Aparna Rajagopal, PT, MHS is the lead therapist at Henry Ford Macomb Hospital's pelvic dysfunction program, where she treats pelvic rehab patients and consults with the sports therapy team. Her interests in treating peripartum patients and athletes allowed her to recognize the role that breathing plays in pelvic dysfunction. She has just joined the Herman & Wallace faculty and co-authored the new course, "Breathing and the Diaphragm: Pelvic and Orthopedic Therapists", which helps clinicians understand breathing mechanics and their relationship to the pelvic floor.
Aparna was kind enough to introduce herself to us here on The Pelvic Rehab Report.
Thank you for your time Aparna! To start, tell us a little bit about yourself.
My name is Aparna. I’ve been a physical therapist for 22 years. About 16 years ago I switched focus from orthopedics to treating pregnancy and postpartum patients and that’s where my initial interest in pelvic care started. In 2006 following my pregnancy and birth of my daughter, my interest in pelvic care grew with my special interest becoming pelvic pain.
I teach and mentor the pelvic health therapists within the fairly large hospital system that I work at and collaborate with our spine center team and our sports team.
What can you tell us about this new breathing course that is not mentioned in the “course description” and “objectives” that are posted online?
Physical therapy has evolved and continues to evolve as we speak. Regional inter dependence, wherein the different systems interplay, and one structure influences another, is fascinating. No longer is the body considered and treated as independent fragmented pieces. The ‘core’ with the contribution of the Diaphragm and the pelvic floor is so much more than just the Transverse Abdominis and the Multifidus working together. Fascial restrictions of the lower abdomen and the pelvis can influence how the low back feels, thoracic stiffness can influence the interplay between the various abdominal muscles by way on their insertion into the lower ribs, musculo- skeletal pain and postural deviations can stem from incorrect breathing patterns etc.
Normal breathing rate is about 10 times every minute. Breathing incorrectly reinforces wrong movement patterns tens of thousand times a day with negative consequences on the musculoskeletal system.
This course offers an in depth look at the diaphragm from the perspective of both orthopedic and pelvic therapists and attempts to tie in the diaphragm to the thoracic spine, the ribs, the pelvic floor, the core, posture and finally the athlete.
What essential skills does the breath course add to a practitioner’s toolkit?
The practitioner will walk away with the ability to view the patient as a “whole”. It offers a different perspective on neck and back pain, posture/ alignment along with the ability to assess for and connect breathing and the diaphragm to stability/ the core, continence issues and the Autonomic Nervous System.
As therapists we already do a great job of addressing strength issues, assessing and correcting posture, mobilizing etc. You can add to your treatment options by learning how the diaphragm works in concert with other muscles (especially the abdominals) and systems, identifying breathing pattern dysfunctions and postures, and movement patterns which may be linked to breathing pattern dysfunctions. This understanding is beneficial for both orthopedic and pelvic patients.
What inspired you to create this course? What void does this new offering fill?
I have used breathing and evaluation of the diaphragm as a part of pelvic care for several years now. As the mentor for the pelvic program at my hospital, and as a part of the spine team and sports team, I work with pelvic therapists, orthopedic therapists, manual certified therapists, and sports certified therapists. Through my interactions I have come to realize that although many of the therapists are aware that the Diaphragm and breathing are important, they are unsure of how to assess for dysfunctions and address those dysfunctions. I initially started conducting classes within the hospital system. At the same time Leeann who is a sports certified therapist and holds a manual therapy certificate and I started collaborating on our patients. Using a combination of her knowledge and effective manual techniques with my pelvic care and breathing techniques we realized that along with my pelvic patients; our back and neck patients, and her sports patients were all benefitting from this combined approach. We realized along the way that we had information worth sharing with our colleagues that would benefit them in treating their patients, and started classes within the hospital system and that is how this class was born!
What was your process like creating this course?
As a trained pelvic therapist, I have incorporated and used breath and the diaphragm in my treatment for over a decade. Leeann and I have created this course using a combination of our clinical experiences, our education in our respective chosen paths of patient care, and most importantly using recent and relevant research articles from journals to guide us extensively in creating this course.
Breathing and the Diaphragm: Pelvic and Orthopedic Therapists is a new course being offered next March 27-29, 2020 in Sterling Heights, MI, and again on December 11-13, 2020 in Princeton, NJ. It is created and taught by Aparna Rajagopal, PT, MHS and Leeann Taptich, PT, DPT. Come learn how the diaphragm and breathing can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi component system that works together.
Faculty member Nari Clemons, PT, PRPC recently created a two-course series on the manual assessment and treatment of nerves. The two courses, Lumbar Nerve Manual Assessment and Treatment and Sacral Nerve Manual Assessment and Treatment, are a comprehensive look at the nervous system and the various nerve dysfunctions that can impact pelvic health. The Pelvic Rehab Report caught up with Nari to discuss these new courses and how they will benefit pelvic rehab practitioners.
What is "new" in our understanding of nerves? Are there any recent exciting studies that will be incorporated into this course?
The course is loaded with a potpourri of research regarding nerves and histological and morphological studies. There are some fascinating correlations we see with nerve restrictions, wherever they are in the body. Frequently the nerves are compressed in fascial tunnels or areas of muscular overlap, then the nerve, wherever the location, frequently has local vascular axonal change, which increases the diameter of the nerve and prohibits gliding without pain. This causes local guarding and protective mechanisms. Changing pressure on the nerve can change that axonal swelling and allow gliding without pain.
New pain theory also supports that much of pain perception is the body perceiving danger or injury to a nerve. By clearing up the path of the nerve and mobilizing it, we can decrease the body's perception of nerve entrapment and thus create change in pain levels.
What do you hope practitioners will get out of this series that they can't find anywhere else?
I hope they will leave the course able to treat the nerves of the region, which is essentially the transmission pathway for most pelvic pain. I don't know of other courses that have this emphasis.
You've recently split your nerve course in two. Why the split?
I didn't want this class to be a bunch of nerve theory without the manual intervention to make change. After running the labs in local study groups, we found it took more time for people's hands to learn the language, art, and techniques of nerve work. To truly do the work justice and for participants to have a firm grasp of the manual techniques without being rushed, we found it takes time, and I wanted to honor that, as well as treating enough of the related factors and anatomy to make real and lasting change for patients.
How did you decide to divide up content?
Basically, we divided them up by anatomical origin:
The lumbar course covers the nerves of the lumbar plexus, the abdominal wall when treating diastasis, and treatment of the inguinal canal (obturator nerve, femoral nerve, iliohypogastric, ilioinguinal, genitofemoral nerves). Also, the lumbar nerves have more effect in the anterior hip, anterior pelvis, and abdominal wall.
The sacral nerve course covers all the nerves of the sacral plexus (pudendal, sciatic, gluteal/cluneal, posterior femoral cutaneous, sciatic, and coccygeal nerves), as well as subtle issues in the sacral base and subtle coccyx derangement work as well as the relationship with the uterus and sacrum, to take pressure off the sacral plexus. The sacral nerves have more effect in the posterior and inferior pelvis and into the posterior leg and gluteals.
What are the main stories that either course tells?
Both courses tell the story of getting closer to the root of the pain to make more change in less time. Muscles generally just respond to the message the nerve is sending. Yet, by treating the nerve compression directly, we are getting much closer to the root of the issue and have more lasting results by changing the source of abnormal muscle tone. Rather than an intellectual exercise of discourse on nerves, we devote ourselves to the art of manual therapy to change the restrictions on the pathway of the nerve and in the nerve itself.
If someone went to the old nerve course, what's the next best step for them?
The first course was initially all the lumbar nerves with a dip into the pudendal nerve. They would want to take the sacral nerve course, as those nerves were not covered in the first round.
Anything else you would like to share about these courses?
Sure. Essentially, we will take each nerve and do the following:
Join Nari at one of the following events to learn valuable evaluation and treatment techniques for sacral and lumbar nerves
Upcoming sacral nerve courses:
Sacral Nerve Manual Assessment and Treatment - Winfield, IL
Oct 11, 2019 - Oct 13, 2019
Sacral Nerve Manual Assessment and Treatment - Tampa, FL
Dec 6, 2019 - Dec 8, 2019
Upcoming lumbar nerve courses:
Lumbar Nerve Manual Assessment and Treatment - Phoenix, AZ
Jan 11, 2019 - Jan 13, 2019
Lumbar Nerve Manual Assessment and Treatment - San Diego, CA
May 3, 2019 - May 5, 2019
In July of this year, I was invited to present in Christchurch, New Zealand as part of a teaching tour that took in Singapore, Australia and Tasmania. The topic of my class was female pelvic pain, so we discussed Endometriosis, Vulvodynia, Sexual Health and many other sub-topics but we had several discussions about the effects of trauma on pelvic pain. For those who have visited Christchurch, it is a beautiful city but it is still reeling from a series of massive earthquakes, that started in September 2010. The most devastating was in February 2011, when 185 people were killed and 6600 people were injured. Everywhere you go in Christchurch, there are reminders – from the constant buzz of ongoing construction, to structures that are waiting demolition, like the beautiful old cathedral that was beside our hotel. Usually, when I teach, we do some ‘housekeeping’ announcements about fire drills and exits; in Christchurch it was ‘In the event of an earthquake…’. I wondered how the near constant reminders were affecting the inhabitants, so I read of how ‘…people called living with continual shaking, damaged infrastructure, insurance battles and unrelenting psychological stress ‘the new normal’. There are several ongoing research studies, looking at the effects of this trauma and how it is still having an effect on the people of Christchurch.
If you’ve attended Pelvic Floor Level 1 with Herman & Wallace, you’ll remember we quote a study from Van der Welde about the effects of perceived danger on muscle activity in the upper trapezius and pelvic floor muscles. We also discuss the work of Levine, of ‘Waking the Tiger’ fame, who explores the somatic effects of trauma in our bodies – and how trauma, much like pain, is whatever we say it is.
I became intrigued with the topic, so I was delighted to hear that Lauren Mansell has created a course to deal exactly with this topic. I was even more delighted when she sat down for a chat with me to explore the nuances of trauma awareness, boundary setting and self-care for therapists, especially pelvic therapists, who work with those who have experienced trauma of any kind.
I hope you find this conversation as interesting as I did! Here is our conversation:
1. ‘Vaginismus, a Component of a General Defensive Reaction. An Investigation of Pelvic Floor Muscle Activity during Exposure to Emotion-Inducing Film Excerpts in Women with and without Vaginismus’ van der Velde, J & Laan, Ellen & Everaerd, W. (2001)
2. ‘Waking The Tiger’ by Peter A. Levine (1997)
The following case study comes from faculty member Deb Gulbrandson, PT, DPT, a certified Osteoporosis Exercise Specialist and instructor of the Meeks Method. Join Dr. Gulbrandson in The Meeks Method for Osteoporosis on September 22-23, 2018 in Detroit, MI!
The first sight I had of my new patient was watching her being wheeled across the parking lot by her husband. A petite 72-year-old, I could see her slouched posture in the wheelchair. With the double diagnosis of osteoporosis and Multiple Sclerosis (MS) it didn’t look good. However, “Maryanne“ greeted me with a wide grin and a friendly, “I’m so excited to be here. I’ve heard good things about this program and can’t wait to get started.“
That’s what I find with my osteoporosis patients. They are highly motivated and willing to do the work to decrease their risk of a fracture. Maryanne was unusual in that she was diagnosed with MS at a very young age. She was 18 and had lived with the disease in a positive manner. She exercised 3X a week and had a caring, involved husband. They worked out at a local health club, taking advantage of the Silver Sneakers program. Maryanne was able to stand holding onto the kitchen counter but had stopped walking five years ago due to numerous falls. She performed standing transfers with her husband providing moderate to max assist. Her osteoporosis certainly put her at a high risk for fracture.
Even though she had been exercising on a regular basis, she was unfortunately doing many of the wrong exercises. Her workout consisted of sit-ups and crunches. She used the Pec Deck bringing her into scapular protraction and facilitating forward flexion. She was also stretching her hamstrings by long sitting reaching to touch her toes.
Spinal flexion is contraindicated in patients with osteoporosis. A landmark study done in 19841 divided a group of women with osteoporosis into 4 groups. One group performed extension based exercises, a second group did flexion. A third group used a combination of flexion and extension and the fourth was the control and did no exercises. Below are the results 1-6 years later.
The results were astounding. Granted, it was a small study- 59 participants and it was done a long time ago. But this is a one study that no one wants to repeat, or volunteer for!
Several take home messages followed this study.
Sadly, many individuals with osteoporosis are told by their physicians to start exercising.......but without any guidance they do what Maryanne did. Just start exercising. And putting themselves at greater risk.
Maryanne was also doing nothing to strengthen her back extensors and scapular area. After giving an overview of the vertebral bodies, pelvis, and hip joint with my trusty spine, I showed both my patient and her husband how forward flexion puts increased compression on the anterior aspect of the spine, particularly in the thoracic curve at T 7, 8, 9, the most common site of compression fractures. We started with Decompression, which is the beginning position for the Meeks method. Many therapists know this as hooklying. This position allows the spinous processes to press against the hard surface of the floor, opening up the anterior portion of the spine and providing tensile forces throughout the length of the spine. With the help of her husband, Maryanne could get down on the floor but I often advise patients who are unable to safely transfer to the floor to lay across the end of their bed. This is less cushy than lying longways where they sleep. Adding a yoga mat or a quilt on top to give more firmness improves the effect.
Supine is the least compressive of all positions; sitting is the most compressive. While Decompression may not seem like much of an exercise it is vital to reduce the effects of gravity and compression on the spine.
We addressed sitting posture by firming up the base of her wheelchair as well as recommending transferring into other chairs and positions frequently throughout the day. Spending time sitting towards the edge of a firm chair in what we call Perch Posture and practicing Foot Presses into the floor created improved alignment in her spine as well as isometrically activating glutes, abs, quads. Using the Foot Press is an example of Newtons 3rd Law, “For every action there’s an equal and opposite reaction” so by pressing her feet down she actually lengthened her torso and head. We also discussed discontinuing the contraindicated exercises in her workout routine and I assured her that the Meeks method would progressively challenge her core (the reason everyone thinks they should do sit-ups) and target the right muscles to help strengthen her bones. We use site specific exercises to target certain muscles that pull on the bone and increase bone strength.2
With instructions to Decompress several times daily to reduce compression on the spine along with the other adjustments made, I felt Maryanne was on her way to reducing her risk of fracture and increasing the quality of her life. She thanked me profusely for the education and the exercise of that session. We both look forward to the next one.
1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984 Oct;65(10):593-6.
2. Frost HM1. Wolff's Law and bone's structural adaptations to mechanical usage: an overview for clinicians. Angle Orthod. 1994;64(3):175-88.
My name is Tina Allen. I teach a course called Manual Therapy Techniques for the Pelvic Rehab Therapist. I developed this course in 2016 out of desire to help clinicians feel comfortable in their palpation and hands on skills.
My journey as a pelvic rehab therapist started with a patient whispering to me in the middle of a busy sports/ortho clinic gym; “is it normal to leak when you laugh”. I was treating her after her total hip replacement and my first question was “where are you leaking”? I was concerned that her incision was leaking, that she had an infection and it was beyond me to understand why it would happen when she laughed! I was 24 years old and 2 years out of PT school. Little did I know, that one whispered question would lead me to where I am today. I am in my 25th year as a PT and 20th year specializing in pelvic rehabilitation.
When I started out there just were not many classes. I spent time learning from physicians, reading anything I could find and applying ‘general ‘orthopedic principles to the pelvis. I traveled to clinics and learned from other clinicians. I soaked up anything I could and brought it back to my clinical practice. When Holly Herman and Kathe Wallace asked me to teach with them I was humbled, honored and terribly nervous. Holly and Kathe where two of my greatest resources and to be able to teach along side them to help others along was humbling. As I prepared to teach I realized the breadth of what we do as pelvic rehab clinicians has grown exponentially since I started out.
Over the past 10 years of teaching the pelvic series with H&W; I noticed that for some of the participants there was a gap in confidence in palpation skills and in treatment techniques applied to the pelvic floor region. For most, it’s confidence in what they are feeling and where they are. This course came out of wanting to fill that gap. I wanted to allow a space that clinicians could come and spend two days learning, affirming and building confidence in their hands. They could then take those skills and confidence back to their clinics and help more patients.
The thought of writing this course was daunting. First off, written words are not my thing. Don’t get me wrong I love to read but me coming up with what to put on paper, much less a power point slide, frightened me. With much encouragement and support from colleagues and H&W, I got to work. The first thing was to think about what techniques to include. At some point after 20 years in the field, your hands just do the work and you don’t think about how you do something. My colleague and dear friend Katy Rice allowed me to sit down with her, practice a technique and then write down each specific step to do the skill. She would read them over and then attempt to do the technique by following only the written instructions. I also had patients who were instrumental in helping me choose what techniques to include. They would say to me “that is what made all the difference for me; it has to be included in what you teach others. “
I would think about who taught me each technique, whether it was a course, another clinician or a patient. I know that I did not make any of these up myself; while I may have modified a technique to work with my hands I did not originate them. Holly Tanner was so kind to brain storm with me and lead me to references for some of the techniques that we as clinicians use every day and that I was planning to include.
What happened next was months of me sitting at the kitchen table combing through books, articles, course manuals and online videos looking for origins of the techniques I use every day in my clinical practice. I wanted to be sure to give credit to sources. It was tedious but also inspiring to realize that some of these techniques have been around and documented since 1956 (Dicke, E., & Bischof-Seeberger, I.) and also that the same techniques are sited by multiple different sources. After about 6 months of our kitchen table not being suitable for dinner it was time to see what I had gathered and how it would all fit together. The result was this 2 day course: Manual Therapy Techniques for the Pelvic Rehab Therapist which has seven labs including internal, external and combination techniques, home program/self care ideas and time for brainstorming treatment progressions. Join me in Philadelphia, PA this October 20 - 21 to learn these essential skills.
There are moments when I pause and realize how far we’ve come in a short period of time, and then others when I’m acutely reminded how far we have yet to go. Our destination is an integrative health care system which addresses nourishment first and early versus last, not at all, or only when all else fails. My mission is to support the concept of nourishment first and early though sharing of “Nutrition Perspectives for the Pelvic Rehab Therapist” through the Herman & Wallace Pelvic Rehab Institute.
After each weekend I teach Nutrition Perspectives for the Pelvic Rehab Therapist, I feel affirmed that this class, this information is vital and at times life-changing for practicing clinicians. And every time I teach, participants share that they take away much more than they expected. It’s a course that makes accessible complex concepts to entry level participants while offering timely and cutting edge integrative instruction to the advanced clinician eager to incorporate this knowledge into their practice. Supportive literature is woven throughout the tapestry of the course.
After the most recent live course event, a participant shared with me a letter she received from a patient in 2016 who mentions the lack of nutritional attention during her cancer treatment. I want to share with you the essence of this letter:
“In October 2015, I was diagnosed with cancer. The following December I started treatments of radiation and chemotherapy. I really appreciate all the fine employees who helped me through care and treatments. Every clinician I came across, whether a doctor, nurse, phlebotomist, radiation and chemo teams, and my PT, were all exceptional in showing care, concern and knowledge.
However, one area I felt was lacking in was nutrition. I was frequently offered a standard hospital-issue protein drink. When offered, I explained that I would not take it due to it containing high fructose corn syrup (HFCS). I asked if they knew that HFCS was like putting and accelerant on a fire? I received a smile and a nod of head as to say they understood.
I was also offered soda pop to wash down bad tasting medicines/ liquids I was to take. I opted to just down the medication without chasing it as I didn’t want to exacerbate my condition. While taking chemotherapy, I was offered snacks containing HFCS and other non-nutritive so-called foods.
I was also offered limited entree choices, but there were plenty of pies, cakes, jellies, and other non-nutritive foods to choose from. All Items I would not consider for a cancer diet or even a healthy diet. I finally took a picture of the menu selection sheet as I thought no one would believe such a thing could happen.
I received excellent care throughout your system with the exception of nutrition . I would ask that you take a look at making menus with truly healthy options as well as giving patients options that do not contain ingredients that feed the cancer.”
While this letter addresses an inpatient issue at one regional health system, it correspondingly brings into focus the irony present in the vast majority of health care settings across the nation from inpatient to outpatient settings: there is a profound lack of clarity about what it means to be nourished, especially when we are at our most vulnerable.
I cannot claim “Nutrition Perspectives” will solve our nation-wide problem, however, I am certainly encouraging a movement towards a collective understanding of the imperative fact that food is medicine - powerful medicine - and we must as front-line practitioners harness what this understanding can offer. Pelvic rehab practitioners are uniquely positioned to process this information and begin immediately sharing it in clinical practice.
Like many providers, this same participant shared with me that upon receipt of this letter two years ago, she struggled to make progress with what and how to offer nutritional information - mainly because of the overwhelming nature of the subject, and also because of the conflicting and oftentimes confusing information traditionally shared with the public. After attending Nutrition Perspectives, she said “I cannot even begin to describe how much your course has met ALL my hopes for helping clients!….I had struggled to put something together and here it all is - so unbelievably grateful.”
And that’s what this course is all about - empowering you as you broaden your scope of knowledge in a way that teaches you not facts, but deep understanding. Once that foundational understanding is laid, this grass-roots effort will progress like putting an accelerant on the integrative movement. Soon we’ll see the inclusion of nourishment information as first-line practice, and the lives impacted in a positive way will continue to grow.
Please join me at the next opportunity to share in this live experience with other like-minded clinicians. Nutrition Perspectives for the Pelvic Rehab Therapist will be coming to Denver, CO September 15 & 16, 2018!
Exciting news! Carolyn McManus, Herman & Wallace instructor of Mindfulness-Based Pain Treatment, will be a presenter in programming at the International Association for the Study of Pain (IASP) World Congress on Pain in to be held in Boston, September 11 - 16. This conference brings together experts from around the globe practicing in multiple disciplines to share new developments in pain research, treatment and education. Participants from over 130 countries are expected to attend. The last time it was held in the U.S. was 2002, so it presents an especially exciting opportunity for those interested in pain to have this international program taking place in the U.S. Carolyn will present a workshop on mindfulness in a Satellite Symposia, Pain, Mind and Movement: Applying Science to the Clinic.
Carolyn has been a leader in bringing mindfulness into healthcare throughout her over-30 year career. She recognized early on in her practice how stress amplified patients’ symptoms and, as she had seen the benefits of mindfulness in her own life, it was a natural progression to integrate mindful principles and practices into her patient care. An instructor for Herman and Wallace since 2014, she has developed two popular courses, Mindfulness-Based Pain Treatment and Mindfulness for Rehabilitation Professionals, enabling her to share her clinical and research experiences with her colleagues.
For many patients, pain is not linearly related to tissue damage and interventions based on structural impairment alone are inadequate to provide full symptom relief. Mindfulness training can offer a key ingredient necessary for a patient to make additional progress in treatment. By learning therapeutic strategies to build body awareness and calm an over-active sympathetic nervous system, patients can mitigate or prevent stress-induced symptom escalation. They can learn to move with trust and confidence rather than fear and hesitation.
A growing body of research in mindfulness-based therapies demonstrates multiples benefits for patients suffering with pain conditions. Research suggests that mindfulness training can be helpful to women preparing for childbirth and patients suffering from fibromyalgia, pelvic pain, IBS and low back pain. In addition, for patients with anxiety, mindfulness training may contribute to reductions in anxiety and in adrenocorticopropic hormone and proinflammatory cytokine release in response to stress. Authors of this study conclude that these large reductions in stress biomarkers provide evidence that mindfulness training may enhance resilience to stress in patients with anxiety disorders.
In addition to her presentation at the IASP World Congress Satellite Symposia, Carolyn will be sharing a more in-depth examination and practice of mindfulness in her upcoming course Mindfulness-Based Pain Treatment, August 4 and 5 at Virginia Hospital Center, Arlington VA, and again November 3 and 4 at Pacific Medical Center in Seattle, WA. Please join an internationally-recognized expert for 2 days of innovative training in mindfulness that will both improve your patient outcomes and enhance your own well-being!
Duncan LG, Cohn MA, Chao MT, et al. Benefits of preparing for childbirth with mindfulness training: A randomized controlled trial. BMC Pregnancy Childbirth 2017 May 12;17(1):140.
Fox SD, Flynn E, Allen RH. Mindfulness meditation for women with chronic pelvic pain: a pilot study. J Reprod Med.2011;56(3-4):158-62.
Garland EL, Gaylord SA, Paisson O. Therapeutic mechanisms of a mindfulness-based treatment for IBS: effects on visceral sensitivity, catastrophizing and affective processing of pain sensations. J Behav Med. 2012;35(6):591-602.
Cherkin DC, Sherman KJ, Balderson BH, et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized Clinical Trial. JAMA. 2016;315(12):1240-9.
Hoge EA, Bui E, Palitz SA, et al. The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Res. 2018;262:328-332.
Last year, I was teaching our Pelvic Floor Series Capstone course. It was the end of day three of the course. Most, students were thanking us for a course that filled in so many gaps in their practice and taught them a whole new way to use their hands. They were feeling energized and excited to bring all the new information back to their patients who had plateaued, so this was a surprising and atypical comment. To those of you who are unfamiliar with Capstone, it is a course for experienced pelvic therapist who have already taken three of the series courses, and it was written to address truly challenging patients, to learn to problem solve with manual therapies, to address all the things that my co-authors and I wished we had known five years into our field. It teaches complex problem solving and more receptive and dynamic use of their hands. So, usually, by this course, therapists are fully committed to this field and geeked-out to get so many more pearls. They are usually on board and looking for more sophisticated tools.
As one student, Soniya (name changed) was walking out, she said, “I took this course to figure out if I want to treat pelvic patients, and I definitely don’t. It confirmed what I already knew about pelvic rehab being wrong for me.” I was so confused at that point. All I could say in that moment was, “Can you please tell me more about that? I’m interested.”
Soniya went on to explain that she used to be a pelvic therapist. She said she loved it at first. But, she got so enmeshed with her patients and found she stopped having energy for the rest of her life: her kids, her health, her own enjoyment. She said she would go into her “dark cave” treatment room with her patients, isolated with them one at a time, and come out spent and depleted at the end of the day. She clarified that it was rewarding helping people so profoundly, but there came a point when she had to choose between helping others and saving herself. She changed back to outpatient ortho, choosing to treat in the gym, dynamically interacting with other PT’s all day and not being one-on-one in a room with patients and her problems. She also changed to part time, stating she just couldn’t be around patients five days a week anymore.
I understood. I totally got it. I hear this all the time at courses from other pelvic PT’s: that they love what they are doing, and they feel called to this line of help, but ultimately, they are depleted. I have been there. Pelvic rehab can get to be a little confusing with all the blurred lines. There are so many boundaries that are different. We ask our patients questions normal PT’s don’t. We do treatments in areas that other therapists don’t normally touch or see. We are one on one in a private room with our clients. We know more private details about our patients than most of their friends and family. And…we care deeply and listen intently….sometimes many hours a day to stories of other people’s pain, fears, and stress. Often, we are a lone pelvic practitioner in a practice with other kinds of PT’s. Let’s face it, our colleagues who don’t do pelvic rehab think we are a little weird! With HIPPAA, we can’t talk to our coworkers about our heart wrenching stories. We are also not trained psychologists, and our training in PT school really didn’t address how to deal with all we face in a day, especially the psychological aspects.
A recent study found nursing students show compassion fatigue before they even graduate and that “Therefore, knowledge of compassion fatigue and burnout and the coping strategies should be part of nursing training”. Yet, as pelvic therapists we are taught to recognize signs of trauma in our patients, but we are not yet taught how to stop ourselves from being traumatized.
I asked “Soniya” if it had worked for her: changing back to outpatient ortho and going part time. She said it had for the most part. She felt she had her life and energy back for the most part.
So, I asked “Soniya” how she landed at Capstone? What brought her here? It turns out her boss had asked her to come to Capstone and consider going back to pelvic rehab. So, she came and heard about all kinds of problem solving and new research with very complex patients at Capstone: cancer, multiple surgeries, systemic inflammation, endometriosis, and even gender affirming/change surgeries. She learned about complex hormonal issues, pharmacology and anatomy she hadn’t ever considered as an experienced pelvic therapist. She spent around 10 hours that weekend in lab, learning new ways to use her hands to make change. At the end, she said the thought of going “back in the cave” with such complex patients and having her hands on them all day long was draining to her. She just couldn’t go back.
There is a point where caring so much and wanting to help becomes counter-productive to us, until we burn out. We can develop true compassion fatigue. Compassion fatigue makes us feel apathetic, spent, and sometimes even jaded or cranky. But, how do we turn that caring off in time? Our compassion is what led us to this field in the first place.
This post is a two-part series on practitioner burnout and compassion fatigue from faculty member Nari Clemons, PT, PRPC. Nari helped to create the advanced Pelvic Floor Series Capstone course, which is available several times each year. Nari is also the author and instructor for Boundaries, Self-Care, and Meditation, Lumbar Nerve Manual Assessment and Treatment, and Sacral Nerve Manual Assessment and Treatment. Stay tuned for part two in an upcoming post on The Pelvic Rehab Report!
Mathias CT, Wentzel DL. Descriptive study of burnout, compassion fatigue and compassionsatisfaction in undergraduate nursing students at a tertiary education institution in KwaZulu-Natal. Curationis. 2017 Sep 22;40(1):e1-e6. doi: 10.4102/curationis.v40i1.1784. PMID: 2904178
I’m Elizabeth Hampton PT, DPT, WCS, BCB-PMD and I teach “Finding the Driver in Pelvic Pain”, which offers practitioners a systematic screening approach to rule in or rule out contributing factors to pelvic pain. This course helps clinicians to understand and screen for the common co-morbidities associated with pelvic floor dysfunction, like labral tears, discogenic low back pain, nerve entrapments, coccygeal dysfunction, and more. Importantly, it also coaches clinicians to organize information in a way that enables them to prioritize interventions in complex cases. I've noticed that there are some questions that course participants frequently have as they talk through common themes in their care challenges and wrote this blog to share some clinical pearls you may find to be helpful for your own practice or as an explanation to your clients.
Here are some of the most common questions that I get when teaching Finding the Driver in Pelvic Pain:
1) Question: How do I even start to organize information when a client has a complex history and I am feeling overwhelmed?
I write down a road map with key categories: Bowel and bladder; Spine; Sacroiliac Joint/Pubic Symphysis; Hip; Pelvic floor muscles; biomechanics; respiration; neural upregulation; whatever details can be fit into ‘big buckets’ of information. I use it to both organize my thoughts for my notes, as well as educate the client as to what my findings are and the design of their treatment program.
2) Question: How do you get your clients to do a bowel and bladder diary?
I am proud to say that I can talk anyone into a 7 day bowel and bladder diary because I tell them how incredibly helpful it is to understand the way their body responds to what they eat, drink, and daily habits. It’s my secret weapon to snag clients to start connecting with their body and listening to their details, educate about defecation ergonomics and what happens in multiple systems when there is pelvic floor overactivity. It’s a great teaching tool that facilitates self-reflection and how their self-care choices impact their body’s behavior.
3) Question: How do you educate clients about pelvic floor function so they don’t focus so much on Kegels?
Pelvic floor muscles do three things:
They contract gently, or powerfully, with no discomfort, and totally normal breathing; PFMs should have the same kind of nuanced control like your voice does: they should be able to do a gentle contraction, like a “whisper” or a powerful contraction, like a “shout”, depending on the task position and intent.
They relax fully and completely when the body is resting in support, or they should be able to relax to a supportive level when they are needed posturally. Relaxation should be its own celebrated event!
They should be able to relax and gently lengthen.
Faculty member Elizabeth Hampton PT, DPT, WCS, BCB-PMD is the author and instructor of Finding the Driver in Pelvic Pain, a course designed to help practitioners utilize differential diagnosis in evaluating pain. Join Dr. Hampton in Portland, OR on July 27-29, 2018 or November 2-4, 2018 in Phoenix, AZ.
Tiffany Ellsworth Lee MA, OTR, BCB-PMD joined the Herman & Wallace faculty to teach a course on biofeedback along with Jane Kaufman, PT, M.Ed, BCB-PMD. The month of April is Occupational Therapy month, and we are celebrating by highlighting the role that Occupational Therapists play in pelvic floor rehabilitation. Tiffany founded a biofeedback program at Central Texas Medical Center in San Marcos in 2004, and currently runs her a pelvic rehab private practice .
Working in this area of biofeedback is extremely rewarding and fulfilling to help change peoples’ lives. I have a private practice now exclusively dedicated to treating patients with pelvic floor dysfunction. I became involved in working with patients with incontinence and pelvic floor disorders because of many opportunities along my career path. I have been an Occupational Therapist since 1994. Both of my parents are also OTs, so I think I was born to do this!
Erica Vitek, MOT, OTR, BCB-PMD, PRPC wrote a blog recently about the role of OTs in pelvic health. She writes:
“As we look closer at the framework and the definition of OT (Occupational Therapy Practice Framework: Domain and Process, 3rd edition 2014), there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as ‘…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.”
The clearest examples of the OT’s role in pelvic health occupations within this section include:
"We believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions"
Occupational therapists wishing to pursue pelvic floor have a few options. The first thing is to find a pelvic floor clinical setting or work with their respective settings to check to see if they can start a women's health program with a strong focus on pelvic floor. OTs quite often do not start out in pelvic health directly after school and since this is a newer area as compared to other certifications such as the NDT and PNF it takes a little bit of research, time and effort to find one’s exact niche. To get started, an OT should seek out courses that teach the basics of bladder and bowel management. It is important to understand the anatomy and physiology of the bladder, bowel, and sexual systems.
Incontinence and pelvic floor disorders have a profound impact on occupation, the daily activities that give life meaning! OTs should have a larger role in treating this patient population. Offering hope to our patients is imperative when he/she is dealing with pelvic floor dysfunction!
Keep an eye out for an upcoming post from Tiffany with some inspiring clinical case studies. You can join Tiffany and Jane Kaufman in Biofeedback for Pelvic Muscle Dysfunction to get lots of hands-on time with surface eletromyography, and to work toward BCIA certification!