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Herman & Wallace Blog

Mindfulness Training for Childbirth Preparation

Childbirth fear is associated with lower labor pain tolerance and worse postpartum adjustment.1,2 In addition, psychological distress during pregnancy is associated with adverse consequences in offspring, including detrimental birth outcomes, long-term defects in cognitive development, behavioral problems during childhood and high levels of stress-related hormones.3 These negative consequences of fear and stress during pregnancy have inspired both interest and research into the role of mindfulness training during pregnancy to reduce fear and stress and improve outcomes.

In a randomized controlled trial, first-time mothers in the late 3rd trimester of pregnancy were randomized to attend either a 2.5-day mindfulness-based childbirth preparation course offered as a weekend workshop or a standard childbirth preparation course with no mind-body focus.4 Participants completed self-report assessments pre-intervention, post-intervention, and post-birth, and medical record data were collected. Compared to standard childbirth education, those in the mindfulness-based workshop showed greater childbirth self-efficacy and mindful body awareness, reduced pain catastrophizing and lower post-course depression symptoms that were maintained through postpartum follow-up. Participants in the mindfulness workshop also demonstrated a trend toward a lower rate of opioid analgesia use in labor.Prenatal Pranayama

In a qualitative study, researchers conducted in-depth interviews at four to six months postpartum with ten mothers at increased risk of perinatal stress, anxiety and depression and six fathers who had participated in a Mindfulness Based Childbirth and Parenting Program (MBCP).5 The MBCP program integrates mindfulness training into childbirth education. Participants meet for eight 2 hour and 15 minute weekly sessions and a reunion after babies are born. Specific mindfulness practices introduced include body scan, mindful movement, sitting meditation and walking meditation. Also, methods to integrate mindfulness into pain management, parenting and activities of daily living are introduced. Participants are asked to practice at home for 30 min per day in between sessions supported by audio guided instructions and informative texts.

Participants in the MBCP Program described gaining new skills for coping with stress, anxiety and pain, as well as developing insight and self-compassion and improving communication. Participants attributed these improvements to an increased ability to focus and gain a wider perspective as well as adopt attitudes of curiosity, non-judging and acceptance. In addition, they described mindfulness training to be helpful for coping with childbirth and parenting, including breastfeeding troubles, sleep deprivation and stressful moments with the baby.

These findings demonstrate potential therapeutic outcomes of integrating mindfulness training into childbirth preparation. Although this is a young field and more research is warranted, there is substantial research demonstrating mindfulness training improves stress management, pain management and decreases physiological markers of stress in a wide range of patient populations.6, 7 While the interventions in the above two studies introduce mindfulness in a group format, I have also found that patients can greatly benefit from being taught mindful principles and practices in one-on-one treatment sessions.

Carolyn will share her over-30 years of training and experience teaching mindfulness to patients both individually and in group settings in her course, Mindfulness-Based Pain Treatment, coming up on October 26 and 27 in Houston, TX. Participants will return to the clinic with skills to not only help patients, but to also help themselves be less stressed, more mindful providers!


1. Alehagen S, Wijma K, Wijma B. Fear during labor. Acta Obstet Gynecol Scand. 2001;80(4): 315–320.
2. Laursen M, Johansen C, Hedegaard M. Fear of childbirth and risk for birth complications in nulliparous women in the Danish national birth cohort. Br J Obstet Gynaecol. 2009:116(10): 1350–1355.
3. Isgut M, Smith AK, Reimann. The impact of psychological distress during pregnancy on the developing fetus: Biological mechanisms and potential benefits of mindfulness interventions. J Perinat Med. 2017 Dec 20;45(9):999-1011.
4. Duncan LG, Cohn MA, Chao MT. The benefits of preparing for childbirth with mindfulness training: a randomized controlled trial with an active comparison. BMC Pregnancy Childbirth. 2017. May 12;17(1):140.
5. Lonnberg G, Nissen E, Niemi M. What is learned from Mindfulness-Based Childbirth and Parenting Education? – Participants’ experiences. BMC Pregnancy Childbirth. 2018; 18: 466.
6. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
7. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.

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Meditation Decreases Physiological Markers of Stress

Most clinicians will agree that stress can amplify a patient’s pain and slow recovery. Mindfulness training provides patients with the ability to self-regulate their stress reaction and has been shown to reduce pain and depression and improve quality of life in patients with chronic pain conditions.1 The growing popularity of meditation training to manage stress has led to an increased interest in the physiological mechanisms by which meditation influences the body’s stress reaction. A systematic review and meta-analysis examined the results of randomized controlled trials that compared the impact meditation interventions to active control groups on stress measures. 2 Forty-five studies were included. Meditation practices examined were focused attention, open monitoring and mantra repetition. Outcome measures studied were cortisol, blood pressure, heart rate, lipid and peripheral cytokine expression. Studies had diverse participants including healthy adults, undergraduate students, army soldiers, veterans, cancer survivors, and individuals with chronic pain conditions, cardiovascular disease, depression and hypertension.

When all meditation forms were analyzed together, meditation reduced blood cortisol, C-reactive protein, resting and ambulatory blood pressure, heart rate, triglycerides and tumor necrosis factor-alpha. The effect of meditation on:

  • Cortisol and resting heart rate was considered to be high level of evidence.
  • C-reactive protein, blood pressure, triglycerides and tumor necrosis factor-alpha was considered to be moderate level of evidence.

Analyzed individually:

  • Open monitoring meditation reduced ambulatory systolic blood pressure, systolic blood pressure following a stress test and resting heart rate. Effects assessed as providing moderate level of evidence.
  • Focused awareness reduced blood cortisol and resting systolic blood pressure. Effects assessed as providing low level of evidence.
  • Mantra repetition reduced systolic blood pressure. Effects assessed as providing low level of evidence.

Authors report the primary reason for downgrading the grade of evidence when analyzing meditation practices individually was the limited number of studies available and small sample sizes. They conclude overall, when compared to an active control (relaxation, exercise or education) meditation practice leads to decreased physiological markers of stress in a range of populations.

Carolyn will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and again in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into pain treatment and the field of physical therapy. Hope to see you there!


1. Hilton L, Hempel S, Ewing BA, et al. Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017;51(2):199-213.
2. Pascoe MC, Thompson DR, Jenkins ZM, Ski CF. Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis. J Psychiatr Res. 2017;95:156-78.

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Carolyn McManus Presenting at NEXT 2019 in Chicago!

We are thrilled to announce that Herman and Wallace instructor, Carolyn McManus, MPT, will co-present an educational session with internationally recognized pain researcher Etienne Vachon-Pressseau, PhD at APTA’s NEXT meeting in Chicago on June 13. Dr. Vachon-Presseau is an assistant professor at the Alan Edwards Centre for Research on Pain at McGill University and has led pioneering research into stress-associated brain changes in patients with persistent pain.

In a presentation entitled, When Stress Complicates Care for Your Patient in Pain: Evidence-Based Mechanisms and Treatment, Dr. Vachon-Presseau will discuss the latest research and theory illuminating the role of stress in the maladaptive neuroplastic brain changes observed in patients with chronic pain. Carolyn will discuss direct clinical applications of this marterial and highlight research on the role of mindfulness in the self-regulation of stress and pain. She will share a practical model for integrating mindfulness into physical therapy for the treatment of persistent pain conditions.

We are excited that Carolyn has been offered this honor to co-present at NEXT with a world renown researcher in the field of pain and contribute her insights from an over 30-year career specializing in mindfulness and pain. She will offer her popular course, Mindfulness-Based Pain Treatment, in Portland OR, July 27 and 28 and in Houston TX, October 26 and 27. We recommend these unique opportunities to train with Carolyn, a nationally recognized leader trailblazing the successful applications of mindfulness into the field of physical therapy. Hope to see you there!

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Distinct Brain Systems Mediate Nociceptive Input and Self-Regulation of Pain

Does cognitive self-regulation influence the pain experience by modulating representations of nociceptive stimuli in the brain or does it regulate reported pain via neural pathways distinct from the one that mediates nociceptive processing? Woo and colleagues devised an experiment to answer this question.1 They invited thirty-three healthy participants to undergo fMRI while receiving thermal stimulation trial runs that involved 6 levels of temperatures. Trial runs included “passive experience” where participants passively received and rated heat stimuli, and “regulation” runs, where participants were asked to cognitively increase or decrease pain intensity.

Instructions for increasing pain intensity included statements such as “Try to focus on how unpleasant the pain is. Pay attention to the burning, stinging and shooting sensation.” Instructions for decreasing pain intensity included statements such as “Focus on the part of the sensation that is pleasantly warm. Imagine your skin is very cool and how good the stimulation feels as it warms you up.” The effects of both manipulations on two brain systems previously identified in the literature were examined. One brain system was the “neurological pain signature” (NPS), a distributed pattern of fMRI activity shown to specifically track pain intensity induced by noxious inputs. The second system was the pathway connecting the ventromedial prefrontal cortex (vmPFC) with the nucleus accumbens (NAc), shown to play a role in both reappraisal and modulation of pain. In humans, the vmPFC tracks spontaneous pain when it has become chronic and potentially dissociated from nociception.2,3 In patients with sub-acute back pain, the vmPFC-NAc connectivity has been shown to predict subsequent transition to chronic back pain.4 In addition, the vmPCF is hypothesized to play a role in the construction of self-representations, assigning personal value to self-related contents and, ultimately, influencing choices and decisions.5

Woo and colleagues found that both heat intensity and self-regulation strongly influenced reported pain, however they did so by two differing pathways. The NPS mediated only the effects of nociceptive input. The self-regulation effects on pain were mediated by the NAc-vmPFC pathway, which was unresponsive to the intensity of nociceptive input. The NAc-vmPFC pathway responded to both “increase” and “decrease” self-regulation conditions. Based on these results, study authors suggest that pain is influenced by both noxious input and cognitive self-regulation, however they are modulated by two distinct brain mechanisms. While the NPS encodes brain activity closely tied to primary nociceptive processing, the NAc-vmPFC pathway encodes information about evaluative aspects of pain in context. This research is limited in that the distinction between pain intensity and pain unpleasantness was not included and the subjects were otherwise healthy. Further research is warranted on the effects of this cognitive self-regulation model on brain pathways in patients with chronic pain conditions.

Even with the noted limitations, this research invites the clinician to consider the role of both nociceptive mechanisms and cognitive self-regulatory influences on a patient’s pain experience and suggests treatment choices should take both factors into consideration. Mindful awareness training is a treatment that contributes to cognitive self-regulatory brain mechanisms.6 When mindful, pain is observed as and labeled a sensation. The term “sensation” carries a neutral valence compared to “pain” which may reflect greater alarm or threat to an individual. The mind is recognized to have a camera lens-like quality that can shift from zoom to wide angle. While pain can draw attention in a more narrow focus on the painful body area, when mindful, an individual can deliberately adopt a wide angle view, focusing on pain free areas and other neutral or positive states. In addition, when mindful, the unpleasant sensation rests in awareness not characterized by fear and distress, but by stability, compassion and curiosity. Patients may not have control over the onset of pain, but with mindfulness training, they can take control over their response to the pain. This deliberate adoption of mindful principles and practices can contribute to cognitive self-regulatory brain mechanisms that can ultimately impact pain perception.

I am excited to share additional research and practical clinical strategies that help patients self-regulate their reactions to pain and other symptoms in my 2019 courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland OH, April 6 and 7 and Mindfulness-Based Pain Treatment in Houston TX, October 26 and 27 and Portland OR May 18 and 19. Hope to see you there!


1. Woo CW, Roy M, Buhle JT, Wager TD. Distinct brain systems mediate the effects of nociceptive input and self-regulation on pain. PLoS;2015;13(1):e1002036.
2. Baliki MN, Chialvo DR, Geha PY, Levy RM, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain.J Neurosci. 2006;26(47):12165-73.
3. Hashmi JA, Baliki MN, Huang L, et al. Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits. Brain. 2013;136(pt9):2751-68.
4. Baliki MN, Peter B B, Torbey S, Herman KM, et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat Neurosci.2012;15(8):1117-9.
5. D’Argembeau. On the role of the ventromedial prefrontal cortex in self-processing: The Valuation Hypothesis. Front Human Neurosci. 2013;7:372.
6. Zeidan F, Vago DR. Mindfulness meditation-based pain relief: a mechanistic account. Ann N Y Acad Sci. 2016 Jun;1373(1):114-27.

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Carolyn McManus to Present on Pain at CSM2019!

Going to the Combined Sections Meeting of the American Physical Therapy Association (CSM2019)? Look for Herman & Wallace instructor Carolyn McManus, MPT, MA at the educational session titled “Pain Talks: Conversations with Pain Science Leaders on the Future of the Field”. Carolyn will be a panelist along with Kathleen Sluka, PT, PhD, Steve George, PT, PhD, Carol Courtney, PT, PhD and Adriaan Louw, PT, PhD. The panel will be moderated by Derrick Sueki, DPT, PhD and Mark Shepherd, DPT, OCS.

These influential leaders will share how they personally became interested in the field of pain and discuss innovative pain treatment, as well as leading edge pain research and its translation into clinical practice. Initiatives to standardize entry-level curriculum, develop pathways to pain specialization and create post-professional opportunities such as pain-specific residencies and fellowships will be explored. The session will conclude with the leaders discussing their views on the future of pain and the role of physical therapy in its management. The audience will be able to submit questions via text or email to the moderator for individual or panel discussion.

We are thrilled to have Carolyn on our faculty and excited that she has been offered this honor to contribute insights from her over 30-year career experience in the field of pain with her colleagues at CSM2019. Carolyn will offer her popular courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland, OH on April 6 and 7, and Mindfulness-Based Pain Treatment in Portland, OR May 18 and 19, and Houston TX, October 26 and 27. We recommend these unique opportunities to train with a nationally recognized leader who pioneered the successful applications of mindfulness to the field of physical therapy. Hope to see you there!

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Mindful Attention to the Breath Reduces Amygdala Activity

As so many of our patients are shallow breathers, I found this research on the effects of mindful attention to the breath (MATB) on prefrontal cortical and amygdala activity especially informative and relevant to patient care. Twenty-six healthy volunteers with no prior meditation experience were introduced to MATB by an experienced meditation teacher and instructed to practice a 20-minute audio guided MATB meditation daily for 2 weeks.1 At the end of the 2-week training period, subjects underwent fMRI scanning while viewing distressing emotional images with MATB and with passive viewing (PV). Participants were shown aversive pictures or no pictures and were instructed to “Please focus your attention on your breath as you were instructed in the training” or “Please watch the picture without changing anything about your feelings.” Subjects indicated their current affect on a 7 point scale ranging from -3 (very negative) to +3 (very positive).Mindfullness

Breathing frequency significantly decreased during MATB compared to PV. Researchers controlled for this by including breathing frequency as a covariate in further behavioral and brain data analysis.

Analysis of affective ratings showed that participants felt significantly less negative affect when viewing distressing visual stimuli during MATB than PV. During negative visual stimuli, MATB significantly decreased bilateral amygdala activation compared to PV. Also, right amygdala activation decrease specifically correlated with successful emotional regulation. That is, those participants with greater reductions in right amygdala activation reported greater reductions in aversive emotions during the MATB. In addition, emotion-related functional connectivity increased between the prefrontal cortex and amygdala during the viewing of negative images and MATB.

It’s exciting to have some initial science behind the benefits of MATB. I teach all of my patients MATB and have found it rewarding to get feedback from participants in my courses about their integration of MATB into their own patient care. Patients with complex pain conditions can be challenging to treat, however sometimes a simple practice of taking 2 to 3 minutes prior to and/or at the end of a treatment to have a patient calmly focus on their breath with the mindful attitudes of acceptance, kindness and curiosity can help a person shift from tension and distress to calm and confidence. I look forward to presenting this and additional research on the impact of mindful meditation on brain structure and function in my upcoming course, Mindfulness-Based Pain Treatment, in Seattle, November 4 and 5. Hope to see you there!


1. Doll A, Holzel BK, Bratec SM, et al. Mindful attention to breath regulates emotions via increased amygdala-prefrontal cortex connectivity. Neuroimage. 2016;134:305-313.

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The Chronic Stress of Chronic Pain: Clinical Implications

For many of our patients, chronic pain is a chronic stress. Unfortunately, the resulting ongoing physiological stress reaction can have neurotoxic influences in key brain regions, including the prefrontal cortex, amygdala and hippocampus, and drive maladaptive neuroplastic changes that may further fuel a chronic pain condition.1 For example, chronic stress generates extensive dendritic spine loss in the prefrontal cortex, hyperactivity in the amygdala, and neurogenesis suppression in the hippocampus.2,3,4 In parallel, patients with chronic pain have been shown to exhibit reduced gray matter in the prefrontal cortex, increased neuronal excitability in the amygdala and reduced hippocampal neurogenesis.5,6,7

These three brain areas have been identified to play an important role in fear learning and memory.8 Modulated by stress hormones and stress-induced neuroplastic changes, stress may:
(a) enhance the memory of the initial pain experience at pain onset
(b) promote the later persistence of the pain memory
(c) impair the memory extinction process and the ability to establish a new memory trace.9

Sections of the brainIn other words, an ongoing stress reaction, triggered by distressing cognitions and emotions in response to pain or other life circumstances, could reinforce and strengthen the memory of pain. The experience of pain could be generated not by nociceptive activity, but by a well-established memory of pain and inability of the brain to create new associations. Leading researchers in the cortical dynamics of pain at Northwestern University suggest this learning process and persistence of pain memory could be a major influencing mechanism driving chronic pain.9,10

In addition, neurogenesis suppression in the hippocampus is associated with depression, while increased amygdala excitability is associated with anxiety, two mood disorders that frequently accompany and complicate chronic pain conditions.11,12

Why is this important? Appreciating the complex factors that contribute to chronic pain conditions can point to treatment strategies that address these factors.13 For example, strategies that help reduce a patient’s stress reaction, mitigate the experience of fear and anxiety, and/or promote relaxation, positive mood and self-efficacy could conceivably reduce the stress reaction and reverse maladaptive neuroplasticity. While chronic pain is a multifaceted and highly complex condition with no simple answers or one-size-fits-all successful treatment strategy, initial research suggests promise for this approach to modulate cortical structure. In a study of cognitive-behavioral therapy (CBT) in the treatment of chronic pain, an 11-week CBT treatment course increased gray matter in the prefrontal cortex and hippocampus.14

In addition, a systematic review of brain changes in adults who participated in Mindfulness-Based Stress Reduction identified increased activity, connectivity and volume in the prefrontal cortex and hippocampus in stressed, anxious and healthy adults.15 Also, the amygdala demonstrated decreased activity and improved functional connectivity with the prefrontal cortex. Although yet to be studied in patients with chronic pain, these neuroplastic changes could potentially promote improved cortical dynamics in our patients.

I am excited to share this model of chronic stress and chronic pain and evidence-based applications of mindfulness to pain treatment in my upcoming course Mindfulness-Based Pain Treatment in Arlington, VA August 4 and 5, 2018 and in Seattle, WA November 3 and 4, 2018. Course participants will learn about mindfulness and pain research, practice mindful breathing, body scan and movement and expand their pain treatment tool box with practical strategies to improve pain treatment outcomes. Research examining the application of mindfulness in the treatment of patients at risk of opioid misuse will be included. I hope you will join me!


Vachon-Presseau E. Effects of stress on the corticolimbic system: implications for chronic pain. Prog Neuropsychopharmacol Biol Psychiatry. 2017; Oct 25. pii: S0278-5846(17)30598-5.
Arnsten AF. Stress signaling pathways that impair prefrontal cortex structure and function. Nat Rev Neurosci 2009:10(6):410-422.
Zhang X, Tong G, Guanghao Y, et al. Stress-induced functional alterations in amygdala: implications for neuropsychiatric diseases. Front Neurosci. 2018 May 29;12:367.
Kim EJ, Pellman B, Kim JJ. Stress effects on the hippocampus: a critical review. Learn Mem. 2015;22(9):411-6.
Fritz HC, McAuley JH, Whittfeld K, et al. Chronic back pain is associated with decreased prefrontal and anterior insular gray matter: results from a population-based cohort study. J Pain. 2016;17(1):111-8.
Veinante P, Yalcin I, Barrot M. The amygdala between sensation and affect: a role in pain. J Mol Psychiatry. 2013;1(1):9.
Vachon-Presseau E. Roy M, Martel MO, et al. The stress model of chronic pain: evidence from basal cortisol and hippocampal structure and function. Brain. 2013;136(Pt 3):815-27.
Greco JA, Liberzon I. Neuroimaging of fear-associated learning. Neuropsychopharmacology. 2016;41(1):320-334.
Mansour AR, Farmer MA, Baliki. Chronic pain: role of learning and brain plasticity. Restor Neurol Neurosci. 2014;32(1):129.
Baliki MN, Apkarian AV. Nociception, pain, negative moods and behavior. Neuron. 2015;87(3):474-491.
Schmaal L, Veltman DJ, van Erp TG, et al. Subcortical brain alterations in major depressive disorder: findings from ENIGMA major depressive disorder working group. Mol Psychiatry. 2016;21(6):806-12.
Shin LM, Liberzon I. The neurocircuitry of fear, stress and anxiety disorders. Neuropsychopharmacology. 2010;35(1):169-91.
Greenwald J, Shafritz KM. An integrative neuroscience framework for the treatment of chronic pain: from cellular alterations to behavior. Front Int Neurosci. 2018 May 23;12:18.
Seminowicz DA, Shpaner M, Keaser ML, et al. Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. J Pain. 2013;14(2):1573-84.
Gotink RA, Meijboom R, Vernooij, et al. 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice – A systematic review. Brain Cogn. 2016;108:32-41.

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Our care is as important as our patients

This post is part two of Nari Clemon's series on practitioner burnout, compassion fatigue, and the story of a pelvic rehab therapist who struggled to care for herself while caring for patients. Read part one here.

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.

That day, I talked to my colleague and close friend, whom I was teaching with, Jen VandeVegte. Jen and I both felt that conversation was a wake-up call. We talked about seeing this same scenario at our courses: so many amazing therapists getting spent, and our best therapists getting burnt out. People were coming back with enhanced skills course after course, but many of them were looking weary and tired...

In the prior years, Jen and I were both trying to be mindful and intentional. But, it hadn’t been enough in our own lives. I remember thinking, “I’m mindful I’m getting drained and there is a creeping sensation of fatigue as I am working with this patient. Now what?” There seemed to be some pitfalls many of us were getting trapped in. We noticed there were certain patients who drained us more: when the role was therapist as hero and patient as victim. There were themes of not being able to leave the patient stories at work, finding ourselves laughing less, being less adventurous. There also seemed to be a link with empathy. Those of us who were more empathic carried burdens differently than our more concrete minded peers.

For myself, I had to hit bottom to learn how to climb back out. It got to the point where I didn’t honestly want to go to my thriving private practice and treat patients. I was treating more and more complex patients and leaving work drained, despite having a repertoire of advanced skills. I remember consulting with many people trying to understand how to stop this process of my patients’ illnesses and moods bleeding into my space and my body. People told me all kinds of things: “Imagine wearing gloves that are impenetrable”, “Picture a plexiglass box around yourself”, or “Just decide it is a one way flow.” None if it worked for me. I studied Reiki and worked with therapists. Still, I was so spent after treating patients. When I moved from Indiana to Portland, I took a whole year off of work with a singular mission: get healthy and figure out how to stay that way in my work. There was no book on this. There were some crazy stories and consults that made me realize I was heading in the wrong direction, and I finally learned the key concepts that changed my life.

And oddly enough, my great friend, Jen, also had to transform. We talked honestly and shared our failures, fears and successes as we learned. We committed to being real and honest about what parts of us were stuck in old, unhelpful paradigms. Some of these were playing the hero, feeling like there should not be limits on our compassion, not holding boundaries with what was ours to own, facing difficult things within ourselves, learning how to deeply own the space in our own bodies, and accepting that as intuitive, empathic women, we can’t expect ourselves to reproduce a very masculine, directive method of treating that denies so much of who we actually are. We also changed how we dialogued with patients from the outset. We read and researched and learned how to apply a shared responsibility model from the first contact with our patients and how to hold that model during the course of care. We then applied more pain theory and how to educate patients on those aspects of their own recovery to encourage a model of mind-body wellness and responsibility for their own reframing with our guidance. I created a mediation for pelvic health CD, so patients had a clear way to practice these home programs.

Jen and I both found that as we healed and re-framed there was a great freedom and honesty that emerged in our lives and our practices. We would get together to teach Capstone and were filled with gratitude for how much had shifted and that work no longer felt like a burden. Our lives were more balanced and we were physically, mentally and emotionally stronger. We felt like we had found the holy grail of balanced practices.

But, there we stood, teaching so many of our peers who were clearly in the same quicksand that had been plaguing us in the past. Where could our colleagues who were at our series courses go to learn how to do this job and navigate their days differently? How could they feel as good at the end of the day as they did before they saw patients? This was the training many pelvic therapists needed to thrive in this field AND their life, but it had taken us so many years. This was our call to action.

We all take courses on how to help our patients and how to reach those few difficult patients and help them. Yet, as medical professionals, we do not have enough training in how to care for ourselves. At some point, we all need to realize that our care is as important as our patients. Our wellness, physical, mental, and emotional also matter and may actually be necessary to keep helping patients. Enjoying our lives is no less important. It is an investment in your family, your future patients, and yourself to take a few days to peel back and deeply examine the root of why work is so taxing and come up with a clear, individualized plan to take your life, joy and passion back…without leaving pelvic rehab.

We need all of you in this field. We want to help you stay in this field and stay in it well! Please come join us in Boundaries, Self-Care and Meditation for a retreat-like weekend to change the framework of your practice and commit to your own wellness as a provider. Come learn how to shift dynamics from your first interaction with patients and how to hold that space. You are worth it!

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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"

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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