Aparna Rajagopal, PT, Mhs, PRPC, and Leeann Taptich, PT, DPT are the authors and instructors of the Breathing and the Diaphragm remote course. Aparna and Leeann bring a wealth of experience to this course.
Aparna: About 10-plus years ago I had a patient who had a large para esophageal hernia which had been surgically repaired. She had been referred to therapy because of general debility and weakness and she couldn't do endurance-based things like gardening or walking for long periods of time. She was in her mid-sixties. She had seen 2 or 3 therapists and they couldn’t figure things out. She had the same complaint that she couldn’t breathe and every time she said she couldn’t breathe the therapist would obviously refer her back to the doctor who would run cardiac tests, and all kinds of other tests and say she was cleared from a medical standpoint and then send her back to therapy. So in this process, the patient came to me and one of the first things she said was that she had difficulty taking in a breath of air -that she felt like she couldn’t expand - not that she couldn’t breathe.
Based on that complaint, I started my assessment. I started looking at the thoracic spine and found that she actually couldn’t expand from the rib cage at all because of her surgery to fix her large para esophageal hernia. One of the things we know about para esophageal hernias is also that it can be associated with increased intraabdominal pressure - related to things like chronic severe constipation, chronic cough, etc. She got better. She healed, and I realized that this was something that patients needed. In the process of treating her, my interest in breathing and the diaphragm developed.
Leeann: I started at Henry Ford Health Systems, where Aparna and I currently work together, about 7 years ago. Around that time, Aparna did a one-hour lecture on dysfunctional breathing and breathing to help us understand the mechanics of the pelvic floor and the abdominals, and the diaphragm. I’ve always looked for my missing link in my treatment, specifically in my lumbar/low back pain patients. The lecture was a lightbulb moment for me, and it made sense to me. What I used to focus on at that time was Transverse Abdominis engagement and it didn't always work for all patients.
I call Aparna my missing link. So, it started off with the one-hour lecture that she delivered. Then we collaborated and worked on developing a four-hour course on the same topic that ended up with eight hours worth of content because of how much great research there was available about the topic. Gradually the four-hour class transitioned into what we have now - a full weekend course. It’s a great mash-up of ortho and pelvic floor approaches for both of us and has really helped both of us treat our patients better from both a pelvic standpoint and an orthopedic standpoint.
Aparna: We work together. We are able to treat patients jointly, bringing in the diaphragm/breathing aspect, incorporating the sports and manual training that Leeann has and the pelvic knowledge that I have. We are able to tie everything together and treat our patients in a very holistic way.
Leeann: My big thing is that we try to incorporate more of the regional interdependence model. When patients come in with symptoms in an area, we look above, below, and beyond to see how the whole system is functioning together. We like to see how the body moves as a whole instead of focusing on just one part of it. That’s where most of our treatment is derived from and how we work together.
Experience Level: Beginner
Contact Hours: 14
Description: This remote course is designed to expand the participant's knowledge of the diaphragm and breathing mechanics. Through multiple lectures and detailed labs, participants will learn how the diaphragm, breathing, and the abdominals can affect core and postural stability through intra-abdominal pressure changes. As an integrated approach, the course looks at structures from the glottis and the cervical region to the pelvic floor and helps in understanding a multi-component system that works together. Optimal function of the diaphragm and breathing patterns are key to a healthy pelvic floor, a normal functioning core, and postural stability. Evidence-based methods to assess the diaphragm and breathing mechanics are presented along with easy-to-apply practical intervention strategies.
This course includes assessment and treatment of the barriers by addressing thoracic spine articulation and rib cage abnormalities in the fascial system of muscles related to breathing and the diaphragm. The assessment concepts and treatment techniques can easily be integrated into a therapist's current evaluation and intervention strategies.
Steve Dischiavi sits down with Holly Tanner to discuss his remote course - Athletes and Pelvic Rehabilitation.
Can you tell us a little bit about yourself and your background?
I’ve been with Herman & Wallace now for about 10 years teaching various forms of this course [Athletes & Pelvic Rehabilitation] in terms of the pelvic floor content bridging the sports medicine world. With me not being an internal physical therapist, it’s been kind of a unique situation having been involved with H&W for so long.
I’m a manually trained orthopedic and sports PT, board-certified through the APTA, Athletic Trainer, PT. I’ve got my masters in PT, went back and got my doctoral degree in PT and now I’m pursuing my Ph.D. and doing some research. My professional background includes ten years of treating outpatient ortho and running clinics for big corporate entity types of places. Then I went for ten years of pro sports with the NHL.
This is really how I got linked into H&W because of all of the hip and pelvic disorders I was dealing with and interacting with pelvic floor therapists. That’s where the blend of pelvic floor content merging with sports medicine came into play for my course Athletes & Pelvic Rehabilitation & Pelvic Rehabilitation.
If I’m an internal pelvic health practitioner, why would I want to go take a course with someone who doesn’t even do that?
I’ve always respected that question. When I look at my course the thing that will attract the experienced physical therapist that is doing internal pelvic health care, would be the amount of consideration that goes into the design of the therapeutic exercise. Specifically how some of the latest research should be impacting the exercises directed at the pelvic floor. For example, those are the relationships between the lower extremity and the pelvic and the lower back, and how does the lumbopelvic-hip complex influence the pelvic floor. When we start looking at exercise prescriptions, specifically for the athletic population, the massive amount of complexity that goes into athletic movement typically is not reflected in the therapeutic exercises in the way we deliver them.
I tie those two roles together in an update on some of the most contemporary evidence concerning lumbopelvic-hip exercise prescription with the specific implications to the pelvic floor, and what should the pelvic floor therapist be thinking about when they start prescribing more global appreciation of exercises specific to that region.
Many of the people who take the Athlete course are first-time H&W course takers. What I see sometimes that they say is that oftentimes they are not internal pelvic floor practitioners. They don’t have the career trajectory to want to do internal work, but like myself, they know that the pelvic floor is an integral part of how athletes perform. I provide a kinematic vision from the entire lower extremity kinematic chain, up through the lumbopelvic-hip region, and how simple concepts like length-tension relationships can alter how the pelvic floor functions.
What is the philosophy that shows up in shifting the chronic pain experience?
One of the unique patterns that we see is that when the exercises are delivered more rotationally when the joint is loaded it seems to have a very interesting effect on the pelvic floor itself. So some of these same benefits that you get in the hip you see in your pelvic floor and other parts of the body. The transitional positions such as half and tall kneeling offer great opportunities to get the best of both worlds where you can be in a relatively stable pattern but still be loaded in the pelvic and the hip joint. It allows a nice transition of exercises between lower-level stability exercises and higher-level athletic-looking exercises.
A lot of times by the end of the course people will say that seems to be the transition that they really like. Now they see a way to get their patients off the table but not doing such high-level exercises that are aggravating to the patient. These transitional positions are a nice place to see some of these neurologic changes in the lumbopelvic hip region and carry over to more athletic maneuvers.
Athletes and Pelvic Rehabilitation is scheduled five more times this year in 2022!