Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with site fellow faculty member Tina Anderson, MS PT.

Urinary incontinence (UI) is defined as ‘any complaint of involuntary leakage or urine’ that has several different subtypes based on when this leakage occurs¹.  UI is a common and relevant condition that has a profound influence on well-being and quality of life of many patients worldwide.  Millions of men and women throughout the world are affected.  According to our body of evidence, UI can affect anywhere between 5-70% of the female population^2-4 and 11-32% of the male population^5,6, contributing to decreased participation in preferred daily, work and recreational activities alongside an immense economic burden for some of those affected.^1-7These symptoms have not only been shown to have a significant impact on a person’s quality of life, but also on their mental health status.⁷

While UI is both common and very bothersome, it is also very treatable. I would love nothing more than to see our society and healthcare continuum recognize that UI is something that is ABNORMAL versus the typical categorization that it is a normal part of the aging, postpartum or postoperative experience.

Common, not normal.  Common, but treatable.
UI can be treated with lifestyle and behavioral interventions, bladder training, electrical stimulation, pelvic floor muscle training (PFMT) with or without biofeedback, physical therapy, neuromodulation, periurethral injections and, in some cases, surgical intervention. ^5,8

Understanding the continence mechanism
In a well-functioning pelvic floor, the connective tissue of the ligaments and fascia act together with the pelvic floor musculature to counteract the impact of any increase in intra-abdominal pressure and ground reaction forces, helping to maintain our continence.^8-10 This is an automatic function, requiring no need to think about voluntary contraction of the pelvic floor musculature. ⁸ When this mechanism is not working adequately, which can undoubtedly be multifactorial, urinary incontinence may occur.

The external urethral sphincter mechanism is a complex system of striated muscle which includes fiber blends from the urogenital triangle musculature and the anterior muscle bundle of the levator ani. ¹¹ The good news here is that we, as rehabilitative clinicians, have many different tissue targets for treatment of UI.

Dry Needling and UI
Dry needling (DN) encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions. DN is both effective and efficient in modulating the central and peripheral nervous systems as well as the somatic tissues, including the pelvic floor.

There is a growing body of evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice as it relates to UI.^12-17 With the external urethral sphincter and associated tissues being a main player in our urinary continence mechanism, it provides a road map on how we can utilize DN to treat UI. This boils down to two things: (1) tissue specificity and (2) utilization of electrical stimulation. DN provides us with an avenue to directly influence a specific tissue as we are able to use an indwelling needle electrode placed strategically into a muscular or perineural tissue target. Using that tactically placed indwelling electrode we can then precisely deliver electrical stimulation, essentially speaking the language of the neuromotor system, making this technique one of the most effective tools we have as rehabilitative clinicians to treat UI.

Ultimately, we are able to stimulate the pudendal nerve alongside the targeted tissues. This can help to improve electric activation, proprioception and coordination in pelvic floor contraction during situations that contribute to UI.^18,19,22 Additionally, the pudendal nerve is an efferent nerve for the external urethral sphincter, so this treatment is capable of increasing the pressure of urethral closure, improving UI. Another important factor is that electrical stimulation has been shown to increase blood flow to the urethra and pelvic floor musculature, lending towards improvements in neuromuscular connections, muscle fiber function and genital atrophy, all leading to improvements in the mechanism of urethral closure. ^19-22

The power of the tissue reset that DN provides has changed clinical outcomes for the better. It has, and will continue to, positively impact and change the lives of many patients through facilitating a more balanced homeostatic baseline within the tissues, healthier motor recruitment patterns and optimal neuromuscular utility to re-establish function.  Want to add this tool to your clinical practice? Check out our Dry Needling course offerings with Herman & Wallace!

 References:

1. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21:5–26
2. Milson I and Gyhagen M. The prevalence of urinary incontinence. Climacteric. 2019;22(3):217-222
3. Carryer, J, Weststrate, J, Yeung, P et al. Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand. Research In nursing & Health. 2017;40(6):555–563
4. Damian, J, Pastor-Barriuso, R, Garcia Lopez, FJ et al. Urinary incontinence and mortality among older adults residing in care homes. Journal of Advanced Nursing. 2017;73(3):688–699
5. Gacci M, Sakalis VI, Karavitakis M et al. European Association of Urology guidelines on male urinary incontinence. European Urology. 2022;82:387-398
6. Cao C, Zhang C, Sriskandarajah C et al. Trends and racial disparities in the prevalence of urinary incontinence among men in the USA, 2001-2020. European Urology Focus. 2022; https://doi.org/10.1016/j.euf.2022.04.015
7. Krhut J, Gartner M, Mokris J et al. Effect of severity of urinary incontinence on quality of life in women. Neurourol Urodyn. 2018;37:1925–1930
8. Bo K. Physiotherapy management of urinary incontinence in females. Journal of Physiotherapy. 2020;
9. Ashton-Miller J, DeLancey JOL. Functional anatomy of the female pelvic floor. In: Bø K, Berghmans B, Van Kampen M, Mørkved S, eds. Evidence based physical therapy for the pelvic floor. Bridging science and clinical practice. Chapter 3. Edinburgh: Elsevier; 2015:19–34
10. DeLancey JOL, Low LK, Miller JM et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol. 2008;199:610.e1–610.e5
11. Suriyut J, Muro S, Baramee P et al. Various significant connections of the male pelvic floor muscles with special reference to the anal and urethral sphincter muscles. Anatomincal Science Internatiional. 2020;95:305-312
12. Feng X, Lv J, Li M et al. Short-term efficacy and mechanism of electric pudendal nerve stimulation versus pelvic floor muscle training plus transanal electrical stimulation in treating post-radical prostatectomy urinary incontinence. Oncology. 2022;160:168-175
13. Wang S, Zhang S. Simultaneous perineal ultrasound and vaginal pressure measurement prove the action of electrical pudendal nerve stimulation in treating female stress incontinence. BJU Int. 2012;110:1338–1343
14. Wang S, Lv J, Feng X, Wang G, Lv T. Efficacy of electrical pudendal nerve stimulation in treating female stress incontinence. Urology. 2016;91:64–69
15. Wang S, Lv J, Feng X, Lv T. Efficacy of electrical pudendal nerve stimulation versus transvaginal electrical stimulation in treating female idiopathic urgency urinary incontinence. J Urology. 2017;197:1496–1501
16. Wang S, Zhang S, Zhao L. Long-term efficacy of electric pudendal nerve stimulation for urgency-frequency syndrome in women. International Urogynecology Journal. 2014;25:397-402.
17. Li T, Feng X, Lv J et al. Short-term clinical efficacy of electric pudendal nerve stimulation of neurogenic lower urinary tract disease: a pilot research. Urology. 2018;112:69-73
18. Monga AK, Tracey MR, Subbaroyan J. A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction. Int Urogynecol J. 2002;23:993–1005
19. Chai TC, Steers WD. Neurophysiology of micturition and continence in women. Int Urogynecol Urol. 1997;8:85–97
20. Spruijt J, Vierhout M, Verstraeten R, et al. Vaginal electrical stimulation of the pelvic floor: a randomized feasibility study in urinary incontinent elderly women. Acta Obstet Gynecol Scand. 2003;82:1043–8
21. Balcom AH, Wiatrak M, Biefeld T et al. Initial experience with home therapeutic electrical stimulation for continence in myelomenin-gocele population. J Urol. 1997;158:1272–6
22. Correia GN, Pereira VS, Hirakawa HS et al. Effects of surface and intravaginal electrical stimulation in the treatment of women with stress urinary incontinence: randomized controlled trial. Euro J of Ob & Gyn and Reproductive Bio. 2014;173:113-118

Dry Needling and Pelvic Health - Live Course

Course Dates:
Worcester, MA - November 12-13, 2022
Katy, TX - January 21-22, 2023
Birmingham, AL - September 16-17, 2023

Price: $995
Experience Level: Beginner
Contact Hours: 26

Description: This is the foundational dry needling course in our three course pelvic health series. Practitioners will learn an innovative approach to treating clients with pelvic floor and neuromusculoskeletal dysfunction commonly associated with lumbopelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This foundational dry needling course will instruct participants in the application of dry needling to female pelvic floor musculature and associated neuroanatomical structures including the lumbosacral spine, abdomen, pelvis, and hip joint complex. This course will provide a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation - Live Course

Course Dates:
Salt Lake City, UT - November 5-6, 2022

Price: $995
Experience Level: Advanced
Contact Hours: 26

Description: Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation is a lab intensive, hybrid course designed with the pelvic health practitioner in mind. This course is an innovative approach to treating clients with pelvic floor dysfunction commonly associated with pelvic pain, incontinence, voiding dysfunction and/or sexual pain or dysfunction. This advanced dry needling course will instruct participants in the application of dry needling to female and male pelvic floor musculature and associated neuroanatomical structures including the thoracolumbar spine, trunk, abdomen, pelvis and hip joint complex. This course will also discuss and integrate the concept of and techniques associated with neuromodulation. Additionally, there will be a comprehensive review of anatomy, a strong emphasis on safety and precautions, ample lab time to optimize dry needling techniques, as well as dialogue surrounding clinical integration and relevant evidence.

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with fellow faculty member Tina Anderson, MS PT.

Pelvic floor dysfunction (PFD) is a common and relevant condition that affects many patients worldwide.  According to our evidence, PFD can affect approximately 20-25% of women and men in the United States¹, contributing to decreased participation in preferred daily, work and recreational activities due to high incidences of lumbopelvic pain, abdominopelvic pain, incontinence, prolapse, and/or other urologic and urogynecologic symptoms.²  These symptoms have a significant impact on a person’s quality of life and mental health status.²

While PFD is common, the general public has not been fully educated that these dysfunctions are not normal.  As clinicians, we have a duty to educate our patient population that PFD is not a normal, nor acceptable, part of the postpartum experience or aging process.  These dysfunctions are very debilitating but are also very treatable.

Common, not normal.  Common, but treatable.

Pelvic floor pathology comes to us as clinicians in a variety of diagnoses, etiologies, and presentations². Patients are often referred to physical therapy with medical diagnoses such as chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, pudendal neuralgia, bowel and urinary incontinence, and chronic prostatitis.^3-5 Symptom presentation is quite varied but often will include bowel, bladder, and sexual dysfunctions. That being said, a multidisciplinary approach is crucial to tailor treatment specific to each patient’s pathology, symptomatology, and clinical presentation.⁶  Many of these patients have seen a variety of gynecologists, urologists, and gastroenterologists without successful symptom mitigation and are being referred to pelvic health practitioners as a last resort. This is unfortunate, as a primary contributor to these symptoms is the neuromusculoskeletal system…and who better to treat the neuromusculoskeletal system than rehabilitative clinicians?!

Multimodal practice is key.

A well-rounded, multimodal treatment approach that is tailored to meet the patient’s specific goals is an important step in successfully treating PFD.  Patient education can be a very powerful modality, which many clinicians tend to overlook. Research suggests education may help to address central nervous system upregulation and may help to retrain the brain in how it is processing input.^7,8 While it is incredibly powerful to be able to influence pain processing, it doesn't stop with education.  As clinicians, we also need to provide non-threatening, nourishing input to the tissues.

Manual therapies may help to desensitize the peripheral nervous system and surrounding soft tissues by providing neural input to alter the source of the pain and disruption.^9,10 These techniques, including joint mobilization, soft tissue release, myofascial techniques, tool-assisted therapies, or any other manual approach, are likely addressing local tissue issues that may be perpetuating chronic pain or tissue dysfunction.

Dry needling is another effective and efficient technique that pelvic health practitioners can utilize to modulate the central nervous system, peripheral nervous systems and local tissues, including the pelvic floor directly.¹⁰  Dry needling encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions.

While the detailed mechanisms of dry needling are not well known, we have seen more and more evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice. Overall, it is thought that dry needling may address hypersensitive neural structures and spinal segments⁵, enhance treatment of myofascial pain and trigger points in the pelvic floor and surrounding musculature, and assist in the facilitation and/or inhibition of abnormal muscle tone and motor recruitment patterns.^10-23 Dry needling has the ability to assist in addressing bladder, bowel, and sexual dysfunction alongside addressing pain syndromes in our patient population that is impacted by PFD.

Dry needling is one of the most effective tools we have as rehabilitative practitioners to reset dysfunctional tissue, providing effective and efficient functional changes for our patients.  Ultimately, we are able to facilitate a more balanced resting tone, healthy motor recruitment patterns, and optimal neuromuscular utility to re-establish ideal function in our patients. The power of the tissue reset that dry needling provides has changed my clinical outcomes for the better and has also positively impacted and changed the lives of many of my clients. Want to add this tool to your clinical practice? Check out our course offerings with Herman & Wallace:

• Dry Needling and Pelvic Health - Waco, TX - June 11-12, 2022
  Dry Needling and Pelvic Health - Milwaukee, WI - September 17-18, 2022
  Dry Needling and Pelvic Health - Hatfield, PA - October 1-2, 2022
  Dry Needling and Pelvic Health - Madison Heights, MI - October 8-9, 2022
  Dry Needling and Pelvic Health - Worcester, MA - November 12-13, 2022
• Dry Needling and Pelvic Health: Advanced Concepts and Neuromodulation - Salt Lake City UT - November 5-6 2022

References:

1. Hallock JK. The epidemiology of pelvic floor disorders and childbirth: an update. Obstet Gynecol Clin North Am. 2016 March;43(1):1-13

2. Messelink et al. Standardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report from the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurology and Urodynamics. 2005;24:374-380

3. Anderson R, Sawyer T, Wise D, Morey A and Nathanson B. Painful Myofascial Trigger Points and Pain Sites in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. The Journal of Urology. 2009;182:2753-2758

4. Hahn L. Chronic Pelvic Pain in Women. Lakartidningen. 2001;98:1780-5

5. Kotarinos R. Myofascial Pelvic Pain. Curr Pain Headache Rep. 2012;16:433.438

6. Srinivasan A, Kaye J, Moldwin R. Myofascial Dysfunction Associated with Chronic Pelvic Floor Pain: Management Strategies. Current Pain and Headache Reports. 2007;11:359-364

7. Moseley G. Widespread Brain Activity During An Abdominal Task Markedly Reduced After Pain Physiology Eduction: fMRI Evaluation of a Single Patient with Chronic Low Back Pain. Australian Journal of Physiotherapy. 2005;51(1):49-52

8. Moseley G. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. Aug 2003;8(3):130-140

9. Baron et al. Peripheral Input and Its Importance for Central Sensitization. Ann Neurol. 2013;74(5):630-6
10. Chou L, Kao M, Lin J. Probably Mechanisms of Needling Therapies for Myofascial Pain Control. Evidence-Based Complimentary and Alternative Medicine. 2012;11

11. Chen J, Chen S, Kuan T, et al. Phentolamine Effect on the Spontaneous Electrical Activity of Active Loci in a Myofascial Trigger Spot of Rabbit Skeletal Muscle. Archives of Physical Medicine and Rehabilitation. 1998;79(7):790-4

12. Cummings T and White A. Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2001;82(7):986-992

13. Gerber L, Shah J, Rosenberger W et al. Dry Needling Alters Triggers Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. Physical Medicine and Rehabilitation. 2015;7(7):711-718

14. Gunn C, Milbrandt W, Little A et al. Dry Needling of Muscle Motor Points for Chronic Low Back Pain: A Randomized Clinical Trial with Long-Term Follow-Up. Spine. 1980;5(3):279-291

15. Hsieh Y et al. Dry Needling to a Key Myofascial Trigger Point May Reduce Irritability of Satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007;86(5):397-403

16. Lewit K. The Needle Effect in the Relief of Myofascial Pain. Pain. 1979;6(1):83-90

17. Shah J. Uncovering the Biochemical Milieu of Myofascial Trigger Points Using In Vivo Microdialysis. Journal of Musculoskeletal Pain. 2008;16(1-2):17-20

18. Shah J, Danoff J, Desai M et al. Biochemicals Associated with Pain and Inflammation are Elevated in Sites Near to and Remote from Active Myofascial Trigger Points. Archives of Physical Medicine and Rehabilitation. 2008;89(1):16-23

19. Sterling M, Valentin S, Vicenzino B, et al. Dry Needling and Exercise for Chronic Whiplash - A Randomized Controlled Trial. BMC Musculskeletal Disorders. 2009;10:160

20. Tough E, White A, Cummings T, et al. Acupuncture and Dry Needling in the Management of Myofascial Trigger Point Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. European Journal of Pain. 2009;13(1):3-10

21. Tuzun E, Gildir S, Angın E, et al. Effectiveness of Dry Needling Versus a Classical Physiotherapy Program in Patients with Chronic Low-Back Pain: A Single-Blind, Randomized, Controlled Trial. Journal of Physical Therapy Science. 2017;29(9):1502-1509

22. Hong C and Torigoe Y. Electrophysiological Characteristics of Localized Twitch Responses in Responsive Taut Bands of Rabbit Skeletal Muscle Fibers. Journal of Musculoskeletal Pain. 1994;2(2):17-43

23. Puentedura E, Buckingham S, Morton D, et al. Immediate Changes in Resting and Contracted Thickness of Transversus Abdominis After Dry Needling of Lumbar Multifidus in Healthy Participants: A Randomized Controlled Crossover Trial. Journal of Manipulative and Physiological Therapeutics. 2017;40(8):615-623