
If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
Thinking “out of the box”…I always say to my patients that there are many pieces to a puzzle and we just have to find the right pieces to fit together for them to be on the path to healing. I believe that pelvic rehabilitation requires a multidisciplinary approach. There are many complementary services; such as, dry needling, visceral therapy, massage therapy, acupuncture, mindfulness meditation and yoga that need to be considered. Be open to try something new and to explore as many avenues as feasible. It is so important to give patients back some control in their lives in a positive and empowering manner.
What has been your favorite Herman & Wallace Course and why?
Myofascial Release for Pelvic Dysfunction taught by Ramona Horton, MPT. Her techniques helped to further refine my ability to load tissue in multiple planes and allow the tissue to direct me to the restrictions both externally and internally. I found that my fingers could be “softer” and I just needed to “feel & follow” to be just as effective! She provided me with a new tool to put in my tool bag! She is a very captivating instructor and provides a wealth of information!
What makes you the most proud to have earned PRPC?
I have been a therapist for thirty years, the last ten years as a Women’s Health Specialist. My husband, also a physical therapist, has always supported my career goals. He said, “What will mean more to you at this stage in your career, a doctorate degree or a specialization certification? My answer to him was to pursue a certification that represented my knowledge and dedication to this field. I wasn’t sure if I was capable of achieving this goal since I hadn’t taken an exam of this caliber since my state’s board examination. When they told me the first exam was going to be longer and harder than subsequent exams I was very intimidated and almost backed out! I can’t describe the excitement and sense of accomplishment I felt when I received the email that I had passed!
What is in store for you in the future?
To continue to learn! I am pursuing my Dry Needling Certification because I have seen how well it complements my services for pelvic pain patients. I also want to promote more homeopathic and holistic services in my practice in the near future.
Learn more about Marci Marshall, PT, 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.
This post was written by H&W founder and instructor Kathe Wallace, PT, BCB-PMD. Kathe's book, “Reviving Your Sex Life after Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby” is available now
In June 2013 the APTA House of Delegates adopted a landmark new vision of the profession of physical therapy: "Transforming society by optimizing movement to improve the human experience." I grinned from ear to ear realizing that the movement of the entire body and the muscles of the pelvic floor are a key experience of human sexuality. Patients with multiple types of dysfunction benefit from physical therapy for the improvement of sexual function, an essential part of the human experience. Evaluating and treating sexual dysfunction is an important part of a pelvic rehabilitation physical therapy practice.
I am excited to announce the publication of my book “Reviving Your Sex Life after Childbirth, Your Guide to Pain-Free and Pleasurable Sex after the Baby”. This book demystifies the rarely talked about problem of pelvic floor health targeting the post-partum woman, where many problems begin. It provides information every woman (from 6 weeks to 60 years postpartum) should know about the common birth-related changes in the pelvic floor muscles and pelvic region. It contains specific graphics for performing perineal and abdominal scar massage techniques and using dilator and pelvic floor massage tools for pelvic floor stretching. Readers will learn techniques for pelvic floor control, release and PELVIC FLOOR PLAY™.
One of the early inspirations to write my book was an article from British Journal of Ob/Gyn which discusses the fact that sexual health problems were very common after childbirth, suggesting potentially high levels of unmet need. I found in my practice that many of my patients just needed some basic information that was not available in one location. With the availability of this book, I hope is that women will learn more about what physical therapy can do for pelvic function.
Visit the author page on my website to learn more and to purchase the book for yourself, your patients and your referral sources.