HW faculty member Carole High Gross, PT, MS, DPT, PRPC instructs her remote course, Eating Disorders and Pelvic Health Rehabilitation, on October 19-20, 2024 that takes a deep dive into the role of pelvic health rehabilitation with individuals with eating disorders.

The role of a pelvic health rehabilitation professional includes caring for individuals with dysfunction within the pelvis and abdominal canister. We treat individuals with constipation, fecal incontinence, pelvic organ prolapse, urinary dysfunction, pelvic pain, abdominal pain, and bloating (to name a few). Individuals with eating disorders often experience ALL of these symptoms. Numerous studies demonstrate bowel, bladder, and pelvic dysfunction in those with eating disorders (see reference list for some of these studies). We CAN help!

Eating disorders are mental health conditions with serious biopsychosocial implications that negatively impact the function of the body, social interactions, and psychological well-being. The American Psychiatric Association characterizes Eating Disorders (ED) as “behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions.” Types of eating disorders include:

• anorexia nervosa (AN)
• bulimia nervosa (BN)
• binge eating disorder (BED)
• avoidant restrictive food intake disorder (ARFID)
• other specified feeding and eating disorders (OSFED)
• pica and rumination disorder

Eating disorders are estimated to affect roughly 5% of the population and are often under-reported and unidentified by the medical community. People of all genders often suffer in silence as eating disorders tend to be a very secretive and all-consuming mental illness that does not discriminate based on gender, culture, race, or nationality. Eating disorders can develop at any time in someone’s life, however, often signs develop in adolescence and early adulthood.

Supporting Research

One noteworthy article, which was published in May of 2024, was written by Monica Williams and colleagues from ACUTE, an inpatient eating disorder treatment facility, in Denver, Colorado.
Williams et al. published a retrospective cohort study of 193 female women highlighting pelvic floor dysfunction in people with eating disorders. This study illustrated the positive effects of management (including education, pelvic floor muscle assessment, biofeedback, and active retraining of the pelvic muscle) on pelvic floor dysfunction (PFD) with the intervention group (n=84). Each of the patients in this study had only one to a few treatment sessions of selected appropriate interventions.

The control group received the standard of care education including mindfulness, relaxation techniques, and diaphragmatic breathing. All participants in the intervention group received a 30-minute education session which included the purpose of the pelvic floor, causes of pelvic floor dysfunction, the relationship between the pelvic floor and diaphragm, typical bladder norms, strategies to improve bowel/bladder emptying and urge suppression techniques. The Education Group (n=26) received education only without other interventions. Although this group showed improvements in the PFDI score, the improvements did not meet statistically meaningful improvement in pelvic floor dysfunction symptoms. However, the other treatment subgroups within the intervention group showed statistically meaningful improvements in pelvic floor dysfunction. The Pelvic Floor Assessment group (n=13) included individuals who received the education (noted above) and internal assessment of pelvic floor musculature with the goal of improving coordination of PFM.

The Urinary Distress Inventory 6 (UDI-6) demonstrated statistically significant improvement in the Pelvic Floor Assessment Group. The UDI-6, the Colorectal-Anal Inventory 6 (CRAD-8), and the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6) improved with the Active Retraining (of the pelvic floor muscles) Group (n=67). The individuals in the Active Retraining group received: Education (mentioned above) and bladder training (improving time between voids) and pelvic floor stretches (deep squat, butterfly, child’s pose, happy baby including coordination of diaphragmatic breathing and movement of the pelvic floor). The Biofeedback Group (n=3) received Education (mentioned above) and biofeedback including visual feedback to instruct patients on how to effectively contract and relax PFM. The Biofeedback Group showed statistical improvement with the POPDI-6 score.

Overall, Williams et al. concluded that patients with eating disorders report an increased level of pelvic floor symptoms. The interventions provided in this study were found to be beneficial. Individuals with the anorexia binge-purge subtype also had higher scores on the PFDI than the anorexia nervosa restricting subtype. The authors recommended future studies to better describe the etiology of PFD in individuals with ED and how PFD contributes to both behaviors and GI symptoms of those with eating disorders.

Ng et al., 2022, discussed research that demonstrated the relationship between eating disorders and urinary incontinence through the lens of psychoanalysis.
This article described mental health co-morbidities with eating disorders that contribute to urinary dysfunction. The authors also encouraged a good psychodynamic understanding of childhood relationships, personality traits, and the inner mental “landscape.” The authors reinforced mental co-morbidities contribute to increased urinary incontinence and dysfunction including poor interoceptive awareness, personality traits, decreased life satisfaction, need for control, and anxiety.

Ng and colleagues described the prominence of poor interoceptive awareness among individuals with eating disorders. Interoceptive awareness refers to awareness of one’s feelings or emotions. This may also affect a person’s perception of stimuli arising in the body, such as to perform bodily functions such as urination. Poor interoceptive awareness would likely also play a factor in awareness of the body’s need to evacuate stool however, this was not within the scope of this article. Bowel dysfunction with ED is well documented in the research.

Ng et al’s article also discusses common personality traits among individuals with some eating disorders including perfectionism and asceticism. Asceticism refers to the self-denial of physical or psychological desires or needs and can also be viewed as a ritualization of life. Often this refers to spirituality or religious practices, however, denial of bodily urges and the need for control is a common characteristic with some eating disorders which include restriction (AN, BN, OSFED). Denial of basic needs, such as urination, would reasonably reinforce the need for control. Often those with restrictive eating disorders excessively control what goes into the body and may also be restricting what is coming out of the body including feces and urine.

Anxiety and other mental health comorbidities are common in individuals with ED and can contribute to increased tone and tension in the pelvic floor contributing to urinary dysfunction. Additional research supports that this increased pelvic tone and tension also contributes to sexual dysfunction, pelvic pain, and bowel dysfunction in individuals with and without eating disorders. Mental health challenges may also lead to closed posturing, tightness in the back, hip, and shoulder musculature as well as upper chest breathing, and poor excursion of the diaphragm.

As pelvic health rehabilitation providers, we need to look at the whole person as so many factors influence pelvic-related dysfunction. Numerous factors affect bowel, bladder, and pelvic function including muscle wasting and atrophy, slow GI motility, medications, hormonal changes, weight fluctuations, purging behaviors, poor pressure management, increased intra-abdominal pressure, mental wellness comorbidities, excessive exercise, water loading, dehydration, malnutrition, poor postural alignment, length and tension of muscular and fascial systems, diaphragmatic/lower costal excursion and diversity of microbiome to name a few.

Septak posted a blog in February 2024 for the aeroflowurology.com website that discussed factors that negatively impact bladder control in individuals with anorexia nervosa and bulimia nervosa based on research.
The author discussed research implying muscle wasting and atrophy caused by malnutrition can lead to weakness in pelvic floor musculature and support structures. This contributes to urinary symptoms, however, also contributes to bowel dysfunction. The musculature around the colon when not used will atrophy and weaken.

Purging behaviors have numerous negative and potentially dangerous effects on the body function of individuals with eating disorders. Vomiting will increase pressure on PFM, pelvic organs, and abdominal musculature. Laxative use will lead to fecal issues such as fecal incontinence and can contribute to increased pressure and trauma on pelvic organs/musculature. Purging will also lead to serious electrolyte imbalances which can lead to organ system dysfunction or failure.

Other medications also influence bowel and bladder function such as diuretics, which are often mis-utilized to lower body weight through the rapid loss of body fluids. Individuals with DM Type 1 may also withhold insulin to result in a diuretic effect. This not only disrupts essential body electrolytes, but it will also lead to dehydration contributing to bowel dysfunction such as constipation. Diuresis of fluids will also increase urinary urgency, frequency, and risk for incontinence.

Constipation may be caused by numerous factors including dehydration, muscle wasting, slow motility, decreased gastric emptying, and poor nutritional intake. Upregulation of the sympathetic nervous system with trauma history, personality traits, and numerous mental health comorbidities such as anxiety, OCD, and depression, play a significant role in constipation. Bowel movement straining places excessive stress on pelvic organs, pelvic musculature, fascia, and suspension structures, as well as the abdominal wall musculature and fascia. Constipation also contributes to urinary dysfunction due to the proximity of pelvic organs and can lead to pelvic organ prolapse.

Hormonal changes due to endocrine dysfunction with eating disorders, such as with AN, BN, and OSFED, can lead to disruptions in body system function. Hormonal disruptions often lead to hypothalamic amenorrhea, reduced levels of important levels of leptin (regulates appetite, energy balance, and metabolism), insulin (regulates blood sugar and is responsible for storage of incoming food as fat/ fuel), incretins (regulates blood sugar by stimulating pancreas to produce insulin), amylin (may contribute to low bone density with AN), plasma sodium and altered osmolarity (may result in nausea, vomiting, energy loss, confusion, seizures, heart, liver, kidney dysfunction). In addition, there are disruptions with other essential electrolytes that can contribute to body organ system malfunction and failure.

As pelvic health rehabilitation providers, we know how to treat pelvic and abdominal dysfunction.

We may, in fact, be the first healthcare professional who asks the important questions or makes insightful observations that illuminate a person’s secret struggle in the darkness. We may be able to lead these individuals to healthcare providers who are skilled in diagnosing, managing, and guiding that individual into the light of recovery. While we do not treat eating disorders, we DO treat the dysfunction caused by eating disorders. So many individuals with eating disorders will benefit from our education and interventions to assist them on their recovery journey.

Join Carole High Gross, PT, MS, DPT, PRPC in Eating Disorders and Pelvic Health Rehabilitation on October 19-20 for a deep dive into the role of pelvic health rehabilitation with individuals with eating disorders. We will discuss the different eating disorders, medical complications, signs and symptoms, screening and observations, interventions, and treatment approaches.

References:

• Abbate-Daga, G., Delsedime, N., Nicotra, B., Giovannone, C., Marzola, E., Amianto, F., & Fassino, S. (2013). Psychosomatic syndromes and anorexia nervosa. BMC psychiatry, 13, 14. https://doi.org/10.1186/1471-244X-13-14[31]
• Abraham, S., Luscombe, G. M., & Kellow, J. E. (2012). Pelvic floor dysfunction predicts abdominal bloating and distension in eating disorder patients. Scandinavian journal of gastroenterology, 47(6), 625–631. https://doi.org/10.3109/00365521.2012.661762
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision DSM- 5TR. Fifth Edition. American Psychiatric Press. 2022.
• American Psychiatric Association. Diagnostic and statistical manual of mental disorders.Fifth Edition. American Psychiatric Press. 2013.
• Andersen AE, Ryan GL. Eating disorders in the obstetric and gynecologic patient population [published correction appears in Obstet Gynecol. 2010 Nov;116(5):1224]. Obstet Gynecol. 2009;114(6):1353-1367. doi:10.1097/AOG.0b013e3181c070f9
• Bodner-Adler, B., Alarab, M., Ruiz-Zapata, A. M., & Latthe, P. (2020). Effectiveness of hormones in postmenopausal pelvic floor dysfunction-International Urogynecological Association research and development-committee opinion. International urogynecology journal, 31(8), 1577–1582. https://doi.org/10.1007/s00192-019-04070-0
• Bulik CM, Reba L, Siega-Riz AM, Reichborn-Kjennerud T. Anorexia nervosa: definition, epidemiology, and cycle of risk. Int J Eat Disord. 2005;37 Suppl:S2-S21. doi:10.1002/eat.20107
• Carvalhais A, Araújo J, Natal Jorge R, Bø K. Urinary incontinence and disordered eating in female elite athletes. J Sci Med Sport. 2019;22(2):140-144. doi:10.1016/j.jsams.2018.07.008
• Castellini, G., Lelli, L., Ricca, V., & Maggi, M. (2016). Sexuality in eating disorders patients: etiological factors, sexual dysfunction and identity issues. A systematic review. Hormone molecular biology and clinical investigation, 25(2), 71–90. https://doi.org/10.1515/hmbci-2015-0055
• Chiarioni, G., Bassotti, G., Monsignori, A., Menegotti, M., Salandini, L., Di Matteo, G., Vantini, I., & Whitehead, W. E. (2000). Anorectal dysfunction in constipated women with anorexia nervosa. Mayo Clinic Proceedings, 75(10), 1015–1019. https://doi.org/10.4065/75.10.1015
• Cortes, E., Singh, K., & Reid, W. M. (2003). Anorexia nervosa and pelvic floor dysfunction. International urogynecology journal and pelvic floor dysfunction, 14(4), 254–255. https://doi.org/10.1007/s00192-003-1082-z
• Dobinson A, Cooper M, Quesnel D. Safe Exercise at Every Stage: A Guideline for Managing Exericse in Eating Disorder Treatment. https://www.safeexerciseateverystage.com/sees-guidelines
• Dreznik, Z., Vishne, T. H., Kristt, D., Alper, D., & Ramadan, E. (2001). Rectal prolapse: a possibly underrecognized complication of anorexia nervosa amenable to surgical correction. International journal of psychiatry in medicine, 31(3), 347–352. https://doi.org/10.2190/3987-2N5A-FJDG-M89F
• Dunkley CR, Gorzalka BB, Brotto LA. Associations Between Sexual Function and Disordered Eating Among Undergraduate Women: An Emphasis on Sexual Pain and Distress. J Sex Marital Ther. 2020;46(1):18-34. doi:10.1080/0092623X.2019.1626307
• Durnea, C. M., Khashan, A. S., Kenny, L. C., Tabirca, S. S., & O'Reilly, B. A. (2014). An insight into pelvic floor status in nulliparous women. International urogynecology journal, 25(3), 337–345. https://doi.org/10.1007/s00192-013-2225-5
• Emerich Gordon, K., & Reed, O. (2020). The Role of the Pelvic Floor in Respiration: A Multidisciplinary Literature Review. Journal of voice : official journal of the Voice Foundation, 34(2), 243–249. https://doi.org/10.1016/j.jvoice.2018.09.024
• Gaudiani, J. L. (2019). Sick enough: a guide to the medical complications of eating disorders. Routledge.
• Gibson, D., Watters, A., & Mehler, P. S. (2021). The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review. The International journal of eating disorders, 54(6), 1019–1054. https://doi.org/10.1002/eat.23553
• Gibson, D., Workman, C., & Mehler, P. S. (2019). Medical Complications of Anorexia Nervosa and Bulimia Nervosa. The Psychiatric clinics of North America, 42(2), 263–274. https://doi.org/10.1016/j.psc.2019.01.009Gong, R., & Xia, Z. (2019). Collagen changes in pelvic support tissues in women with pelvic organ prolapse. European journal of obstetrics, gynecology, and reproductive biology, 234, 185–189. https://doi.org/10.1016/j.ejogrb.2019.01.012
• Guarda A. (2023, February). What are Eating Disorders? . American Psychiatric Association. https://www.psychiatry.org/patients-families/eating-disorders/what-are-eating-disorders
• Harm-Ernandes, I., Boyle, V., Hartmann, D., Fitzgerald, C. M., Lowder, J. L., Kotarinos, R., & Whitcomb, E. (2021). Assessment of the Pelvic Floor and Associated Musculoskeletal System: Guide for Medical Practitioners. Female pelvic medicine & reconstructive surgery, 27(12), 711–718. https://doi.org/10.1097/SPV.0000000000001121
• Imgart H, Zanko A, Lorek S, Schlichterle PS, Zeiler M. Exploring the link between eating disorders and persistent genital arousal disorder/genito-pelvic dysesthesia: first description and a systematic review of the literature. J Eat Disord. 2022;10(1):159. Published 2022 Nov 10. doi:10.1186/s40337-022-00687-7
• Juszczak, K., & Thor, P. J. (2012). The integrative function of vagal nerves in urinary bladder activity in rats with and without intravesical noxious stimulation. Folia medica Cracoviensia, 52(1-2), 5–16.
• Karwautz, A. F., Wagner, G., Waldherr, K., Nader, I. W., Fernandez-Aranda, F., Estivill, X., Holliday, J., Collier, D. A., & Treasure, J. L. (2011). Gene-environment interaction in anorexia nervosa: relevance of non-shared environment and the serotonin transporter gene. Molecular psychiatry, 16(6), 590–592. https://doi.org/10.1038/mp.2010.125
• Keel, P. K., Eckel, L. A., Hildebrandt, B. A., Haedt-Matt, A. A., Murry, D. J., Appelbaum, J., & Jimerson, D. C. (2023). Disentangling the links between gastric emptying and binge eating v. purging in eating disorders using a case-control design. Psychological medicine, 53(5), 1947–1954. https://doi.org/10.1017/S0033291721003640
• Kim H, Jung HR, Kim JB, Kim DJ. Autonomic Dysfunction in Sleep Disorders: From Neurobiological Basis to Potential Therapeutic Approaches. J Clin Neurol. 2022;18(2):140-151. doi:10.3988/jcn.2022.18.2.140
• Laino, F. M., de Araújo, M. P., Sartori, M. G. F., de Aquino Castro, R., Santos, J. L. F., & Tamanini, J. T. N. (2023). Urinary incontinence in female athletes with inadequate eating behavior: a case-control study. International urogynecology journal, 34(2), 431–438. https://doi.org/10.1007/s00192-022-05349-5
• Leonardo, K., Seno, D. H., Mirza, H., & Afriansyah, A. (2022). Biofeedback-assisted pelvic floor muscle training and pelvic electrical stimulation in women with overactive bladder: A systematic review and meta-analysis of randomized controlled trials. Neurourology and urodynamics, 41(6), 1258–1269. https://doi.org/10.1002/nau.24984
• Marjoux, Sophie & Bennadji, Boubekeur & de Parades, Vincent & Mosnier, Henri & Atienza, Patrick & Barth, Xavier & François, Yves & Faucheron, Jean & Roman, Sabine & Mion, Francois & Damon, Henri. (2012). Mo1059 Rectal Prolapse and Anorexia Nervosa: About 24 Cases. Gastroenterology. 142. S-584. 10.1016/S0016-5085(12)62240-9.
• Mazi, B., Kaddour, O., & Al-Badr, A. (2019). Depression symptoms in women with pelvic floor dysfunction: a case-control study. International journal of women's health, 11, 143–148. https://doi.org/10.2147/IJWH.S187417
• Micali N, Martini MG, Thomas JJ, et al. Lifetime and 12-month prevalence of eating disorders amongst women in mid-life: a population-based study of diagnoses and risk factors. BMC Med. 2017;15(1):12. Published 2017 Jan 17. doi:10.1186/s12916-016-0766-4
• Micali N, Treasure J, Simonoff E. Eating disorders symptoms in pregnancy: a longitudinal study of women with recent and past eating disorders and obesity. J Psychosom Res. 2007;63(3):297-303. doi:10.1016/j.jpsychores.2007.05.003
• Mitchell, N., & Norris, M. L. (2013). Rectal prolapse associated with anorexia nervosa: a case report and review of the literature. Journal of eating disorders, 1, 39. https://doi.org/10.1186/2050-2974-1-39
• Ng QX, Lim YL, Loke W, Chee KT, Lim DY. Females with Eating Disorders and Urinary Incontinence: A Psychoanalytic Perspective. Int J Environ Res Public Health. 2022;19(8):4874. Published 2022 Apr 17. doi:10.3390/ijerph19084874
• Nitsch, A., Watters, A., Manwaring, J., Bauschka, M., Hebert, M., & Mehler, P. S. (2023). Clinical features of adult patients with avoidant/restrictive food intake disorder presenting for medical stabilization: A descriptive study. The International journal of eating disorders, 56(5), 978–990. https://doi.org/10.1002/eat.23897
• Onur, Ö. Ş., & Teksin, G. (2023). Clinical Features of Women with Genito-Pelvic Pain, Penetration Disorder and Disordered Eating Attitudes: A Cross Sectional Study. Noro psikiyatri arsivi, 60(4), 327–334. https://doi.org/10.29399/npa.28313
• Panariello F, Borgiani G, Bronte C, et al. Eating Disorders and Disturbed Eating Behaviors Underlying Body Weight Differences in Patients Affected by Endometriosis: Preliminary Results from an Italian Cross-Sectional Study. Int J Environ Res Public Health. 2023;20(3):1727. Published 2023 Jan 18. doi:10.3390/ijerph20031727
• Paslakis G, de Zwaan M. Clinical management of females seeking fertility treatment and of pregnant females with eating disorders. Eur Eat Disord Rev. 2019;27(3):215-223. doi:10.1002/erv.2667
• Peinado-Molina, R. A., Hernández-Martínez, A., Martínez-Vázquez, S., Rodríguez-Almagro, J., & Martínez-Galiano, J. M. (2023). Pelvic floor dysfunction: prevalence and associated factors. BMC public health, 23(1), 2005. https://doi.org/10.1186/s12889-023-16901-3
• Prescott SL, Liberles SD. Internal senses of the vagus nerve. Neuron. 2022;110(4):579-599. doi:10.1016/j.neuron.2021.12.020
• Porges SW. The polyvagal theory: new insights into adaptive reactions of the autonomic nervous system. Cleve Clin J Med. 2009;76 Suppl 2(Suppl 2):S86-S90. doi:10.3949/ccjm.76.s2.17
• Schmidt U, Sharpe H, Bartholdy S, et al. Treatment of anorexia nervosa: a multimethod investigation translating experimental neuroscience into clinical practice. Southampton (UK): NIHR Journals Library; August 2017.
• Silvernale, Casey & Kuo, Braden & Staller, Kyle. (2020). Sa1678 PELVIC FLOOR PROLAPSE ASSOCIATED WITH GI-SPECIFIC HEALTHCARE UTILIZATION AND ANOREXIA NERVOSA IN AN EATING DISORDER PATIENT COHORT. Gastroenterology. 158. S-379. 10.1016/S0016-5085(20)31642-5.
• Tobias A, Sadiq NM. Physiology, Gastrointestinal Nervous Control. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 26, 2022.
• Vrijens, D., Berghmans, B., Nieman, F., van Os, J., van Koeveringe, G., & Leue, C. (2017). Prevalence of anxiety and depressive symptoms and their association with pelvic floor dysfunctions-A cross sectional cohort study at a Pelvic Care Centre. Neurourology and urodynamics, 36(7), 1816–1823. https://doi.org/10.1002/nau.23186
• Weigel, A., Löwe, B., & Kohlmann, S. (2019). Severity of somatic symptoms in outpatients with anorexia and bulimia nervosa. European eating disorders review : the journal of the Eating Disorders Association, 27(2), 195–204. https://doi.org/10.1002/erv.2643
• Williams, M., Blalock, D., Foster, M., Mehler, P. S., & Gibson, D. (2024). Pelvic Floor Dysfunction in People with Eating Disorders and the Acute Effect of Different Interventions – A Retrospective Cohort Study. Clinical and Experimental Obstetrics & Gynecology, 51(5), 116. https://doi.org/10.31083/j.ceog5105116 
• Worman, R. S., Stafford, R. E., Cowley, D., Prudencio, C. B., & Hodges, P. W. (2023). Evidence for increased tone or overactivity of pelvic floor muscles in pelvic health conditions: a systematic review. American journal of obstetrics and gynecology, 228(6), 657–674.e91. https://doi.org/10.1016/j.ajog.2022.10.027.
• Wojcik, M. H., Meenaghan, E., Lawson, E. A., Misra, M., Klibanski, A., & Miller, K. K. (2010). Reduced amylin levels are associated with low bone mineral density in women with anorexia nervosa. Bone, 46(3), 796–800. https://doi.org/10.1016/j.bone.2009.11.014
• Zachovajeviene, B., Siupsinskas, L., Zachovajevas, P., Venclovas, Z., & Milonas, D. (2019). Effect of diaphragm and abdominal muscle training on pelvic floor strength and endurance: results of a prospective randomized trial. Scientific reports, 9(1), 19192. https://doi.org/10.1038/s41598-019-55724-4

AUTHOR BIO:
Carole High Gross, PT, MS, DPT, PRPC

Carole High Gross, PT, MS, DPT, PRPC (she/her) earned her Doctorate of Physical Therapy from Arcadia University in 2015, and her Masters of Science in Physical Therapy in 1992 from Thomas Jefferson University. Carole earned her Pelvic Rehabilitation Practitioner Certification and enjoys working as a Pelvic Clinical Rehabilitation Specialist for Lehigh Valley Health Network. Carole serves as a Lead Teaching Assistant for the Herman and Wallace Pelvic Rehabilitation Institute for pelvic floor education courses. She is also an instructor with the Herman and Wallace Institute for Eating Disorders and Pelvic Health Rehabilitation: The Role of a Rehab Professional. Carole serves on the Pelvic Workgroup of the Ehlers-Danlos International Consortium. Carole has a special interest in working with individuals living with eating disorders, and hypermobility throughout the pregnancy and postpartum journey. In addition, Carole enjoys working with all genders with pelvic, bowel, bladder, and abdominal issues. Carole is passionate about lifelong learning. She resides in Bucks County, Pennsylvania, and enjoys spending time with her family and pups.

Are you treating patients with chronic pelvic pain who aren’t responding to conventional treatments? Maybe you are working with a client who has a prolapse, but no matter what you do, nothing is helping. You’ve tried everything and the underlying cause has you stumped.

You’re not alone. The diagnosis of what is now known as Pelvic Venous Disorders (PeVD) is missed every day. We aren’t taught about it in school or in our continuing education. The concepts that are taught center around outdated research and misleading terms like “Pelvic Congestion Syndrome” that can negatively impact diagnostic imaging selection, treatment, and overall patient outcomes.

Up to 30% of people with chronic pelvic pain have PeVD, yet the average time to diagnosis can take years simply because providers just don’t know any better. One of the biggest risk factors for the development of PeVD is pregnancy. Who better to screen for and identify this often-overlooked condition than you — a pelvic PT/OT?

As a pelvic PT, I was used to treating others with complex chronic pain and pelvic floor dysfunction. But a few years after the birth of my two children, I began to experience a new symptom myself: chronic pelvic pain. Nothing I tried helped and no healthcare provider could offer me an explanation. I went from leading an incredibly active life to being unable to sit or stand for 10 minutes without pelvic pain, or a heaviness and aching in my pelvic floor.

I saw multiple specialists across disciplines for several years, only to be told that this was “just motherhood for some people” and that it “might go away in menopause” -- I was 36 at the time! I began to immerse myself in the vast world of research involving venous disorders of the pelvis until it became very clear that I had what is now known as pelvic venous disorders (PeVD).

I couldn’t find a healthcare provider who would take me seriously, and if they did, they didn’t know how to help me or where to send me for care. Eventually, I pursued my own vascular imaging and got my diagnosis of PeVD confirmed by a vascular surgeon who was skilled in treating it. When I woke up from surgery already feeling better, I immediately thought to myself, “I need to tell everyone about this.”

This course was born out of my desire to expedite the diagnostic and treatment process for you and your patients so that everyone can access the evidence-based care they deserve. PeVD is not a rare disease process, and it is very treatable if you know what you are looking for! In fact, it often co-exists with many of the diagnoses we are already seeing in the clinic, such as EDS, POTS, and MCAS.

I’m honored to announce that my live, online course Pelvic Venous Disorders will debut on November 2, 2024. This course will offer you a clinical roadmap designed to enhance your ability to screen, assess, and comprehensively treat your clients with pelvic venous disorders (PeVD), a notoriously under-recognized and misdiagnosed cause of chronic pelvic pain. I hope to see you there!

AUTHOR BIO
Julia Baron, PT, DPT, CSCS

Dr. Julie Baron PT, DPT, CSCS, PCES (she/her) is a pelvic floor physical therapist and the Director of the Pelvic Health and Performance Center in Bellevue, WA. Her commitment to treating patients with and educating others on pelvic venous disorders (PeVD) grew out of her own experience with misdiagnosed, severe chronic pelvic pain from PeVD.

Dr. Baron’s comprehensive, holistic approach to patient care is based on her extensive professional experience in orthopedics, pelvic floor physical therapy, prenatal/postpartum care, and concepts of postural restoration (PRI). Her approach allows for the thorough identification of venous pain, musculoskeletal issues, and compensatory patterns in patients, with the goal of optimizing diaphragmatic excursion and maximizing venous return to improve patient outcomes.

Dr. Baron has led symposiums and webinars on various pelvic and orthopedic conditions and has given presentations at global conferences on the role of pelvic PT in the treatment of PeVD. She is an active member of the American Physical Therapy Association (APTA) Section on Pelvic Health, the National Strength and Conditioning Association, the International Society for the Study of Women's Sexual Health and the American Vein and Lymphatic Society.

Stacey Roberts PT, RN, MSN is an expert on shockwave therapy. Since 2020, Stacey Roberts has been analyzing shockwave research extensively to develop clear and concise therapeutic applications in the rehabilitation setting for pelvic health, sexual health, and muscular-skeletal patients. She is finding extraordinary results with her patients using this modality in her cash-based practice. Stacey joined the Herman & Wallace faculty in 2021 with her course Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research.

Below Stacey provides some FAQs and answers to the most commonly asked questions about shockwave therapy.

What is a Shockwave?
A shockwave is an interesting phenomenon and can be both natural and manmade. The Encyclopedia Britannica defines a shockwave as "a strong pressure wave in an elastic medium such as air, water, or a solid substance, produced by supersonic aircraft, explosions, lightning, or other phenomena that create significant changes in pressure.”

What is Shockwave Therapy?
Shockwaves used in therapeutic settings are produced by modalities that create supersonic waves. These waves penetrate the human tissue and can travel to areas of the body, producing a biological effect. The first therapeutic use of shockwave therapy was lithotripsy. This procedure was first used in the 1970s and utilizes high-energy high-intensity shockwaves to break apart kidney stones without surgical intervention.

Clinics now use low-intensity focused and unfocused shockwaves to exhibit a form of energy within the tissues. The shockwaves are made up of 3 phases: a mechanical phase, a chemical phase, and a biological phase. A true shockwave device impacts the tissue and can increase blood flow, activate connective tissue, modulate the inflammatory response, and contribute to pain relief.

Is there just one type of Shockwave device?
No, there are 3 types of true shockwave devices.

• Electrohydraulic (deepest biological effect) The only type of shockwave that has two different applicators (focused only and broad-focused)
• Electromagnetic (minimal to moderate biological effect) Applicator: Focused only
• Piezoelectric (minimal biological effect) Applicator: Focused only

Why is Shockwave therapy beneficial?
When a true shockwave device is used, patients often note faster improvement than with manual therapy alone or with other standard modalities such as ultrasound, laser, and radial wave therapies.

In my experience, the depth of penetration also allows my skills as a manual therapist to be used more effectively. By using shockwave therapy, I can now treat an area in 5 minutes that previously would have taken 10-15 minutes. It also tends to be much more comfortable for the patient.

Are radial, pneumatic, or EPAT true shockwave devices?
No, they have been lumped under the shockwave umbrella but do not produce the force or effect of a true shockwave. These devices have therapeutic value for superficial musculoskeletal injuries, including plantar fasciitis and lateral epicondylitis. However, the energy produced by the mechanical pounding of the tissue from a radial wave device does not produce a shockwave.

The energy produced by radial pneumatic devices disseminates just below the surface of the skin. An electrohydraulic shockwave device can produce a biological effect up to four to six inches from its point of contact, making this particular type of shockwave device especially useful for pelvic floor therapy.

Electromagnetic shockwave devices can penetrate approximately two inches depending on the device. And the piezoelectric device produces most of its effects within an inch or so below the surface.

I see ESWT in the research a lot. Is that shockwave therapy?
ESWT stands for Extracorporeal Shockwave Therapy. This is a common abbreviation used in the literature that originally was meant to label shockwave devices. However, other non-shockwave devices, such as radial pressure wave devices, also use ESWT to describe them in research studies.

In the true sense of the word, and shockwave definition based on the physics of what is produced by the applicators,, a radial device is not true shockwave. There is much confusion in the research that takes time to unravel, so I have dedicated a portion of the Shockwave course to tease out the differences. Many clinicians own a radial device and were told that it was a shockwave device. Unfortunately, according to the International Society for Medical Shockwave Treatment (ISMST) that is not completely accurate.

What can be treated with true Shockwave therapy related to Pelvic Rehab?
True shockwave therapy has been shown to be beneficial for the following issues:

• Erectile Dysfunction
• Peyronie’s Disease
• Chronic Prostatitis
• Chronic Pelvic Pain
• Incontinence
• Urgency
• Cystitis
• Vaginismus
• Vulvodynia
• Vestibulodynia
• Dyspareunia
• Persistent Genital Arousal Disorder (PGAD)

Other areas of upcoming research:

• Dysmenorrhea
• Endometriosis
• Testicular Pain and Dysfunction
• Premature ejaculation
• Urinary retention
• Fibroids

How is shockwave different from ultrasound?
A wave produced by ultrasound is a sinusoidal wave versus a shockwave that has a strong positive pressure followed by a longer negative pressure wave. See chart:

This results typically in shockwaves creating larger cavitation bubbles around the cellular structures and fewer treatments to reach patient goals. Continuous ultrasound produces its effect by heating the tissue, whereas a shockwave device does not cause any heating of the tissue to produce its therapeutic effect.

Is shockwave therapy covered by insurance?
Like other valuable modalities, insurance does not typically cover low-intensity shockwave therapy. However, in times of decreasing reimbursement, patients are increasingly turning to fee-for-service methods and paying out of pocket for treatments that result in positive outcomes in shorter periods of time.

Why should I take your course Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research?
You should take this course if you are interested in:

• Learning how one of the most effective non-invasive treatment modalities of our time related to pelvic and sexual health produces its results
• Understanding how this modality produces its results and how it is being utilized in clinics to improve treatment outcomes related to pelvic health
• How this modality can enhance results when combined with manual treatment techniques and other treatments such as dry needling, PRP, or stem cell therapy.
• How to save enormous amounts of time while reviewing the research efficiently without combing through data that may or may not be actual Shockwave research
• Being able to differentiate one machine from another to make an educated decision on which shockwave device may fit best into your clinic
• What questions to ask company sales reps who are selling devices to make sure you are talking about a true shockwave device

If you would like to learn more about incorporating shockwave therapy into your daily practice, then join H&W Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research on October 27, 2024.

AUTHOR BIO
Stacey Roberts, PT, RN, MSN

Stacey Roberts, PT, RN, MSN (she/her), has been a physical therapist specializing in outpatient orthopedics and sports medicine, since 1990. After completing a sports medicine fellowship and working at several hospitals and outpatient clinics, in 2000 Stacey had an opportunity to move overseas, where she became adept with complementary medicine approaches, becoming a master in herbalism in 2003. From 2004 to 2017, Ms. Roberts owned and operated a cash-based health and wellness clinic on the Gold Coast of Australia specializing in women’s health and hormones and couples' fertility, where she began seeing patients via Telehealth in 2006.

Combining her knowledge of functional medicine, conventional medicine, and complementary medicine, Stacey emphasizes lifestyle changes, and her treatment programs are based on cutting-edge evidence-based research. Currently, she is a co-principle investigator for an IRB-approved study related to shockwave and Dyspareunia.

She has written 3 hard-copy books and 7 ebooks on women’s health and couples' fertility. Her new book, The Pain-Free Formula: A Holistic Approach to Finally Getting Rid of Pain Without Surgery, Drugs, Or Injections, is coming out in 2025. Ms. Roberts has mentored over 100 medical professionals in her women’s health and couples fertility training program. After returning to the United States, Stacey was hired by a national physical therapy company, Aegis Therapies, from 2018 to 2020 to assist in the growth and development of their orthopedic outpatient practice in Wisconsin. She set records for the company related to bringing clinics to profitability faster than any of their other outpatient clinics in the country at that time.

From 2016- to 2020 Stacey was an associate clinical professor at the University of Wisconsin Milwaukee’s Physical Therapy doctoral program until opening New You Health and Wellness, a cash-based clinic, where she brings her knowledge of wellness, hormone health, fat loss, and musculoskeletal health to treating patients with issues related to musculoskeletal injuries, sexual health, and pelvic health. Since 2020 she has been analyzing Shockwave research extensively to develop clear and concise therapeutic applications and protocols for pelvic health, sexual health, and muscular-skeletal patients. She is finding extraordinary results with her patients using this modality in her cash-based practice.

Stacey completed her MBA in 2021, her RN license, and her master’s in nursing (MSN) in 2020. She will eventually complete a nurse practitioner certificate. Stacey has also appeared on World News Now in New York, was featured on Oprah, locally on TMJ4’s Morning Blend, and on several news shows and radio stations in the United States and Australia.

• Do you work with postpartum patients and wish you could help them recover more quickly in the postpartum time period?
  Do you work with pelvic pain patients who have sacroiliac joint pain?
  Do you work with patients that have a weak core?

Rehabilitative ultrasound imaging is a tool that is very helpful for the clinician to assess motor control and muscle morphology. It is also very helpful as a biofeedback tool for patients trying to improve their pelvic floor or core strength.

In an article published in 2021, researchers performed a systematic review of the efficacy of rehabilitative ultrasound imaging for improving motor control exercises compared to no feedback and other feedback methods. Studies included in the systematic review assessed the abdominal wall muscles, pelvic floor, serratus anterior, and/or lumbar multifidus. What they found was that rehabilitative ultrasound imaging was more effective than tactile and verbal biofeedback for motor control exercise performance. Patients using ultrasound imaging demonstrated increased muscle activity, muscle thickness, and target exercise success compared to tactile and verbal biofeedback. Additionally, longer retention was noted when ultrasound imaging was used. Having constant feedback by watching the monitor of the ultrasound while performing an exercise compared to feedback after performing an exercise showed superior motor learning long-term (Valera-Calero, 2021).

Using ultrasound is a marketing tool and something that will enhance your clinical offerings. Patients enjoy using this biofeedback method!  When asked what they thought of the use of ultrasound, this is how a few patients responded:

• “Using the ultrasound has helped me to learn to use my deep core muscles. This has helped me to recover from back pain after having twins. I am a radiologist and Allison's use of ultrasound in therapy was very unique for me and made the difference between getting better and living with pain.”  (RK, 39 years)
• "I loved using ultrasound to view my pelvic floor muscles to help with my incontinence. It was so easy and made therapy kind of fun. I highly recommend using ultrasound.” (AJ, 65 years)
• “My doctor told me to get on the waitlist for therapy using ultrasound instead of going elsewhere. He was right, it was totally worth it! I have tried therapy several times before but this time, I feel I am actually getting stronger and better!” (MK, 29 years)

Learn to use rehabilitative ultrasound in your practice and take the course with Herman & Wallace. Rehabilitative Ultrasound Imaging: Pelvic Health and Orthopedic Topics is offered at multiple locations. If you have a  US machine with a curvilinear transducer that images a frequency that ranges from 3 to 10 MHz and is capable of abdominal viewing then you can also register as a "Self-hosted" attendee. This course is offered in a two-day option (Orthopedic Topics) with external labs, and a three-day option (Pelvic Health & Orthopedic Topics) that includes transperineal labs.

Join us to learn how to use this great clinical tool!

Rehabilitative Ultrasound Imaging: Orthopedic Topics - Satellite Lab Course - October 25-26, 2024

• Fort Wayne IN
• Little Rock AR
• Oklahoma City OK
• Self-Hosted

Rehabilitative Ultrasound Imaging: Pelvic Health & Orthopedic Topics - Satellite Lab Course - October 25-27, 2024

• Fort Wayne IN
• Little Rock AR
• Oklahoma City OK
• Self-Hosted

Reference:

Valera-Calero JA, Fernández-de-Las-Peñas C, Varol U, Ortega-Santiago R, Gallego-Sendarrubias GM, Arias-Buría JL.(2021). Ultrasound Imaging as a Visual Biofeedback Tool in Rehabilitation: An Updated Systematic Review. Int J Environ Res Public Health. 18(14):7554. doi: 10.3390/ijerph18147554. PMID: 34300002; PMCID: PMC8305734.

AUTHOR BIO:
Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC

Allison Ariail has been a physical therapist since 1999. She graduated with a BS in physical therapy from the University of Florida and earned a Doctor of Physical Therapy from Boston University in 2007. Also in 2007, Dr. Ariail qualified as a Certified Lymphatic Therapist. She became board-certified by the Lymphology Association of North America in 2011 and board-certified in Biofeedback Pelvic Muscle Dysfunction by the Biofeedback Certification International Alliance in 2012. In 2014, Allison earned her board certification as a Pelvic Rehabilitation Practitioner. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain. Lastly, Allison has a passion for helping oncology patients, particularly gynecological, urological, and head and neck cancer patients.

In 2009, Allison collaborated with the Primal Pictures team for the release of the Pelvic Floor Disorders program. Allison's publications include: “The Use of Transabdominal Ultrasound Imaging in Retraining the Pelvic-Floor Muscles of a Woman Postpartum.” Physical Therapy. Vol. 88, No. 10, October 2008, pp 1208-1217. (PMID: 18772276), “Beyond the Abstract” for Urotoday.com in October 2008, “Posters to Go” from APTA combined section meeting poster presentation in February 2009 and 2013. In 2016, Allison co-authored a chapter in “Healing in Urology: Clinical Guidebook to Herbal and Alternative Therapies.”

Allison works in the Denver metro area in her practice, Inspire Physical Therapy and Wellness, where she works in a more holistic setting than traditional therapy clinics. In addition to instructing Herman and Wallace on pelvic floor-related topics, Allison lectures nationally on lymphedema, cancer-related changes to the pelvic floor, and the sacroiliac joint. Allison serves as a consultant to medical companies, and physicians.

An Ancient Science with a Modern Evidence-Based Approach

A 15-year-old patient walked into the clinic with her mom presenting with symptoms of constipation, lower abdominal spasms, and pain with bowel movements. Over the course of the visit, I learned that she was on medication for depression and was also suffering from chronic anxiety. Anxiety pervaded every aspect of her life, from things happening during the day to her near and far future. Her symptoms were worse when her anxiety was high and she struggled to relax her body and mind.

So, in addition to teaching her a program with breathing exercises, self-abdominal massage, pelvic girdle stretching, and the use of a squatty potty, I also taught her perineal self-acupressure at the acupoint Central Vessel 1 (CV 1) for constipation and two self-regulation points Central Vessel 17 (CV 17) and Yintang (EX-HN 3) for alleviating her anxiety.

CV1 also known as Huiyin is located at the perineum. A study by Abbott et al. reported that the perineal self-acupressure technique was found to be remarkably effective with statistically significant and clinically meaningful improvements in Patient Assessments of Constipation Quality of Life (PAC-QOL All), modified Bowel Function Index (BFI), and the Short-Form Health Survey (SF-12v2). Huiyin is used in Traditional Chinese Medicine (TCM) not only to treat constipation, but also a variety of conditions including impotence, hemorrhoids, rectal prolapse, and dysmenorrhea. CV17 is located at the center of the chest and is known to be a point for emotional healing while Yintang (EX-HN 3) is located between the eyebrows and is known to have a mentally stabilizing effect in Traditional Chinese Medicine (TCM).

The patient returned the next visit and reported that her abdominal spasms were 50% better and she no longer had pain with bowel movements. She also reported that she felt calmer and was able to use the perineal self-acupressure technique to evacuate very quickly. Over the past several years, I have found that adding Acupressure to my clinical practice has added so much value as an Integrative holistic tool to complement traditional care.

Evidence-based Integrative health and medicine practices blend traditional physical therapy methods with holistic practices that address the whole person-physically, mentally, emotionally, and spiritually (Justice et al). Acupressure is considered an Integrative medicine practice and is based on traditional Chinese meridian theory in which acupuncture points are pressed to stimulate the flow of energy or Qi. Acupuncture meridians are believed to form a network throughout the body, connecting peripheral tissues to each other and to the central viscera. This tissue network is also continuous with more specialized connective tissues such as periosteum, perimysium, perineurium, pleura, peritoneum, and meninges (Kaptchuk).

There is robust scientific evidence supporting acupressure as an effective non-pharmacological therapy for the management of a host of conditions such as anxiety, insomnia, chronic pelvic pain, dysmenorrhea, infertility, constipation, digestive disturbances, and urinary dysfunctions to name a few.

Acupressure has demonstrated the ability to improve heart rate variability, and thus decrease sympathetic nervous system activity. By decreasing sympathetic nervous system stimulation, the release of stress hormones such as epinephrine and cortisol is decreased, and the relaxation response can be augmented, which may correlate with decreasing levels of pain, stress, and anxiety (Monson et al).

To learn more about Acupressure, join the upcoming remote course Acupressure for Optimal Pelvic Health scheduled for October 12th-13^th. This course introduces practitioners to the basics of traditional Chinese medicine (TCM), acupuncture & acupressure, and provides an introduction to Yin yoga. Of the 12 major Meridians or energy channels, the focus is on the majority of acupoints in the Bladder, Kidney, Stomach, and Spleen meridians. In addition, there are other important meridian points that stimulate the nervous system and can be used for self-regulation, improving the flow of Qi the life force energy to improve the physiological functioning of the organs. The course also explores Yin poses within each meridian to channelize energy through neurodynamic pathways with powerful integrative applications across multiple systems. If you are not able to attend the October course date, then check out the website for the options scheduled for 2025.

References

1. Chen SR, Hou WH, Lai JN, Kwong JSW, Lin PC. Effects of Acupressure on Anxiety: A Systematic Review and Meta-Analysis. J Integr Complement Med. 2022;28(1):25-35. doi:10.1089/jicm.2020.0256
2. Abbott R, Ayres I, Hui E, Hui KK. Effect of perineal self-acupressure on constipation: a randomized controlled trial. J Gen Intern Med. 2015;30(4):434-439.
3. Kaptchuk TJ. 2000. The web that has no weaver. Understanding Chinese medicine. Chicago: Contemporary Publishing Group, Inc.
4. Justice C, Sullivan MB, Van Demark CB, Davis CM, Erb M. Guiding Principles for the Practice of Integrative Physical Therapy. Phys Ther. 2023;103(12):pzad138. doi:10.1093/ptj/pzad138
5. Monson E, Arney D, Benham B, et al. Beyond Pills: Acupressure Impact on Self-Rated Pain and Anxiety Scores. J Altern Complement Med. 2019;25(5):517-521.
6. Abaraogu UO, Igwe SE, Tabansi-Ochiogu CS. Effectiveness of SP6 (Sanyinjiao) acupressure for relief of primary dysmenorrhea symptoms: A systematic review with meta- and sensitivity analyses. Complement Ther Clin Pract. 2016;25:92-105
7. He Y, Guo X, May BH, et al. Clinical Evidence for Association of Acupuncture and Acupressure With Improved Cancer Pain: A Systematic Review and Meta-Analysis. JAMA Oncol. 2020;6(2):271-278. doi:10.1001/jamaoncol.2019.5233

AUTHOR BIO
Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 (she/her) graduated from Columbia University, New York with a Doctor of Physical Therapy degree. Rachna has been working in outpatient hospital and private practice settings for over 15 years with a dual focus on Orthopedics and Pelvic Health. She was instrumental in starting one of the first Women’s Health Programs in an outpatient orthopedic clinic setting in Mercer County, New Jersey in 2009. She has authored articles on pelvic health for many publications. She is a Certified Integrated Manual Therapist through Great Lakes Seminars, is Board-certified in Orthopedics, is a certified Pelvic Rehab Practitioner, and is also a registered yoga teacher through Yoga Alliance. Rachna has trained in both Hatha Yoga and Yin Yoga traditions and brings the essence of Yoga to her clinical practice.

Rachna currently practices in an outpatient setting. The majority of her clinical orthopedic practice has focused on treating musculoskeletal, neurological, pre- and post-operative surgical conditions to name a few. She specializes in working with pelvic health patients who have bowel & bladder issues with high pelvic pain which sparked her interest in Eastern holistic healing traditions and complementary medicine. She has spent many hours training in holistic healing workshops with teachers based worldwide. She is a member of the American Physical Therapy Association and a member of APTA’s Academy of Orthopaedic Physical Therapy and Academy of Pelvic Health Physical Therapy.

Rachna also owns TeachPhysio, a PT education and management consulting company. Her course Acupressure for Optimal Pelvic Health brings a unique evidence-based approach and explores complementary medicine as a powerful tool for holistic management of the individual as a whole focusing on the physical, emotional, and energy body.

If you’ve spent any time on social media as a healthcare practitioner, you’ve probably encountered a flood of ads promoting shockwave therapy as a miracle solution for everything from orthopedic pain to urological and gynecological conditions. The marketing push for these devices has skyrocketed over the past five years, driven by claims of its ability to treat a wide range of diagnoses. Recent research, including a comprehensive review published in The Journal of Clinical Medicine, confirms that shockwave therapy is making significant waves in modern medicine. But with all the buzz surrounding this technology, the real question remains: is it truly a game changer for patients and clinics alike?

As a medical professional, my approach to any new treatment, procedure, or modality begins with skepticism. I believe it is my responsibility to ensure that the interventions I offer in my clinic are grounded in solid research, and proven efficacy. When I first encountered shockwave therapy in early 2020, I was highly skeptical. The companies I spoke with made sweeping claims, portraying shockwave therapy as a universal solution for virtually every condition. Despite their promises, I remained cautious. However, after hearing positive feedback from a few trusted colleagues and witnessing a session that yielded seemingly impressive results, I decided to delve deeper into the research.

I found that while there is a substantial amount of literature available, much of it is confusing and, it lacks clarity — especially in the area of pelvic health. The majority of the research outside of orthopedics focuses on conditions such as erectile dysfunction, with little attention given to men’s pelvic health concerns and even less given to women’s pelvic health issues.

Recent advances in shockwave therapy have highlighted its growing potential in the field of men's and women’s sexual and pelvic health. The latest research trends are clear. As a non-invasive treatment, shockwave is no longer considered solely beneficial for orthopedics and sports medicine. Its applications are expanding rapidly in gynecology, urology, and pelvic floor disorders. This shift is driven by the therapy’s ability to enhance blood flow immediately and provide significant pain relief faster than traditional methods, making it an innovative option for conditions such as chronic pelvic pain, dyspareunia, and vaginal atrophy.

However beneficial, the fact remains that confusion abounds when, as a clinician, you are deciding which device would be best for your patients. At the forefront of the confusion when you delve into the research are:

1. protocols vary substantially between devices
2. energy levels and units of measure aren’t consistent among devices,
3. There are popular devices in the research labeled shockwave, when in fact, they do not produce shockwaves and create different outcomes.

If you would like to learn more about incorporating shockwave therapy into your daily practice, register for my one-day remote course Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research scheduled for October 22, 2024. This course provides an introduction to using this cutting-edge technology in the clinic for improved patient outcomes and an understanding of how shockwave can enhance manual therapy treatment skills. Course lectures cover what is shockwave, how it decreases pain and potentially accelerates healing, the research behind it, the different types of shockwave devices, and the best indications of use for each of them as well as case studies discussing patient protocols and outcomes.

AUTHOR BIO
Stacey Roberts, PT, RN, MSN

Stacey Roberts, PT, RN, MSN (she/her), has been a physical therapist specializing in outpatient orthopedics and sports medicine, since 1990. After completing a sports medicine fellowship and working at several hospitals and outpatient clinics, in 2000 Stacey had an opportunity to move overseas, where she became adept with complementary medicine approaches, becoming a master in herbalism in 2003. From 2004 to 2017, Ms. Roberts owned and operated a cash-based health and wellness clinic on the Gold Coast of Australia specializing in women’s health and hormones and couples' fertility, where she began seeing patients via Telehealth in 2006.

Combining her knowledge of functional medicine, conventional medicine, and complementary medicine, Stacey emphasizes lifestyle changes, and her treatment programs are based on cutting-edge evidence-based research. Currently, she is a co-principle investigator for an IRB-approved study related to shockwave and Dyspareunia.

She has written 3 hard-copy books and 7 ebooks on women’s health and couples' fertility. Her new book, The Pain-Free Formula: A Holistic Approach to Finally Getting Rid of Pain Without Surgery, Drugs, Or Injections, is coming out in 2025. Ms. Roberts has mentored over 100 medical professionals in her women’s health and couples fertility training program. After returning to the United States, Stacey was hired by a national physical therapy company, Aegis Therapies, from 2018 to 2020 to assist in the growth and development of their orthopedic outpatient practice in Wisconsin. She set records for the company related to bringing clinics to profitability faster than any of their other outpatient clinics in the country at that time.

From 2016- to 2020 Stacey was an associate clinical professor at the University of Wisconsin Milwaukee’s Physical Therapy doctoral program until opening New You Health and Wellness, a cash-based clinic, where she brings her knowledge of wellness, hormone health, fat loss, and musculoskeletal health to treating patients with issues related to musculoskeletal injuries, sexual health, and pelvic health. Since 2020 she has been analyzing Shockwave research extensively to develop clear and concise therapeutic applications and protocols for pelvic health, sexual health, and muscular-skeletal patients. She is finding extraordinary results with her patients using this modality in her cash-based practice.

Stacey completed her MBA in 2021, her RN license, and her master’s in nursing (MSN) in 2020. She will eventually complete a nurse practitioner certificate. Stacey has also appeared on World News Now in New York, was featured on Oprah, locally on TMJ4’s Morning Blend, and on several news shows and radio stations in the United States and Australia.

September is Ovarian Cancer Awareness Month. Ovarian cancer is the seventh most common type of malignant neoplasm in women and the eighth cause of mortality for women (Gaona-Luviano et al, 2020). In women who have died from gynecological cancers, ovarian cancer is the leading cause of death (Arora et al., 2021). This type of cancer can originate from any of the ovary's three main components, including the epithelium, stroma, and germinal cells. Per Gaona-Luviano et al., 2020, “epidemiology of this cancer shows differences between races and countries due to several factors including genetic and economic.” Detection of ovarian cancer is problematic because there is no standardized screening process and most cases of ovarian cancer are found in the advanced stages (Gaona-Luviano et al, 2020).

How is ovarian cancer diagnosed?
Sadly, the existing screening tests have a low predictive value. A gynecological evaluation, transvaginal ultrasound, and tumor marker testing (cancer antigen-125/CA-125 assay) can help with early detection strategies but this has not shown a significant effect on the morbidity or mortality of this cancer (Arora et al., 2021).

How is ovarian cancer treated medically?

Research shows that the standard line of care treatment includes surgery and platinum-based chemotherapy. Additional options including anti-angiogenic bevacizumab and Poly(ADP-ribose) polymerase (PARP) inhibitors have also been used more recently. (Arora et al., 2021)

What are the outcomes of an ovarian cancer diagnosis?
There is a high rate of recurrence after the initial detection treatment. Many of the cases re-occurred and these secondary cases were less curable with increased incidence of treatment failures (Arora et al., 2021).

What are ovarian cancer risk factors?
Some risk factors include advanced age, early menarche, late menopause, family history, nulliparity, obesity, perineal talc use, smoking, endometriosis, and hormone replacement therapy (Arora et al., 2021). Some protective factors include oral contraceptives, bilateral tubal ligation or salpingectomy, breastfeeding, and multiparity (Arora et al., 2021).

Some research shows there may be some health disparities in the diagnoses between Non-Hispanic Black women compared to Non-Hispanic White women. In a study by Washington et al. in 2023 53,367 women were included in the analysis with the profile being 82% Non-Hispanic White, 8.7% Non-Hispanic Black, 5.7% Hispanic, and 2.7% Non-Hispanic Asian/Pacific Islander. They found that the Non-Hispanic Black race was associated with a higher risk of death than Non-Hispanic White race and Non-Hispanic Black women versus Non-Hispanic White women had an increased risk of mortality among those with low and mid socioeconomic status groups.

In response to this potential inequity, the National Cancer Institute has launched 3 studies to look at these patterns to “better understand the causes of racial and ethnic disparities among women with ovarian cancer.” These studies will examine whether the treatments with these patient populations were consistent with standard clinical guidelines and ensure all patients received quality care. Additional studies will look at a “cells-to-society approach” to assess the biology behind these trends. In both cases, the researchers will assess a range of potential factors that can affect disparities, from the molecular makeup of tumors to environmental factors, and comorbidities (NCI, 2024).

What can pelvic health providers do to help?
As pelvic health providers, we can educate ourselves on how best to screen and refer our patients to ensure early diagnosis and medical treatment if we hear anything suspicious. It is difficult to self-advocate in this current medical climate and having a skilled provider guiding the questions to ask and the support to seek is invaluable. If a patient is already into their treatment journey, we can provide the needed rehabilitation support including things like coordination and strengthening of the core and pelvic floor, stretching and positioning to lengthen tight areas, scar mobilization, patient education, and symptom management with the patient for any symptoms that may pop up throughout their course of care.

If you’re unsure that you have these skills in your skill set, please check out the Oncology of the Pelvic Floor Series to gain more knowledge and experience in these areas to better help patients with these diagnoses. Certified Lymphatic Therapists may skip this course and move on to the level Oncology of the Pelvic Floor Level 2A and Level 2B courses.

• Oncology of the Pelvic Floor Level 1, next scheduled for November 2-3, 2024, is the first course in the series and focuses on topics that prepare practitioners to be part of the interdisciplinary oncology team. Topics will include the basics of cancer: terminology, staging, medical treatment, and the sequelae of these medical treatments. These topics include the lymphatic system as well as issues that are commonly seen in a patient who has been diagnosed with cancer such as cardiotoxicity, peripheral neuropathy, and radiation fibrosis.
• Oncology of the Pelvic Floor Level 2A, (not yet scheduled for 2025), builds on information presented in Oncology of the Pelvic Floor Level 1 and focuses on male pelvic cancers (prostate cancer, penile cancer, and testicular cancer), colorectal cancer, and anal cancer including risk factors, diagnosis, and prognosis. Topics discussed include sequelae of the medical treatment of cancer and how this can impact a patient’s body and quality of life, rehabilitation, and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy. Participants MUST register with a partner, or plan to have a volunteer available to work on during course labs.
• Oncology of the Pelvic Floor Level 2B, next scheduled for December 7-8, 2024, builds on information presented in Oncology of the Pelvic Floor Level 1 and focuses on gynecological and bladder cancers including risk factors, diagnosis, and prognosis. Topics discussed include sequelae of the medical treatment of cancer and how this can impact a patient’s body and quality of life, rehabilitation, and nutritional aspects focusing on these specific cancers, as well as home program options that patients can implement as an adjunct to therapy. Participants MUST register with a partner, or plan to have a volunteer available to work on during course labs.

References:

• Arora, T., Mullangi, S., & Lekkala, M. R. (2021). Ovarian cancer.
• Gaona-Luviano, P., Medina-Gaona, L. A., & Magaña-Pérez, K. (2020). Epidemiology of ovarian cancer. Chinese Clinical Oncology, 9(4), 47-47.
• NCI. Ovarian cancer studies aim to reduce racial disparities. Ovarian Cancer Studies Aim to Reduce Racial Disparities - NCI. (2024, June). https://www.cancer.gov/news-events/cancer-currents-blog/2020/ovarian-cancer-racial-disparities-studies#:~:text=Credit:%20iStock,impeded%20research%20in%20this%20area.
• Washington, C. J., Karanth, S. D., Wheeler, M., Aduse-Poku, L., Braithwaite, D., & Akinyemiju, T. F. (2024). Racial and socioeconomic disparities in survival among women with advanced-stage ovarian cancer who received systemic therapy. Cancer Causes & Control, 35(3), 487-496.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

Mora Pluchino, PT, DPT, PRPC (she/her) is a graduate of Stockton University with a BS in Biology (2007) and a Doctorate of Physical Therapy (2009). She has experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. She began treating Pelvic Health patients in 2016 and now has experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much she has not treated since beginning this journey and she is always happy to further her education to better help her patients meet their goals.

She strives to help all of her patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, She opened her own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. She has been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. She has also been a TA with Herman & Wallace since 2020 and has over 150 hours of lab instruction experience. Mora has also authored and instructs several courses for the Institute.

If you saw Ethical Considerations for Pediatric Pelvic Health and thought “Why are they making ANOTHER ethics class?” please let me take a moment to explain its origin and purpose in the Herman and Wallace course offerings. I wrote my Pediatric Pelvic Floor Play Skills course when I had colleagues asking for ways to play with their patients. When I started teaching this class, some of the most common questions that came up seemed like ETHICAL questions. How do we handle pediatric care in different settings? How do we get consent from minors? If a child says no but their legal guardian wants the assessment done, what does the provider do?

Pediatric Pelvic Floor Play Skills is a class written to help providers take the pelvic health knowledge they have, and learn activities they can perform with different ages of children to help work on their pelvic floor function. One of the tricky parts of working with children is including the child in their care plan and coordinating with caregivers. In this course, talk about specific concerns and considerations by age, as well as strategies to bring to a provider's practice. This class is for the provider who does not have a lot of experience treating pediatric patients and wants to learn how to make sessions enjoyable and effective. While in Ethical Considerations for Pediatric Pelvic Health, we review the different overall milestones, as well as what age-appropriate expressions of sexuality may look like as children develop toward adulthood.

Let's talk about Pediatric Care
When we say “pediatric” this can span from infants to teenage age groups. Dealing with a crying baby will be different decision-making versus a toddler in a tantrum or a defiant teen. The pediatric population is a vulnerable group because they can’t advocate for themselves, their own interests, and their health to protect themselves from harm. When we consider decision-making with a child, a therapist should consider things like their development, family structure, competence, and education levels. Children develop in a variety of areas including their fine and gross motor skills, language, cognitive, social, emotional, and behavior.

In pediatric care, obtaining informed consent has two parts because it requires therapists to secure consent from caregivers and to seek assent from the child. Once they have obtained the parent’s permission, therapists should explain the procedures, potential benefits, and risks in an age-appropriate manner to the child. Therapists have to make sure the child feels comfortable and involved in their care at each step.

Pelvic health providers should establish clear guidelines about what information will be shared with caregivers and what will remain confidential when working with children, especially tweens and teens. This helps the therapist to build trust with the patient and encourages open communication with the patient. We must also consider what the caregivers are entitled to hear about their child’s life and medical care. For example, if a tween wants to talk to you about sex, do you feel equipped with the ethical implications for yourself in your practice? What about if a child discloses a sexual assault at school? What about if a teenager tells you they are pregnant but hasn’t told their parents? This class will give some guidelines to make these decisions and provide a peer “think tank” to further discuss.

One of the easiest ways to be an effective pediatric provider includes communication with the patient and their support system. Make sure to review topics like the condition, treatment options, and expected outcomes to empower them to make informed decisions. Keep your communication clear and provide educational materials that are accessible and understandable. Make sure to check with caregivers about what words and pictures they are comfortable with the child seeing and hearing. Some children or caregivers may have personal, religious, or cultural implications that may limit what education they want the child to be exposed to.

Every child is unique, and their treatment should reflect their individual needs, preferences, and circumstances. Therapists should listen to the child and their support network, and incorporate their feedback into the plan of care. Consider their life and routine to make sure their care and homework fit into their daily schedule. Advocating for the needs and rights of pediatric patients is a critical aspect of ethical care. Therapists may need to recommend resources, treatments, and accommodations, and promote awareness and education about pediatric pelvic health issues within the broader community. This may include coordinating with a child’s daycare, school, or other medical providers.

What course is right for you?

• Ethical Considerations for Pediatric Pelvic Health on October 13th - Learn more about the ethical challenges pediatric pelvic health practitioners may experience including consent, managing situations of trauma and abuse, and managing autonomy for minors. If you work with pediatric patients on a regular basis, this class can be an additional step in your practice. It will review topics like consent, abuse, education, communication, and diagnoses that tend to have more ethical considerations with pediatric patients. Join us to review background information and then discuss, as a group, different cases and ethical situations to help further your pediatric clinical practice.
• Pediatric Pelvic Floor Play Skills on October 20th - This is a beginner-level course and is a good fit for providers who do not have a lot of experience treating pediatric patients and want to learn how to make sessions enjoyable and effective. In this course, we discuss specific concerns and considerations by age, strategies to bring to a provider's practice, sample home programs, equipment purchase lists (with a budget in mind), tips for helping get families on board with the implementation of care, and resources such as outcomes measures, developmental milestone checklists, and recommendations things parents ask for like how to talk about periods and sex.

AUTHOR BIO:
Mora Pluchino, PT, DPT, PRPC

I am a graduate of Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman and Wallace since 2020 and have over 150 hours of lab instruction experience.

Dawn Sandalcidi will be a keynote speaker at HWConnect 2025 on March 28-30, 2025. You can also join her in upcoming courses: Pediatric Pelvic Floor, Diaphragm, and Postural Development: Intro to Core Function and Continence in Children on September 29th, Pediatrics Level 1 -Treatment of Bowel and Bladder Disorders on October 26-27, or Pediatrics Level 2 - Advanced Pediatric Bowel and Bladder Disorders on November 2-3.

As physical and occupational therapists, we aim to provide the best possible care for our young patients by understanding and addressing the underlying mechanisms affecting their health. The diaphragm is one of the most important yet often overlooked structures. This muscle plays critical roles in both respiratory and postural functions and has far-reaching implications for the stability and health of children.

In this blog, we’ll explore the anatomy, function, and clinical relevance of the diaphragm, its connections to the pelvic floor muscles, and the broader implications for pediatric therapy.

Anatomy Of The Diaphragm

In order to appreciate the functions that the diaphragm plays in breathing and movement, you must first understand the anatomy. The diaphragm is the thin, dome-shaped muscle that separates the thoracic and abdominal cavities. Its structure is divided into two primary components:

1. The Crural (Vertebral) Portion: The crural portion, or muscular “legs” of the diaphragm, originates from vertebrae of the lumbar spine, providing stability and anchoring the diaphragm in place.
2. The Costal Portion: The costal portion originates from the xiphoid process of the sternum and the upper margins of the lower rib pairs.

At the center of the diaphragm lies the “central tendon”, the non-muscular aponeurosis at which the muscular fibers converge. This tendon acts as a pivotal point during the contraction of the diaphragm.

When the diaphragm contracts during inspiration, the dome of the diaphragm descends, shortening the muscle fibers and increasing the volume of the thoracic cavity. This action decreases intrapleural pressure, allowing the lungs to expand and fill with air. At the same time, abdominal pressure increases as the diaphragm displaces the rib cage and moves downward.

The relationship between the diaphragm and the rib cage is vital for effective breathing and functional movement. Keep this in mind when working with kids who have low tone or poor strength. Breathing mechanics and diaphragm optimization are essential to assess. Proper contraction of the diaphragm not only facilitates lung expansion but also ensures that the core and extremities are stabilized, leading to efficient and stable movement patterns.

Let’s take a closer look at these functional connections.

The Diaphragm’s Connections To Posture And Pelvic Floor

A critical concept in understanding the diaphragm’s function is the Zone of Apposition (ZOA). The ZOA is the vertical area of the diaphragm that extends from the inside of the lower ribs to the top of the diaphragm. This zone maintains the diaphragm's dome shape, which is important for effective breathing.

When the ZOA is well-maintained, the diaphragm can contract efficiently without the need for accessory muscle recruitment. This efficiency prevents compensatory breathing patterns that can lead to respiratory and postural issues.

Conversely, a decreased ZOA can result in poor diaphragm contraction, leading to inefficient breathing and overuse of accessory muscles. Musculoskeletal effects on posture can include issues such as:

• Anterior rib flare
• Lung hyperinflation
• Hyperlordosis
• Protruding abdomen
• Weakness of the anterior core muscles with poor pressure system management

The diaphragm works in close coordination with the pelvic floor muscles (PFM) and the abdominal muscles. This interaction is vital for managing intra-abdominal pressure (IAP) and maintaining stability in both the thoracic and abdominal cavities when breathing.

1. During inspiration, the diaphragm descends, causing an eccentric lengthening of the abdominals and the PFM, which stabilizes the core.
2. During exhalation, the diaphragm relaxes and ascends, while the abdominals and PFM contract concentrically.

This basic overview of the diaphragm's connections is expanded upon in my live online course, Pediatric Pelvic Floor Diaphragm and Postural Development, where I delve deeper into how these relationships impact children with pelvic floor issues like constipation, diastasis rectus, and even cystic fibrosis.

The diaphragm, in coordination with the abdominal muscles and the PFM, helps to stabilize the spine and pelvis during movement. This stabilization is essential for maintaining balance and posture when learning developmental motor skills.

This coordination also ensures that pressure within the thoracic and abdominal cavities is managed effectively, influencing respiratory capacity and lymphatic drainage.

Furthermore, the fascial connections from the diaphragm establish healthy function of many organ systems. Let’s take a look at this in more detail, so you can understand how this directly affects your practice as a pediatric therapist.

The Diaphragm’s Fascial Connections To Organ Systems
Beyond its muscular and respiratory functions, the diaphragm is also deeply interconnected with the body’s fascial system. Fascia surrounds every structure in the body, providing support and facilitating movement. Fascia has contractile properties, so a problem with the diaphragm or its related structures can cause dysfunction along the entire fascial chain.

The diaphragm has direct fascial connections to several key organs, including:

• Heart
• Lungs
• Liver and Colon
• Esophagus

These fascial connections highlight the diaphragm’s role in managing information between the chest and abdomen, as well as its influence on organ function. When kids have dysfunction in their diaphragm or its associated fascial structures, this can lead to a range of issues, such as digestive, breathing, and swallowing problems.

The diaphragm also influences postural stability through its relationship with the glottis, which controls airflow through the vocal cords. Engagement of the glottis during upright perturbations or stability tasks enhances thoracic stability. The proper function of the glottis needs to be considered when working with kids on breathing mechanics, trunk stability, or pelvic floor engagement.

You must also look at neurological connections to the diaphragm, such as those involving the phrenic, vagus, trigeminal, and hypoglossal nerves. What many therapists often see as classic mechanical issues or classic digestive issues, can actually have distal neurological origins. This includes mechanical conditions such as headaches and thoracic outlet syndrome, and autonomic digestive conditions such as gastroesophageal reflux, aerophagia, and functional gastrointestinal disorders.

Get good at connecting the pieces and understanding the root causes of dysfunction, rather than simply treating the kids’ symptoms.

Clinical Implications For Pediatric Therapy
For pediatric therapists, understanding the diaphragm’s role in respiration, postural stability, and its broader connections within the body is essential for effective treatment. Children with conditions such as cerebral palsy (CP), respiratory issues, constipation, and musculoskeletal pain can benefit significantly from interventions that target the diaphragm and its associated structures.

For example, in children with CP, research has shown that kids with better diaphragmatic function exhibit greater ambulatory mobility, abdominal expansion, and respiratory function compared to kids with impaired diaphragmatic function. You should prioritize treatment of the diaphragm for children with CP, especially those who are non-ambulatory. [1]

Similarly, addressing diaphragmatic function can play a critical role in managing pediatric patients with respiratory conditions, such as asthma. Ensuring that the diaphragm maintains its dome shape and ZOA can improve the child’s breathing efficiency, reduce the reliance on accessory muscles, and enhance overall respiratory function.

Lastly, the diaphragm’s role in maintaining intra-abdominal pressure and coordinating with the pelvic floor muscles is crucial for managing conditions like constipation and urinary incontinence. By optimizing diaphragmatic function, you can support children’s pelvic floor function and help improve their bowel motility and urinary continence.

There are many widespread health implications that you have the power to influence as a pediatric therapist! If you are looking to deepen your understanding of the diaphragm and its role in pediatric health, join me virtually for my live Pediatric Pelvic Floor Diaphragm and Postural Development course on September 29, 2024.

This course will provide you with the knowledge and tools you need to enhance your practice and improve outcomes for your young patients. Don't miss this opportunity to expand your skill set and make a meaningful difference in the lives of the children you treat.

Reference:

1. Bennett S, Siritaratiwat W, Tanrangka N, Bennett MJ, Kanpittaya J. Diaphragmatic mobility in children with spastic cerebral palsy and differing motor performance levels. Respir Physiol Neurobiol. 2019 Aug;266:163-170. doi: 10.1016/j.resp.2019.05.010. Epub 2019 May 21. PMID: 31125702.

AUTHOR BIO

Dawn Sandalcidi PT, RCMT, BCB-PMD

Dawn Sandalcidi is a trailblazer and leading expert in the field of pediatric pelvic floor disorders. She graduated from SUNY Upstate Medical Center in 1982 and is actively seeing patients in her clinic Physical Therapy Specialists, Centennial CO.

Dawn is a national and international speaker in the field, and she has gained so much from sharing experiences with her colleagues around the globe. In addition to lecturing internationally on pediatric bowel and bladder disorders, Dawn is also a faculty instructor at the Herman & Wallace Pelvic Rehab Institute. Additionally, she runs an online teaching and mentoring platform for parents and professionals.

In 2017, Dawn was invited to speak at the World Physical Therapy Conference in South Africa about pediatric pelvic floor dysfunction and incontinence. Dawn is also Board-Certified Biofeedback in Pelvic Muscle Dysfunction (BCB-PMD). She has also been published in the Journals of Urologic Nursing and Section of Women’s Health.

In 2018, Dawn was awarded the Elizabeth Noble Award by the American Physical Therapy Association Section on Women's Health for providing Extraordinary and Exemplary Service to the Field of Physical Therapy for Children.

Movement competence (or Movement Literacy) is defined as the development of sufficient skills to ensure successful performance in different physical activities. Often used in the world of sports and youth, it also applies to our everyday activities. For example, standing up from a chair or toilet, getting in/out of a car, moving our body from Point A to Point B (and the difference between the ground being even and dry vs uneven and icy).

In our course, Osteoporosis Management: An Introductory Course for Healthcare Professionals, Dr Frank Ciuba and I approach the starting point for individuals with low bone mass (osteopenia or osteoporosis), from an “optimal alignment position.” Patients start supine with hips and knees flexed and are educated on what optimal alignment feels like. Many need to be propped using pillows, towels, or blocks behind their heads, forearms, or between their knees to achieve “their optimal alignment.” Breathing and awareness play a huge role in activating core musculature to sustain this alignment when moving to a vertical position such as sitting or standing. In vertical, our weight-bearing forces and gravity should pass down through the skeleton to take advantage of bone-building benefits. We use dowel rods, broom handles, and walls to give feedback. Optimal alignment can and should be taught in a variety of positions: side-lying, prone, hands and knees, ½ kneeling as we move up the developmental chain.

Hip Hinging, a well-known concept by therapists, must be practiced and mastered for patients with low bone mass to reduce the risk of vertebral fractures. Activities that involve bending at the waist such as brushing teeth, making a bed, and putting dishes in the dishwasher all place the anterior portion of the vertebral bodies under pressure and increase fracture risk.

Advancing from static optimal alignment postures to dynamic optimal alignment is a whole different ballgame; akin to advancing from sitting in a car to driving a car. There are many moving parts - pun intended.

Just as in athletics, mastery comes from repetition. It is not enough to teach patients a safe movement pattern one time, hand them a sheet of paper with pictures, and expect them to be able to comply and gain competence. Reinforcing proper technique and helping them become aware of compensation strategies (hunching shoulders when lifting objects, overarching the back when reaching overhead, etc.) are critical if Movement Competency is to “stick.”

I like to think of movement competency as building a house. First, you need a firm foundation before putting up the walls and roof. Our patients require that foundation to be able to layer on more complicated patterns of movement.

Please join us for this one-day course on September 14th or November 2nd to learn more Osteoporosis-safe exercises, balance and gait activities, and additional ways to help your patients build a strong foundation for movement competence!

AUTHOR BIO:
Deb Gulbrandson, PT, DPT

Deb Gulbrandson, DPT has been a physical therapist for over 49 years with experience in acute care, home health, pediatrics, geriatrics, sports medicine, and consulting to business and industry. She owned a private practice for 27 years in the Chicago area specializing in orthopedics and Pilates. 5 years ago, Deb and her husband “semi-retired” to Evergreen, Colorado where she works part-time for a hospice and home-care agency, sees private patients as well as Pilates clients in her home studio and teaches Osteoporosis courses for Herman & Wallace. In her spare time, she skis and is busy checking off her Bucket List of visiting every national park in the country- currently 46 out of 63 and counting.

Deb is a graduate of Indiana University and a former NCAA athlete where she competed on the IU Gymnastics team. She has always been interested in movement and function and is grateful to combine her skills as a PT and Pilates instructor. She has been certified through Polestar Pilates since 2005, a Certified Osteoporosis Exercise Specialist through the Meeks Method since 2008, and a Certified Exercise Expert for the Aging Adult through the Geriatric Section of the APTA.