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Herman & Wallace Blog

Visceral Mobilizations and "Pathological Adhesions"

c-section

Insights in fascial mobility and dysfunctions are provided in this article by Gil Headley, and instructor who spends a significant amount of time working with anatomical dissections. Visceral fascia, according to Hedley, contains 3 layers: a fibrous outermost layer, a parietal serous layer, and a visceral serous layer. Fascial layers are, for the most part, designed to be able to slide over one another. Dysfunction can occur when there is a fixation in the connective tissues that prevents such sliding. A disruption in visceral fascial mobility may impair the necessary functional movement of the organs. Consider the mobility of the lungs and the heart when neuromuscular functions cause air or blood to expand and contract within the organ spaces. Bringing the concept to pelvic rehabilitation, what impairments are encountered when the bladder cannot easily fill or contract, or when movement of the bowels tugs on fascial restrictions? How are the tissues of the vaginal canal influenced by restrictions in tissues above, behind, or below the structure?

Examples of causes of adhesions may include (but not are limited to) inflammation from infections or disease, post-surgical scarring, dysfunctions caused by prior adhesion or limitation, and intentional therapeutic adhesions (think of a prolapse repair). While fibrous adhesions, once palpated, may be manually pulled apart, this is not the recommendation of the article author. Unfortunately, such an approach can result in further opportunity for inflammation and adhesions. One method of improving tissue mobility is to manually facilitate "…movement towards the normal range of motion of the fixed tissues with gentle traction…" timed with deep breathing. This technique may improve the ability of the organs and tissues to slide upon one another, and also may help in prevention of further movement restrictions. Would this type of intervention always require hands-on care? The author provides an example of a patient providing gentle traction by reaching to a pull-up bar, performing deep breathing and various trunk rotation positions following a thoracic surgery.

Visceral mobilization techniques may be a part of a patient's healing approach, and these techniques may be therapist-directed, patient-directed, or both. The Institute is pleased to offer two upcoming visceral mobilization continuing education courses next month instructed by faculty member Ramona Horton. Visceral Mobilization of the Reproductive System takes place in Boston, and Visceral Mobilization of the Urologic System is being hosted in Scottsdale.

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Vulvar Pain: What's the Evidence?

This post was written by H&W instructor Dee Hartmann, PT, DPT. Dee will be instructing the course that they wrote on "Assessing and Treating Women with Vulvodynia" in Connecticut this September.

Dee Hartmann

Within the last 4 years, two papers have been published looking at pelvic floor muscle function (PFMF) in women with and without provoked vestibulodynia (PVD). Gentilcore-Saulnier et al. sought to compare PFMF of those with and without vulvar pain and to prospectively assess how those with PVD respond PT intervention. In the first phase of their study, PFMF of 11 women diagnosed with PVD was compared to PFMF of 11 age matched controls. Outcome measures included 1) sEMG measurement of superficial and deep pelvic floor muscle (PFM) responses (both at rest and with contraction) to increasingly painful stimuli at the vulva and 2) PFMF as determined by digital internal assessment of tone, flexibility, ability to relax following contraction, and strength. In the second phase of the study, women with PVD attended 8 PT sessions (it is not clear how many were recruited from the first phase for the treatment portion and there were no controls). A specific PT protocol was utilized that included patient education, intravaginal manual therapy (including soft tissue mobilization, stretching, and desensitization), insertion activities with vaginal dilators, pelvic floor sEMG biofeedback followed by intravaginal electrical stimulation, and home exercises that included active, daily PFM exercises and every other day use of vaginal dilators.

The sEMG findings suggested that PFMF in women with PVD when compared to controls showed increased superficial PFM response to pain stimuli to the vulva but not for the deep PFMs, and significant PFM hypertonicity in the superficial but not the deep PFMs. Digital findings suggested decreased PFM flexibility and impaired ability to relax PFMs following active contraction. During intravaginal digital assessment- evaluating both superficial and deep muscles concurrently- in those with PVD, the authors found higher levels of pain with maximum voluntary contraction as well as elevated vestibular pressure sensitivity and pain intensity in both superficial and deep PFMs.

The authors concluded that women with PVD have an increased PFM response to pain and that that response was most likely due to a protective mechanism, causing active PFM contraction with impending touch, penetration, tampon insertion, fear, etc. Surface EMG showed evidence of elevated PFM activity at rest and increased PFM responsiveness in the superficial muscles following painful vulvar stimuli in those with PVD. Following 8 visits to physical therapy, women with PVD showed improvements in overall PFM tone, flexibility, strength, and ability to relax after contraction as well as improved quality of life. Patients treated also gained an increased ability to relax the PFMs following contraction which the authors hypothesize may be indicative of either increased flexibility and/or less tension at rest, or a sign of improved motor control and/or learned behavior responses gained from PT treatment.

Morin et al. studied PFMF with 4D transperineal ultrasound in 49 women with PVD and 51 matched controls. Transperineal ultrasound was chosen for the ability to measure PFMF externally at the perineum without provoking pain via specific vulvar touch or internal exam (i.e. intravaginal digital or sEMG measurements.) The working hypothesis in the study was that PFM morphology at rest would differentiate those with a history of pain from controls; that is, there would be greater PFM hypertonicity in women with PVD than those without a history of pain. Ultrasound readings at rest and with maximum PFM contraction provided the main outcome measures. Parameters measured included the levator plate angle, the anorectal angle, the area of the levator hiatus, and the anterior to posterior (AP) and right to left (RL) diameters in the midsagittal and axial planes.

The resulting data in the study confirmed the hypothesis; women with PVD exhibited morphological differences from controls both at rest and with maximum contraction, suggesting elevated PFM resting tone, decreased strength, and decreased control over active PFM mobility. All parameters measured (except left to right diameter) showed statistically significant differences at rest when comparing PVD to controls as were the levator plate angle and RL diameter with contraction. When reviewing changes from baseline at rest to full contraction, all parameters measured showed statistically significant differences between the two groups—displacement of the bladder neck, levator plate and anorectal excursion, narrowing of the levator hiatus, and reduction in both the AP and RL diameters.

The conclusion of the study included that women with PVD have altered PFM morphometry at rest, suggesting an increase in PFM resting tone that appears to be chronic rather than occurring only as a defense or protective mechanism. They also suggest that those with PVD have lesser strength with maximum contraction.

Both papers provide fodder for conversation. There is very little in the literature that suggests or validates a proper treatment protocol for PFM hypertonicity. The first study cited utilized a varied treatment intervention that included daily PFM exercises, but the research lacked a control group. Authors of both papers recommended PFM retraining for women with PVD. Several retrospective reviews were published in the early 2000’s that suggested protocols including regular PFM training resulting in successful decreases in vulvar pain and improvement in sexual function and quality of life. The only published randomized, controlled trial (RCT) utilizing PFM exercise showed efficacy of all modalities when comparing vulvectomy (removal of the vulvar tissues), cognitive behavioral therapy, and sEMG education (home program included 20 minutes of PFM exercises twice daily). Report on a 10 year follow-up to the paper I published (Hartmann & Nelson, 2008) demonstrated continued improvement of symptoms, quality of life, and sexual function without further treatment. And 2/3 of the subjects were still doing PFM exercises as a home program.

What do you do with patients who have vulvar pain? Let’s talk!

Learn more about Dee Hartmann and her course by visiting Assessing and Treating Women with Vulvodynia and join her in Waterford, Connecticut next month!

References

1.Gentilcore-Saulnier E, et al. Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. J Sex Med. 2010;7:1003–22.

2.Morin M, et al. Morphometry of the Pelvic Floor Muscles in Women With and Without Provoked Vestibulodynia Using 4D Ultrasound. J Sex Med. 2014;11:776–785.

3.Bergeron S, et al. Physical therapy for vulvar vestibulitis syndrome: A retrospective study. J Sex Marital Ther. 2002;28:183–92.

4.Hartmann EH, Nelson CA. The perceived effectiveness of physical therapy treatment on women complaining of chronic vulvar pain and diagnosed with either vulvar vestibulitis syndrome or dysesthetic vulvodynia. Journal of the Section on Women’s Health, APTA. 25(4), Dec 2001.

5.Bergeron S, et al. A randomized comparison of group cognitive—behavioral therapy, surface electromyographic biofeedback, and vestibulectomyin the treatment of dyspareunia resulting from vulvar vestibulitis. Pain. 2001;91:297–306.

6.Hartmann D, Nelson CA. Ten years after physical therapy for vulvodynia: are there lasting benefits? J Repro Med. 2008;53(11).

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Avoid Burnout! Take a Mindfulness Class!

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What is the best reason to take a mindfulness or meditation course? Self-care! How many of us make choices in our daily lives that put our own health and wellness first? While we stay busy doing the important work of taking care of our patients, we can often forget to take care of ourselvs. Oftentimes, in addition to perhaps not learning to value self-care as we were growing up in our own families, we don't have strategies or the time-management skills to implement self-care. What is self-care? Self-care, as suggested by compassionfatigue.org, can include healthy lifestyle practices involving physical activity and healthy dietary habits, setting boundaries (saying "no"), having a healthy support system in place, organizing daily life to be proactive rather than reactive, reserving energy for worthy causes, and creating balance in life. (Check out this link for a prior blog post on compassion fatigue!)


The truth is, healthcare providers are stressed and burnout is common. So how does taking a course in mindfulness benefit the health care provider? Recent research including a university center based mindfulness-based stress reduction course was implemented with 93 providers including physicians, nurses, psychologists, and social workers. The training involved 8 weeks of 2.5 hour classes in addition to a seven hour retreat. Participants were instructed in mindfulness practices including a body scan, mindful movement, walking and sitting meditations, and were involved in discussions in how to apply mindfulness practices in the work setting. Outcomes included the Maslach Burnout Inventory and the SF-12. Results of the training, which was offered 11 times over a 6 year period, included improved scores relating to burnout and mental well-being.

But where can you take a course to learn valuable self-care tools? First up, there's the Meditation and Pain Neuroscience continuing education course happening at the beginning of next month. Then there is the Mindfulness-based Biopsychosocial Approach to the Treatment of Chronic Pain taking place in November in Seattle! Join us as we spread the word about how to not only take good care of your patients, but also of yourself.

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Why 1x/week?

Hip

In pelvic rehab, if you ask therapists from around the country, you will most often hear that patients with pelvic dysfunction are seen once per week. This is in contrast to many other physical therapy plans of care, so what gives? Perhaps one of the things to consider is that most patients of pelvic rehab are not seen in the acute stages of their condition, whether the condition is perineal pain, constipation, tailbone pain, or incontinence, for example.

The literature is rich with evidence supporting the facts that physicians are unaware of, unprepared for, or uncomfortable with conversations about treatment planning for patients who have continence issues or pelvic pain. The research also tells us that patients don't bring up pelvic dysfunctions, due to lack of awareness for available treatment, or due to embarrassment, or due to being told that their dysfunction is "normal" after having a baby or as a result of aging. So between the providers not talking about, and patients not bringing up pelvic dysfunctions, we have a huge population of patients who are not accessing timely care.

What else is it about pelvic rehab that therapists are scheduling patients once a week? Is it that the patient is driving a great distance for care because there are not enough of us to go around? Do the pelvic floor muscles have differing principles for recovery in relation to basic strengthening concepts? Or is the reduced frequency per week influenced by the fact that many patients are instructed in behavioral strategies that may take a bit of time to re-train?

Pelvic rehabilitation providers are oftentimes concerned about the plans of care (POC) being once per week not because patients always need more visits, but because insurance providers are accustomed to seeing a POC with ranges of 2-3 visits per week, and in some cases, even 4-7 visits per week, based upon diagnosis, facility, and patient needs. To justify and support our once per week POC, we need only look to research protocols, to clinical care guidelines, and to clinical recommendations and practice patterns of our peers. For the following conditions, most of the cited research uses a once per week (or less) protocol or guideline:

Braekken et al., 2010: randomized, controlled trial with once per week visits for first 3 months, then every other week for last 3 months.

Croffie et al., 2005: 5 visits total, scheduled every 2 weeks.

Fantl & Newman, 1996: Meta-analysis of treatment for urinary incontinence, recommends weekly visits.

Fitzgerald et al., 2009: Up to 10 weekly treatments (1 hour in duration) was used in the largest randomized, controlled trial of chronic pelvic pain.

Hagen et al., 2009: Randomized, controlled trial using an initial training class, followed by 5 visits over a 12 week period.

Terra et al., 2006: Protocol used 1x/week for 9 weeks.

Weiss, 2001: 1-2 visits per week for 8-12 weeks.

Vesna et al., 2011: Children were randomized into 2 treatment groups with 1 session per month for the 12 month treatment period.

 

While not every patient is seen once per week in pelvic rehabilitation, Herman & Wallace faculty can tell you that once a week is the most common practice pattern observed for urinary dysfunction, prolapse, and pelvic pain. Certainly, a patient with an acute injury, a need for expedited care (limited insurance benefits, goals related to upcoming return to work or travel plans, or insurance expectations that dictate plan of care) may lead to frequency of visits that are more than once per week.

If you are interested in learning more about treatment care plans for a variety of pelvic dysfunctions, sign up for one of the pelvic series courses, and for special populations such as pediatrics, check out the Pediatric Incontinence continuing education course taking place in South Carolina at the end of this month!

References

Braekken, I. H., Majida, M., Engh, M. E., & Bo, K. (2010). Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randominzed, controlled trial. American Journal of Obstetrics and Gynecology, 203(2), 170.e171-170.e177. doi: 10.1016/j.ajog.2010.02.037

Croffie, J. M., Ammar, M. S., Pfefferkorn, M. D., Horn, D., Klipsch, A., Fitzgerald, J. F., . . . Corkins, M. R. (2005). Assessment of the effectiveness of biofeedback in children with dyssynergic defecation and recalcitrant constipation/encopresis: does home biofeedback improve long-term outcomes. Clinical pediatrics, 44(1), 63-71.

Fantl, J., & Newman, D. (1996). Urinary incontinence in adults: Acute and chronic management. Rockville, MD: AHCPR Publications.

FitzGerald, M. P., Anderson, R. U., Potts, J., Payne, C. K., Peters, K. M., Clemens, J. Q., . . . Nyberg, L. M. (2009). Adult Urology: Randomized Multicenter Feasibility Trial of Myofascial Physical Therapy for the Treatment of Urological Chronic Pelvic Pain Syndromes. [Article]. The Journal of Urology, 182, 570-580. doi: 10.1016/j.juro.2009.04.022

Hagen, S., Stark, D., Glazener, C., Sinclair, L., & Ramsay, I. (2009). A randomized controlled trial of pelvic floor muscle training for stages I and II pelvic organ prolapse. International Urogynecology Journal, 20(1), 45-51. doi: 10.1007/s00192-008-0726-4

Terra, M. P., Dobben, A. C., Berghmans, B., Deutekom, M., Baeten, C. G. M. I., Janssen, L. W. M., ... & Stoker, J. (2006). Electrical stimulation and pelvic floor muscle training with biofeedback in patients with fecal incontinence: a cohort study of 281 patients. Diseases of the colon & rectum, 49(8), 1149-1159.

Weiss, J. M. (2001). Clinical urology: Original Articles: Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. . [Article]. The Journal of Urology, 166, 2226-2231. doi: 10.1016/s0022-5347(05)65539-5

Vesna, Z. D., Milica, L., Stankovi?, I., Marina, V., & Andjelka, S. (2011). The evaluation of combined standard urotherapy, abdominal and pelvic floor retraining in children with dysfunctional voiding. Journal of pediatric urology, 7(3), 336-341.

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What is Thiele's Massage?

Hip

George Thiele, MD, published several articles relating to coccyx pain as early as 1930 and into the late 1960's. His work on coccyx pain and treatment remains relevant today, and all pelvic rehabilitation providers can benefit from knowledge of his publications. Thiele's massage is a particular method of massage to the posterior pelvic floor muscles including the coccygeus. Dr. Thiele, in his article on the cause and treatment of coccygodynia in 1963, states that the levator ani and coccygeus muscles are tender and spastic, while the tip of the coccyx is not usually tender in patients who complain of tailbone pain. The same article takes the reader through an amazing literature review describing interventions for coccyx pain in the early 20th century.

Examination and physical findings, according to Dr. Thiele, include slow and careful sitting with weight often shifted to one buttock, and frequent change of position. He also describes poor sitting posture, with pressure placed upon the middle buttocks, sacrum, and tailbone. Postural dysfunction as a proposed etiology is not a new theory, and in Thiele's article he states that poor sitting posture is "…the most important traumatic factor in coccygodynia…" and even referred to postural cases as having "television disease."

In reference to treatment, Thiele suggests putting a patient in Sims' position (left lateral side lying or recumbent position), and placing the gloved index finger into the rectum with the thumb over the coccyx externally, palpating the coccyx between the thumb and index finger. The finger is then moved laterally, in contact with the soft tissues of the coccygeus, levator ani, and gluteus maximus muscles. The finger is moved with moderate pressure "…laterally, anteriorly, and then medially, describing an arc of 180 degrees until the finger tip lies just posterior to the symphysis pubis." The massaging strokes, applied to a patient's tolerance, are applied 10-15 repetitions on each side with the patient being asked to bear down during the massage strokes. Dr. Thiele recommended daily massage 5-6 days, then every other day for 7-10 days, and gradually less often until symptoms are resolved.

Thiele's massage for coccygodynia is one excellent tool in the treatment of coccyx pain. For a comprehensive view of coccyx pain, check out faculty member Lila Abatte's Coccyx Pain Evaluation and Treatment continuing education course, coming up in New Hampshire in September!

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PTSD in the Postpartum Period

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Posttraumatic Stress Syndrome, also known as PTSD, is an unfortunate consequence of many women's birth experiences. While there are known risk factors, there is not currently a standardized screening method for identifying symptoms of PTSD in the postpartum period. One recent meta-analysis of 78 research studies identified a prevalence of postpartum PTSD as 3.1% in community samples and as 15.7% in at-risk or targeted samples. Risk factors for PTSD included current depression, labor experiences (including interactions with medical staff), and a history of psychopathology. In the targeted samples, risk factors included current depression and infant complications. Other authors have explored the relationships between preterm birth and PTSD, preeclampsia or premature rupture of membranes, and infants in the neonatal intensive care unit.

One of the main concerns of failing to identify and treat for PTSD in the postpartum period is the potential negative effect on the family. High levels of anxiety, stress, and depression may impact not only the mother's health, but also may affect her ability to meet her new infant's needs, or complete usual functions in work and home life. One study suggested that "…maternal stress and depression are related to infants’ ability to self-sooth during a stressful situation." Clearly, healthy moms promote healthy families, and each mother deserves the attention that her new infant often receives from the world!

 

 

How can we be a part of the solution? We have previously posted on the blog about screening for depression in the postpartum period. The US Department of Veterans Affairs lists multiple screening tools for PTSD as well. Here's another bit of exciting news: yoga has been identified as a method to reduce symptoms of PTSD. In a randomized, controlled clinical trial, the treatment arm was given 10 weeks (1x/week at 1 hour sessions) of "trauma-informed" yoga, whereas the control group was given information about women's health and self-efficacy in various domains. Interestingly, while both groups showed positive effects from intervention in the first half of the treatment, the yoga group maintained the improvements during the latter half of the study, while the control group relapsed.

 

 

You can learn about yoga for postpartum mothers, and learn how to integrate strategies to help heal postpartum symptoms of PTSD this summer at Ginger Garner's Yoga as Medicine for Labor & Delivery and Postpartum. The continuing education course takes place in Seattle, and we still have a few spots left! Don't miss this chance to add more amazing tools to your toolbox in support of women of any postpartum age.

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Hey Doc, Why Do You Meditate?

This post was written by H&W instructors Nari Clemons, PT and Dr. Shawn Sidhu, MD, psychiatrist. Nari and Shawn will be instructing the course that they wrote on "Meditation and Pain Neuroscience" in Illinois this September.

Shawn Sidhu

We caught up with Dr. Shawn Sidhu, MD, psychiatrist on why he thinks it is good for himself and his patients to have a meditation practice.

Why, as a physician and father, do you meditate?

Meditation can do a lot of things for different people. Some people say that it helps them to stay grounded. Others comment that it helps them to focus and organize their mind. I’ve also heard that people feel more in touch with their emotions and their thoughts when they’ve been meditating regularly, even for brief periods of time. While I feel that all of the above are certainly benefits of meditation that I have experienced, the single greatest thing that meditation does for me is to help increase my level of awareness as it pertains to my surroundings. In other words, when I am able to meditate, my observational skills improve significantly. This is incredibly important for a Child and Adolescent Psychiatrist. Those of us who work in mental health must first observe our patients, and really see them clearly through multiple layers if we are going to have any chance of helping them and getting to the root causes of their suffering. Only after observing clearly and effectively can we begin to think about treatment. On days when I don’t meditate and I’m not as in touch with my inner self, I lose a great deal of awareness of the outside world as well. My patients notice it, too, and will comment that I am not as in tune with them or not as engaged on days when I do not meditate. So in a sense meditation sets a great foundation from which I can really reach patients and their families in a meaningful way.

As a father, the benefit is slightly different. While having awareness and observational skills is incredibly important with both our children and our spouses, I feel that really being grounded and present with my family is the most important goal for me. Many of us have likely experienced what it feels like to rush home from work, possibly eating and listening to the radio while we drive or fueling with even more caffeine as we burst through the door at home while simultaneously being on our cell phones. At times, when our minds are distractible and having great difficulty being in the presence, being around our spouses and children can seem like a nuisance because it doesn’t allow us to get through our mental checklist. And yet, in our elderly years when we’re looking back on our lives, will the checklists be what we remember? For most of us the answer is no, and yet it can be really hard to pull ourselves away from the busy demands of life and focus on our families. Meditation is a great tool to use to help us transition from one task to another smoothly.

In our course, Meditation and Pain Neuroscience, we give participants practical, hands on, meditation techniques to apply in clinic with an understanding of how and when to use them. It’s a very practical course, with an interactive versus didactic focus, so that participants are fully empowered to use techniques when they return to the clinic.

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How Does the Trunk and Pelvis Interact?

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While many of the Herman & Wallace Pelvic Rehabilitation continuing education courses focus on study of the pelvic floor muscles, the inclusion and consideration of the trunk, breathing, form and force closure, and posture are also needed to truly understand the pelvis. Our professional education does not prepare us well in regards to understanding the pelvic floor and pelvic girdle, and the foundational concepts that provide clinical meaningfulness come from a variety of research camps. If you feel that you were never provided this foundational information about the pelvic girdle and trunk, and wish to better apply practical concepts in movement and muscle facilitation (or inhibition), you might be looking for the Pelvic Floor/Pelvic Girdle continuing education course that is coming to Atlanta in late September.

The course covers interesting topics such as pelvic floor muscle activation patterns in health and in dysfunction, use of load transfer tests such as the active straight leg raise, orthopedic considerations of pelvic dysfunction, pelvic floor muscle (PFM) exercise cues, risk factors for pelvic dysfunction, and treatment of the coccyx. If you (or a friend you want to take a course with) is not quite sure about internal pelvic floor coursework at this time, the good news is that this course addresses pelvic dysfunction using an external approach. Experienced therapists can appreciate the research-based approach to muscle dysfunctions that can cause or perpetuate a variety of symptoms, and newer therapists have the chance to learn how to integrate pelvic floor/pelvic girdle concepts into current practice. A biofeedback lab introduces use of surface electromyography (sEMG) as well.

There is still time to sign up for the September course in Atlanta, the only remaining opportunity to take the Pelvic Floor/Pelvic Girdle continuing education course this year. Bring a friend, or a colleague, and work together to combine external and internal approaches to pelvic dysfunction.

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Donna Calwas - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Donna Calwas PT, PRPC

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

Our hospital-based system was getting a growing number of pelvic floor referrals, and I offered to help fill the need. I was mentored by our current Women’s Health therapist and began the gradual process of learning through the Herman and Wallace courses. I thought I knew what I was getting into, thinking I would be better able to help my low back and SI patients, but I was blown away by all the NEW information I received. I learned as much about my bad bladder and bowel habits as I learned about helping my patients. The pelvic floor hadn’t even been mentioned in my college anatomy class and I was very impressed by the intricacy of the anatomy “down there.” After Pelvic Floor I, I needed to keep learning to satisfy my curiosity and be able to help the increasingly complex patients I was encountering.

What has been your favorite Herman & Wallace Course and why?

Pelvic Floor I was amazing just for the sheer amount of new material, and of course, having Holly teach us to practice saying “vagina” in front of the mirror to decrease our discomfort was priceless.

I would have to say the favorite treatment techniques I learned were in the Ramona Horton Visceral Mobilization courses. I am a very tactile practitioner, and I loved learning to feel the tissues and how they would respond to the techniques. I am frequently surprised by the seemingly miraculous changes these techniques can make in my patients. I have shared my enthusiasm for visceral mobilization with my colleagues, and teach them what I have learned as often as I can.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?

Don’t be afraid to just do it. I can’t remember who said this, probably more than one instructor in different forms. You need to learn to trust your instincts, trust your hands, and listen to your patients. The rest will come with time and practice.

What motivated you to earn PRPC?

Primarily, I was expecting it to be a good learning experience, and it was! It helped me truly synthesize all the information I have been receiving and finally read all the research. I also learned from a great group of women in my study group. Thanks, gals!

Secondarily, since the knowledge we have is truly unique in the physical therapy field, I think some sort of recognition testifying to this knowledge is important.

To those considering the PRPC….Don’t be afraid to just do it.

Learn more about Donna Calwas 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.

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Pudendal Neuralgia - Caused by Hip Scopes?

Hip

In this study investigators tested the hypothesis that following hip arthroscopy, the number of patients who developed pudendal neuralgia would exceed 1%. Development of pudendal neuralgia symptoms following hip arthroscopy was assessed in 150 patients (female = 79, male = 71) who were operated on in one facility by a single surgeon. Indications for the surgery included post-trauma foreign-body, osteochondromatosis, and labral lesion resection. The Nantes criteria were utilized for diagnosis, which includes as "essential" criteria the following: pain in the region of the pudendal nerve; pain that is worsened by sitting, relieved by sitting on a toilet seat; pain does not interrupt sleep, pain with no objective sensory impairment and that is relieved by a pudendal nerve block.

The operated hip was placed in a position of 30 degrees of adduction, internal rotation and flexion. The hip was operated on with a single anterolateral approach in most cases, with a second anterolateral approach needed in eight cases. Study results include an incidence rate of 2% in the population of 150 patients. 3 of the patients (2 female, 1 male) were diagnosed with pudendal neuralgia presenting in all 3 as "pure sensory" with symptoms of perineal hypoesthesia and dysesthesia on the operated side. The 3 cases resolved spontaneously within 3 weeks to 6 months. Two cases of sciatica following hip arthroscopy were documented, and these cases resolved without intervention other than a short course of analgesics. The patients also presented with gluteus medius insertion tenderness.

Although the study also aimed to determine risk factors for development of pudendal neuralgia following hip scope, the small number of patients who developed symptoms made the analysis for risk factors difficult. The authors also point out that the one-way surgical technique (not the standard surgical technique) also may have created some bias in the study. In conclusion, although the cited study reported a low incidence of pudendal neuralgia onset following hip arthroscopy, larger numbers have appeared in the literature, and according to the authors, surgical risk factors for developing nerve complications following a hip scope include the amount of traction placed on the joint, the length of surgery, and appropriate pelvic support bilaterally. The take-home point for pelvic rehabilitation providers is that patients are at some risk for pelvic nerve dysfunction following hip arthroscopy, and we have a role in educating providers and in screening patients for such conditions.

The Herman & Wallace Pelvic Rehabilitation Institute offers many relevant courses regarding the hip and pelvis, and if you are interested in learning more about the pudendal nerve, hurry to sign up for the continuing education course "Pudendal Neuralgia Assessment, Treatment, and Differentials." You can also attend "Biomechanical Assessment of the Hip & Pelvis" continuing education course to learn all about testing, treatment, and diagnosis of the hip and pelvis.

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Upcoming Continuing Education Courses

Boundaries, Self-Care, and Meditation - Remote Course

Sep 12, 2020 - Oct 11, 2020
Location: Replacement Remote Course

Pelvic Floor Level 2A - Atlanta, GA (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Emory Healthcare

Nutrition Perspectives for the Pelvic Rehab Therapist - Winfield, IL (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Houston, TX (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: Texas Children’s Hospital

Sacral Nerve Manual Assessment and Treatment - Vancouver, WA (Postponed)

Sep 25, 2020 - Sep 27, 2020
Location: PeaceHealth Southwest Medical Center

Pelvic Floor Level 1 - Mequon, WI Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Health In Balance Physical Therapy

Pelvic Floor Level 1 - Atlanta, GA (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Emory Healthcare

Coccydynia and Painful Sitting - Philadelphia, PA (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Core 3 Physical Therapy

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Milwaukee, WI (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Aurora Medical Center

Pelvic Floor Level 1 - Columbia, SC (Postponed)

Sep 26, 2020 - Sep 27, 2020
Location: Columbia Rehabilitation Clinic

Pelvic Floor Level 1 - Self-Hosted

Sep 26, 2020 - Sep 27, 2020
Location: Self-Hosted Course

Pelvic Floor Level 1 - Decatur, GA Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Emory Healthcare

Pelvic Floor Level 1 - Columbia, SC Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Columbia Rehabilitation Clinic

Pelvic Floor Level 1 - Minnetonka, MN Satellite Location (SOLD OUT)

Sep 26, 2020 - Sep 27, 2020
Location: Viverant

Pelvic Floor Level 1 - Marietta, GA Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Southern Pelvic Health

Pelvic Floor Level 1 - Satellite Lab Course

Sep 26, 2020 - Sep 27, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Orland Park, IL Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Palos Community Hospital

Pelvic Floor Level 1 - Columbus, OH Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Fitness Matters

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

Sep 26, 2020 - Sep 27, 2020
Location: Strive Physical Therapy

Pelvic Floor Level 1 - Torrance, CA Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Women's Advantage Inc

Pelvic Floor Level 1 - Kenosha, WI Satellite Location (Sold Out)

Sep 26, 2020 - Sep 27, 2020
Location: Aurora Health Care

Pelvic Floor Level 1 - Lansing, MI Satellite Location

Sep 26, 2020 - Sep 27, 2020
Location: Physical Therapy Services of Lansing

Mobilization of Visceral Fascia: The Urinary System - Phoenix, AZ (Postponed)

Oct 2, 2020 - Oct 4, 2020
Location: Banner Physical Therapy and Rehabilitation

Mobilization of Visceral Fascia: The Urinary System - Medford, OR Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: Asante Rogue Valley Medical Center

Mobilization of Visceral Fascia: The Urinary System - Self-Hosted

Oct 2, 2020 - Oct 4, 2020
Location: Self-Hosted Course

Mobilization of Visceral Fascia: The Urinary System - San Diego, CA Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: FunctionSmart Physical Therapy

Mobilization of Visceral Fascia: The Urinary System - Colorado Springs, CO Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: Manual Edge Physiotherapy

Mobilization of Visceral Fascia: The Urinary System - Fairlawn, NJ Satellite Location

Oct 2, 2020 - Oct 4, 2020
Location: Bella Physical Therapy