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Fascia

Fascia is finally getting proper respect, rather than being that "white stuff" that was cut away during anatomy labs. Researchers continue to explore the cellular mechanisms and the total body functions that require healthy fascial layers. Fascial planes and connections are increasingly considered in strengthening programs as well, rather than only being considered in the design of stretching or flexibility programs. Tom Myers author of Anatomy Trains, and student of Rolfing founder Ida Rolf, contributes not only to the anatomical knowledge of therapists, but also to the functional applications of fascia in daily life and in exercise regimens.

Within the world of exercise training and physical fitness, muscles have often been considered in isolation, as is pointed out in this article written by Tom Myers in IDEA Fitness Journal. Yet muscles rarely work functionally as an isolated structure. Consider this fact when teaching pelvic floor muscle training. How many times have you instructed a patient to utilize thigh adductor muscles, exhale (respiratory diaphragm), or activate transversus abdominis to augment or facilitate the pelvic floor? While there is value in requesting that a patient focus on or emphasize a pelvic muscle contraction, or in teaching a patient to quiet dominant abdominals or gluteals, rarely do we find it effective to teach total isolation of a muscle in functional re-training.

Mr. Meyers uses anatomical information to drive the emphasis on fascial training, pointing out that there are ten times more sensory nerve endings in fascia than in muscles, and describes fascia as requiring our knowledge of accurate anatomy to engage the fascial planes as an "organ system of stability." Myers makes the case that fascia responds better to variation than to a repeated program when aiming to build fascial resilience. Varied tempo, varied loads, and varied movements are key to improving fascial health and efficiency. Integration of kinesthetic awareness via the fascial tissues rather than the muscles is also an important concept that is discussed- bringing awareness to movement through skin and superficial tissue movement rather than directing attention only to joint motion is another concept proposed for advancing movement training programs.

Considering these concepts may or may not change how you are currently designing your patients' fitness and rehabilitation programs, depending upon how you were trained and upon how you have continued to access continuing education and research. Breaking old habits and re-learning how to train movement does take effort on the part of the rehabilitation therapist, and fortunately, many instructors are integrating concepts of fascial planes into coursework. One such course that focuses clearly on integrating fascial training into sports-specific rehabilitation is Biomechanical Assessment of the Hip and Pelvis taking place this August in Arlington, Virginia. Instructor Steve Dischiavi, physical therapist and athletic trainer to the Florida Panthers, offers an excellent course that includes exercise concepts specific to the idea of fascial "slings" and that is sure to add some new exercises to your tool bag.

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Elizabeth Kemper - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Elizabeth Kemper MPT, PRPC, BCB-PMD

Elizabeth Kemper

Describe your clinical practice:

I see both male and female patients in a private practice clinic and devote 100% of my time to pelvic therapy (“pelvic” being loosely defined as from the thorax to the knees). It is a privilege to share in some very personal and complicated portions of each person’s life. Just showing up for pelvic therapy can be daunting and I don’t take that trust lightly. The majority of people I see present with diagnoses of pelvic pain, prolapse, obstetrical issues, elimination dysfunction, abdominal pain and/or sexual dysfunction. I have the luxury and responsibility to give these patients undivided attention with one-on-one scheduling and treatments that are heavily weighted on patient education, manual techniques combined with neurologic re-education and progression into exercise-based support. I try to design the home programs to fit into the lifestyle and interests specific to that client. I love what I do and try to share that enthusiasm for pelvic health with each person who walks through the door!

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

I think the most important message to spread in the PT community is that pelvic rehabilitation is not a completely separate category. A good pelvic therapist integrates portions of all aspects of therapy – orthopedic, neurologic, geriatric, pediatric, oncologic, cardiovascular, etc! As is often found, the cause of the dysfunction with any diagnosis may be local or distant from the actual symptoms. While pelvic therapists specialize in the pelvic region, we have to incorporate the entire body in our evaluation and treatment in order to fully resolve the issue. There is sometimes a false image of pelvic therapists - that we just teach Kegels or do biofeedback - and that couldn’t be farther from the truth.

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

Each of the Herman & Wallace courses I’ve taken have been excellent in their own ways. They are consistently innovative, evidence-based, clinically applicable, challenging, and always fun. For me the Differential Diagnosis course (with Peter Philip) was one of the most helpful in connecting the dots – tying together the orthopedic, visceral and neurologic parts of evaluation of chronic pelvic pain. Ramona Horton’s visceral course content has also proved to be vital in so many cases. You really can’t go wrong – there are so many aspects to pelvic rehab and I am looking forward to taking many more of the courses!

What advice would you give to physical therapists interested in earning PRPC?

The time I spent studying and preparing for this exam was the most important component to me. I’ve been out of school for many years which made the studying and test-taking process somewhat intimidating at first. What I found, though, is that delving back into the basics and reapplying them in the context of the more complex pelvic issues was so helpful. My advice – take your time to enjoy the process and really integrate the information into your daily practice. Yes, the letters of distinction are nice to have – but the path to get there is what made me a better, more thorough, more contemplative therapist.

Learn more about Elizabeth Kemper, MPT, PRPC, BCB-PMD at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.< p>

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Why Every Expectant Mom Needs Yoga

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.

yoga

Pregnancy brings the most enormous changes in a woman’s life, and is arguably the most profound change that the body can experience.

It is no secret that America claims the most shameful maternal health and birth outcomes in the developed world. For more information, read my previous post on American Childbirth: A Human Rights Failure? However, physical therapy can have quite a bit to do with turning those statistics around. Informing mothers about their right to access physical therapy can help improve birth statistics by improving a mother’s health and well-being, not just treating a case of pregnancy-associated low back pain or sciatica.

But it takes more than exercise to influence a mother’s overall well-being and to give her a sense of empowerment. It takes mindfulness.

Yoga is an ancient mind-body practice that supplies both the exercise and mindfulness component. A recent systematic review agrees that “mind-body practices cultivate general health, diminish stress, and increase overall body awareness,” variables that are incredibly important to improve mom and baby’s health.

What are the specific benefits that yoga can infer to expectant moms?

The study reports that although more RCT’s are necessary (aren’t they always?), yoga may improve a mother’s “stress levels, quality of life, aspects of interpersonal relating, autonomic nervous system functioning, and labour parameters such as comfort, pain, and duration.”

A 40-year systematic review also published in 2012, came to similar conclusions. In RCT’s and nonrandomized trials, a “significant reduction in preterm labor, intrauterine growth retardation, low birth weight, pregnancy discomforts, and perceived sleep disturbances” were found in moms that practiced yoga during pregnancy. Additionally, yoga was also reported to lower perceived pain, discomfort, lower stress, and improve quality of life in physical domains.

These reviews underscore the importance of doing not just more research on yoga during pregnancy, but yoga applied through the lens of physical therapy intervention. Yoga applied via physical therapy can be even more efficacious.

Yoga, using the familiar clinical tools we already know in physical therapy, make integrated physical therapy practice readily accessible and immediately applicable for mothers. Ginger’s new course, Yoga as Medicine for Pregnancy, teaches yoga from the physical therapy evidence-based practice perspective. Yoga can be comfortably and easily used in physical therapy to affect not just a mother’s fitness, but her overall well-being and health, which can be a major factor in helping improve birth outcomes for every mother and child.

Since, according to a systematic review by Curtis et al in 2012, 35% of women aged 28-33 years of age already practice yoga, it makes sense for physical therapists to be in the know about how yoga can be best used clinically. Having physical therapists regularly using yoga in their practice could save moms time, lower the burden of healthcare costs, and more readily improve overall all-health outcomes. Those are statistics that we would all like to see for birth in America.

To learn more about Ginger’s course, visit Yoga as Medicine for Pregnancy

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The Athlete and the Pelvic Floor

This post was written by H&W instructor Michelle Lyons, PT, MISCP . Michelle will be instructing the course that she wrote on "The Athlete and the Pelvic Floor" in Ohio this August.

michelle

Ample literature has shown that high impact and high intensity sporting activities are linked to pelvic floor dysfunction (Nygaard 1994, Nygaard 1997) and research has demonstrated that young female athletes participating in high-impact sports may be at particular risk for urinary incontinence.

Several epidemiological studies have shown that symptoms of SUI are frequent in populations of nulliparous female athletes. In a landmark study by Bo and Sundgot Bergen in 2001 on the prevalence of urinary incontinence in elite female athletes compared to age matched controls, the participants were asked ‘Do you currently leak urine during coughing, sneezing and laughter, physical activity (running and jumping, abrupt movements and lifting) or with urge to void (problems in reaching the toilet without leaking?’ The authors found equal prevalence of overall SUI and urge incontinence in both groups but the prevalence of leaking during physical activities was significantly higher in the elite athletes.

But what about pelvic pain in athletes, both male and female? Sports which involve kicking, side to side cutting, interval sprinting, rapid or sudden changes of direction, repetitive hip and pelvic girdle rotation have a high incidence of groin injuries. According to Lovell (1995) in Nam et al (2008) determining a differential diagnosis is essential as 27-90% of patients who present with groin pain present with more than one injury.

In a recent comprehensive review of the literature, Sommer et al (2010) concluded that there is a significant risk in relationship to cycling related uro-genital symptoms in both men and women. Some of the more common problems are pudendal nerve dysfunction, genital pain and numbness, erectile dysfunction in men and in women ‘bicyclist’s vulva’ or lymphedema of the labia majora.

In the sporting arena, the primary source of specialist consultation is the orthopaedic surgeon, who may perform a wide ranging assessment of the musculo-skeletal system with no real evaluation of the pelvic girdle of pelvic floor. The patient is unlikely to be asked about urinary, bowel or sexual dysfunction and often the patient does not volunteer this information unless prompted (Taylor et al 2012). Likewise, the urological specialist may carry out a thorough examination of the pelvic floor, sexual, bladder and bowel function but without the musculo-skeletal component.

So where can these patients seek and find comprehensive assessment and treatment of their complex and multi-layered dysfunctions, addressing both orthopaedic and pelvic health concerns?

It is the goal of this course to bridge the gap between orthopaedic assessment of pelvic dysfunction in athletes, with our pelvic rehab expertise. We will describe the relationship between the lumbo-pelvic, hip and pelvic floor complexes and examine how to integrate a multi-system evaluation approach, utilizing orthopaedic, respiratory and pelvic perspectives, with our objective being to return the athlete to her/his chosen sport or activity in the shortest time possible.

References:

1. Nygaard IE. ‘Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians’. Obstet Gynecol. 1997 Nov; 90(5):718-22.

2. Nygaard IE1, Thompson FL, Svengalis SL, Albright JP. ‘Urinary incontinence in elite nulliparous athletes’. Obstet Gynecol 1994 Sep; 84(3):342.

3. Bo K, Borgen J 2001 ‘Prevalence of stress and urge urinary incontinence in elite athletes and controls’ Medicine and Science in Sports and Exercise 33:1797-1802

4. Nam, et al 2008 ‘Management and therapy for sports hernia’ (Review) {63 refs} J. Am. Coll. Surg. 206, 154-164

5. Sommer et al 2010 ‘Bicycle riding and erectile dysfunction: a review’ J Sex Med 7, 2346-2358

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Yoga for Depression

yoga

A recent literature review addressing the effectiveness of yoga for depression reports that the positive findings are promising. The 2007 National Health Interview Survey (NHIS) found that yoga was one of the top 10 complementary health approaches used among adults in the United States. (The linked page for the NHIS also includes a video of the scientific results of yoga for health.)

Yoga is not only about bodies bending- ancient yoga traditions offer physical, mental, and spiritual techniques that are designed to be holistic in nature. Many instructors in the US focus on the many physical benefits of yoga, yet there are many types of yoga, many instructors with varied levels of training, and many health issues that require an individualized program of yoga therapy. In relation to the potential effects of yoga on depressive symptoms, theories in neurobiology point to the potential positive effects on the HPA (hypothalamic-pituitary-adrenal) axis, according to the linked article by Lila Louie.

While none of the articles described in the literature review are specific to the one patient group or population, the subjects studied include incarcerated women, older patients, university students, and patients from the general population who struggle with depression. One group of patients known to be at risk for severe depression is postpartum women. The definition of postpartum varies, and a generous definition may include any issue that, once imparted in a postpartum period and left unaddressed, could persist throughout a woman's lifetime. This is commonly seen in the clinic as uncorrected postural dysfunction, pelvic floor dysfunction, or gait changes, for example.

Because both yoga and exercise "appear to ameliorate depression," the author of the literature review states that motivation and compliance towards either modality should be considered during treatment planning for patients. Louie further states that yoga practice of asanas is safe, cost-effective, versatile, and can be used on its own or as an adjunct to medication. If you would like to learn more about the use of yoga for the postpartum population, sign up for Ginger Garner's continuing education course: Yoga as Medicine for Labor and Delivery and Postpartum offered in Seattle in August. To read about Ginger's Yoga as Medicine for Pregnancy course, click here.

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Brook Browning - Featured Certified Pelvic Rehabilitation Practitioner

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Brook Browning, MPT, PRPC

Brook Browning

How did you get involved in the pelvic rehabilitation field?

As a second year PT student, I read a PT Magazine featuring Fatima Hakeem and thought “What?? PT’s do that... and here I have been learning about shoulders!” I was intrigued and got lucky enough to complete a clinical rotation with Susan Giglio, PT at Woman’s Hospital in Baton Rouge. I loved the idea of helping someone with an issue that cannot only be physically debilitating but can also impact the patient’s social and personal life on such an intimate level. Fourteen years later, I still have the magazine in my office as a reminder of my drive and passion for pelvic health.

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

I think that most PTs think we just treat urinary incontinence and have no idea the breadth of diagnoses we treat. I also think that there are many things that ALL PTs could do to improve bowel, bladder and sexual function that are “clothes on” so to speak. Sometimes just a handout on sexual positioning with back pain or a simple bowel massage can make a huge difference in a patient’s quality of life.

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

“The victim screams the loudest, the culprit hides in the shadows” – Ramona Horton describing how the pain generator may not be anywhere near where the patient thinks it is located or where hurts the most.

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

The most useful resource I have is a group of pelvic health PTs in my region – The Triangle Pelvic Health study group. We get together every other month to talk about research, listen to guest speakers and share ideas. When I have a troubling case or just a quick question, it is easy to email or call these wonderful ladies and get immediate feedback!

Learn more about Brook Browning, MPT, 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.< p>

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Athlete and the Pelvic Floor

Athlete

While information about "core" strengthening and pelvic dysfunction can be found in the athletic literature, often there remains a disconnect between the level of depth of knowledge among many of the coaches, trainers, and athletes when related to issues of urinary continence. The prevalence of urinary and fecal incontinence related to impact sports has been established, and it has been determined that having children is not a necessary precursor to developing symptoms of leakage. It has been my experience that the term "athlete" can mean different things to different professionals. For example, Institute founder Holly Herman has always been adamant about mothers as "athletes" regardless of the level of sport involved; the simple act of lifting strollers, car seats, children, grocery bags, and kneeling, squatting, lunging involved requires a significant level of athletic ability. With this in mind, knowing the actual requirements of the typical daily activities of any patient is critical to providing a meaningful rehabilitation approach.

So how is the pelvic floor related to athletics? Faculty member Michelle Lyons addresses this question in her new course (offered for the first time in the US this August in Ohio) titled The Athlete and the Pelvic Floor. The course is designed to "bridge the gap between pelvic floor therapists and sports medicine practitioners." Gender and sport specific issues will be covered, and participants will have the opportunity to combine concepts from respiratory, pelvic, and orthopedic perspectives.

With regards to urinary incontinence in female athletes, pelvic floor rehabilitation has been demonstrated to be an effective approach. In a study by Rivalta et al., three nulliparous women described urinary leakage during sport (volleyball) and daily life. Intervention included functional electrical stimulation with internal sensor completed 20 minutes 1x/week using a 50 Hz frequency, biofeedback 1x/week for 15 minutes, pelvic floor muscle exercises, and pelvic floor muscle exercises with a vaginal cone, all for three months. The vaginal cones were weighted, of three different weights, and used for up to 10 minutes at a time. Treatment adherence was recorded by a physician at a weekly visit. The pelvic floor muscle strengthening protocol used the "Kegel" protocol from 1952- at least 300 pelvic floor muscle contractions/day divided into six sessions, avoiding coactivation synergies. The chosen protocol is interesting to note as most therapists trained in pelvic rehabilitation would choose a functional approach to exercising, with less emphasis on avoiding co-contractions as long as the patient performs pelvic muscle contractions appropriately. The combination of biofeedback, and electrical stimulation, and cones is also not typical, yet is evidence that pelvic muscle strengthening in a relatively short period of time can ease symptoms of leakage with functional activities.

The good news is that all women at a four month follow-up were able to report involvement in sport and daily life without urinary leakage. All three women were also able to discontinue use of a panti-liner used to prevent leakage into clothing. Join Michelle Lyons as she covers a wide range of pelvic dysfunctions in athletes and how the best evidence combines with clinical practice pearls to get your patients back to function.

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Quality of Life in Children who have Urinary Incontinence

The goals of a recent research article were to determine the degree to which lower urinary tract symptoms (LUTS) are related to quality of life (QOL) and also the reliability of parents to accurately report on QOL disturbance in children who have urinary incontinence (UI). Outcomes tools utilized in the study include the Dysfunctional Voiding Symptom Score (DVSS) and the Pediatric Urinary Incontinence QOL tool (PIN-Q). Parents of forty children ages 5-11 (10 males and 30 females) and diagnosed with non-neurogenic daytime wetting completed the outcomes tools and responded to open-ended questions about incontinence and QOL. All children had daytime wetting, more than 50% of them had recurrent urinary tract infections (UTI's), and 89% reported urinary urgency.

According to the National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), night-time wetting affects 30% of children who are 4 years of age, with the condition resolving in about 15% of children each year. Additionally, wetting at night persists in about 10% of 7 year-old, 3% of 12 year-olds, and 1% of 18 year-olds. A summary handout about Urinary Incontinence in Children is available here.

The study found that parents were reliable in reporting quality of life and symptoms in their children, as the outcomes scores completed were not different between them. (I would point out that nearly all parents involved were the patient's mothers; and it may be interesting to know more information about how the responsibility of managing urinary incontinence in children is shared among parents or caregivers.) Confirmed in the research was the knowledge that urinary dysfunction in children causes significant quality of life impact.

The subjective complaints of how some of the children avoid activities such as sleepovers, or worry that classmates can see or smell leakage is heartbreaking. The parents' complaints of feeling frustrated and angry about the issue is also understandable as there is a variable amount of support and understanding that each family has about how to manage the incontinence. A child's teacher or friends will also display a wide variety of supporting or sabotaging reactions that can add dramatic increases in stress. The authors point out that there is a significant "…need to improve teacher education and make attempts to engage the educational system to help these children."

If you would like to learn how to be a part of the solution, you can attend the Pediatric Incontinence and Pelvic Floor Dysfunction continuing education course taking place in August in South Carolina. It's the last chance to take the course this year!

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Sandy Gibson - Featured Certified Pelvic Rehabilitation Practitioner

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

Sandy Gibson

Describe your clinical practice.

Hospital-based Outpatient Rehabilitation clinic. I provide care to all types of Pelvic Rehabilitation Dysfunctions including men and women, obstetric related musculoskeletal pain, continence issues, bowel and bladder dysfunction as well as treating all orthopedic related issues for all patients.

I am leader of Special Interest Group in Kansas City area. Therapist from around the city gather to share and learn information related to Pelvic Floor Rehabilitation, and it’s also a great resource to refer patients to therapist close to home or work to allow easy access to services.

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

In 1999 there was a push to increase the number of therapists involved in Pelvic Rehabilitation for the corporation that I was employed by at the time. Personally, I was having some issues as I recently had been pregnant and delivered my third child. I decided I could learn to help myself. It was so helpful! I was very motivated to market the program so that I could share this in order to help other women.

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

The pelvic floor is the CORE to our well being. If the Pelvic Floor isn’t functioning correctly, one can experience problems with spine, bowel and bladder function, sexual function, and progressive dysfunction. I would love to see therapists be able to offer more preventive education so that patients don’t have to suffer unnecessarily.

What advice would you give to physical therapists interested in earning PRPC?

The courses that Herman and Wallace offer will provide you with information you need to treat patients effectively and obtain PRPC.

What is in store for you in the future?

I hope to continue to learn. I am in the process of hosting Herman & Wallace Bowel Dysfunction course at our facility so that I can continue to stay up to date on the newest information, but it will also allow other therapists in area to take these courses in location close to home.

Learn more about Sandy Gibson 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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Sacroiliac Joint Pain and the Long Dorsal Sacral Ligament

SIJ

Sacroiliac joint pain can be a challenging condition to treat. One of the clinical pearls that I feel changed my practice for the better is the palpation and direct treatment of the dorsal sacral ligament. At a course many years ago, I listened to Diane Lee describing some ofAndry Vleeming's work addressing the potential role of the long dorsal sacral ligament (LDL) in pelvic pain. His valuable research was conducted in women who had complaints of peripartum pain, and it has been my experience that the information is easily extrapolated to other patient populations.

Vleeming and colleagues describe the long dorsal sacroiliac ligament anatomy as attaching to the lateral crest of the 3rd and 4th sacral segments (and sometimes to the 5th segment), and as having connections to the aponeurosis of the erector spine group, the thoracolumbar fascia, and the sacrotuberous ligament. Functionally, nutation in the sacroiliac joint will slacken the ligamentous tension in the LDL and counternutation will tension the ligament. This structure can be palpated directly caudal to the posterior superior iliac spine (PSIS).

The referenced study examined how many women had tenderness in the LDL who were also diagnosed with peripartum pelvic pain. Patients included in the study had pain in the lumbopelvic region, pain beginning with pregnancy or within 3 weeks of childbirth, were not pregnant at the time of the study, and were between the ages of 20-40. In patients with peripartum pelvic pain, 76% of the women reported tenderness in the LDL- this number increased to 86% when only patients scoring positively on the active straight leg raise test and posterior pelvic pain provocation (PPPP) test were included.

The study proposes that strain in the LDL may occur from a counternutated sacrum and/or an anterior pelvic tilt position. In my clinical experience and as instructed to many pelvic health therapists by expert clinicians such as Diane Lee, balancing the pelvic structures, activating stabilizing muscles of the inner core (pelvic floor, multifidi, transverses abdominis), and addressing soft tissue dysfunction in the ligament frequently resolve long standing localized pain in the sacroiliac joint area. The authors of the study conclude that "…knowledge of the anatomy and function of the LDL and the simple use of a pain provocation test…could be helpful in gaining a better understanding of peripartum pelvic pain." They also reported that combining tests such as the ASLR, the PPPP test, and the long dorsal sacral ligament palpation test "seems promising" in the differentiation of patients categorized as having pelvic pain versus lumbar pain.

To learn more about sacroiliac joint anatomy and function, diagnosis and treatment, come to Peter Philip's very popular continuing education course, Sacroiliac Joint Treatment, offered for the last time this year in Baltimore in July!

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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