This March, H&W is launching a brand new course on Oncology and the Male Pelvic Floor. This course was developed by H&W faculty member Michelle Lyons, PT, MISCP.

Pelvic Rehab Report sat down with Michelle to learn more about her course.

PRR: What inspired you to create this course?

ML: I am very passionate about oncology rehab and pelvic physical therapy. While it has been great to see the huge advancements being made in the provision and recognition of pelvic physical therapy, I often feel that cancer survivors don’t always get the treatment they deserve – they don’t fall exclusively into the domain of the pelvic therapist or the oncology therapist. Add to this the lack of awareness in the medical community about the benefits of physical therapy generally (and pelvic physical therapy especially) and it becomes obvious that a lot of pelvic oncology patients, both men and women, have many issues that we can help address. The first step is creating awareness, both with our medical colleagues and with cancer survivors, about the benefits of physical therapy

What resources and research were used when writing this course?

I like to use a wide range of resources when creating a course. My main priority was to determine if there was a need for this service – I visited cancer survivorship websites and forums and asked on various social media sites, as well as talking to medical and therapy colleagues, about their opinions on the topic. The answer was a resounding ‘We need this!’

I read hundreds of journal articles, interviewed healthcare professionals and patients as well as drawing on my own professional experience. I want this course to be based on the best evidence based medical practice out there, but more importantly, I want to make the information immediately clinically applicable, so there will be a generous allotment of time to discussing and practising manual therapy techniques and exploring different ideas for exercise prescription. I believe we are all students and we are all teachers; I know I learn something new every time I teach, so I am really hoping these classes will be a forum to get therapists brainstorming and planning how best to serve this community

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

We will be looking at how to apply the skills we have to help problem solve pelvic issues such as bladder, bowel and sexual dysfunction, but also thinking about the sequelae and complications of cancer treatments such as osteoporosis, fatigue and cognitive changes. I want to discuss the necessary precautions and contraindications we need to be aware of but also to look at how to develop the skillset we already have to really enhance cancer survivors’ quality of life

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

Fortunately, we are seeing more people living longer lives as cancer survivors – there have been huge advances in the treatment of many pelvic cancers. But these treatments do have side effects that impact on the pelvic health of the many men and women who battle pelvic cancers. We are the experts in pelvic rehabilitation and I think we need to expand our skillsets to offer cancer survivors access to our expertise. The many exciting changes we are seeing in cancer care means that therapists need to be able to not only assess, treat and educate cancer survivors but also to be able to show that the work we do has a body of research to demonstrate the value of what we do. I think developing an expertise in pelvic oncology will be of huge value to a therapist’s repertoire of marketable skills, but I can also tell you that working with pelvic cancer survivors will be one of the most rewarding aspects of your career. You will literally be changing people’s lives.

The course will be offered January 25-26 in San Diego, CA. Don't miss this brand new offering - Register today!

This August, Herman & Wallace is thrilled to be offering a brand new course, Biomechanical Assessment of the Hip and Pelvis in Tampa, FL. This two-day, orthopedic course was developed and is instructed by Steven Dischiavi, MPT, DPT, ATC, COMT, CSCS.

Pelvic Rehab Report sat down with Steve to learn more about his practice, his experience in the clinic and with the Florida Panthers hockey team and this brand new course.

What can you tell us about this continuing education course that is not mentioned in the "course description" and "objectives" that are posted online?

This course was designed to bring a sports medicine approach to pelvic health clinicians. The exercise philosophy is intimately integrated into the pelvic health specialty. As a PT who currently works with a NHL hockey team I am constantly challenged by a sport dominated with pelvic injury. It was crucial for me to learn more about a specialty that has always been known to me as “women’s health.” I feel this course blends some of the knowledge of the pelvic health specialty with the sports medicine arena to develop a series of functional exercises designed to treat individuals with pelvic issues.

What inspired you to create this course?

I have seen several exercise regimes targeted at the “core” for both the highest functioning athlete to the PT client whose functional goals are far less. None of these programs target the entire human system from an anatomic, orthopedic, and neurologic approach. I was once told “all orthopedic clients are neurologic clients, but not all neurologic clients are orthopedic clients.” I think this is a good axiom to describe how you may start treating your orthopedic clients with techniques typically reserved for neurologic clients. The exercise system uses orthopedic strategies applied with a neuroscience approach all based in functional anatomy.

What resources and research were used when writing this course?

This course was bred from many different approaches and thought processes. The main influences to my philosophy come from Thomas Meyers and his work with “Anatomy Trains.” Diane Lee is a clinician whom I dearly respect and she has heavily influenced my thought process with regard to the pelvis. Although, I felt that Diane Lee’s approach to corrective exercise is where the greatest demand lay. I cite numerous studies on the hip, pelvis, and rehabilitation, all of which can be found in the course manual. The manual therapy approach I utilize is mainly influenced by the Ola Grimsby Institute, where my manual therapy certification was obtained. As with any clinician, the philosophy behind their practice is a unique blend of art and science reflective of their experiences and exposures to the profession.

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

The whole focus of this course is to allow an individual to function on a centered or balanced pelvis. This is first achieved through a sound physical exam, which will be reviewed in the course. The course will offer manual techniques to help correct pelvic imbalance. The bulk of the class is then focused on the corrective exercises and aims to strengthen the whole body functionally through movement efficiency. The class should not be thought of as a manual therapy course, although there are manual strategies offered, it is not the primary focus of the course.

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

The profession of outpatient physical therapy needs to change. Fitness and wellness centers are offering more and more programs targeting areas that should remain in the realm of physical therapy. This course outlines an exercise system that can be utilized by the physical therapist to cover a wide variety of clients. These exercises can be used for an elderly client who needs to move more efficiently in order to achieve a functional task. These exercises can also be used, for example, in a circuit fashion for the highest-level athlete. I have seen success with these exercises in my private clinic as well as with the professional athletes I work with on a daily bases. The skills learned, if implemented correctly, are a great way to market more than just physical therapy to the community.

If you'd like to learn more about these techniques and approaches from Steve, don't miss his course in Tampa in August. Seats are limited, so let us know if we can save you a seat!

This fall, Herman & Wallace is thrilled to be offering two brand new courses instructed by Ginger Garner, MPT, ATC. The first, Yoga as Medicine for Pregnancy, will be offered in Greenville, SC on September 21-22.

Our Pelvic Rehab Report blogger sat down with Ginger to talk about this course. Here's what Ginger had to say:

PRR: What can you tell us about this continuing education course that is not mentioned in the “course description” and “objectives” that are posted online?

Ginger: First I want to say how excited I am about this opportunity to be able to write and teach this landmark integrative maternal health course for Herman and Wallace (H&W). H&W’s progressive philosophy in educational programming has made it possible for me to pen (and teach) a course that can directly affect our poor maternal health outcomes in the US.

Second, what isn’t discussed in the online description is that the core of the Yoga for Pregnancy, Labor & Delivery, and Postpartum coursework (32 CE/hours) is built upon the Institute of Medicine’s (IOM) 2011 “Blueprint for Transforming Prevention, Care, Education, and Research” in medicine, in which the Institute puts its full support behind the biopsychosocial model of integrative care. This is important because the June 2011 reports efficacy in health care could be improved through adoption of the model, since it is found to be the most effective and proven method for patient-centered care, especially when managing pain. Both the prenatal and postpartum course are built on utilization of the biopsychosocial approach.

Third, American mothers deserve a better birth and right now there are definitive measures we can take to influence those outcomes. Combining conventional rehabilitation and therapy with integrative methods, based on the evidence-base and a review of systemic changes during prenatal and postpartum, can be a major tool in empowering mothers and improving care.

Lastly, clinicians who attend either the prenatal and/or labor & delivery/postpartum course will be equipped to be agents of change in improving maternal health, since they will be prepared to apply conventional therapy and integrative yoga methods with their patients. In this way, clinicians who attend the courses will able to offer the best of both worlds.

PRR: What inspired you to create this course?

Ginger: I have two sources of inspiration in creating this coursework. Both are equally important and have prepared me to teach coursework that is both integrative and conventional.

The chief source of my inspiration is my activism in maternal health. Since 2009 I have been blogging, through Breathing In This Life (www.gingergarner.com), and other mediums, on behalf of mothers. Two of my posts, How America’s Broken Health Care System Affects Women and Why Childbirth Needs to Change are both favorites because they establish the urgent need to improve women and maternal health care in America. My inspiration for creating the coursework can be found in these two posts.

The second but equally important source of inspiration for me is infant well-being. I have three sons of my own, and I feel very strongly that there is no greater satisfaction than helping a woman through what is the most transforming and miraculous time of her life: becoming a mother. If we can strive to better support mothers, all American families will be healthier and happier. Caring Economics theory also posits that egalitarian care for mothers would vastly improve American health and wealth (www.caringeconomy.org)

The National Association of Mothers’ Centers recently asked for my input on motherhood in a series entitled, “Researching Motherhood.” The interview really crystallizes my motivation and inspiration for creating this course. Read the interview here

PRR What resources and research were used when writing this course?

Ginger: As I mentioned above, maternal health is very important to me, both personally and professionally. For that reason, I sourced over 250 research articles, from sources like Cochrane database reviews, systematic reviews, and randomized controlled trials. The World Health Organization, ACOG, State of the World’s Mothers report, and the latest perinatal and midwifery recommendations and bulletin updates are also included, which discuss the latest evidence for maternal health and well-being, systemic changes during pregnancy, and the intervention clinicians should consider. All of the intervention techniques I teach utilize the evidence and provide the clinician with an integrative biopsychosocial model of assessment combining physical therapy and yoga as its chief modality. I also draw on the first generation course I wrote for integrative yoga prenatal and postpartum intervention back in 2005. So actually this course has been in the making for almost 10 years.

PRR: Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

Ginger: The coursework (both prenatal and labor/delivery/postpartum) cover intervention in maternal health using the biopsychosocial model. The model has five facets and covers physical, psycho-emotional-social, intellectual, energetic, and spiritual well-being.

The model acknowledges that individual health and well-being of the mother means more than just an absence of disease, as the World Health Organization also supports, and is made up these five facets which depend on integral balanced intervention. Clinical intervention in these five facets happens through assessment and prescription of physical yoga postures (asana) which also includes some Pilates, breath techniques (pranayama), guided meditation and imagery, physical therapy, manual therapy and soft tissue mobilization, myofascial release, neural mobilization, and specific yoga and physical therapy based plans of care for each trimester, including specific intervention for common diagnoses and conditions, as well as labor & delivery and the phases of postpartum.

PRR Why should a therapist take this course? How can these skill sets benefit his/ her practice?

Ginger: The US spends more money than any other country on both overall health care and maternal health care, yet, we have some of the poorest outcomes in the world. America’s healthcare shortcomings in particular include maternal (and infant) health outcomes, pain management, and chronic disease management. What this coursework does is uniquely enable the clinician to change these outcomes and engage mothers on a level that conventional care is unable to accomplish.

What’s more is clinicians who have training in integrative medicine are among the most marketable and sought after by employers. Additionally, this course is interdisciplinary, meaning nurses, midwives, and other maternal health professionals can engage in a dialogue that has not yet happened in the US in maternal health. Interdisciplinary education is also well supported as a means for improving patient satisfaction and patient care.

This course gives clinicians a distinct and measurable advantage because it provides both interdisciplinary interaction and integrative education in maternal health. This is good news for everyone – both patient and provider - because this coursework provides a medical model that empowers everyone. It works because it can improve healthcare and its delivery, and at the same time, reduce clinician burnout. Through its multi-faceted integrative approach, the coursework provides a long-overdue full circle return to holistic healing in an evidence-based container; and that creates a win-win situation for us all.

The Institute is thrilled to be offering these new courses taught by Ginger. Don't miss your chance to learn more about this approach - register today!

This post was written by H&W instructor Ginger Garner, MPT, ATC, PYT. Ginger will be instructing the course that she wrote on "Yoga as Medicine for Pregnancy" in New York this November.

The power of language is inarguable. The spoken word affects how we see, perceive, and interpret the world around us. Language can also influence our actions and behavior, especially toward people around us.

The power of language in health care is not only important, but critical in prenatal health. The language a provider uses can help or harm a mother’s confidence and even her beliefs about birth.

Action to recognize and respond to the importance of language in general health care began with People First Language (PFL) movement. PFL advocates for mindful use of language that identifies the person first, rather than identifying the person based on their disability. Advocacy groups first started the movement for children’s sake. Mother’s who had given birth to children with Down’s syndrome wanted their children to be recognized as people first, rather than by their disability.

An example of People First Language would be, “Beth is a child who has Down’s syndrome,” instead of “Beth is a Down’s (syndrome) child.”

The second statement can be dehumanizing, whether intentional or subconscious. The effects of being identified as a disability, rather than as a human being, are far reaching on psycho-emotional and physical health, and can project a negative connotation on the individual. Read more on People First Language

However, have you noticed that no such language is used for prenatal care?

The shameful statistics on American childbirth and mortality rates for mothers and babies is no secret, internationally. However, many US mothers may not realize that their likelihood of receiving poor prenatal care is so high. In fact, it is dangerously high. Read my post: American Childbirth: A Human Rights Failure?

However everyone, including health care providers who provide prenatal care, can have a powerful impact on improving childbirth in America.

How? Through language.

Yoga as Medicine for Childbirth & Postpartum courses I teach for Herman & Wallace Pelvic Rehabilitation Institute, language is a powerful part of the empowerment process for women. It is an integral part of the biopsychosocial model available to 21st century healthcare providers who use yoga in prenatal and postpartum care. Yoga can improve postpartum physical therapy care and help moms who want to have a natural childbirth. Yoga is also a powerful prenatal mind-body fitness aid as well and works to decrease pain across the journey of pregnancy and into postpartum. Read this post on Why Every Expectant Mom Needs Yoga.

Yoga is a mind-body practice that places paramount importance on language. In fact, yoga uses an entirely different language than biomedical prenatal or postpartum care. Yoga focuses on empowerment through language and action.

Prenatal care using women-centered language looks very different than the historically patriarchal driven vernacular that is still being used today. These statements describe the same situation, but have profoundly different effects on a woman and her confidence and ability to give birth. Consider these common scenarios from a perspective on The Power of Birth Language.

Which scenario would you rather give birth in:

“My doctor/midwife is going to let me use a birthing tub.”

VERSUS “My doctor/midwife supports my plan to give birth in water.”

“My doctor/midwife delivered my baby.”

VERSUS “I gave birth to my baby (in the are of ______).

The first scenario in each example takes power from the mother and negates her participation and involvement in pregnancy and birth. The first scenarios also place her in a dominator relationship under the authority and order of the health care provider.

The second scenario in each example recognizes that mothers should be full partners in their own healthcare, not subordinates without a voice. The second scenario also recognizes that birth should be women-centered, not healthcare provider-centric.

Woman-centered language can usher in a powerful shift in prenatal care, helping tip the scales toward the positive for birth reform in America. Adopting the mindfulness of an ancient system, like yoga, can likewise enrich and expedite the process of reclaiming the full power of birth.

To learn more about Ginger's Women-centered continuing education for health care providers seeking integrated care when working with women during pregnancy or postpartum, visit Yoga as Medicine for Childbirth & Postpartum and join her for Yoga as Medicine for Pregnancy

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 Labor and Delivery and Postpartum" in Washington this August.

Physical therapists often see women during pregnancy and postpartum, but what can physical therapists do to foster better birth outcomes?

A 2012 study conducted in Norway underscores the importance of childbirth education, which can take place as part of patient education and counseling in physical therapy. The study looked at 2206 women with intended vaginal delivery in order to assess the association between fear of childbirth and duration of labor. Labor duration was found to be significantly longer in women with fear of childbirth, with the rate of epidural analgesia, induction, and instrumental vaginal delivery also being higher in fearful women. The authors posit that “anxiety and fear may increase plasma concentrations of catecholamines, and high concentrations of catecholamines have been associated with both enervated uterine contractility and a prolonged second stage of labour.” (Adams et al 2012).

Yoga is a mind-body intervention that is supported to lower pain perception, anxiety, reported stress, and discomfort, all variables that can improve overall birth outcomes and reduce fear of childbirth. Integrative physical therapy practice uses a biopsychosocial model, one that uses energetic, emotional, physical, intellectual, and spiritual support methods to prepare a mother for her labor, delivery, and beyond. Mason et al (2013), in a study that compared standard diaphragmatic breathing to yogic breathing, found yogic breathing to be superior in all measured areas, including increasing/affecting: 1) cardiac-vagal baroreflex sensitivity, 2) oxygen saturation, 3) oxygen absorption, 4) tidal volume, 5) vagal stimulation, 6) parasympathetic activation, and 7) overall reported physical and mental health.

Yoga can address more than just flexibility or relaxation for laboring moms. It fosters calm awareness, mind-body concentration and focus, develops postural control and lumbopelvic health, including neural and myofascial health and motor patterning, all of which, combined with conventional physical therapy practice, can be more efficacious than exercise prescription or childbirth education alone. Ginger’s course, Yoga as Medicine for Labor, Delivery, and Postpartum addresses the systems-based changes of the pregnant patient, and prepares the physical therapist to meet the needs of the laboring or new mom with a mind-body holistic perspective.

To learn more about Ginger’s course, visit Yoga as Medicine for Labor, Delivery, and Postpartum

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 Labor and Delivery and Postpartum" in Washington this August.

Note: This post is for colleagues, patients, and friends whose greatest desire is to have a healthy baby via natural childbirth. In this article, natural childbirth refers to an unmedicated delivery of your baby, assisted with natural, non-pharmaceutical means. While not all women have the luxury of natural childbirth, and some choose other means, please know that Ginger’s course supports all women and their personal decisions about birth.

My first natural birth was December 27, 2005. After a long, hard labor that started on Christmas, my son Michael arrived safe and healthy into my arms.

But something was missing.

I could have better prepared for birth. Bradley technique had reinforced that yoga was a wonderful way to relax and give into the sensations of contractions. Prenatal Pilates and walking, along with yoga, had also provided me with the endurance to go the long 36-hour distance during labor.

What was missing was my active, deliberate, and planned participation during birth.

A birth plan helps to organize your thoughts, but a mother needs her own, personal birth plan too. After Michael’s birth, I began to create my own future personal birth plan, which also changed the way I saw, and helped, my own prenatal patients.

That personal birth plan carried me beautifully (and with less pain and more control) through my next two births, William and James. An n of 2 (subject size of 2, in research terms) was small, but very soon after science began investigating the actual effects of using yoga for childbirth preparation and actual labor and delivery. The results are very promising, as I’ll discuss below.

Expectant women should work directly with an experienced physical therapist to create their own personal birth plan based on their individual mind-body needs. Mind-body needs should consider the following variables:

• Physical Labor Needs: Adapt labor and birth positions based on the patient’s specific orthopaedic injuries or aches and pains that can prevent focus or certain positioning during birth. This could include but is not limited to problems like hip impingment, shoulder impingement, sacroiliac joint pain, back pain, limitations in ROM, or existing pelvic pain.
• Psychoemotional/Physical Labor Needs: Consider previous birth trauma or history such as prior C-section, episiotomy, or difficulty with pain management or dilation that may affect labor progression.
• Psychoemotional/Energetic/Spiritual Labor Needs: Establish adequate birth support during labor. A 2012 Cochrane review of RCT’s found that women with continuous support were more likely to have a spontaneous vaginal birth, less likely to have pain medications, epidurals, negative feelings about childbirth, vacuum or forceps-assisted birth, and C-sections. Women with support also had shorter labors by 40 minutes, higher APGAR scores, and the best overall outcomes. Constant support means a mother has someone continuously at her side during the entirety of labor. That person must also be an active, knowledgeable participant in the labor process, not just a warm body taking up space.
• Intellectual Labor Needs: Educate the mother and her birth partner about how to execute the personal birth plan, which can include yogic breathing, a bevy of yoga posture options for individualized labor and birth positions, guided imagery and/or motor imagery techniques, and hands-on manual therapy techniques.
• Psychoemotional/Energetic Labor Needs: Address any previous birth or sexual trauma which could create anxiety and fear. Anxiety and fear of childbirth can prolong labor more than 90 minutes (Adams et al 2012).

Yoga is an amazing, proven method to directly diminish perceived pain during labor, immediate postpartum pain, and shorten labor duration, as well as improve maternal comfort and birth outcome scores, as found in a 2008 randomized trial of 78 pregnant Thai women.

Ginger’s course, Yoga as Medicine for Labor, Delivery, and Postpartum prepares the physical therapist to meet the needs of the laboring mother with an evidence-based mind-body holistic perspective, which includes designing individualized birth plans for labor and delivery. Future posts will also address the postpartum curriculum included in the course. To learn more about Ginger’s course, visit Yoga as Medicine for Labor, Delivery, and Postpartum.

This post was written by H&W instructor, Ginger Garner, PT, MPT, ATC, PYT, who teaches the Yoga as Medicine for Pregnancy and Labor & Delivery and Postpartum courses, and is teaching her brand new course, Extra-Articular Pelvic and Hip Labrum Injury, in June in Akron, OH.

Research into the surgical and nonsurgical management of acetebaular labral tears is young, but growing fast. Physical therapy is considered an integral part of nonoperative management of acetabular labral tears, with a trial of therapy also serving as the newest standard in preoperative and postoperative care. Conservative care becomes even more important in young dancers.

A critical concern in all individuals is hip joint preservation and prevention of premature joint degeneration and development of osteoarthritis. Especially in young females, who start with a higher risk of labral tears, sports like figure skating, dancing, and gymnastics further increase risk and prevalence of tears.

There are several reasons young women can experience a labral tear, but in general the etiology will fall under five possible categories: 1) congenital, 2) traumatic, 3) degenerative (far less likely with a young population), 4) capsular laxity, and/or 5) idiopathic causes such as femoral acetabular impingement. There are many more causes that fall under each category, but early intervention is repeatedly found in the literature to be perhaps the most important variable in long-term hip joint preservation and outcomes. Duke University physical therapist and orthopaedic surgeon, Michael Reiman and Chad Mather, respectively, authored a 2014 article with colleagues from Ohio that outlines the five major etiological categories, discussing the increasing prevalence of labral tears in high-risk populations and underscoring the need for early intervention. Citing diagnosis of labral tears as “continuously challenging”, the article emphasizes that a battery of tests and screening, rather than a single diagnostic viewpoint, are requisite in identifying an acetabular labral tear.

For young dancers, early intervention is of utmost importance. A case study currently in press (April 2014) reports success with a 12-year-old skeletally immature figure skater with a diagnosis made within the first month of the onset of pain and impairment. A six-week trial of physical therapy began immediately on consensus of three pediatric orthopaedic surgeons specializing in arthroscopic management of the acetabular hip labrum. At the 4-week follow-up, progress in PT was being objectively made with pain levels diminishing and functional performance improving (with no return to skating yet). After a continuation of therapy for an additional 6 weeks, the figure skater was able to return to skating and perform single jumps and double Lutz at 75% of her normal jump height without pain. At that time, PT was decreased to 1x/day weekly while continuing her normal home therapy program. After another month of therapy, she returned to her full training schedule. At the four-month visit she had returned to full competition with full spins and jumps (double axels) without pain. The one-year follow-up found the young patient pain-free and competing at local and national competitions.

The importance of physical therapy cannot be underestimated in young athletes, especially females, due to their inherently increased risk of labral injury. Further, multiple studies cite the importance of a multi-disciplinary, integrated approach in managing the hip labrum.

My Hip Labrum Injury course will focus on this biopsychosocial and integrated approach, including both conventional and integrative techniques in order to obtain the best outcomes for patients.

You can read some of my previous posts on evaluating risk and prevalence of hip labral injury:

• Lady Gaga’s Hip Labral Tear: Are you at Risk?

• The Postpartum Hip and Labral Tear Risk

• The Importance of Early Intervention in Labral Tears

• Implicating the Iliopsoas in Acetabular Labral Tears: Focus on Anatomy

Want to learn more from Ginger? Join us in June!

This post was written by H&W instructor, Ginger Garner, PT, MPT, ATC, PYT, who teaches the Yoga as Medicine for Pregnancy and Labor & Delivery and Postpartum courses, and is teaching her brand new course, Extra-Articular Pelvic and Hip Labrum Injury, in June in Akron, OH.

Pregnancy brings with it a bevy of physiological and hormonal changes, both of which greatly influence orthopaedic health, not to mention psychoemotional well-being. However, what has historically been overlooked is the risk at which the acetabular hip labrum and related structures are placed during pregnancy, labor, delivery, and the postpartum. Hip labral tears are debilitating and painful, preventing normal ambulation, ADL completion, or participation in any recreational activity, including sex. Tears can also lead or contribute to pelvic pain, with the average time of injury to diagnosis being an average of 2.5 years. This delay in diagnosis can put mothers at high risk for developing chronic pelvic pain.

Several theories have been posited as to why pregnancy brings increased risk of hip labral pathology. Increased joint laxity has been widely debated but is generally accepted as a plausible mechanism in back pain, sacroiliac joint dysfunction, pubic symphysis dysfunction, or related pain. Increased (axial) loading through the joint combined with joint laxity are thought to be compounding factors. These changes alone could explain the presence of a prenatal tear, says researchers Brooks et al (2012).

Unavoidable changes in joint structure and function during labor and delivery also place mothers at higher risk, which means screening for hip joint intra-articular pathology is vital in the clinical setting. Further, forces applied externally during labor can be responsible for hip labral tears. Brooks et al (2012) found 4 of 10 women (all with labral tears) reported a specific incidence during labor, such as a pop, twist, or sudden sharp pain in the hip, that led to their diagnosis of hip labral tear. The range of motion that is most often forced in the hip during labor is flexion and internal or external rotation, combined with abduction. This is a common mechanism of injury that applies torque at the hip joint and can commonly be delivered by a birth assistant (husband, relative, or health care professional). Birth biomechanics education is an important aspect of hip labrum preservation that should be included in interdisciplinary care.

Screens to identify mothers at highest risk for hip joint pathology and special tests to target the hip labrum and related structures should be considered a regular part of prenatal and postpartum care in women’s health physical therapy. Hunt et al (2007) raises the importance of interdisciplinary interaction in maternal health care since “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.”

Finally, pre-existing conditions of the hip and pelvis, such as femoral torsion, femoracetabular impingement (FAI), hip dysplasia, shallow acetabulum, and lumbopelvic instability or failed load transfer can all contribute to the incidence of, and increased risk for, hip labral tears. Since over 80% of women give birth in the United States during their lifetime, the vast majority of women are at risk for hip labral tears. Universal screening and education for hip joint preservation should be made available, through women’s health PT, as part of national agenda to improve birth and maternal health outcomes.

A discussion of postpartum risk, screening, and education are offered in the new Hip Labrum Differential Diagnosis course. This course emphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. My courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. At the course, I will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip.

Want more from Ginger on this topic? Join us in June!

This blog was written by H&W course instructor Ginger Garner PT, MPT, ATC, PYT, who will be teaching her brand-new course, Extra-Articular Pelvic and Hip Labrum Injury: Differential Diagnosis and Integrative Management, in Akron, OH this June.

Hip labral injury is now recognized as a “major cause of hip dysfunction and a primary precursor to hip osteoarthritis.” Although acetabular labral tears were first identified in 1957, attention has only been directed toward the acetabulum in the last 10-15 years.

Populations at highest risk for hip labral injury include women, expectant mothers, women who have had vaginal hysterectomies, and young and middle-aged athletes. Women suffer from hip labral injuries more frequently than men, putting women at highest risk for premature aging in the hip and osteoarthritis.

Adding to insult to injury is the average time between injury and diagnosis is typically 2.5 years, significantly reducing long-term outcomes for joint preservation. Pelvic girdle pain, lumbopelvic pain, and extra-articular hip injury are also common comorbidities that accompany hip labral tears, making differential diagnosis essential to successful management.

Hunt et al (2007) cites that “differential diagnosis of anterior hip, groin, and pelvic pain spans many health care specialties from gynecology to general surgery to musculoskeletal medicine and orthopedic surgery.” This statement underscores the vital importance of a collaborative, interdisciplinary partnership in medicine. Early intervention in hip joint preservation requires teamwork on the part of all health care specialties involved in a patient’s care. Physical therapists are a critical part of that team.

Structural disorders of the hip are not the only culprit for hip labral injury, and as a result, development of a unique skill set for hip labral injury assessment that includes soft tissue and structural integrity evaluation is required. This positions physical therapists as perhaps one of the most ideal clinicians to differentially diagnosis hip impairment due to their expertise in both structural and soft tissue assessment.

It cannot be overemphasized that missing a hip labral diagnosis can mean a devastating long-term prognosis for a patient. What’s more is diagnosis is elusive, making it even more important for physical therapists and related providers to establish parameters for early intervention through critical evaluation of the hip. Hunt et al (2007) state diagnosis requires “a high index of suspicion, special attention to subtle patterns of presentation, and timely consideration for imaging studies.” A 10-12 week trial of physical therapy is recognized in the literature as the standard for initial conservative management and should address not only the primary pathology but the sequela that complicates hip labral management, such as pelvic, spine and lower-extremity abnormalities.

If you would like more from Ginger on this topic, the new Hip Labrum Injury courseemphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. Ginger's courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. Ginger will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip. Registration is available here.

This post was written by H&W instructor, Ginger Garner, PT, MPT, ATC, PYT, who teaches the Yoga as Medicine for Pregnancy and Labor & Delivery and Postpartum courses, and is teaching her brand new course, Extra-Articular Pelvic and Hip Labrum Injury, in June in Akron, OH.

In my previous two posts, I have discussed The Postpartum Hip and Labral Tear Risk and The Importance of Early Intervention in Labral Tears. Today I want to highlight the importance of the iliopsoas and its potential contribution to intraarticular injury sequelae at the hip joint.

A recent collaborative paper including Harvard University’s Department of Orthopaedic Surgery, New York’s Hospital for Special Surgery and the Midwest Bone and Joint Institute in Illinois took on the task of a 3-D cross-sectional analysis of the iliopsoas in order to explain its relationship to the acetabular labrum. The findings are important not only for athletes, the targeted population who most frequently experiences labral tears, but also for the postpartum population I discussed in a previous blog post, The Postpartum Hip. This study represented the first attempt of 3-D analysis of the iliopsoas musculotendinous unit, and here is what the study found from dissection of 8 joints:

• The iliopsoas is found anterior to, and at the level of, the anterosuperior capsulolabral complex at the 2-3 o’clock position, or slightly lateral.

• The iliopsoas is comprised of about 44.5% tendon and 55.5% muscle belly at the exact level of the anterior labrum.

• An inflexible, not just a snapping, iliopsoas could possibly increase labral tear risk and prevalence in athletes.

• A labral tear associated with FAI (femoroacetabular impingement) is typically found at the 11:30-1 o’clock position, as opposed to an iliopsoas-induced tear, which is found at the 2-3 o’clock position.

• The researchers were led to study the iliopsoas’ contribution because the 2-3 o’clock position labral tear was being found with similar frequency as the typically expected 11:30-1 o’clock position during hip arthroscopy.

The acetabular labrum is responsible for not only maintaining joint congruity but also for pressurization. This means that In the absence of an intact labrum, contact forces are greatly increased in the hip joint, leading to premature aging of the hip and early osteoarthritis. In addition, repeat hip arthroscopy can be reduced and hip labral injury prevented or even mediated by addressing the iliopsoas length/tension relationship conservatively. The option also exists to release the tendon surgically at the level of the labrum (rather than the trochanter), and for athletes, early intervention using a team approach could mean the difference between hip joint preservation or hip joint degeneration.

Ginger's new Hip Labrum Injury course emphasizes evidence-based assessment and management of the hip in an interdisciplinary educational environment. Her courses are known for their interprofessional focus on partnership in medicine and welcome physical therapists, physicians, physician assistants, midwives, physical therapy assistants, nurses, and anyone who works with populations where hip labral injury could be a concern. The course will address differential diagnosis and assessment of extra-articular factors that implicate hip labral injury. Ginger will discuss both conventional rehabilitation and integrative medicine techniques for management and preservation of the hip.