This week we end with a fantastic interview with our featured pelvic rehab practitioner. Nancy Suarez, MS, PT, BCB-PMD, PRPC just joined the ranks of the elite Certified Pelvic Rehabilitation Practitioners! Check out our interview below:

Describe your clinical practice:
I work in a private practice specializing in women’s and men’s pelvic floor disorders including bowel and bladder issues, prolapse and sexual dysfunction, prenatal and postpartum rehabilitation, pre and postprostatectomy care, and lumbopelvic pain.

How did you get involved in the pelvic rehabilitation field?
As a physical therapist who regularly took continuing education courses following PT school, I happened to be looking for a course that might give me more knowledge to help some of my geriatric patients improve their urinary incontinence. I took my first Pelvic Floor course given by Hollis Herman and Kathe Wallace in 2000, and immediately began to make a difference in many of my patient’s lives.

What/who inspired you to become involved in pelvic rehabilitation?

Really it was my patients that inspired me to become involved in pelvic floor rehabilitation; I knew embarassingly little about it on my own until my first course! I was very fortunate to have been given the opportunity to join a pelvic floor specialty practice a few years after that first course, and there I honed my skills and began adding more pelvic floor courses to improve my practice.

What patient population do you find most rewarding in treating and why?

It is honestly difficult for me to choose one type of patient that I find MOST rewarding; it is such a privilege to see patients getting better when they may have thought there was no hope. I do find that I love helping middle aged and older women learn about their pelvic floor and learn how to overcome their incontinence, prolapse and pain.

Happy Tuesday! Today we are fortunate enough to hear from Stefanie Foster, who just earned her designation as a Certified Pelvic Rehabilitation Practitioner! Thank you for your time, Stefanie, and congratulations!

Describe your clinical practice:
I have a private practice specializing in pelvic health and related orthopedic conditions. My clinical practice is infused with my training in yoga, pelvic rehab, women’s functional nutrition, orthopedic manual physical therapy, and movement system impairment syndromes.

How did you get involved in the pelvic rehabilitation field?
I first became curious about the pelvic floor muscles as a consequence of treating orthopedic conditions. No matter what you’re working with in that setting– back pain, hip pain, even shoulder or foot, central stability or the core is of utmost importance. I started to wonder what was going on with the respiratory diaphragm and pelvic floor when we were doing all this abdominal bracing that was (and still is in some circles) all the rage. I arranged a clinical in-service with Susan Steffes to come give us a little overview and talk about how to screen for when someone needed to see a pelvic PT. After that little hour, my interest was piqued and I knew I had to learn more…hence my first H&W class.

What/who inspired you to become involved in pelvic rehabilitation?
It was a gradual inspiration, beginning with Susan. Then, I would have to say Holly and Kathe; my experience in Level 1 forever changed my professional trajectory. As far as the “what”, clinically I am always very attracted to the zebras, the complex conditions, the things that are slipping through the cracks in the medical system, the underserved…and everything about pelvic rehabilitation is that. It’s also a big public health...uh I’ll say opportunity rather than crisis. As a profession, we are doing better, but we still have a long way to go before everyone knows what we can do. Imagine how many people we could help if EVERYONE knew?! It’s really exciting!!

What patient population do you find most rewarding in treating and why?
I love working with patients who come in with a student’s mind. The ones who are curious, ask questions, take notes, and consistently do their homework typically develop a great working relationship with me and have excellent outcomes.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
To my former orthopedic-focus-only self and anyone in the same boat, it would be to stop pretending the pelvic floor doesn’t matter in your practice. At the very least, when you’re doing your red flag screen and ask if the patient has had any changes in bowel or bladder, stop downplaying it when the patient mentions they have had some minor leaks or constipation. Refer them to a pelvic rehab specialist! Don’t scare them, just tell them it’s common and there’s pharma-free help out there!

What has been your favorite Herman & Wallace Course and why?
Holly and Kathe taught my Level 1 and it was one of THE BEST courses I’ve ever taken (I’m not just saying that because it’s for their site!). They somehow managed to simultaneously have us rolling on the floor laughing, feeling incredibly supported and comfortable, and leave us ready to walk out the door and treat patients Monday morning. Incredible.

What is in store for you in the future?
More teaching and research. I am passionately curious about several unanswered questions and could keep myself busy the rest of my life investigating and sharing my findings. Right now, the relationship of orthopedic conditions and movement impairments of the hip with pelvic floor-related complaints has mesmerized me!

What role do you see pelvic health playing in general well-being?
If you look at the yoga tradition, the pelvic floor is our base, our ground, our safety, our manifestation into the world… Everything we work with - bladder, bowel, sexual function, birth – is so basic to life on earth! Treatment of these conditions is truly life enhancing! Without the pelvic floor and related structures functioning optimally, it’s challenging to get the rest of the system to function optimally.

Today we get to hear from Sherine Aubert, PT, DPT, PRPC who just earned her certification! Sherine was kind enough to share her story about discovering pelvic rehabilitation.

Tell us a bit about your clinical practice
Men and women across the life span with urogynecological, colorectal, orthopedic, as well as pre and post-surgical cases including sexual reassignment surgeries make up the majority of the population I treat. Most patients are working towards improving their bedroom and bathroom issues including prolapse, urinary frequency, urinary urgency, incontinence, pelvic pain, coccydynia, voiding dysfunctions, interstitial cystitis, vaginismus and dyspareunia. Educating and setting male patients up with pre surgical prostatectomy pelvic floor muscle strengthening programs and as well as improving outcomes of patients who have undergone sexual reassignment surgeries.

How did you get involved in the pelvic rehabilitation field?
I have always had such respect and fascination with the pelvic floor muscles. They are underestimated and overlooked in many physical therapy settings and I feel passionate about changing this! I have made it my goal to educate and empower individuals while making a comfortable environment to ask questions to further understand their anatomy, function and optimize their health.

What/who inspired you to become involved in pelvic rehabilitation?
I have been very lucky to have many wonderful influences in my academic and professional career. The two pelvic floor “geniuses” who have always had time to discuss new treatments, brainstorm, and optimize my skill set would be Dr. Chris Eddow PT, DPT, OCS, WCS, CHT and Dr. Jamie Taylor PT, DPT. Thanks for always pushing me to the next level ladies, I look forward to advancing the pelvic floor world with you gals!

What do you find is the most useful resource for your practice?
During every initial evaluation I use a pelvic model to show all the pelvic floor muscles, organs and connective tissue with an overview of anatomy and function. I find patients are very appreciative of the explanation and find extreme value in understanding their own anatomy. Every time I show the model, I feel like I am sharing the world’s best secret about their bodies!

What motivated you to earn PRPC?
I appreciated the fact that "PRPC" included men and women's knowledge base.

This week we are proud to feature Christy Ciesla, PT, DPT, PRPC! She just earned her Pelvic Rehabilitation Practitioner Certification, and was kind enough to share some of her thoughts with the Pelvic Rehab Report. You can read the interview below. Congratulations to Christy and all the other PRPC practitioners!

Tell us about your clinical practice:
I am currently coordinating a Women and Men’s Health program at the Miriam Hospital (The Men’s Health Center and The Women’s Medicine Collaborative) in Rhode Island. We are fortunate to be a team of 5 skilled pelvic therapists and to work with the some of the best physicians and surgeons in New England. We work with so many different patients. I am currently most excited about our involvement in a tremendous Cancer Survivorship Program offered here at the Women’s Medicine Collaborative.

How did you get involved in Pelvic Rehab?
I have always been actively involved in women’s issues, even as a college student, helping with programming for the Women’s Resource Center on campus. After I had my first son in 2003, I became very interested in working with pregnant and postpartum women, and the pelvic rehab involvement took off from there. I was sent my first male patient in 2008, and found that I enjoyed working with men just as much as working with women in this area.

What/who inspired you to become involved in pelvic rehabilitation?
I went to Elizabeth Noble’s OB/Gyn and Prenatal Exercise Courses in 2004. During the course, we talked quite a bit about birth and the pelvic floor. I left there fascinated with the field, and took my first pelvic floor course a couple of years later.

What patient population do you find most rewarding in treating and why?
I love treating all of my patients, but perhaps the most rewarding feeling is when I can help a cancer survivor SURVIVE their cancer. All too often, when the treatment ends, the patient is left to feel alone with all of the effects of chemo, radiation and surgical trauma. They have incontinence, pelvic pain, and sexual dysfunction, and feel lost. Being able to offer a light in the darkness to these people is the greatest gift that pelvic rehabilitation has given me.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
You will never have more of a rewarding experience than you will when you help your patients pee, poop and have sex without dysfunction. I mean, really….what else is there to life?!

What has been your favorite Herman & Wallace Course and why?
PF 1 has still got to be my favorite. It was the most packed with great info, Holly was my instructor, and I was first introduced to the magical world of pelvic rehabilitation. I will never forget that experience.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
One of the things that has been consistently conveyed in all of my courses with H&W is the importance of caring for, respecting, and honoring our patients for having the bravery to address these sensitive issues, and to share them with us. The coursework prepared me with the knowledge I needed to help my patients, but the amazing instructors also helped me be a better provider in other ways.

What motivated you to earn PRPC?
So far, I have taken 7 Herman and Wallace courses (8 including the PF 1 course that Holly did privately for my facility and I was able to assist with). It just seemed right to be certified through this wonderful institute. It is what I do every day, all day, and I felt that I needed these credentials to go further with my career in this field.

The following is a contribution from Elisa Marchand, PTA, PRPC. Elisa is the first PTA to become a Certified Pelvic Rehabilitation Practitioner! Elisa started a Pelvic Floor program with a locally-owned rehab company where she mentored 3 different PT's through the years. In that time, Elisa also taught as an adjunct with the local PTA program. Elisa works at McKenna Physical Therapy in Peoria, IL.

As a physical therapist assistant, the following should cause me to rethink my passion for and practice within women's health PT. "The SOWH is opposed to the teaching of internal pelvic assessment and treatment to all supportive personnel including physical therapist assistants." (Position Statement on Internal Pelvic Floor Assessment and Treatment: Section on Women's Health, APTA; Feb 2014) It should have stopped me from sitting for and becoming the first-ever PTA certified as a PRPC. Fortunately, this is not the case.

I want to be clear from the start; I understand the need for clear boundaries with regards to the scope of practice of PTAs. However, the interpretation of these rules can get quite muddy. In the APTA's "Guide for Conduct of the PTA", the following clarifications are made, including their interpretations:

3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge, there may be areas of physical therapy interventions in which he or she displays advanced skills...To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence.

3E. [PTA's] shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient/client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient/client status indicate that modifications to the plan of care may be needed.

Through the years of working as a PTA, I have practiced in a variety of settings. Some of these settings have allowed for a high level of autonomy (such as in my current workplace), and some have operated in quite the opposite-- where my treatments were dictated step-by-step by the PT. No matter the state in which one lives, physical therapy clinics will vary in their method of treatment and utilization of PTAs. In Illinois, where I practice, the following is the detailed description of a PTA per the Illinois Practice Act:

"'Physical therapist assistant' means a person licensed to assist a physical therapist and who has met all requirements as provided in this Act and who works under the supervision of a licensed physical therapist to assist in implementing the physical therapy treatment program as established by the licensed physical therapist. The patient care activities provided by the physical therapist assistant shall not include the interpretation of referrals, evaluation procedures, or the planning or major modification of patient programs." (http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapterID=24)

Additionally, per the APTA's Standards of Ethical Conduct for the Physical Therapist Assistant: "6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy." (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) Personally, I take this as a green light for PTA's to immerse themselves in whatever their niche or passion may be. Thus, if a PTA is following this standard, and the advances in PT call for more trained therapists with an understanding of the pelvic floor, and the appropriate oversight provided-- as in my case; what is the hold-up?

Counter to the above expectations, the Section on Women's Health's Position Statement on Internal Pelvic Floor Assessment and Treatment states:

"Any internal pelvic (vaginal or rectal) myofascial release or soft tissue mobilization techniques that would require a continuous ongoing re-evaluation and reassessment should be performed by the physical therapist and not delegated to supportive personnel including physical therapist assistants. The SOWH recognizes that therapeutic exercise, neuromuscular reeducation and behavioral retraining techniques for pelvic floor dysfunction at times requires ongoing critical decision making while at other times are relatively routine. In the routine circumstances, those techniques may be delegated. When the higher level of critical decision making is necessary those techniques should be performed by the physical therapist and not delegated to support personnel including the physical therapist assistant."

In this above set-up, PTA's are made to sound as if incapable of using any critical thinking skills. Or, at the least, able to operate with very limited critical reasoning. Furthermore, in the typical treatment of pelvic floor conditions, how is the decision-making process required for individualized treatment any different than that to the external pelvis, or the low back, or the foot for that matter?! The skill and awareness that was required in transferring a patient in the ICU when I was a new grad was in some ways more complex with more of a direct impact on a person's survival and well-being, than what I do now. Yet, how am I not qualified to do something in which I have extensive training? This seems inconsistent.

In my opinion, the PTA is more than just "supportive personnel". On the other hand, I also believe that new PTA grads may not have a place in pelvic floor PT. There are complexities within, and knowledge required of anatomy and physiology of the pelvis, which the PTA does not get from his or her program. Though doctorate students entering the PT world today also do not have much exposure to the pelvic floor, they at least have gone through a more thorough coverage of anatomy, physiology, and disease processes. Despite the differences in schooling, MANY physical therapists see their assistants as vital assets to their clinics.

One incredibly positive aspect of being a PTA is the follow-through I have with my clients. I LOVE getting to know my patients, and feel that I am allowed this luxury more frequently than PT's whose schedules may need to stay open for new evaluations. I frequently have clients say to me, "I would never have dreamed that I'd be talking about (fill in the blank) with ANYBODY!" Usually, this is after a few sessions of working together. I cherish seeing the freedom and healing that comes when people feel comfortable enough to open up their physical, emotional, and spiritual selves.

Yes, as a PTA we are limited by the scope of practice placed before us. However, I do not see that as a set of limitations that binds us to a very narrow existence. With the training one receives through continuing education such as with Herman & Wallace, the PTA can gain the necessary skills for treatment. And from this, the possibilities are endless!

We're excited to have the chance to interview Lisa Odabachian, MPT, BSN, RN, PRPC, this week's featured Certified Pelvic Rehabilitation Practitioner! Lisa earned her certification in May of 2015 and she was kind enough to share her thoughts with us. Thank you for your contributions to the field of pelvic rehab, Lisa, and congratulations on your certification!

What motivated you to earn PRPC?
For patients and referring providers to have confidence that I have expertise in treating pelvic floor dysfunctions.

What makes you the most proud to have earned PRPC?
That I have evolved into a practitioner that can make a difference in this patient population’s quality of life.

What advice would you give to physical therapists interested in earning PRPC?
Take as many courses with hands on lab work that you can so you can treat with a broad base of knowledge to get the best outcome for your patients!

Tell us a little about your clinical practice:
I am a full-time clinician at a well-known and well-respected hospital-based outpatient women's clinic. I have been at the Beaumont's Women's Urology Center, a multidisciplinary clinic focusing exclusively on women's health, for the past 5 years. incontinence, pelvic organ prolapse, urinary urgency and frequency, chronic pelvic pain conditions (painful intercourse, interstitial cystitis, vulvodynia, abdominal pain), post-surgical pain and weakness, colo-rectal dysfunctions (fecal incontinence, constipation, rectal pain). I have been in clinical practice treating women and men with pelvic dysfunctions for over 14 years at Beaumont Hospital. Prior to that I was a clinical nurse treating patients in a variety of settings. I am currently an ABPTS candidate to sit for the 2016 WCS specialist certification examination in Women's Health physical therapy.

How did you get involved in the pelvic rehabilitation field?
Through the years of being a nurse, family member and friend I have heard many stories from women and men who have had symptoms that were unsuccessfully or only partially helped with medications and/or surgical interventions. When I learned that there were specially trained physical therapists who treat bladder, bowel and sexual problems by providing the patients self-help education and rehabilitation techniques to help resolve these issues, I became charged up to get my master’s in physical therapy so I could then specialize in treating pelvic floor dysfunctions.

What/who inspired you to become involved in pelvic rehabilitation?
When I learned that there were specially trained physical therapists who treat bladder, bowel and sexual problems by providing the patients self-help education and rehabilitation techniques to help resolve these issues, I became charged up to get my master’s in physical therapy so I could then specialize in treating pelvic floor dysfunctions.

What patient population do you find most rewarding in treating and why?
The patients who are motivated in helping themselves by being compliant in their rehabilitation by doing their home exercise program and asking questions are the patients who typically have the best outcomes.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
There are so many women and men who could benefit from a skilled pelvic floor physical therapist. Many patients with pelvic floor dysfunction have difficulty being appropriately evaluated and referred to pelvic floor physical therapy, and then if that occurs they often have to travel long distances to find a proficient provider.

What has been your favorite Herman & Wallace Course and why?
I have learned so much from each and every course I have taken. My first course was in Akron Ohio in May 2001 with Holly Herman and Kathe Wallace, so of course that is my most memorable course because it was like opening a Pandora’s Box, in a good way! It all made sense!

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Perform a good orthopedic evaluation first

What do you find is the most useful resource for your practice?
I often refer to course/lab course notes.

What is in store for you in the future?
My application has been approved to sit for the 2016 specialist certification examination in Women’s Health in physical therapy to obtain WCS credentials through the APTA.

What role do you see pelvic health playing in general well-being?
It’s huge! When people have bladder, bowel and/or sexual dysfunction, their relationships, social, career, education, emotional, recreational and/or psychological, etc. well-being is affected to varying degrees. People often do not even know they have pelvic floor muscles until there is pain or a functional impairment.

This week we get to feature Katie Tredo, DPT, PRPC, one of the first people to earn her Pelvic Rehabilitation Practitioner Certification! Katie co-owned a private practice in Maryland, and has recently relocated to the Milwaukee area to practice her trade. She was kind of enough to offer her insights with the Pelvic Rehab Report today.

Hi Katie! Tell us a little bit about your clinical practice
I recently joined the staff at Health In Balance Physical Therapy in Mequon, WI. Our team is made up of experienced physical therapists with a variety of interests and specialties. Along with two of my coworkers, my practice is focused on treating men, women, and children with pelvic dysfunctions. I think a practice with such a skilled and diverse set of physical therapists allows us to better serve our patients.

What patient population do you find most rewarding in treating and why?
I find treating patients with pelvic dysfunctions, especially pelvic pain, to be extremely rewarding. Pain, incontinence, and other pelvic dysfunctions can leave patients feeling very isolated and hopeless. Watching my patients open up about their issues then progress toward their goals, returning to their previous activities and relationships without pain or dysfunction is amazing. There are so many quality of life issues that go along with pelvic dysfunctions and I am honored to be a part of each of my patient’s journey to recovery.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
I would encourage physical therapists to get comfortable asking about bowel, bladder, and sexual dysfunction on their initial intake forms. Many people will not think to report these issues without being asked and a pelvic dysfunction can be a major component of a hip or back issue. If your patient reports a pelvic dysfunction, be comfortable acknowledging it and make an appropriate referral for them. I enjoy working closely with and sharing patients with other physical therapists so that we can maximize our patients’ recovery.

What role do you see pelvic health playing in general well being?
In the past discussing pelvic dysfunctions was considered embarrassing or taboo. In the past few years, I have seen more and more of my patients educating themselves, discussing their issues with other men or women, and finding themselves the help they need. Many patients are going into their referring physicians and requesting to receive help instead of waiting for their doctor’s suggestion. Patients are becoming more empowered over their own care. I see pelvic health becoming more and more of a focus in people’s lives and that fewer patients will be content living with their dysfunction.