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Compiling the essential manual therapy skill set

Compiling the essential manual therapy skill set

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.

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An Accelerant on the Integrative Movement

An Accelerant on the Integrative Movement

Nutrition Perspectives for the Pelvic Rehab Therapist

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!

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Carolyn McManus Presentating at the World Congress on Pain!

Carolyn McManus Presentating at the World Congress on Pain!

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.

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"Pelvic rehab is wrong for me"

"Pelvic rehab is wrong for me"

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

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Questions from Finding the Driver in Pelvic Pain

Questions from Finding the Driver in Pelvic Pain

Elizabeth Hampton PT, DPT, WCS, BCB-PMD

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.

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The OT's Path to Pelvic Rehab

The OT's Path to Pelvic Rehab

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:

  1. ADL section: toileting and hygiene (continence needs, intentional control of bowel movements and urination) and sexual activity.
  2. IADLs section: sleep participation (sustaining sleep without disruption, performing nighttime care of toileting needs).
  3. Achieving full participation in work, play, leisure, and social activities, requires one to be able to maintain continence in a socially acceptable manner in which they can feel confident and comfortable to fulfill their roles and duties.

"We believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions"

How to get started as an OT

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!

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Why do we need a prostatectomy rehabilitation course?

Why do we need a prostatectomy rehabilitation course?

Sara Chan Reardon, DPT, WCS, BCB-PMD is a pelvic floor dysfunction specialist practicing in New Orleans, LA. Sara was named the 2008 Section on Women’s Health Research Scholar for her published research on pelvic floor dyssynergia related constipation. She was recognized as an Emerging Leader in 2013 by the American Physical Therapy Association. She served as Treasurer of the APTA’s Section on Women's Health and sat on their Executive Board of Directors from 2012-2015. Today she was kind enough to share a bit about her course Post-Prostatectomy Patient Rehabilitation, which is taking place twice in 2018.

My name is Sara Reardon, and I teach the Post-Prostatectomy Patient Rehabilitation course, which I wrote and developed in the year 2015. At the time, I had been a pelvic health Physical Therapist for over 10 years. Earlier in my career, I had taken the Pelvic Floor 2A course by Herman and Wallace Institute, which was a fantastic and thorough introduction to treating a male patient.

Over the years, I started seeing more and more men with post-prostatectomy urinary incontinence and erectile dysfunction in my clinic. Urinary incontinence is the most common and costly complication in men following prostate removal surgery, and their quality of life is directly related to their duration of experiencing those symptoms. Evidence supports that pelvic floor muscle training started as soon as possible after surgery can help decrease incontinence and improve quality of life. I enjoyed being able to help men decrease their incontinence and improve their other symptoms after all they had been through following a cancer diagnosis and treatment.

No courses focused specifically on treating post-prostatectomy pelvic floor dysfunction were offered at the time, so I scoured the research, shadowed with physicians, observed surgeries, and attended urology conferences to understand how to effectively treat these individuals. Treating this population of men is fun, fulfilling, and rewarding, and I was inspired to help other pelvic health physical therapists dive deeper as I witnessed the impact pelvic health physical therapy can have on the quality of life of these patients. I love teaching this course, and I am excited to help other pelvic health professionals learn evidence based and effective treatment strategies to help these men navigate their recovery after prostatectomy.

Join Dr. Reardon in Philadelphia, PA on June 2-3, 2018 or in Houston, TX on November 10-11, 2018 to learn evaluation and treatment techniques for men recovering from prostatectomy surgery.

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An Orthopedic Approach to Coccyx Pain

An Orthopedic Approach to Coccyx Pain

Most of us spend our day sitting and do not think about the position of our ilia, sacrum or coccyx during the change from standing to sitting. Weightbearing through a tripod of bilateral ischial tuberosities and a sacrum that should have normalized form closure should be easy and pain free. The coccyx typically has minimal weight bearing in sitting, about 10%, just like the fibula, however, it can be a major pain generator, if the biomechanics of the ilia, sacrum and femoral head positions are not quite right.

Coccydynia and Painful Sitting is a course that can be related to all populations that physical therapists treat. A lot of patients will state “my pain is worse with sitting” which can mean thoracic pain, low back/sacral pain and even lower extremity radicular pain. Women’s health providers treat anything regarding the pelvis, so we are seeing a lot of complicated histories and symptoms.

Scanning the literature for coccyx treatment does not always yield the best results for physical therapists. Most literature states what the medical interventions can be, and physical therapy is never at the forefront. However, as we are musculoskeletal and neuromuscular specialists, this is no different on our thinking patterns relating to coccyx pain or painful sitting.

During sitting, the coccyx has a normal flexion and extension moments that will change or become dysfunctional once mechanics above and below that joint change. A simple ankle sprain from 2 years ago can result in chronic knee pain, sacroiliac pain, and can lead to coccyx pain over time. Even the patient who has long standing TMJ (temporomandibular joint) and cervical dysfunction, now has a thoracic rotation and your correction of their coccyx deviation cannot maintain correction.

This course sparks your orthopedic mindset, encouraging the clinician to evaluate the coccyx more holistically. What are the joints doing? How does it change from sitting to standing? Standing to sitting? What is the difference from sitting upright to slump activities? Working through the basics and the obvious with failed results, takes you to the next step of critical thinking within this course. How does the patient present, what seems to be lacking and how to correct them biomechanically to achieve pain free sitting?

Related coccyx musculature and nerve dysfunction can seem like the easiest to treat, but what happens when those techniques fail? This course looks at the entire body, from cranium to feet, to determine the driver of coccyx pain and dysfunction. A better understanding of ilial motion, with accompanied spring tests (Hesch Method), normalizing spinal mechanics and lower extremity function is highlighted in this course. Internal vaginal and rectal release of pelvic floor muscles can lead to normalized coccyx muscle tension that are supported via coccyx taping.

Join me for "Coccydynia and Painful Sitting: Orthopedic and Pelvic Floor Muscle Implications", taking place May 6-7 in Dayton, OH and October 13-14 in Houston, TX.

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Reflections on course design and development: Neuroanatomy

Reflections on course design and development: Neuroanatomy

In an effort to provide the best possible educational experience for clinical rehabilitation application of neuroanatomy, I was on a mission. Having a core, base knowledge review of the nervous system is essential when leading into talking about dysfunction and disease of that system. I went on a search for anatomical depictions that could clearly identify the structures and processes I was trying to portray. New books from the library and books I own from when I was in college serve as great resources when trying to get back into studying the specifics, but do not offer the opportunity to easily get these images into a powerpoint. Online resources are also challenging. I am learning how time consuming the process can be to determine who owns the online image, if it is free to copy, save and utilize for my own teaching purposes, or if I need to go through the process of requesting permissions for use.Nervous System

Through my employer, where I treat patients in the clinic, I have access to a program called Primal Pictures. I had used this in the past for clinic related marketing presentations and educational materials for patients and other clinicians I have mentored. Looking into the product further, I came to find out that there is a newer version of the program which offered so many more options. A truly unlimited amount of images which can be manipulated into an optimal position depicting the most clear neuroanatomical views I have ever been able to find. Not only does it provide me with the images I need in order to depict the treacherous pathways of the nerves in our body, but it also provides some amazing depictions of the physiological processes that occur within our nervous system to allow for healthy day to day functioning and protection of our bodies.

I also came across the title of a journal article that I was sure would provide some excellent depictions of neuroanatomy. The article titled, Sectional Neuroanatomy of the Pelvic Floor, provides cross sectional views of both the male and female pelvises. I obtained the article which has an excellent color-coded system, each nerve colored the same as the muscles and skin surface it innervates, going from superior to inferior cross sections. This makes for a clear understanding of each structures anatomical position. It is a great reference when looking at the anatomical relationships to adjacent structures and can help guide palpation skills. The article was more specifically written for physicians to best direct needle procedures/injections in the most accurate location possible when targeting nerves and structures. Neuroanatomy and physiology can be essential to understanding certain patient populations we encounter as we practice pelvic floor rehabilitation. Having clear depictions to refer to can help you provide the best possible base knowledge to your patients as you help them understand the challenges they face and how to overcome them.


Kass, J. S., Chiou-Tan, F. Y., Harrell, J. S., Zhang, H., & Taber, K. H. (2010). Sectional neuroanatomy of the pelvic floor. Journal of computer assisted tomography, 34(3), 473-477.

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The Male Course, 10 Years Later

The Male Course, 10 Years Later

In 2007, after only speaking on the phone and never meeting in person, my new friend and colleague Stacey Futterman and I presented at the APTA National Conference on the topic of male pelvic pain. It was a 3 hour lecture that Stacey had been asked to give, and she invited me to assist her upon recommendation of one of her dear friends who had heard me lecture. I still recall the frequent glances I made to match the person behind the voice I had heard for so many long phone calls.

Upon recommendation of Holly Herman, we took this presentation and developed it into a 2 day continuing education course, creating lectures in male anatomy (we definitely did not learn about the epididymis in my graduate training), post-prostatectomy urinary incontinence, pelvic pain, and a bit about sexual health and dysfunction. Although it truly seems like the worst imaginable question, we asked each other “should we allow men to attend?” As strange as this question now seems, it speaks volumes about the world of pelvic health at that time; mostly female instructors taught mostly female participants about mostly female conditions.

Make no mistake- women’s health topics were and are deserving of much attention in our typically male-centered world of medicine and research. Maternal health in the US is dreadful, and gone are the days when providers should allow urinary incontinence or painful sexual health to be “normal”, yet it is often described as such to women who are brave enough to ask for help. Times have changed for the better for us all.

The Male Pelvic Floor Course was first taught in 2008, and so far, 22 events have taken place in 18 different cities. 73 men have attended the course to date, with increasing numbers represented at each course. Rather than 20-25 attendees, the Institute is seeing more of the men’s health course filling up with 35-40 participants. In my observations, the men who attend the course are often very experienced, have excellent orthopedic and manual therapy skills, and have personalities that fit very well into the sensitive work that is pelvic rehabilitation.

"We are creating male pelvic rehabilitation in real time"

The course was expanded to include 3 days of lectures and labs, and this expansion allowed more time for hands-on skills in examination and treatment. The schedule still covers bladder, prostate, sexual health and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease. In my own clinical practice, learning to address penile injuries has allowed me to provide healing for conditions that are yet to appear in our journals and textbooks. As I often say in the course, we are creating male pelvic rehabilitation in real time.

Because the course often has providers in attendance who have not completed prior pelvic health training, instruction in basic techniques are included. For the experienced therapists, there are multiple lab “tracks” that offer intermediate to advanced skills that can be practiced in addition to the basic skills. Adaptations and models are used when needed to allow for draping, palpation, and education when working with partners in lab, and space is created for those therapists who want to learn genital palpation more thoroughly versus those who are deciding where their comfort zone is at the time. One of the more valuable conversations that we have in the course is how to create comfort and ease in when for most us, we were raised in a culture (and medical training) where palpation of the pelvis was not made comfortable. Hearing from the male participants about their bodies, how they are affected by cultural expectations, adds significant value as well.

We need to continue to create more coursework, more clinical training opportunities so that the representation of those treating male patients improves. If you feel ready to take your training to the next level in caring for male pelvic dysfunction, this year there are three opportunities to study. I hope you will join me in Male Pelvic Floor Function, Dysfunction and Treatment.

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