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Feeding the Microbiota-Gut-Brain Axis

Anxiety and depression are frequently encountered co-morbidities in the clients we serve in pelvic rehabilitation. This observation several years ago in clinical practice is one of many that prompted me down the path of exploring the connection between the gut, the brain, and overall health. In answering the question about these connections, I discovered many nutritionally related truths that are being rapidly elucidated in the literature.

A recent study by Sandhu, et.al. (2017) examines the role of the gut microbiota on the health of the brain and it’s influence on anxiety and depression. The title of the study, “Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry” gives us pause to consider the impact of our diets on this axis and in turn, on the health of our nervous system. The authors state:

It is diet composition and nutritional status that has been repeatedly been shown to be one of the most critical modifiable factors regulating the gut microbiota at different time points across the lifespan and under various health conditions.

With diet and nutritional status being the most critical modifiable factors in the health of this system, it becomes our responsibility to seek to understand this system and its influencing factors. We need to learn how to nourish the microbiota-gut-brain axis.

While anxiety and depression are common co-morbidities we encounter, we also commonly detect imbalance between the sympathetic and parasympathetic nervous system in our patients leading to, for example, pelvic floor muscle tension. In light of this study we must first and foremost ask: what is the microbiota? How can it influence our nervous system? How does this correlate to anxiety and depression? The answers to these questions provide clinical insight with far-reaching impact. We also consider: which circumstances disrupt the health of this system and which improve it? Finally, could understanding of this axis, among other nutritional correlates, provide a novel approach to bowel dysfunction, bladder dysfunction, chronic pelvic pain?

Be a part of the paradigm shift to integrative understanding as we explore these and many other burning questions. Please join us for insightful discussion in White Plains, NY March 31-April 1, 2017 for our next offering of Nutrition Perspectives for the Pelvic Rehab Therapist.


Sandhu, K. V., Sherwin, E., Schellekens, H., Stanton, C., Dinan, T. G., & Cryan, J. F. (2017). Feeding the microbiota-gut-brain axis: diet, microbiome, and neuropsychiatry. Transl Res, 179, 223-244. doi:10.1016/j.trsl.2016.10.002

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Pudendal entrapment or a tumor?

In the comedy, Kindergarten Cop, Detective John Kimble may only have had a headache, not a tumor, but sometimes our patients do have a tumor. One of my patients was actually just diagnosed with a brain tumor after responding poorly to a cortisone injection for her neck pain. Tumors in other areas of the body, even in the pelvis, can be the source of symptoms that may seem like a nerve entrapment. This is a serious consideration to be given when diagnosing pudendal neuralgia.

In 2008, Labat et al. published the “Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment” in Neurourology and Urodynamics . A group in Nantes, France, established criteria in 2006, since the diagnosis is primarily clinical in nature. The results of this paper concluded the five essential diagnostic criteria (Nantes criteria) are as follows:

  • Pain located in the anatomical region of the pudendal nerve.
  • Pain worsened with sitting.
  • Pain does NOT awaken the patient at night.
  • Negative sensory loss upon clinical exam.
  • Pain is relieved with an anesthetic pudendal nerve block.

A recent study by Waxweiler, Dobos, Thill, & Bruyninx explored the Nantes criteria as related to choosing surgical candidates for pudendal neuralgia from nerve entrapment. They looked at how a patient’s response to the anesthetic block corresponded to appropriate selection of patients for a successful surgical outcome. Six of 34 patients in the study had a negative anesthetic pudendal nerve block, and 100% of those patients had no symptom relief after surgery. In contrast, 64% of the patients who met all five of the Nantes criteria responded positively to surgery. The authors concluded confirmation of the 5th criteria as essential for predicting success of surgery for pudendal neuralgia by pudendal nerve entrapment.

In Pain Physician in 2016, Ploteau et al. present two case studies where consideration of the Nantes criteria helped diagnose rare tumors in patients who demonstrated red flags during examination. Warning signs such as nocturnal awakening, point-specific pain, pain of a neuropathic nature, and neurological deficits cannot be overlooked when a patient presents with pudendal neuralgia. In the case studies presented, the 31 year old woman did not have pain exacerbated with sitting and woke at night with pain, and the 62 year old woman was awakened at night with pain. Each patient had magnetic resonance imaging performed, and rare diagnoses of endometrial stromal sarcoma and adenoid cystic carcinoma were made, respectively. The tumors arose in the ischiorectal fossa and compressed the pudendal nerve, presenting as pudendal neuralgia in atypical forms requiring careful clinical examination and referral for MRI for accurate diagnosis.

Although a tumor rarely exists, it is our duty to recognize signs and symptoms that do not follow established criteria. Paying attention to what your patients say just may be lifesaving. Proper diagnosis of pudendal neuralgia is essential and sometimes falls in our hands.


Labat, JJ., Riant, T., Robert, R., Amarenco, G., Lefaucheur, JP., Rigaud, J. (2008). Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourology and Urodynamics. 27(4):306-10. doi: 10.1002/nau.20505.
Waxweiler, C., Dobos, S., Thill, V., Bruyninx, L. (2016). Selection criteria for surgical treatment of pudendal neuralgia. Neurourology and Urodynamics. doi:10.1002/nau.22988.
Ploteau, S., Cardaillac, C., Perrouin-Verbe, M. , Riant, T., & Labat, J. (2016). Pudendal Neuralgia Due to Pudendal Nerve Entrapment: Warning Signs Observed in Two Cases and Review of the Literature. Pain Physician. 19:E449-E454.

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Bedwetting: Facts and Myths

How often have you heard that bedwetting was behavioral or caused by deep sleep and your child would outgrow it? 15% of children per year will “outgrow” bedwetting. What if your child is in the percentile at the end of that range?

Facts:

  • Bedwetting affects 15% of girls and 22% of boys
  • 5 - 7 Million US children
  • Boys are 50% more likely than girls to wet the bed
  • 10% of 6 year olds continue to wet
  • Spontaneous cure rate 15% per year thereafter
  • 1-3% of 18 year olds still wet their beds
  • Less than 50% of all bedwetting children have bedwetting alone, without also experiencing daytime urinary leakage or constipation
  • Bedwetting is genetic – if one parent was a bed wetter the child has a 40% chance of wetting the bed and if both parents were bedwetters the percentile goes up to 77%

Myths:

  • Your child is lazy
  • Your child is doing this to get attention
  • Your child is just a deep sleeper
  • You must wait to grow out of it

Research from the International Children’s Continence Society (ICCS) is a great resource for exploring the research on this topic and other pediatric voiding issues. www.i-c-c-s.org

What causes Bedwetting?

There are many philosophies discussed in the research. Here are some listed below:

  1. Hormone deficiency- our bladders empty about every 2-3 hours during the day however at night we can hold over 8 hours! This happens because our bodies produce an antidiuretic hormone when we sleep to slow kidney function and produce less urine to empty into the bladder. If this hormone is not being produced, the kidneys produce as much urine at night as they do during the day. In this case, it's good that the bladder empties out in our sleep, otherwise our bladders would be dangerously large and possibly reflux urine backward into the kidneys. Clearly not behavioral!!
  2. Dr. Steven Hodges has researched and written extensively on the topic of constipation causing pressure from the rectum against the bladder making it irritable during sleep. His research has supported the fact that once the bowel is cleaned out daily the bedwetting episodes diminish. See It’s No Accident by Dr. Hodges or visit https://www.bedwettingandaccidents.com for more information on this topic. Again, a physiological cause of bedwetting versus behavioral.
  3. Sleep Disturbance and Nasal Airway Obstruction. Dr. Neveus and colleagues reported that 43.5% of children with snoring or obstructive sleep apnea became dry after adenotonsillectomy. Dr. Kovacevic also found increases in antidiuretic hormone seen in responders post-operatively.

 

Take Home Message

  1. Active treatment for bedwetting should begin at age 6
  2. The impact of bedwetting is mainly psychological and may be severe
  3. Children with bedwetting have abnormal psychological test scores, however once the bedwetting is resolved the test scores return to normal
  4. “Treatment is not only justified but mandatory”
    -ICCS Standardization document 2010

 

There is help!

At Physical Therapy Specialists we specialize in bedwetting, urinary leakage, constipation and other voiding issues in children. Let us eliminate the need for your family to suffer through this very treatable condition!

 


Al- Zaben FN, Sehlo MG. Punishement for bedwetting is associated with child depression and reduced quality of life. Child Abuse Negl. 2014
Hodges SJ, Colaco M. Daily enema regimen is superior to traditional therapies for nonneurogenic pediatric overactive bladder. Global Pediatric Health, 2016, 3: 1–4
Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.
Treatment response of an outpatient training for children with enuresis in a tertiary health care setting. J Pediatr Urol. 2012.
Hodges SJ,Anthony EY::aunrecognizedof. Urology.2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Kovacevic L, Wolfe-Christensen C, Lu H, Toton M, Mirkovic J, Thottam PJ, Abdulhamid I, Madgy D, Lakshmanan Y. Why does adenotonsillectomy not correct enuresis in all children with sleep disordered breathing? J Urol. 2014 May;191(5 Suppl):1592-6.
Nevéus T, Leissner L, Rudblad S, Bazargani F. Acta Paediatr. 2014 Jul 15. doi: 10.1111/apa.12749. [Epub ahead of print]Orthodontic widening of the palate may provide a cure for selected children with therapy-resistant enuresis.
Hodges, Steve J. It’s No Accident-Breakthrough solutions for your child’s wetting, constipation, UTI’s and other potty problems. © 2012. Lyons Press, Guilford, Connecticut.

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Viscera and Fascia: Find and Release Hidden Restrictions

My manual therapist husband once wrote a paper on the visceral referral pattern of the liver. Although he knows I injured my right shoulder shoveling snow a few years ago, whenever I have an exacerbation of shoulder pain, he likes to joke it is from my liver. (I would laugh if I had not acquired an affinity for red wine since having kids!) Sometimes pain in remote areas of our body really can be related to an organ in distress or simply “stuck” because of fascial restrictions around it. The kidneys in particular can refer pain into the low back and hips, and the bladder and ureters can provoke saddle area pain.

Tozzi, Bongiorno, and Vitturini (2012) looked into the kidney mobility of patients with low back pain. They used real-time Ultrasound to assess renal mobility before and after osteopathic fascial manipulation (OFM) via the Still Technique and Fascial Unwinding. The experimental group receiving OFM consisted of 109 people, and the control group receiving a sham treatment had 31 people, all with non-specific low back pain. For comparison, 101 subjects without back pain were also assessed with the ultrasound to determine a mean Kidney Mobility Score (KMS). The landmarks for measuring the renal mobility were the superior renal pole of the right kidney and the pillar of the right diaphragm, and they subtracted the distance at maximal inspiration (RdI) from that of maximal expiration (RdE). A significant difference was found in the KMS scores of asymptomatic versus symptomatic subjects with low back pain. Pre and post-RD values of the experimental group were significantly different from the control group. The short-form McGill Pain Questionnaire also demonstrated significant differences in the experimental versus control groups. The results of the study revealed a correlation between decreased renal mobility and non-specific low back pain and showed an improvement in renal mobility and low back pain after an osteopathic manipulation.

In 2016, Navot and Kalichman presented a case study of a 32 year old professional male cyclist with right hip and groin pain after an accident that caused a severe hip contusion and tearing of the tensor fascia latae and the gluteus medius muscles. A few rounds of physical therapy gave him partial relief of his pain in sitting and with cycling, and his hip range of motion only improved slightly. Despite no complaints of pelvic floor dysfunction, he was evaluated for involvement of the pelvic floor musculature and fascia. Pelvic Floor Fascial Mobilization was performed for 2 sessions, and the cyclist’s symptoms resolved completely. This case implied the efficacy of manual fascial release of the pelvic floor to reduce hip and groin pain.

When something seemingly orthopedic in nature does not respond with full resolution of symptoms from traditional physical therapy, the source of the pain may be deeper. Often times, we just need to ask the right questions to uncork the mystery of why a pain is lingering. No matter how skilled we are with our techniques, if we are not reaching the area in need, we are wasting our effort and our patients’ time and money. “Mobilization of Visceral Fascia: The Urinary System” is a course that provides a practitioner with the extra insight and tools to address potential sources of unresolved symptoms of low back, hip, and groin pain.


Tozzi, P., Bongiorno, D., and Vitturini, C. (2012) Low back pain and kidney mobility: local osteopathic fascial manipulation decreases pain perception and improves renal mobility. Journal of Bodywork and Movement Therapies. 16(3):381-91. doi: 10.1016/j.jbmt.2012.02.001
Navot, S and Kalichman, L. (2016). Hip and groin pain in a cyclist resolved after performing a pelvic floor fascial mobilization. Journal of Bodywork and Movement Therapies. 20(3):604-9. doi:10.1016/j.jbmt.2016.04.005

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Sacroiliac Dysfunction: Self Stabilization or Surgical Fixation

In this “quick fix” society, few people accept that musculoskeletal pain will require a commitment to following an exercise program for an extended period of time. If a hypomobile joint just needs to get moving and lubricated, one may get relief with a few manual therapy treatments and exercise sessions. However, if a joint is hypermobile (unstable) or degenerative and provokes a high level of pain, the rehab requires more time. The sacroiliac (SI) joint is one of those areas often requiring patients to work harder for the resolution of pain and dysfunction, but many seek surgical intervention instead.

Polly et al. (2016) performed a randomized controlled trial of minimally invasive sacroiliac joint fusion (SIJF) with placement of a system of triangular titanium implants using a lateral transiliac approach versus non-surgical management (NSM) for SI dysfunction. Of the 148 subjects, 102 underwent SIJF and 46 had NSM. The NSM group received medication, physical therapy per American Physical Therapy Association guidelines, steroid injections and radiofrequency ablation of sacral nerve root lateral branches. The surgical group showed superior outcomes at a 2 year follow up, as clinical improvement per VAS pain score was 83.1% and ODI was 68.2%. The NSM group showed <10% improvement.

Sachs et al. (2016) studied outcomes of patients ≥3 years after SIJF for chronic (>5 years) SIJ dysfunction secondary to degenerative sacroiliitis or SIJ disruption. One hundred and seven patients participated in the study, and minimally invasive transiliac SIJF was definitively correlated with decreased pain, low disability scores, and improvements in activities of daily living performance. Sadly, these authors stated, “there is no high-quality evidence that physical therapy is effective in chronic SIJ pain.”

Even radiofrequency neurotomy or neural ablation revealed positive results for patients according to Reddy et al. (2016). The authors explored 14 patients’ responses 1 year after Simplicity radiofrequency (RF) of the lateral branches of S1-S3 in a retrospective review. Improvements in global health per SF12 as well as pain reduction were statistically significant.

Jonely et al. (2015) presented a case study of a woman with a 14-year history of SIJ pain whose symptoms persisted after 2 months of physical therapy. A multi-modal approach was then pursued with success, even at the 1 year follow up. The patient received 4 prolotherapy injections, SIJ manipulation into nutation, a pelvic girdle belt, and specific stabilization exercises. Over a 12-month period, the patient had 20 physical therapy sessions. Her Oswestry Disability score improved from 34% to 14% at 6 months and was 0% at 1 year. Numeric pain scale rating improved to 4/10 at 6 months and 0/10 at 1 year. The authors concluded a multimodal approach can be successful to manage SIJ dysfunction.

Clearly, if quality of life is so poor a person cannot function because of SIJ pain and therapy has failed, surgery may be the only choice. I exhaust all conservative measures before I cry “uncle” for a surgical fix. Despite a paucity of literature on manual therapy and sacroiliac treatment, I know there are clinicians successfully treating patients with SI dysfunction. Taking the Sacroiliac Joint Evaluation and Treatment can broaden your scope of understanding the SI joint and how to provide the most effective treatment, possibly preventing more invasive techniques for patients.


Polly, D. W., Swofford, J., Whang, P. G., Frank, C. J., Glaser, J. A., Limoni, R. P., … and the INSITE Study Group. (2016). Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. International Journal of Spine Surgery, 10, 28. http://doi.org/10.14444/3028
Sachs, D., Kovalsky, D., Redmond, A., Limoni, R., Meyer, S. C., Harvey, C., & Kondrashov, D. (2016). Durable intermediate-to long-term outcomes after minimally invasive transiliac sacroiliac joint fusion using triangular titanium implants. Medical Devices (Auckland, N.Z.), 9, 213–222. http://doi.org/10.2147/MDER.S109276
Anjana Reddy, V. S., Sharma, C., Chang, K.-Y., & Mehta, V. (2016). “Simplicity” radiofrequency neurotomy of sacroiliac joint: a real life 1-year follow-up UK data. British Journal of Pain, 10(2), 90–99. http://doi.org/10.1177/2049463715627287
Jonely, H., Brismée, J.-M., Desai, M. J., & Reoli, R. (2015). Chronic sacroiliac joint and pelvic girdle dysfunction in a 35-year-old nulliparous woman successfully managed with multimodal and multidisciplinary approach. The Journal of Manual & Manipulative Therapy, 23(1), 20–26. http://doi.org/10.1179/2042618614Y.0000000086

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Half Full or Empty: A Cup of Mindfulness for Healing

After greeting a patient referred for temporomandibular joint dysfunction, the conversation began with an outpouring of emotion over a failed bladder sling surgery that left the woman with significant chronic pain, causing her to clench her jaw all the time. No matter what I was to find objectively with the examination, there was no doubt the treatment had to extend beyond joint mobilization, soft tissue work, and exercise. This woman clearly saw her cup as half empty, so filling her mind with a new approach to thinking about and dealing with her pain was essential for relieving her secondary jaw pain.

Su et al. published a study called, “Pain Perception Can Be Modulated by Mindfulness Training: A Resting-State fMRI Study” (2016). The pain-afflicted group had 18 participants while the control group had 16. Brain behavior response of all subjects was measured per resting-state functional magnetic resonance imaging and 3 forms (Dallas Pain Questionnaire, Short Form McGill Pain Questionnaire-SFMPQ, and Kentucky Inventory of Mindfulness) before and after 6 weeks of mindfulness-based stress reduction treatment. Training consisted of mindfulness meditations such as a body scan, hatha yoga, walking and sitting meditation, and instruction on how to use the methods for pain management. After six 2.5-hour sessions/week and one 8-hour non-verbal session in the 4th week, the fMRI showed an increased connection from the anterior insular cortex (AIC) to the dorsal anterior midcingulate cortex (daMCC), and the SFMPQ scores were significantly improved in the pain-afflicted group. The authors suggested mindfulness training can change the brain connectivity responsible for our perception of pain.

Chadi et al.2016 performed a pilot study of female adolescents with chronic pain regarding the efficacy of mindfulness-based treatment. The experimental group (n=10) and the wait-list control group (n=9) consisted of girls between the ages of 13 and 18. For 8 weeks they met for a 90 minute session led by a psychiatry resident. Some of the mindfulness practices in this study included body scan, sitting and walking meditations, love and kindness meditations, mindful eating, compassion and deep listening, and breathing exercises. The wait-list control group also completed the 8-week program. Although all participants reported a positive change in the way they coped with pain, no statistically significant changes in quality of life, depression, anxiety, pain perception, and psychological distress were found. Significant salivary cortisol level improvements were observed (p<0.001) post mindful-based treatment session, indicating feasibility in pursuing further research with a larger randomized controlled trial.

Panahi and Faramarzi2016 studied mindfulness therapy effects on anxiety and depression for premenstrual syndrome (PMS). Sixty students (30 experimental, 30 control with no treatment) with mild to moderate PMS with depression underwent 8 weekly 120 minute sessions of mindfulness-based cognitive therapy (MBCT). Mean score improvements in depression, anxiety, and PMS were statistically significant from pre to post treatment for the subjects receiving MBCT. The authors stated MBCT psychotherapy could be considered beneficial for depression in mild to moderate PMS.

If jaw-clenching chronic pain owns a patient, he or she could benefit from managing the relationship through mindfulness. Our perception of pain is at the core of “whole body” treatment. The Mindfulness Based Pain Treatment course could help fill your patients’ as well as your own cup with healing.

If you're interested in learning more about mindfulness-based treatment techniques, Herman & Wallace offers three courses which you should consider. Mindfulness-Based Pain Treatment focuses on patient treatment, and the Mindfulness for Rehabilitation Professionals.


Su, I.-W., Wu, F.-W., Liang, K.-C., Cheng, K.-Y., Hsieh, S.-T., Sun, W.-Z., & Chou, T.-L. (2016). Pain Perception Can Be Modulated by Mindfulness Training: A Resting-State fMRI Study. Frontiers in Human Neuroscience, 10, 570. http://doi.org/10.3389/fnhum.2016.00570
Chadi, N., McMahon, A., Vadnais, M., Malboeuf-Hurtubise, C., Djemli, A., Dobkin, P. L., … Haley, N. (2016). Mindfulness-based Intervention for Female Adolescents with Chronic Pain: A Pilot Randomized Trial. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(3), 159–168.
Panahi, F., & Faramarzi, M. (2016). The Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual Syndrome. Depression Research and Treatment, 2016, 9816481. http://doi.org/10.1155/2016/9816481

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Mindfulness and the Descending Modulation of Pain

The following comes to us from Carolyn McManus, PT, MS, MA, our resident expert in the power of mindfulness and it's applications to rehabilitation. Carolyn was recently featured in a video from the Journal of the American Medical Association for her contributions to a newly published research article. Join Carolyn at her course, Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain on May 14th and 15th in California's Bay Area!

Neuroimaging studies show that cortical and sub-cortical brain regions associated with cognitive and emotional processing connect directly with descending pain modulating circuits arising in the brainstem. As diminished nociceptive inhibition by descending pain modulation is a likely contributing factor to the persistence of pain, these cortical and sub-cortical connections to relevant brainstem regions provide a means by which maladaptive cognitive and emotional processing can contribute to the persistence of pain1. It is possible that strategies to help patients self-regulate cognitions and emotions could promote pain reduction through restoring the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

To be mindful is to rest the mind in the present moment with stability and acceptance and without additional cognitive or emotional elaboration. Mindful body awareness is a central component. Training in mindful awareness has been shown to improve attention regulation, emotional processing and body awareness and contribute to reduced pain intensity, catastrophizing, depression and anxiety2,3,4,5. Training in mindfulness has also been shown to modulate brain activity in areas associated with body awareness and pain processing6,7. It is possible that the adaptive modulation of cortical and sub-cortical areas engaged with mindful cognitive, emotional and physical self-regulation could contribute to reducing pain through improving the balance between excitatory and inhibitory mechanisms of the descending pain modulatory system.

One of my patients reflected the clinical benefits of mindfulness training when he said, “I needed to learn how to not freak out when my exercises or daily activities increased my pain. Focusing my mind on the present moment was enormously helpful. I would tell myself, “Breathe. Just be here. Calm down.” By breathing and relaxing I could take control of how I was reacting and I immediately saw a difference. My pain did not increase out of control.”

I am thrilled to be sharing my 30+ year experience in mindfulness and patient care in my upcoming course through Herman and Wallace.

1. Ossipov M, Morimura K, Porreca F. Descending pain modulation and chronification of pain. Curr Opin Support Palliat Care 2014;8(2):143-151.
2. Holzel BK, Lazar SW, Guard T, et al. How does mindfulness meditation work? Proposing mechanisms of action from a conceptual and neural perspective. Perspect Psychol Science. 2011;6: 537–559.
3. Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013 Feb;14(2):230-42.
4. Lakhan SE, Schofield KL. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One. 2013 Aug 26;8(8):e71834.
5. Schutze , Slater H, O’Sullivan P, et al. Mindfulness-based functional therapy: A preliminary open trial of an integrated model of care for people with persistent low back pain. Front Psychol. 2014 Aug 4;5:839.
6. Zeidan F, Martucci KT, Kraft RA, et al. Brain mechanisms supporting modulation of pain by mindfulness meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
7. Nakata H, Sakamoto K, Kakigi R. Meditation reduces pain-related activity in the anterior cingulated cortex, insula, secondary somatosensory cortex and thalamus. Front psychol. 2014;5:1489.

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Dyssynergic Defecation: A Common Culprit of Chronic Constipation and Abdominal Pain

Faculty member Lila Bartkowski- Abbate PT, DPT, MS, OCS, WCS, PRPC teaches the Bowel Pathology, Function, Dysfunction and the Pelvic Floor course for Herman & Wallace. Join her in Tampa on April 2-3, or one of the other two events currently open for registration.

Constipation, an often under reported health issue, afflicts about 30% of Americans. ¹ The diagnosis of chronic constipation may seem like a simple concept, however the etiology of chronic constipation presents itself in many different forms. Dyssynergic defecation is one of many factors that can lead to a presentation of chronic constipation in a patient. Dyssynergic defecation or “paradoxical contraction” occurs when the muscles of the abdominals, puborectalis sling, and external anal sphincter function inappropriately while attempting a bowel movement. ² The lack of coordination of these muscles results in a contraction versus a lengthening of the pelvic floor muscles with baring down. Dyssynergic defecation is different than a structural issue such as a rectocele or hemorrhoids causing the inability to pass stool effectively or constipation due to slow colon transit time or pathological disease. Making the diagnosis of dyssynergic defecation by symptoms alone is often not reliable secondary to overlap of similar symptoms with chronic constipation due to factors such as a structural issue, irritable bowel syndrome (IBS), or irritable bowel disease (IBD). The diagnosis of dyssynergic defecation can be difficult and is often made through physiologic testing such as balloon expulsion testing or MRI with defecography. ² However, physical therapists can often manually feel that a paradoxical contraction is happening when asking a patient to bare down on evaluation.

Patients with dyssynergic defecation may present to pelvic floor physical therapy with complaints of: ¹ ²

  1. Abdominal symptoms such as bloating, pain, and cramping
  2. Poor response to laxatives and fiber supplementation that does not fully resolve their issue
  3. Have had testing for anatomical or neurological abnormalities with no significant findings
  4. Complaints of concomitant pelvic pain due to over activity of the pelvic floor muscles

Physical Therapists specializing in pelvic floor rehab can be a valuable part of the medical team with treating these patients. Biofeedback training by physical therapists has been shown to decrease anorectal related constipation symptoms and abdominal symptoms in patients with dyssynergic defecation. In a sample of 77 patients with dyssynergic defecation, physical therapists provided biofeedback training for 6-8 weeks that included manual and verbal feedback, surface EMG, exercises using a rectal catheter, rectal ballooning to improve rectal sensory abnormalities, ultrasound, pelvic floor and abdominal massage, electrical stimulation if needed, and core strengthening and stretching to improve the patients’ maladaptive habits while attempting to pass a bowel movement. Significant decreases were seen on all three domains (abdominal, rectal, and stool) on the PAC-SYM (Patient Assessment of Constipation) questionnaire post biofeedback training. ² It is noteworthy that 74% of these patients presented to the clinic with complaints of abdominal symptoms such as bloating, pain, discomfort, and cramping.

Knowing how to effectively treat these patients and ask the right questions is valuable in the scheme of pelvic floor rehab secondary to overlapping symptoms of different causes of chronic constipation. Physical therapists are able to provide these patients with conservative treatment that can effectively improve or eliminate their problem, recognize dyssynergic defecation as a possible differential diagnosis, and refer to the appropriate medical professional for further testing. Recognizing and treating dyssynergic defecation is something physical therapists will learn how to become effective at in the upcoming Herman and Wallace Course: Bowel Pathology, Function, Dysfunction & the Pelvic Floor April 2-3 in Tampa, FL and October 8-9 in Fairfield, CA.


1. Sahin M, Dogan I, Cengiz M et al. (2015). The impact of anorectal biofeedback therapy on quality of life of patients with dyssynergic defecation. Turk J Gastroenterol. 26(2):140-144

2. Baker J, Eswaran S, Saad R, et al. (2015). Abdominal symptoms are common and benefit from biofeedback therapy in patients with dyssynergic defecation. Clin Transl Gastroenterol. 30(6)e105. doi: 10.1038/ctg.2015.3

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Maternal Morbidity in Pregnancy

Many therapists start their career feeling a bit intimidated to work with women who are pregnant. A common and understandable concern is that something the therapist will do during examination or treatment may harm the patient. While there are certainly things to avoid when working with a patient who is pregnant there are also many therapeutic strategies that can help a woman thrive during her pregnancy and beyond. When women have pre-existing issues such as a disease or physical challenge, or when she develops an illness during pregnancy, the therapist needs to rely upon more knowledge- this knowledge is something she rarely learns in school, but more likely in continuing education environments. A recent article asked the question “are women getting sicker, and are there more high-risk pregnancies now than ever before?”

Researchers studied trends in maternal morbidity and mortality in the United States in order to answer this question, and the answer is a definitive “yes”. Several studies describe increases in the rates of maternal morbidity, with issues such as cardiac and pulmonary complications, and the severe blood pressure fluctuations associated with eclampsia. Gestational diabetes, and postpartum rates for hemorrhage, perineal lacerations, and maternal infections have also risen. Part of the reason for more women carrying pregnancies more successfully or longer when they are ill may be contributed to newer treatments for conditions such as diabetes, yet this does not explain entirely the increase in maternal morbidity. Increased cesarean births, longer labors with epidural anesthesia, pre-pregnancy obesity, rates of multifetal pregnancies, and the rising age of mothers are other factors to be considered.

The more we know as health care providers about how maternal morbidity affects our rehabilitation efforts, the more we can contribute to a woman’s pregnancy and postpartum health. If you would like to learn more about caring for women during pregnancy and during the postpartum period, Herman & Wallace offers the Pregnancy and Postpartum Series. The following courses are available this year:

Care of the Pregnant Patient - Somerset, NJ
Apr 30, 2016 - May 1, 2016

Care of the Pregnant Patient - Akron, OH
Sep 10, 2016 - Sep 11, 2016

Peripartum Special Topics - Seattle, WA
Nov 12, 2016 - Nov 13, 2016


Tillett, J. (2015). Increasing Morbidity in the Pregnant Population in the United States. The Journal of perinatal & neonatal nursing, 29(3), 191-193.

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Pediatric Voiding Dysfunction

As pelvic rehabilitation providers, it may be safe to assume a lot of us are treating adults with bladder and bowel dysfunction. Often we get questions from these patients about treatment for children with voiding dysfunction. How comfortable are we treating children for these problems and what would we do? Pediatric voiding dysfunction and bowel problems are common and can have significant consequences to quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated. No clear gold standard of treatment for pediatric voiding dysfunction has been established and treatments range from behavioral therapy to medication and surgery.

A randomized controlled trial in 2013 that was published in European Journal of Pediatrics, explores treatment options for pediatric voiding dysfunction. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral striated sphincter during voluntary voiding. The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and abnormal flow of urine from bladder back up the ureters (vesicoureteral reflux).

The 2013 study compared 60 children over one year who were diagnosed with dysfunctional voiding into two treatment groups. One group received behavioral urotherapy combined with PFM (pelvic floor muscle) exercises while the other group received just behavioral urotherapy. The behavioral urotherapy consisted of hydration, scheduled voiding, toilet training, and high fiber diet. Voiding pattern, EMG (electromyography) activity during voids, urinary urgency, daytime wetting, and PVR (post-void residue) were assessed at the beginning and end of the one year study with parents completing a voiding and bowel habit chart as well as uroflowmetry with pelvic floor muscle sEMG (surface electromyography) was administered to the child for voiding metrics.

All parents and children in both groups received education about urinary and gastrointestinal tract function as well as healthy bladder habits, effects of high fiber diet, scheduled voiding, and normal mechanics of toilet training. For the group that completed PFM exercises and education, they participated in 12 sessions (2x/week for 30 minutes) to learn the PFM exercises under the guidance of a single physical therapist. There was bimonthly follow up for both groups throughout the 12 months to ensure retention and application of the behavioral urotherapy.

The goal of the PFM exercises for the children was too restore the normal function of the PFM’s and their coordination with abdominal muscles. The exercises that the children completed, included exercises with and without a swiss ball. The exercises without a swiss ball included breathing with the diaphragm, Transversus Abdominus muscle isolation, hip adductor squeeze (isolation), bridging with PFM relaxation, and cat/camel to improve lumbopelvic coordination. Swiss ball exercises included seated PFM contraction and relaxation exercise with a seated lift and relax, supine bridge with roll out on the ball with PFM contraction, and supine swiss ball lift with the legs and pelvic contraction. (Pictures and more details about how the exercises were carried out in the article itself.)

The conclusion of the study was that the functional PFM exercises with swiss ball combined with behavioral urotherapy reduced the frequency of urinary incontinence, PVR (post void residue), and the severity of constipation in children with voiding dysfunction. The children in the combined group showed improvements with voiding pattern, reduced EMG activity during voids, reduced urgency, reduced daytime wetting, and improvements with more complete emptying with voids (reduced PVR).

The Functional PFM exercises are easy to teach and easy for children to complete. They are a safe, inexpensive, and effective treatment option for children with dysfunctional voiding. PFM exercises combined with behavioral urotherapy seems to be a logical treatment option for treating pediatric voiding dysfunction.

To learn more about pediatric bowel and bladder dysfunction and treatment for it consider attending Dawn Sandalcidi's Pediatric and Pelvic Floor Dysfunction course. The three opportunities in 2016 are Pediatric Incontinence - Augusta, GA April 16-18, Pediatric Incontinence - Torrance, CA June 11-12, and Pediatric Incontinence - Waterford, CT on September 17-18.


Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.

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