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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nari Clemons

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

Allison Ariail

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

Jennifer van de Vegte

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

H&W instructor Dustienne Miller, CYT, PT, MS, WCS wrote this post.

As specialists in pelvic health, we have the honor of being trusted with very private information. Our patients trust us with their secrets, their emotions, and their bodies. Sometimes patients reveal traumatic personal stories, both past and present. Even if our patients have not suffered emotional, physical, or sexual abuse, we can assume that the diagnosis of pelvic floor dysfunction is traumatic itself. Bouncing from clinician to clinician and inability to share their pain and experience with coworkers and friends is enough to increase baseline anxiety and depression levels. Yoga has proven to be an effective method in helping to heal Post Traumatic Stress Disorder and other mental comorbidities associated with pelvic floor dysfunction. But where do you start? How do you make your patient feel safe?

In David Emerson and Elizabeth Hopper?s book Overcoming Trauma through Yoga, there is guidance on how to appropriately guide your patient or yourself through a yoga program that feels safe and appropriate. As clinicians, we are very aware of monitoring patient response in the treatment room. If we notice guarding or dissociation we do not continue the session according to the goals we have set for the patient, rather we meet the patient where they are at that time on that day and work accordingly. I recommend we utilize the same sensitivity with our patients when creating a home program and working with our patients in open gym areas. What might feel great for us (ie: downward facing dog) may trigger trauma for another. Be mindful of the transition from the emotionally charged manual treatment to a less contained room like an open gym. Instructing a patient in pelvic tilts and bridging with other people around could trigger an emotional response, especially if their emotions were primed after myofascial release in the pelvis and abdomen. Bottom line: take the sensitivity you have at the plinth and carry it over into the exercise component of your treatments. Your patient will lead the way.

Dustienne Miller is a board certified women?s health clinical specialist and Kripalu Yoga teacher. She is the creator of the DVD Your Pace Yoga: Relieving Pelvic Pain, a musical theatre performer, and a terrible cook. Her two day class offered through Herman and Wallace, Yoga for Pelvic Pain, is being offered in San Diego next March.

This post was written by H&W faculty instructor Peter Philip, PT, ScD, COMT. Peter instructs the Differential Diagnostics of Chronic Pelvic Pain and the Sacroilliac Joint Evaluation and Treatment courses.

Have you ever palpated “marbles” - rolling masses along the SIJ that just don’t seem to go-away? Let’s take into consideration that you are a competent clinician, and that your patient is compliant with all of your requests. Clinical testing is negative for lumbar involvement, and both provocation and movement tests alike indicate involvement of the SIJ. Despite countless treatments directed at core training, and pelvic stabilization, the “marbles” persist.

Clinically speaking, often what is seen is that the innominate structures attain a more neutral alignment, where the sacrum maintains its hyper-nutated position. As a synovial joint, the SIJ is prone to swelling and subsequent scarring when placed under mechanical stress - hence the “marbles”. With great sincerity, the patient and clinicians alike focus on core strengthening, which often produces the correction of the innominate, but for reasons “unknown” to many clinicians and patients alike, the relative angle of the sacrum remains unchanged. Why would this be, how could this occur?

As a clinician, have you ever considered evaluating, and subsequently treating the anterior SIJ ligament? Running obliquely across from the sacrum to the innominate, the anterior SIJ ligaments have been found to be an underlying cause of chronic lower back pain, and sacroiliitis. As ligaments will do under mechanical stress, the anterior SIJ ligaments will stretch and scar, forming fibrous unions that limit their flexibility and hinder your manual techniques to improve SIJ osteokinematic motion. Akin to other ligaments of the body, once the origin of the mechanical insult has been addressed, the ligament can be directly treated via cross fiber massage, and to the surprise of many clinicians and patients alike heal in an expedient fashion; regardless of symptom duration. To best serve their patients, it would behoove the clinicians to take into consideration the concepts of central sensitization and knowledge that the anterior portion of the SIJ is innervated by segments L4 to S3! These and other strategies are discussed and implemented in both the Differential Diagnostics of Pelvic Pain, and The Evaluation and Treatment of the Sacroiliac Joint & Pelvic Ring courses.

Want more from Peter? You can catch him teaching his course on the SI Joint in Baltimore in July and the Differential Diagnostics course in New Canaan, CT in October.

This post was written by H&W instructor Dee Hartmann PT, DPT. This year, H&W is thrilled to be offering a brand new coure instructed by Dee, Assessing and Treating Women with Vulvodynia.This course will be offered in September in Waterford, CT.

What's love (and sex) got to do, got to do with it?

Tina Turner said it well. (Obviously I’m taking a little liberty here.) Some think that love and sex go together, you know, like bread and butter. Others? Not so much. Many think that love thrives even though the sex may slow down because of things like babies, work, stress, dinner with friends, and cleaning the bathroom…you name it. A lot can come between you and a good bedroom romp. But what if those bedroom romps had NEVER been good? What if the only fireworks you remember when earning your womanhood badge were akin to hot, searing sparklers—held way too close for comfort above your knees and between your legs. What’s with that, right?

Tina goes on “…that the touch of your hand/makes my pulse react…”. We all remember that feeling, that first titillation. It was there “…It’s physical/Only logical/You must try to ignore/That it means more than that”.

Boy meets girl. Hugging. Touching. Kissing. All that normal stuff that’s so good. Further progression might be awkward and clumsy but ‘it’ usually works nonetheless. But not always. Sometimes, the sex afterglow is more like, “Wow. That was way overrated…and who lit the fire in my vagina?” That burning pain lingers for days and celibacy, though considered, doesn’t really seem like a good alternative. You try again and again and along with more failed attempts, the pain gets worse. Your brain begins to think that any time anything comes too close to your vagina – like a tampon, fingers, a vibrator, the doctor, or a bicycle seat – it needs to shut the doors for business. As we say in the business, the pelvic floor muscles go into overdrive. Everything can get a bit goofy. You become all too familiar with your work bathroom as your bladder doesn’t seem to want to hold as much as it used to. Emptying your bowels becomes an effort. And those tampons that wouldn’t go in? Now you know why. There’s no room for anything down there! Armed with the sparkler analogy, the only help you get from most medical providers is “just relax, honey” or “have a glass of wine first” or “maybe your boyfriend/husband is just too big for you.” That stinks. And it’s not normal. Sex and reproduction (remember we’re the only mammals—besides dolphins—who do it for fun) are built in to our primitive brain, just like breathing and eating. “It may seem to you/That I'm acting confused/When you're close to me/If I tend to look dazed.” After the whole relaxing and drinking things fail and you kind of like your partner’s parts, what’s a girl to do?

“I've been taking on a new direction/But I have to say/I've been thinking about my own protection/It scares me to feel this way.” Once pain and fear have taken the place of excitement and arousal, your sexual future may appear less and less clear. As you and your partner begin experiencing nothing but frustration, there are my tips for making it through this tough stage.

1) Your best tool is always communication, communication, communication. First and foremost, sex should never hurt. Never. Ever. Discuss it with your partner long before you’re in bed, the lights are out, and you’re pretending to be asleep to dodge foreplay. Desire and arousal go together to create increased blood flow and lubrication, but no one can deny that it’s pretty hard to get excited about a hot stick in the eye (my analogy). Fear of impending pain can throw a wet blanket on the whole idea of sex unless you’ve agreed first to work together.

2) You may have learned to fear touching because of where it might lead, but avoiding hugging, touching, cuddling, and kissing is the first step in the wrong direction. Enjoying your partner’s touch—sexual or not—is a prerequisite for good love-making and will make you both happier in the long run.

3) Make a deal that there will be no sexual contact until you’re ready and will help you to begin dealing with the pain. Keeping your love alive matters for your relationship. Holding back in resentment and fear of the next sexual move chips away at the trust you’ve built.

4) As you begin to regain control, try to be the intimacy initiator at least once a week (or some predetermined time frame). Getting yourself mentally prepared goes a long way to gently urge arousal. Often it takes putting a sticky note on the fridge or work computer screen to remind you to think about it during the day (we women have so many other more important things to think about; sex, even in the best of times, usually doesn’t make the top five). Partners love it as they’ve usually shut down their advances to avoid yet more frustration, rejection, and heartache.

5) Once you’re ready to go for it, remember that your body that might not be too excited about entertaining an extended stay visitor. By agreeing to short visits in the beginning, the brain catches on and doesn’t shut down into protection mode. Go for more foreplay rather than less. Then, once his climax is close at hand, actual penetration time is kept at a minimum. You’ll be happier. He’ll be happier. And your vulva will appreciate the plan.

And here’s where Tina and I part ways. She may have gotten to go on singing (and making millions), but I get to gently guide women to their desired sexuality. Incredible women fill my office every day and continue to amaze me with what they’re able to do with and for their bodies. I don’t fix anyone. Instead, I help them find the power they need to fix themselves. “What's love got to do, got to do with it/What's love but a sweet old fashioned notion.” Call me old fashioned but I can’t think of a greater gift as women’s health PTs than to be able to help women feel more comfortable as women. And to think they call this work!

Want more from Dee? Consider joining us for the Septmber course!

This post was written by H&W instructor Dawn Sandalcidi, PT, RCMT, BCB-PMD. Dawn's course that she wrote on "Pediatric Incontinence" will be presented in in South Caroline this August.

I will never forget the morning I was called by one of my referring pediatricians to tell me an 11-year-old boy with fecal incontinence hung himself because his siblings ridiculed him. If you ever ask me why I do what I do, I will tell you so that nothing like that would ever happen again.

When we think of pediatric bowel and bladder issues we primarily focus on the physiologic issue itself and treating the underlying pathology. I think it is imperative to teach a child that she/he did not have a leak but their bladder or bowel had a leak. It makes the incident a physiological problem and not a problem of the child.

It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In more recent studies by Sureshkumar, 2009; Joinson 2007 it was noted that elevated psychological test scores returned to normal after the urologic problem was cured. Lettgen et al. 2002, Kuhn et al, 2008, van Gontard, 2012 all reported that children with urge incontinence are distressed by their symptoms but the family functioning is intact.

I frequently get testimonials from my patients. I would say the common denominator is the child and/or parental report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.

The International Children’s Continence Society (i-c-c-s.org) is filled with standardization documents that support the work we do to take care of kids with elimination issues. The work we do to take care of these kiddos in not only necessary but also mandatory to avoid these psychological disorders.

Read about Suzanne's Story

To learn more about Dawn's course visit Pediatric Incontinence

Read more about what Dawn does in PT in Motion

This post was written by H&W instructor Dawn Sandalcidi, PT, RCMT, BCB-PMD. Dawn's course that she wrote on "Pediatric Incontinence" will be presented in in South Caroline this August.

Years ago when my oldest daughter was 4 years old and in Pre-school I received an urgent call at the office that she had an accident. Immediately my head began to race, “What hospital is she in?” “What did she break?” Then the director informed me she wet her pants. I collapsed in my chair with a huge sense of relief and I began to ponder “Did she have an ‘accident’ or did her bladder leak?

Merriam-Webster defines an accident as:

1. 1. An unforeseen and unplanned event or circumstance
2. 2.An unexpected and medically important bodily event especially when injurious
3. 3.Used euphemistically to refer to an involuntary act or instance of urination or defecation

Now lets think about that. How would you feel if someone approached you after noticing a smell or a wet spot and asked you “Did you have an accident?” My first thoughts are maybe shame, embarrassment, guilt or failure. “I” had an accident. Children feel without easily being able to express these emotions thus internalizing their feelings. This then can be expressed with inappropriate behaviors.

When I work with children, and adults for that matter, I frame the conversion with the physiology of the anatomical structure that is unable to do the job it is designed to do. I teach the children about their anatomy and bladder/bowel function and I am clear to let them know that their bladder and/or bowel had a leak, they did not. It takes ownership away from the person and places it on the body part that is currently dysfunctional. At that point we discuss we can re-train the body part to do the job they were designed to do. The kids become empowered that they will be able to become “The Bladder/Bowel Boss”.

To learn more about Dawn's course visit Pediatric Incontinence

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with Herman & Wallace instructor Tina Allen, PT, BCB-PMD, PRPC

How did you get started in pelvic rehab?

I was about 5 years into my career as a PT when for some reason I had patients who where comfortable with me enough to ask questions like, "I'm leaking. Is that normal after giving birth?", "Since my total hip replacement I've been leaking urine" and "I have pain sometimes when I'm have sex...is that normal?". I was working in Outpatient Orthopaedics and I had no idea if it was normal. I searched and found out that it wasn't. After whispering to my patients that it wasn't normal, that I read that there where things they could do about it and then slipping them pieces of paper with instructions on how to maybe make it better; I decided I should learn if there was something a PT could do to help. I spent time with Ob/Gyn's and Urologists learning from them and applying my musculoskelatal knowledge to what they taught me. I was still in denial that I could help folks but then I started getting patients specifically referred to me for these conditions. I finally found that there where classes I could take! Imagine! That was 20 years ago now!

Who or what inspired you?

My patients have always been who inspires me! The questions they ask and how they face what they are going through has always pushed me to figure out ways to help them along their paths to healing and improved function!

I must also include all the PT's whom take our courses. Watching everyone lean into the uncomfortableness of what we teach and the questions everyone asks all in the hopes of helping that client whom walks into the clinic on Monday is inspiring.

What have you found most rewarding in treating this patient population?

It has to be that first session with a patient whom when you educate them on anatomy and function of the urogynecolgical system including fascia and what is needed for function (intimacy, continence etc) and I can see the light bulb go off for them on how everything is connected and everything has to be treated as a whole.

What do you find more rewarding about teaching?

This has to be the inspiration I get a thrill from being with a room of Pelvic Rehab therapists. We all work behind closed doors all day and getting to be in a room with such amazing like-minded therapists gives me a shot in the arm. To watch us all click in and problem solve how to serve our population of clients is inspiring for me.

How did you get started teaching pelvic rehab?

I was lab assisting courses for Kathe and Holly for years. Then one year Holly Herman just kept saying to me, "Why aren't you teaching?" "You could teach this?" "Tina, why don't you take this lecture?" "Tina, how many patients do you see like this in a day? What would you do?" I almost starting avoiding her Then I talked to Kathe about teaching and she said she was just waiting for me to say I was ready to start. That's our founders; always encouraging us to do more and contribute more!

What was it like the first time you taught a course to a group of therapists?

The first time I taught was terrifying! I'm a bonafide introvert (have multiple personalty tests to prove it) and standing in front of 40+ folks talking was not my idea of a fun way to spend a weekend. After the first lecture or two I found a rhythm and relaxed into it. By the afternoon or maybe the next day I was very excited to be around so many clinicians interested in learning and treating Pelvic Rehab.

What have you learned over the years that has been most valuable to you?

That my clients journey is their journey and I get to be a part of it. It's a privilege but it is still their journey. My hope is that where ever they meet me along their path I can assist them to their next step. As long as I get out the way that can happen.

What is your favorite topic about which you teach?

My favorite part of every course are the lab sessions. Getting to teach at each table in small groups and helping clinicians refine their observation and palpation skills is what makes me happy!