Lumbopelvic pain is a common diagnosis in pregnancy that can be challenging for both the patient and the provider. A recent study assessed the effectiveness of 10 weeks of Hatha yoga in women between 12-32 weeks of gestation. 60 pregnant women ages 14-40 were divided into two groups, with the intervention group being guided in yoga exercises, and the control group instructed in postural activities. Nine pregnant women in the yoga group and six women in the control group were lost to withdrawal, obstetric complications, or refusal to participate. Excluded were women with twin pregnancies, medical restrictions, women using analgesics or those participating in physical therapy. Outcomes included a Visual Analog Scale (VAS) to measure pain intensity, and tests of lumbar and posterior pelvic pain. Lumbar provocation tests used in the study included trunk flexion and circumduction, paraspinal muscle palpation, and pelvic tests included the posterior pelvic pain provocation test.

Yoga intervention included weekly one hour sessions including 34 poses. The sessions focused on, in this order, breathing and joint warm-ups (10 minutes), poses and breathing exercises (40 minutes), and meditation and relaxation (10 minutes.) Pain intensity was assessed at the beginning and end of each session. Control group participants were instructed in typical postural changes during pregnancy as well as suggested postural support for various positions.

Results of the research include lower pain scores in the yoga group, with the authors concluding that yoga is an effective intervention for women who have pelvic girdle pain in pregnancy. A final VAS score of no pain, or "0" was reported in 71% of the yoga group and in 21% of the control group. The women in this study also reported emotional benefits of tranquility, lowered stress, "an easy mind," mental balance, and increased sense of closeness to the baby. While the lumbar provocation tests improved in both groups in response to intervention, pelvic girdle provocation tests remained positive in both groups at conclusion of the study even in those who had lowered pain scores.

This brings up interesting questions about the nature of the causative factors for the patient's pain. Also of interest is that in the control, or "postural orientation" group, lumbar provocation tests were improved even when reports of pain were not noted. You can discuss this research and more at the upcoming Yoga for Pelvic Pain course taking place in California in March with Dustienne Miller, yoga therapist and physical therapist.

Throughout the Guidelines on Chronic Pelvic Pain created by the European Association of Urology, the recognition of anxiety and depression as a concomitant symptom of chronic pelvic pain is made. Various types of pelvic dysfunctions have been demonstrated to have an association with anxiety and depression, including urethral pain, chronic pelvic pain, anorectal disorders, and sexual dysfunction. While a first line of medical treatment for patients who complain of neuropathic pain type, according to the Guidelines, is the prescribing of antidepressants, there are other interventions identified in the literature for alleviating anxiety and stress related to chronic pain. One of the studied interventions for pain, anxiety, and stress is yoga.

In a systematic review and meta-analysis for yoga and low back pain (which is also a common comorbidity of pelvic pain) yoga was found to have "…strong evidence for short-term effectiveness and moderate evidence for long-term effectiveness…" and the study concludes that yoga can be recommended for patients who have chronic low back pain. In this review of ten randomized controlled trials including 967 subjects with chronic low back pain, no serious adverse events were reported. A report in the journal Alternative Medicine Review states that yoga, which may be considered an adjunct therapy for stress and anxiety, is supported by good compliance among patient populations and a lack of drug interactions. The same study states that better research is needed before strongly recommending yoga for the specific purposes of reducing anxiety and stress. The current research is plagued with common statistical challenges: lack of a control group, variations in studied physiological markers, lack of validated scales, and heterogenous study populations.

For the pelvic rehabilitation provider, having a working knowledge of common yoga terminology and postures can assist in modification or adaptation of a patient's current routine. In addition, learning to apply yoga concepts and postures such as breathing, trunk and pelvic coordination, soft tissue lengthening within a patient's comfort can add to a pelvic rehab provider's toolbox. There is room for you to join Dustienne Miller, physical therapist and yoga instructor, in California at the Yoga for Pelvic Pain course. Contact the Pelvic Rehabilitation Institute if you have any questions about this continuing education course.

In our weekly feature section, Pelvic Rehab Report is proud to present this interview with newly certified practitioner Amy C. Sanderson, PT, OCS, PPRC.

Describe your clinical practice.:

I am a co-owner of a private physical therapy practice in the Spokane, Washington area. We currently have 3 clinics and staff 14 providers overall. I have been an Orthopaedic Certified Specialist since 1996, and our clinic is primarily an orthopedic setting. We do, however, provide several specialties, including Pelvic Rehab, Vestibular Program, and Video Gait Analysis for athletes.

How did you get involved in the pelvic rehabilitation field?

I have been practicing since 1993 and began a Women’s Health program in 1994 at a previous place of employment. When I had interviewed for the position of a staff physical therapist for this clinic, I was asked if I would be interested in starting any new programs for the company. The manager had recommended that I develop a Women’s Health program. Truthfully, I had not heard of Women’s Health in the early 90’s, but I really wanted the job, so I said “absolutely!” I figured that I was a woman and I knew some things about health, so how hard could it be. Countless hours of continuing education and several years of marketing to the local physicians and community, we have now built our Pelvic Rehab program up to 3 physical therapists providing treatment to all of our clinics in the Spokane, Washington area.

What patient population do you find the most rewarding in treating and why?

I have enjoyed the patients who are experiencing sexual pain disorders for the past 15 years and have found this to be the most rewarding. Several times, I have been contacted after the birth of children to be told how grateful the couple has been to achieve such a life experience. Most recently, I received an email from a patient whom I had not seen in 3 years because she wanted to let me know that she and her husband were finally able to achieve intercourse after several years of counseling and my help with physical therapy. It is extremely gratifying to know that we can make a difference in peoples’ lives.

What motivated you to earn PRPC?

I have been practicing for greater than 20 years, including treating patients with all types of pelvic conditions, and after so many years, I wanted to challenge myself to see if truly what I was doing as a practitioner was effective, appropriate, and up to date. I decided that reviewing my education, seeking further education, and testing would be an effective way to do so. I felt that as I was preparing for this exam, I was able to realize that my treatment techniques are effective and appropriate. I am extremely grateful to the Herman & Wallace Pelvic Rehabilitation Institute for providing such great instructors to teach these skills.

Learn more about Amy C. Sanderson, PT, OCS, PPRC at her Certified Pelvic Rehabilitation Practitioner bio page. You can also learn more about the Pelvic Rehabilitation Practitioner Certification at www.hermanwallace.com/certification.

A recent on-line survey queried fourty-four Obstetrician-Gynecologists (OB-GYNs) in British Columbia to learn more about the needs of physicians who treat women who have endometriosis and chronic pelvic pain (CPP). Physicians reported that women who present with endometroisis or chronic pelvic pain usually require more visits than other patients, for reasons including medical and pain management, lack of a clear diagnosis, and lack of improvement in condition. Evaluation techniques utilized by the physicians often included laparoscopy and ultrasound, and despite these practices, the OB-GYNS reported challenges in making a diagnosis or successfully treating their patients with CPP. In fact, survey results indicated that 5% of the respondents were able to diagnose a patient for a cause of pelvic pain in > 70% of patients. Most of the physicians reported that less than half of the women treated had a good response to interventions. Although the highest rate of referral for these providers was to another OB-GYN specializing in pelvic pain, nearly 60% of the time a referral to physical therapy was reported.

Although some of the narrative comments encountered in this survey were positive, including one physician's report of having "…good success with physiotherapy…", more often the providers expressed frustration and annoyance when faced with not only the challenges of diagnosis and treatment, but also the poor compensation and the longer visits required for counseling and teaching of patients. In addition to wanting more clear guidelines on diagnosis and management of female CPP, physicians expressed interest in having group educational sessions for patients, and more resources such as educational brochures on self-management for patients.

How can pelvic rehabilitation providers fill in this knowledge gap? I recall asking a referring provider if he was pleased with his patients' rehabilitation outcomes, and he expressed such a relief that I was taking the "dregs of the practice." He meant nothing disparaging about the patients themselves, he explained, just that when these patients walked in the door he felt a sinking feeling because he did not know what to do for them. Now, he reported, these same patients were returning from a pelvic rehabilitation referral and excitedly reporting on progress they had made. So many physicians and other referring providers still do not understand the scope of the patient populations that we can treat in pelvic rehabilitation. We can provide a necessary bridge between the challenge of diagnosing and medically treating chronic pelvic pain and the rehabilitation approach that addresses the chronic pain issues. Differential diagnosis of chronic pelvic pain from a rehabilitation standpoint is a skill set that every therapist must continually improve upon. If you are interested in learning more about these skills, sign up for faculty member Peter Philip's continuing education course Differential Diagnostics of Chronic Pelvic Pain next month in Connecticut.

Herman & Wallace Pelvic Rehabilitation Institute would like to express thanks to the following therapists who participated in the development of our new certification, the Pelvic Rehabilitation Provider Certification, or PRPC. There were many stages of development in the rigorous process required to create a certification. Expertise was needed to provide input about examination content, format, and scope. Item writers were needed to create the 450 items needed for our test bank. Teams of reviewers volunteered time to revise items prior to the first exam offering, and raters spent many hours in team web conferences following the exam so that a cut score could be created.

Each of the following therapists contributed in some way to this process, and we are grateful for their time and expertise. (If I have forgotten to list anyone, let me know- we want to give credit where credit is due!) The PRPC is the only certification available that recognizes pelvic rehabilitation providers treating men and women across the lifespan. Congratulations to the first group of PRPC!

Dustienne Miller

Allison Ariail

Peter Philip

Karen Vande Vegte

Elizabeth Hampton

Lila Abbate

Holly Tanner

Nari Clemons

Heather Rader

Deanna Dreier

Joyce Steele

Michelle Lyons

Susannah Haarmann

Christine Cabelka

Brandi Kirk

Sagira Vora

Teri Elliott-Burke

Holly Herman

Pamela Downey

Genne DeHenau-McDonald

Tina Tyndall

Rachel Kilgore

Tina Allen

Kristina VanNiel

Megan Kranenburg

Rachel Brandt

As therapists are increasingly immersed in understanding of mechanisms of chronic pain and central nervous system phenomena, a question persists: what should we do with the peripheral tissues? As is usual in discussions that can take an either/or approach, the answer may lie somewhere in the middle. A recent article discussing myofascial trigger points (TrP) discusses the hypotheses surrounding this phenomena as a peripheral versus central mechanism. In a very well-cited summary of the issue, the authors come to some very helpful conclusions that you may find useful in your clinical practice.

If a trigger point, by definition, is a hyperirritable spot in a taut band of skeletal muscle that may or not have referred pain, what then, is driving the soft tissue dysfunction? Some authors argue that the peripheral nervous system is at fault, while others point to the central nervous system as the driver. Peripherally, nociceptive input may sensitize dorsal horn neurons. Centrally, patients who have chronic pain will have larger areas of pain, described as being a result of higher central neural plasticity. This is a controversial topic, and the authors are quick to point out that experimental evidence is "sparse." While there is support in the literature for peripheral trigger points creating central sensitization, the article states that "…preliminary evidence suggests that central sensitization can also promote TrP activity."

While this study does an excellent job describing various clinical and experimental research, hypotheses, and strength of evidence to support the hypotheses, the summary points are that trigger points may be both a central and peripheral phenomena, and that chronicity of the condition may drive the focus of rehabilitation efforts. Specifically, the authors state that when a patient presents with peripheral sensitization, treatment should be directed towards inactivation of the trigger point, mobilizing joints and nerves, and functional activity. Patients who present with persistent pain may require more attention directed to the central system utilizing a multidisciplinary approach such as medications, medical and physical therapy management, and psychological therapy. Fear, anxiety, and the neuroscience approach to pain should be addressed.

These issues are discussed throughout many the Institute's courses, but if you hope to get an earful about connective tissue and chronic pain research AND add tools to your toolbox, Institute faculty member Ramona Horton offers Myofascial Release for Pelvic Dysfunction. Join Ramona in June in Ohio, the last chance to take the course in 2014!

How the concepts of stigma and taboos affect bowel function is the focus of a recent article by Chelvanayagam, a lecturer in mental health in England. The author establishes that previously taboo subjects are becoming less hidden in the media, such as sexual function or urinary incontinence, but that in the UK, bowel function is still considered taboo. When people are not given language and social permission to discuss health concerns, conditions go underreported or unrecognized and under treated.

The author points out that patients with bowel dysfunction such as irritable bowel disease, fecal incontinence, and stomas feel stigmatized and are hesitant to discuss concerns with heath care providers or loved ones. The social implications of bowel disorders can lead to socially isolating behaviors including difficulty going out to eat, participating in physical activities, or taking sick leave from work.

Because pelvic rehabilitation providers discuss intimate issues including bowel function with patients, communication skills are very important in order to allow the patient to feel comfortable about the topic. Both verbal and non-verbal techniques will be observed and responded to by the patient. Various stigma-reducing strategies are described in the article. At the interpersonal level, cognitive-behavioral and empowerment strategies are recommended, and at the community level, education and advocacy are listed. Each of these strategies are ones that the pelvic rehabilitation provider is capable of providing.

If you have been wanting to learn more about bowel dysfunction and pelvic rehabilitation, the Institute added to our offeringsa bowel course that is next offered in June in Minneapolis, and November in Los Angeles area.

As I looked through this post by an accomplished yoga instructor on the "Top 10 Yoga Postures for Strength," I tried to look at the words and images through the eyes of our typical patients. The chosen postures made the list as they contained foundational "alignment and strength needed to master many more advanced postures." While this may be true for some, I can easily imagine the trouble that most of my patients would find by attempting to cruise through the demonstrated techniques. With jump backs, headstands, handstands, and one arm side planks, there is little caution made about hyper extensibility, about "gripping" postures as Diane Lee explains so well, or about compensatory patterns that can cause strain or injury.

The yoga instructor is not to be blamed- any magazine, blog post, or website that sells fitness or wellness attempts to package information to the public in attractive and efficient methods. An impressively toned, graceful, and high-level yoga practitioner is perfect for such a marketing goal. Unfortunately, any person reading an instructor's guide to finding your physical strength does not have said instructor giving the required feedback about joint position, compensations, and necessary modifications or starting postures.

Patients everywhere espouse the benefits of a yoga practice, and we all have likely met someone whose life was drastically changed for the better after finding yoga. Can yoga also be the cause of an injury? I recall entering a new yoga class at a gym (where the instructor had created a "guru" type following) and I was horrified at the instructor's lack of restraint in guiding a room of 70 or more students through very advanced poses that they were simply expected to push themselves through. The students wore their suffering like a badge, telling each other to "stick it out" as they would keep getting stronger. The instructor then approached me and, without knowing anything about me or my body, twisted me aggressively into a posture that I quickly unraveled as soon as she moved away. As if students cannot find enough ways to push the body outside of a comfort zone, having an instructor violate basic safety principles (was I returning to yoga after a spinal surgery?) adds to the potential for injury.

In a systematic review of adverse events associated with yoga, Cramer, Krucoff & Dobos describe musculoskeletal injuries such as fractures, ligament tears, joint injuries, disc annular tears, and several cases related to breathing techniques. Headstands were a common method for acquiring a yoga-related injury. The authors suggest that for patients who have physical or mental ailments, yoga can be adapted to a patient's "…needs and abilities and performed under the guidance of an experienced and medically trained yoga teacher."

While yoga does not need to be discouraged, we may need to consider the patient's abilities and challenges, and be familiar with our community resources prior to suggesting that a patient begin yoga. If you are more interested in advancing your own practice and in learning how to apply yoga principles and postures to your patient populations, the Institute has several means to accomplish this. For patients who have pelvic pain, Dustienne Miller will teach Yoga for Pelvic Pain in March, where you can learn how to tailor specific yoga techniques for specific patient presentations and conditions. You can also check out Ginger Garner's live and on-line yoga courses by clicking here (scroll down to Yoga as Medicine).

In a recent study examining demographic and obstetric factors on sleep experience of 202 postpartum mothers, researchers report that better sleep quality correlated negatively with increased time spent on household work, and correlated positively with a satisfactory childbirth experience. Let's get right to the take home points: how are we addressing postpartum birth experiences in the clinic, and how can we best educate new mothers in self-care? You will find many posts in the Herman Wallace blog about peripartum issues, and you can access the link here.

The authors recommend that healthcare providers "…should improve current protocols to help women better confront and manage childbirth-related pain, discomfort, and fear." Do you have current resources with which you can discuss these issues (and a referral to an appropriate provider) when needed? In our postpartum

course, we highlight the challenges a new mother faces due to the commonly-experienced fatigue in the postpartum period. According to Kurth et al., exhaustion impairs concentration, increases fear of harming the infant, and can trigger depressive symptoms. Issues of lack of support, not napping, overdoing activities,, worrying about the baby, and evenworrying about knowing you should be sleepingcan worsen fatigue in a new mother. (Runquist et al., 2007)

Back to what we can do for the patient: investigate local resources. This may include knowing what education is happening in local childbirth classes (and providing some training when possible respectfully inquiring of new mothers how they are doing with sleep and demands of running a household (and business or work life and finding out what support/resources the new mother has but is not accessing. Patients are often hesitant to ask for help, or may feel guilty in hiring someone to help clean for the first few months, feeling that she "should" be able to handle the chores and tasks. Educating women about results of the research and about potential improvements in quality of life can help the entire family.

If you are interested in learning more about Care of the Postpartum Patient, sign up today for our next continuing education course taking place next month in the Chicago area. (Don't you have a friend to visit in Chicago?) If you can't attend the Postpartum course, how about the Pregnancy and Postpartum Special Topics course taking place in October in Houston? Check the website as we add more Peripartum course series events, including Care of the Pregnant Patient, for 2015!

In a study conducted in Western Sydney, Australia, researchers aimed to discover the barriers and enablers to attending preoperative pelvic floor muscle training for men scheduled for a radical prostatectomy. Semi-structured interviews were completed with referral sources (urological cancer surgeons, nurses, and general practitioners pelvic rehabilitation providers (physical therapists and continence nurses and male patients having surgery at a public and a private hospital.

Key factors that encouraged men to attend pelvic muscle training included having a referral from a provider that was for a specific therapist or center. Barriers to attending rehabilitation included potential cost of private pelvic floor muscle training, and lack of awareness about pelvic muscle rehab among both providers and patients. The providers were often not aware of public sector providers of pelvic muscle training, and patients were unaware of potential benefits of rehabilitation.

While the numbers of referrers (11 providers (14 and patients (13) do not represent a large population, the recorded and transcribed interview allowed the subjects to express themselves without constraint. Some of the providers described the challenge of patients getting lost between the general practitioner and the specialists, the physiotherapists stated that formal training for male pelvic rehab was lacking and that providers were in the habit of referring for women, rather than men, and that the physiotherapist had not made an attempt to market services for male rehabilitation.

Physicians also noted that they refer to pelvic floor rehabilitation because the current and emerging literature is so positive regarding preoperative pelvic muscle training. The patients who were given a specific referral (especially when convenient regarding location and making an appointment) were more likely to schedule rehabilitation.

From this research, we can ask some questions of our current practices. Is a therapist at your facility trained to treat male urinary incontinence? Are the providers and the community aware of your pelvic rehabilitation program? Are the providers aware of the research promoting preoperative physiotherapy for urinary incontinence post-prostatectomy? If you are interested in knowing more about this patient population, the Male Pelvic Floor Function, Dysfunction, and Treatment course takes place at the end of the month in California. In the course we discuss prostatectomies and post-operative recovery, male pelvic pain, and male sexual health.