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Osteoporosis Management Is For All Practitioners

An interview with Frank Ciuba.

Frank Ciuba, co-instructor of Osteoporosis Management< alongside Deb Gulbrandson, explains that practitioners need the information provided in their course. "This course is the latest up-to-date research compiled by my partner Deb Gulbrandson and myself in the management of osteoporosis for clinicians." He shares that similar to learning about the pelvic floor, "when physical therapists go to school they get only a small amount of what osteoporosis is and very little on how to treat a patient."

Frank explains that he became interested in teaching osteoporosis management when he learned "that one in four men statistically will get osteoporosis or an osteoporosis-related fracture in their lifetime and they're really not being identified." Osteoporosis Management provides an exercise-oriented approach to treating these patients and it covers specific tests for evaluation, appropriate safe exercises and dosing, basic nutrition, and ideas for marketing your osteoporosis program.

In pelvic health rehabilitation, it's seen that osteoporosis-related kyphosis (curvature of the spine) can affect pelvic organ prolapse, breathing, and digestion. Patients who go through the osteoporosis management program with Frank and Deb, are shown that they reduce the likelihood of compression fracture by 80%.

This course, Osteoporosis Management, is not just for practitioners working with osteoporosis or osteopenia patients. Frank lists the types of patients he's been able to help. "I've used this on high school backpack syndrome, whiplash injuries, adhesive capsulitis, spinal stenosis, low back pain, lumbar strain, even some hip pathologies." He concludes with "We just need to get the word out to more individuals that this a program that can help them. Not only in the short term, but in the long term. This is a program for life."

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Short Interview Series - Episode 3 featuring Lauren Mansell

Holly Tanner Short Interview Series - Episode 3 featuring Lauren Mansell

Lauren Mansell shares, "We're never ready to do this work. We're never ready to be perfect." Her course, Trauma Awareness for the Pelvic Therapist, is for all practitioners, not just physical therapists. Anyone licensed who works with patients can benefit from this topic. However, it can be offputting to put ourselves into a vulnerable position by registering for a course on this topic. Lauren understands this and comes prepared to teach other practitioners about trauma-informed care in the gentlest way possible.

Lauren Mansell, DPT, CLT, PRPC, CYT curated and instructs this course. Lauren worked in counseling and advocacy for sexual assault survivors before becoming a physical therapist. She also brings her experience as a 2017 Fellow of the Chicago Trauma Collective to teach trauma-informed care to medical providers. Trauma-informed care is especially important as the field of pelvic rehabilitation becomes more inclusive.

Pelvic rehabilitation and pelvic therapists really do treat the whole patient. Patients can present with pain, long-term issues, and undisclosed trauma that can be compounded when it includes sex, bladder, or bowel issues. Trauma Awareness for the Pelvic Therapist addresses several topics under this umbrella and spends time on each of the following:

  • Explaining and describing compassion fatigue, trauma-informed care as well as anatomy, neurobiology, physiology of trauma, and the polyvagal autonomic nervous system
  • Identifying risk factors and Adverse Childhood Experiences (ACEs)
  • Formulating techniques for reducing compassion fatigue, secondary trauma, and retraumatization

To learn more about trauma-informed care join H&W this weekend at Trauma Awareness for the Pelvic Therapist this September 25-26, 2021. The course will be offered again in 2022 if you are not available this weekend!

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Circumferential Electrodes – An Option for Penile Pelvic Pain

Circumferential Electrodes – An Option for Penile Pelvic Pain

Male Pelvic Floor

 Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI is a faculty member and the Director of Education at Herman & Wallace. She owns a private practice that focuses on pelvic rehabilitation and on chronic myofascial pain. Along with H&W faculty member Stacey Futterman, she co-authored the Male Pelvic Floor course.

In the article by Schneider and colleagues (2013) “Refractory chronic pelvic pain syndrome in men: can transcutaneous electrical nerve stimulation help?” the authors conclude that TENS can be effective and safe as a treatment for pelvic pain. What is interesting about the technique they utilize in the intervention is that the electrodes are circumferential, designed to be worn around the penis itself. While this particular treatment may not be of interest for or applicable to all patients with pelvic pain, it may indeed be a valuable tool to add to the list of a comprehensive treatment approach, particularly for the patients who have penile pain or involvement of nerves such as ilioinguinal or the dorsal branch of the pudendal nerve that supplies the penis.

The patients in the report are defined as having “refractory pain” meaning that they have been treated and failed to improve. (Although the definition of “treated” would likely not include a comprehensive pelvic rehabilitation approach.) Patients treated themselves at home for 30 minutes, twice per day at 80 Hz, 150 µs at the sensory threshold level. Outcomes tools included a pain diary using a visual analog scale (VAS) and NIH-CPSI quality of life item at baseline, at 3 months after TENS use, and at last known follow-up appointment. 60 men aged 21-82 years were

Results included successful treatment after 12 weeks in 48% of subjects, and a positive effect was maintained in 21 patients after a mean follow-up of over 43 months. Success meant a greater than 50% reduction in pain VAS and a VAS less than or equal to 3. Pain visual analog scale decreased from 6.6 to 3.9, and QOL improved significantly as well. Fortunately, no adverse events were reported.

While circumferential electrodes are not the only type of electrodes that can be used in pelvic pain TENS application, these electrodes that have a stretchy band to help increased comfort and approximation of the treating surface can allow easy re-use of the electrode and direct placement over the penile tissues. in the image below, one electrode has been placed around the body of the penis and the other is left off simply for viewing the surface of the treatment surface of the electrode. One of 2 leads and electrodes could be used depending on location and extent of pain, and depending on patient preference. Current Medical Technologies carries circumferential electrodes if you are interested in purchasing them.

Although there is no one best treatment pathway for chronic pelvic pain, we can rely on the fact that most patients need multidisciplinary and multimodal support. For conditions that involve overactive nerves or referred pain into the penis, or even for distal treatment for more proximal discomfort, TENS may serve as one “tool in the toolbox” for chronic pelvic, and in particular, chronic penile pain. Pain in the glans, or end of the penis, can be a debilitating and frustrating aspect of pelvic pain (see prior blog post on Pain in the Glans Penis here (link: https://hermanwallace.com/blog/dysfunction-in-glans-penis), and the annoying, distracting sensation of clothing touching the penis can be a source of near-constant irritation. Neuromodulation can be one pathway to assist in moving beyond pain patterns, and it’s a pathway that can be relatively affordable and portable. Because TENS can be applied independently by many patients, TENS can also be a way to improve self-efficacy and provide one strategy for self-care that can be an adjunct to clinical care.

If you’d like to learn more treatment strategies for pelvic pain, the next Men’s Pelvic Health is taking place November 6-7, 2021. Click here (https://hermanwallace.com/continuing-education-courses/male-pelvic-floor-function-dysfunction-and-treatment-satellite-lab-course) to sign up for this course that will sell out! If you are unable to attend a Satellite location, you can easily sign up on your own by scheduling your own lab partner!

If you would like to purchase electrodes, you can find them on the CMT site here: https://www.cmtmedical.com/product/circumferential-penile-electrodes-for-chronic-pelvic-pain/


 

Schneider, M. P., Tellenbach, M., Mordasini, L., Thalmann, G. N., & Kessler, T. M. (2013). Refractory chronic pelvic pain syndrome in men: can transcutaneous electrical nerve stimulation help?BJU Internationa

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Post-Vasectomy Syndrome

Post-Vasectomy Syndrome

Holly Tanner, PT, DPT, MA, OCS, WCS, PRPC, LMP, BCB-PMB, CCI is a faculty member and the Director of Education at Herman & Wallace. She owns a private practice that focuses on pelvic rehabilitation and on chronic myofascial pain. Along with H&W faculty member Stacey Futterman, she co-authored the Male Pelvic Floor course.

 

In the US, vasectomy is one of the most common procedures performed, and it is often completed in an outpatient setting with a local anesthetic. Fortunately for most folks, it’s well-tolerated and the advice to rest and ice is enough to allow full recovery. Unfortunately, there are those who don’t recover with ease and are left with chronic pain complications. This is a population that is often left out of the clinical rehabilitation setting, and there is not yet robust literature to catch up with the positive clinical results pelvic rehab providers observe when treating post-vasectomy pain.

 

The Procedure

The goal of a vasectomy is typically contraception. The tube known as either the vas deferens or the ductus deferens is interrupted so that sperm does not travel to its typical destination outside the body via the urethra. This disruption in the tube takes place within the spermatic cord as it passes through the scrotum as this area is easily accessible. There are several techniques that can disrupt the tube where the sperm travels including, but not limited to, clamping, cauterization, or excision. The procedure leaves a small incision in the scrotal tissue.

Vasectomy 1

 

Post-vasectomy Complications

Complications of a vasectomy may include bleeding and hematoma, infection, sperm granuloma (discussed below), chronic scrotal pain, seminal vesicle abscess (rare), and early or late canalization. (Sihra et al., 2007) Interestingly, some patients report less pain after vasectomy. (Leslie et al., 2007) Theories about the cause of post-vasectomy pain include interstitial fibrosis in the epididymal duct and perineurial fibrosis. (Lee et al., 2012) When we consider the anatomy, within the canal there may also be nerve irritation from the genitofemoral nerve, for example, or other connective tissues. If a patient had pain prior to the procedure in the low back, lower abdomen, or groin, the patient’s system may have been vulnerable to complications due to a sensitized system.

Spermatic Cord

Examination & Rehab Efforts

When a patient presents with pain post-vasectomy, symptoms may worsen with prolonged sitting, with pressure from clothing, or in association with sexual or fitness activities. Because there has been a local insult to the tissues, it is logical to check the site of the procedure for any breakdown, signs of significant inflammation, swelling, and to examine for signs of infection such as fever. (Most patients have returned to their medical provider once pain develops, but if they haven’t, a referral is appropriate.) If the pain can be reproduced locally at the site of the procedure, the pain can often be managed by local treatment. You might find benefit in exam procedures such as a trunk or hip extension for the soft tissue tensioning as well as mechanical loading; palpation to the abdominal wall as well as within the spermatic cord. Treatment can address guarding of the area, general wellness (nutrition, movement, mental health), simple modalities such as heat, and gentle self-mobilization to the painful area.

 

Granulomas

Granulomas can form following a vasectomy, and while usually asymptomatic, a granuloma may be responsible for post-vasectomy pain. They are described as a “bag-like” structure with disintegrating spermatozoa that form at the cut ends of a vasectomy. (Chatterjee et al., 2001) If the granuloma is painful, very light manual mobilization of the thickened area may be done to alleviate pain (see image below). Mobilization of the spermatic cord itself via the testicle or more proximally may also prove helpful. Local modalities such as ultrasound or heat may improve symptoms as well, but clinically I have found that gentle manual therapy and movement exercises are enough to resolve the pain within a few weeks. Patients can be instructed to complete self-mobilization to the area of the granuloma, and as they often are scared to touch the area, helping alleviate this fear is useful in healing.

Image from iOS 6

 

Post-vasectomy syndrome is very challenging for patients to manage, as they are often dismissed once the procedure is completed. Patients will share that they have been told “everything looks healed” and that the pain should go away on its own. Most providers are unaware of the role of pelvic rehab clinicians, and many pelvic rehab providers are less knowledgeable about conditions related to the scrotum and spermatic cord. For patients who do not respond to conservative intervention, vasectomy reversals have been found to be significantly helpful in reducing pain, though it’s often undesired due to the goal of contraception that inspired the vasectomy. (Herrel et al., 2015; Polackwith et al., 2015). Ideally, patients will be provided with an early recommendation to pelvic rehab so that further procedures or undoing of the vasectomy is avoided.

 

If you’d like to learn more about post-vasectomy syndrome and many other conditions that can go unrecognized and under-treated, the next opportunity to take the Male Pelvic Floor course is coming up July 9-10,2021!


Chatterjee, S., Rahman, M. M., Laloraya, M., & Pradeep Kumar, G. (2001). Sperm disposal system in spermatic granuloma: a link with superoxide radicals. International journal of andrology, 24(5), 278-283.

Herrel, L. A., Goodman, M., Goldstein, M., & Hsiao, W. (2015). Outcomes of microsurgical vasovasostomy for vasectomy reversal: a meta-analysis and systematic review. Urology, 85(4), 819-825.

Lee, J. Y., Chang, J. S., Lee, S. H., Ham, W. S., Cho, H. J., Yoo, T. K., ... & Lee, S. W. (2012). Efficacy of vasectomy reversal according to patency for the surgical treatment of postvasectomy pain syndrome. International journal of impotence research, 24(5), 202-205.

Leslie, T.A., R.O. Illing, D.W. Cranston, J. Guillebaud (2007). “The incidence of chronic scrotal pain after vasectomy: a prospective audit.” BJU International 100: 1330-1333.

Polackwich, A. S., Tadros, N. N., Ostrowski, K. A., Kent, J., Conlin, M. J., Hedges, J. C., & Fuchs, E. F. (2015). Vasectomy reversal for postvasectomy pain syndrome: a study and literature review. Urology, 86(2), 269-272.

 

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Organic Food vs. Conventional: Is There Any Difference?

640px-USDA_organic_seal.svg The question about organic vs. conventional might just be the most important one deserving a thoughtful discussion to unravel the complexities around the topic of food.

Megan Pribyl, PT, CMPT is a practicing physical therapist at the Olathe Medical Center in Olathe, KS treating a diverse outpatient population in orthopedics including pelvic rehabilitation. Megan’s longstanding passion for both nutritional sciences and manual therapy has culminated in the creation of her remote course, Nutrition Perspectives for the Pelvic Rehab Therapist, designed to propel understanding of human physiology as it relates to pelvic conditions, pain, healing, and therapeutic response. She harnesses her passion to continually update this course with cutting-edge discoveries creating a unique experience sure to elevate your level of appreciation for the complex and fascinating nature of clinical presentations in orthopedic manual therapy and pelvic rehabilitation.

 

As a course developer and instructor for the Herman & Wallace Pelvic Rehab Institute, it is a privilege to continue sharing my passion for nutrition and pelvic rehabilitation with professionals nationwide. Interest in the topic continues to grow, and many pelvic rehab providers have identified nutrition as the “missing link” in their clinical practice. Nutrition Perspectives for the Pelvic Rehab Therapist has helped hundreds of pelvic rehab professionals integrate nutrition-related information into their clinical practice since 2015.

In the realm of nutrition, few questions provoke discussion with the same fervor as our title question: Organic Food vs. Conventional: Is There Any Difference? This question deserves a multi-dimensional answer - not unlike many topics in nutrition - including accessibility concerns, ethical factors for farmers, socio-economic factors, and our unique agricultural construct here in the United States. But the question about organic vs. conventional might just be the most important one deserving a thoughtful discussion to unravel the complexities around the topic of food.

You see, the answer to this question has profound implications for us. As we expand our ability to identify potential root contributors to conditions commonly encountered in pelvic rehabilitation, we must factor in nutrition. At first glance, it might be a stretch to see how one might link organic foods and potential effects on conditions such as constipation, inflammatory bowel diseases, IBS, PBS, and endometriosis for example. However, looking at food in a functional way, we acknowledge there may be under-appreciated qualitative differences between foods grown organically or produced conventionally.

Take, for example, the recent article by Kesse-Guyot et.al., 2020. which discusses the prospective association between organic food consumption and the risk of type 2 diabetes. In this study of over 30,000 participants, those with the highest quintile of organic food consumption compared to those with the lowest quintile had a 35% lower risk of having type 2 diabetes. The conclusion made by the authors was that organic food consumption was inversely associated with the risk of type 2 diabetes.

Said a different way, the study described a phenomenon where, for example, you might eat an organic bowl of oatmeal for breakfast and I might eat the same serving size conventional bowl of oatmeal for breakfast. If we extrapolate the comparison over our entire dietary intake pattern, you would have a 35% lower risk for developing type 2 diabetes compared to me…..despite you and I “eating the same foods”. How can this be possible? And might this begin to explain the sheer exasperation and frustration that can evolve in persons trying to make positive dietary changes - only to find they have no notable effect? How many times do you hear someone say “I am trying to eat healthily but it doesn’t seem to make a difference”.

Keeping in the context of type 2 diabetes, it is very well established that reductions in the richness and diversity of healthy microbes inhabiting the large intestine (gut dysbiosis) are correlative to metabolic syndrome. In those with type 2 diabetes, microbiomes showed a decrease in anti-inflammatory, probiotic, and other [beneficial] bacteria that could be pathogenic. (Das et al, 2021) Appreciating the differences between organic vs conventional - it is also well established that organic foods do carry less residue of herbicides and pesticides. These residues - which are found in higher concentration in conventionally produced foods - have been implicated in the same reduction in richness and diversity of microorganisms in the gut - which is contributory to dysbiosis. (Rueda-Ruzafa et all, 2019) Therefore it now seems not just plausible - but probable that there is a distinguishable difference between organic and conventional diets - to a degree at which all health care providers would do well to take notice.

In a report on the history of organic agriculture, author George Kuepper points out that:

Pioneers of the organic movement believed that healthy food produced healthy people and that healthy people were the basis for a healthy society.

And if organic foods can be a part of that, our patients deserve to know that these scientifically documented differences exist.

As our awareness of the connection between nutrition and health grows, so does the need to follow the science to share evidence-based and evidence-informed information. It is now more important than ever to have a working knowledge of nutrition basics as a pelvic rehabilitation professional. Plan to join us at one of our upcoming remote offerings of “Nutrition Perspectives for the Pelvic Rehab Therapist”: June 19-20 where we will explore this and many additional - and fascinating facets of the nutrition discussion.


Das, T., Jayasudha, R., Chakravarthy, S., Prashanthi, G. S., Bhargava, A., Tyagi, M., . . . Shivaji, S. (2021). Alterations in the gut bacterial microbiome in people with type 2 diabetes mellitus and diabetic retinopathy. Sci Rep, 11(1), 2738. doi:10.1038/s41598-021-82538-0

Kesse-Guyot, E., Rebouillat, P., Payrastre, L., Alles, B., Fezeu, L. K., Druesne-Pecollo, N., . . . Baudry, J. (2020). Prospective association between organic food consumption and the risk of type 2 diabetes: findings from the NutriNet-Sante cohort study. Int J Behav Nutr Phys Act, 17(1), 136. doi:10.1186/s12966-020-01038-y

Kuepper, George. (2010) A Brief Overview of the History and Philosophy of Organic Agriculture. Kerr Center for Sustainable Agriculture. http://kerrcenter.com/wp-content/uploads/2014/08/organic-philosophy-report.pdf Accessed May 14, 2021.

Rueda-Ruzafa, L., Cruz, F., Roman, P., & Cardona, D. (2019). Gut microbiota and neurological effects of glyphosate. Neurotoxicology, 75, 1-8. doi:10.1016/j.neuro.2019.08.006

Images:
Par, Cecilia for Unsplash.
USDA organic seal.svg. Public Domain.
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Upcoming Continuing Education Courses

Nutrition Perspectives for the Pelvic Rehab Therapist - Remote Course

Dec 3, 2021 - Dec 4, 2021
Location: Replacement Remote Course

Mobilization of the Myofascial Layer - Self-Hosted

Dec 3, 2021 - Dec 5, 2021
Location: Self-Hosted Course

Mobilization of the Myofascial Layer - Medford, OR Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Asante Rogue Valley Medical Center

Mobilization of the Myofascial Layer - Derby, CT Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Griffin Hospital

Mobilization of the Myofascial Layer - West Hills, CA Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Touch of Life PT

CANCELED - Mobilization of the Myofascial Layer - Columbia, MO Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Mizzou Therapy Services

CANCELED - Mobilization of the Myofascial Layer - Houston, TX Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Memorial Hermann Health System

Mobilization of the Myofascial Layer - Madison Heights, MI Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Team Rehabilitation Physical Therapy

Canceled - Mobilization of the Myofascial Layer - Jacksonville, FL Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Summit Physical Therapy

Mobilization of the Myofascial Layer - Asheville, NC Satellite Location

Dec 3, 2021 - Dec 5, 2021
Location: Cornerstone Physical Therapy of North Carolina

Pelvic Floor Capstone - Wallingford, CT Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Ivy Rehab Physical Therapy

Pelvic Floor Capstone - Self-Hosted

Dec 4, 2021 - Dec 5, 2021
Location: Self-Hosted Course

Pelvic Floor Capstone - Charlottesville, VA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Ivy Rehab Physical Therapy

Pelvic Floor Capstone - Charlotte, NC Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Ivy Rehab Physical Therapy

Pelvic Floor Capstone - Virginia Beach, VA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Southeastern Physical Therapy

Pelvic Floor Capstone - Los Angeles, CA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Origin Physical Therapy

Pelvic Floor Capstone - Marietta, GA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Southern Pelvic Health

Pelvic Floor Capstone - Athens, GA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Thrive Integrated Medicine

Pelvic Floor Capstone - Richmond, VA Satellite Location (CANCELED)

Dec 4, 2021 - Dec 5, 2021
Location: Pivot Physical Therapy

Pelvic Floor Capstone Satellite Location - Livonia, MI

Dec 4, 2021 - Dec 5, 2021
Location: Mendelson Kornblum Physical Therapy

Pelvic Floor Capstone Satellite Location - Washington, DC

Dec 4, 2021 - Dec 5, 2021
Location: Georgetown University Hospital

Pelvic Floor Capstone Satellite Location - Wichita, KS

Dec 4, 2021 - Dec 5, 2021
Location: Summit Physical Therapy

Pelvic Floor Capstone - Greenville, SC Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: His Therapy

Biofeedback for Pelvic Muscle Dysfunction - Self-Hosted

Dec 4, 2021 - Dec 5, 2021
Location: Self-Hosted Course

Biofeedback for Pelvic Muscle Dysfunction - Tampa, FL Satellite Lab Course

Dec 4, 2021 - Dec 5, 2021
Location: Bloom Pelvic Floor Therapy & Wellness

Pelvic Floor Capstone - Garden City, NY Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Metro Physical & Aquatic Therapy

Pelvic Floor Capstone - Houston, TX Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Select Physical Therapy - Fannin

Doula Services and Pelvic Rehab Therapy - Remote Course

Dec 4, 2021
Location: Short Form Remote Course

Pelvic Floor Capstone - Lansdale, PA Satellite Location

Dec 4, 2021 - Dec 5, 2021
Location: Ivy Rehab Physical Therapy