Be the Detective: Using Differential Diagnosis

SEXMED THUMBNAIL 1

The following is an excerpt from the short interview between Holly Tanner and Tara Sullivan discussing her course Sexual Medicine in Pelvic Rehab. Watch the full video on the Herman & Wallace YouTube Channel.

Hi Tara, can you introduce yourself and tell us a little bit about your background?

Sure! So I’m Tara. I’ve been a pelvic health rehab therapist for about 10 years now. I started right out of PT school and I got a job at a local hospital where they were looking to grow and build the pelvic rehab program. So of course, I found Herman & Wallace and started taking all of the classes there that I could and just kept learning over the years. Now the program is expanded across the valley, we have nine different locations, and it’s been very successful and fulfilling. It’s my passion.

Recently, I would say the past four to five years of my career, I’ve started getting more into sexual dysfunctions. I was always into pelvic floor dysfunction in general - bowel, bladder, sexual dysfunction, and chronic pelvic pain, but I  didn’t get specifically into the sexual medicine side of it until recently. I did the fellowship with ISSWSH that really pulled all of that information together with what I’ve learned through the years.

Can you explain what ISSWSH is and how that combined with the knowledge base that you already had?

I feel like ISSWSH for me, where I came full circle. I finally was like “I get it.” ISSWSH is the International Society for the Study of Women’s Sexual Health and it’s all the gurus like Dr. Goldstein, Rachel Rubin, and Susan Kellogg that have been around forever doing the research on sexual medicine. I started attending their conferences, became a faculty member, and presented at their annual fall meeting here in Scottsdale. Then I ended up doing their fellowship. Every year I would attend the conference, but it took a couple of years for all of that knowledge to soak in and for me to be able to really apply it.  For example, that patient with that sticky discharge, maybe that is lichen planus – that’s the kind of medical side that you don’t necessarily learn in physical therapy school.

That for me just really helped my differential diagnosis which means that you can get the patient’s care faster. Get them to that resolution faster because you are working with a team of people and we all have our roles. As PTs and rehab practitioners, we have the time to sit with our patients. We are so blessed to have an hour, and the medical doctors don’t, for us to really take that time to figure out the patient’s history and what they’ve been through, and what could be the cause of it. We have the time to be the detective and help them get the care they need. Whether it’s with us, or in conjunction with something else. My goal is to never tell someone that I can’t help them because it’s not muscular.

How has this knowledge helped you in your collaboration with other practitioners in your practice?

I feel like this knowledge was the missing link for me. It brings it all together for the patient. So the patients come here and the urologist says “that’s not my area,” and then the gynecologist says “that’s not my area.” Then they come to you and you’re like “it’s kind of my area, but I can’t prescribe the medication that you need.”

My practice got so much better, just in the sense of the overall quality of care, when I was able to develop those relationships with the doctors. I could pick up the phone and say “Hey, that patient that you sent me – I think they have vestibulodynia, and I think it’s from their long-term use of oral contraceptive pills. I think that they might benefit from some local estrogen testosterone cream.” They would say, I don’t know about that, and I’d respond “let me send you some articles. Let me tell you what I’ve learned.”

Now I can just pick up the phone or send them a text asking them to prescribe so and so. It really helped bridge that gap. The doctors now will say “Ok. I know something’s going on, but I don’t know if it’s muscular or tissue. I don’t have that training, what do you think?” So it’s just been such a collaboration, it’s been so great. Then I’ll go the reverse of that and watch them do a surgery, watch them do a procedure.

For our patients, we need to take that time and work with the physicians and develop that relationship with them, because it’s easy to pass it off as “that’s not my job.” Especially the vestibule! The gynecologist goes right through it and looks into the vaginal canal and then the urologist is like I’m going to look at the urethra but I’m not looking around it, let me just stick that scope in. This knowledge and ability to use differential diagnosis, for me just brings it all together.

Does your course have an online, pre-recorded portion as well as a live component?

Yes. There are about nine lab videos on manual techniques because everyone wants to know what to do. For me, it’s more about what you know. What can you identify and differentiate with the differential diagnosis. Then we have about two hours of just the basic lectures on general pain and overactivity of the pelvic floor so that we can spend our time in the live lecture getting into the very specific conditions that we as PTs are, not necessarily diagnosing, but recognizing and sending for further care. That’s really where I wanted this class to fill the gap between the urologist, the gynecologist, and the PT.

Is your course primarily vulvo-vaginal conditions or are there some penile, scrotal, or other conditions?

It is both male and female dysfunctions, and I have a few transgender cases. I don’t personally treat the transgender population very often so I only have a couple of examples of that. I have a lot of examples where I’m trying to get practitioners to recognize the problem by what the patient is saying and their history, and how to funnel this into their differential diagnosis. Case studies include different types of vestibulodynia and causes, all the different skin conditions…and it’s not necessarily something that they didn’t learn in one of the Pelvic Floor Series courses, but I wanted one class where they could just talk about all the sexual dysfunctions and get into some of the ones that we don’t see as often but are present.

We also talk about PGAD (persistent genital arousal disorder), and with male dysfunctions, we talk about spontaneous ejaculation and urethral discharge, post vasectomy syndrome. All of these things that you might not see every day, but when you see them you’ll recognize them so that you can help patients talk to the doctor and get the proper care. There are a lot of random, not as obvious, conditions that are not as prevalent. Then there are the common conditions that we see every single day like lichens.

What is the biggest takeaway that practitioners have who come into your class?

It is really being able to access and effectively use differential diagnosis. A lot of practitioners in the course are like “I always wondered what that was.” I have a ton of pictures that I share, and I’m like, I know you guys have seen this before. I think a lot of it is the differential diagnosis. The feedback that I get from every class is “I feel like I can go to the clinic on Monday and apply what I learned.” “I’m going to go buy a q-tip and start doing a q-tip test because now I know what to do with that information.” They feel that confidence of really being able to apply it, talk to the patient, talk to the doctors, and figure out that meaningfulness.


Sexual Medicine in Pelvic Rehab - Remote Course
SEXMED NL

2022 Course Dates:
July 16-17 2022 and October 15-16 2022

Sexual Medicine in Pelvic Rehab is designed for pelvic rehab specialists who want to expand their knowledge, experience, and treatment in sexual health and dysfunction. This course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions for all people and sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, as well as multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Lecture topics include hymen myths, female squirting, G-spot, prostate gland, female and male sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy, as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. Upon completion of the course, participants will be able to confidently treat sexual dysfunction related to the pelvic floor as well as refer to medical providers as needed and instruct patients in the proper application of self-treatment and diet/lifestyle modifications.

Audience:
This continuing education course is appropriate for physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals of all levels and experience. Content is not intended for use outside the scope of the learner's license or regulation. Physical therapy continuing education courses should not be taken by individuals who are not licensed or otherwise regulated, except, as they are involved in a specific plan of care.

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The Menstrual Mentor: Niko Gaffga Discusses Women's Health and Menstruation

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The following is an excerpt from an interview between Niko Gaffga, MD, FAAFP, MPH (NG) and Holly Tanner (HT) about why he is interested in women’s health and the menstrual experience. Niko and Amy Meehan, PT, DPT, MTC have co-authored a specialty course for H&W all about Menstruation and Pelvic Health – to learn more join us in the upcoming remote course on July 16th-17th, 2022. You can watch the full video interview below, or on the Herman & Wallace YouTube Channel.

HT – So menstruation as a topic, what is it that got you so passionate about this particular topic?

NG -Throughout my career and my training, women’s health and OB have been one of my favorite parts of my job. In recent years there was a patient who really inspired me. I came into the room, and she was sitting in the corner in the exam room of the clinic where I worked and she was crying. I came in and I asked, she only spoke Spanish…and  I asked her “ How are you doing? What’s happening?” and she was very reluctant to say anything.

I found out through a little bit of discussion that she was feeling pain, and she couldn’t make the pain go away. That she had seen many doctors about it and no one had been able to help her. She was reluctant to show me where on her body – maybe it’s because I’m a man, or maybe it was because she was from a different country – she didn’t feel secure. So I drew a little picture on a piece of paper, and I said “Just point to me on this paper where you feel the pain.” After a while of pointing, talking, and smiling I got to a point where she could explain to me what was happening.

 It turns out that she had painful bladder syndrome, or interstitial cystitis, and we worked over the months to get that better. And I have to say, that the next time that I walked into that the next time that I walked into that same room and she was there – she was smiling. She stood up and she gave me a hug – and I said to myself, “This is why I do medicine.”

I think really the breakthrough came when I met her where she was. I took the time to talk to her in her language, show her a piece of paper, and wait for her to say what she felt. Cause many doctors, you know how they only have two or three minutes to talk with their patients. When I met her halfway, she was able to talk to me about the pain she was feeling, about her menstrual cycles – which I don’t think she had ever discussed with any doctors before.

So that started me down the road in being interested in what can I do – what more can I do to help women. When I see women in the clinic a lot of them don’t want to say anything about their menstrual cycle, and again maybe it’s because I’m a man. Maybe it’s because it’s just a difficult topic to discuss, but I realize that in society we don’t have a lot of chance as men or women to talk about the menstrual cycle.

I feel that it is a disservice to women that they don’t have a chance to talk about things that genuinely interest them, are concerning to them, or have questions and are curious about. I feel that there is a stigma, and I think that this course will begin to address it within a small group. But I think eventually, training and working with healthcare providers is one step in making that message available to other people, and to other patients all around the country. So that is how it evolved for me.

One of the most important things for me is that talking about the menstrual experience and women’s health, in general, allows me to change, to give people information, to make decisions in their life that are in alignment with the way that they see the world. I think that not many professions can say that. You know medical professions, physical therapists, doctors, and many other professions - we help people do what they want to do for themselves, and that’s powerful. That’s very powerful.

I think that the most important thing is that I can make a difference in someone else’s life. I’ve seen it when talking to women in the clinic who I’ve seen before. Discussing their menstrual cycle and having them tell me this is the first I’ve spoken about to anyone, much less to a female or a male provider. Hearing someone say that is meaningful. It is a lot of trust that they place in someone to tell them these kinds of things because they are difficult topics. Seeing that you can make a difference in someone else’s life...it means a lot to me, and this is the reason why [I’m so passionate about women’s health and the menstrual experience].


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Menstruation and Pelvic Health - July 16-17 2022

The Menstrual cycle is one of the most natural of all human processes and is experienced by half of the population of the world. At any given time, 800 million individuals are menstruating. The Menstrual cycle occurs roughly once a month for roughly 35 to 40 years in a lifetime. That ends up being almost 3000 days, or about 8 years of menses. Many menstruators experience “period shaming” and other forms of socialized stigma around the menstrual experience. It is therefore important to become familiar with this experience and provide care to patients that takes into account their Menstrual Experience.

This two-day remote continuing education course is designed for clinicians who want to obtain advanced knowledge and skills to educate patients on non-hormonal, non-surgical, and non-prescription interventions for improving the Menstrual Experience. Developed by Nicholas Gaffga, MD, MPH, FAAFP, and presented together with Amy Meehan, PT, DPT, MTC, this course is geared toward the pelvic rehab provider looking to impart Menstrual Interventions that:

  1. Put control in the hands of people who menstruate to identify and carry out the interventions that are appropriate to them
  2. Use a holistic approach and advanced knowledge and familiarity with body and mind
  3. Emphasize healthy practices that can positively impact the Menstrual Experience and beyond, in areas such as mental health and chronic diseases
  4. Discover root causes of issues, rather than quick fixes, to have benefits that are sustainable across the lifespan.

 

 

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An OTs Journey through Parkinson Disease and Pelvic Health

This week for the Pelvic Rehab Report, Holly Tanner sat down to interview faculty member Erica Vitek, MOT, OTR, BCB-PMD, PRPC on her specialty course Parkinson Disease and Pelvic Rehabilitation. If you would like to learn more about working with this patient population join Erica on June 24th-25th for the next course date!

 

This is Holly Tanner with the Herman and Wallace Pelvic Rehab Institute and I'm here with Erica Vitek who's going to tell us about of course that she has created for Herman and Wallace. Erica, will you tell us a little bit about your background?

Yes. Absolutely. Thanks for chatting with me today about my course! So my course is Parkinson Disease and Pelvic Rehabilitation. I'm just so excited to be part of the team and to be sharing all this great information. How I got the idea for the course is that there was a need for more neuro-type topics related to pelvic health, and individuals were reaching out to me because my specialty is in both Parkinson disease, rehabilitation, as well as pelvic health, and I always talked about the connections and wanting to bring that information to more people. So I wanted to plate all that information together in this great course. 

I got started specializing in Parkinson's back in the early 2000s. I was hired at a hospital as an occupational therapist working with people with Parkinson disease. But when I was in college my real interest was pelvic health. So I kind of got thrown into learning a whole lot about Parkinson disease at that time and I got really interested in how it all related to what I really wanted to do, which was pelvic health. I was able to connect that all, really right from the beginning of my career. Even though I started more on the physical rehabilitation side of Parkinson disease, which I continue to this day. I am able to combine those two passions of mine.

I also am an instructor with LSVT Global(1)and so we do LSVT BIG®(2) course training and certification workshops and I work with them a lot. I also have still a physical rehab background, as well as my connection to the public health background, and I bring that all together in my course Parkinson Disease and Pelvic Rehabilitation. We have two packed-full days of information and I think really it does translate well to the virtual environment.


What are the connections between neuro and pelvic health? Can you talk about what some of the big cornerstone pieces are that you get to dive into with your class?

The beginning of the course on the first day is going back to the basics of neuro in general. Really getting our neuro brains on and thinking about terminology, topics related to neurotransmitters and the autonomic nervous system. Individuals with Parkinson’s specifically, their motor system is affected but also their non-motor systems. This includes autonomic function, the limbic system, and all of the different motor functions that also affect the pelvic floor in addition to all of the other muscles in the body.

We have all of this interplay of things going on that affect the bladder, bowel, and sexual health systems in individuals with Parkinson's that is a little bit different than your general population. There are a multitude of bladder issues that are very specific to the PD population, for example, overactive bladder. 

This is just one example of the depths we go into right in the beginning on day one where we get into the neuroanatomy and neurophysiology of why that is actually happening. This then helps us go into day two where we talk about the practicality of what you do in the clinic about the things that are happening neurologically which is causing all of these bladder, bowel, and sexual health issues.

 

What kind of tools do you give to people to help practitioners understand and implement a treatment program?

People with PD are on very complex medication regimens and many of them are elderly, so the medication complexity is much more challenging in this population. At the end of day one, the last lecture, we go through the pharmacology very specifically for people with Parkinson’s in order to have a base of understanding of how that is interplaying with the pelvic health conditions. 

We set the baseline of getting that information from your patient off the bat, then discuss what you want to be looking for when you start off with that patient and the importance of finding out what kind of bladder and bowel medications they have taken thus far and how that can potentially interplay with their Parkinson’s. Individuals with PD can have potentially worse side effects from some of those medications that are used for bladder issues specifically. We dig into what to look for, we talk a lot about practical behavioral modifications using bladder and bowel diaries and things like that to weed out some things in addition to using our other skills as pelvic health practitioners.


How can people prepare themselves to come to Parkinson Disease and Pelvic Rehabilitation, are there required readings or things that would be helpful for people to catch up a little bit on the pelvic health or neuro side?

I feel like, and I hope, that I did a really good job at the basic review right at the beginning so we can talk through these topics together. I prefer to take a course and not have to spend a lot of extra time on the pre-recordings because sometimes that can be overwhelming with busy lifestyles. When I put together this course I really wanted us to focus together as a group as we start the class to dig into those basics at the beginning and not have a lot of required things to do prior.

So what I did at the beginning of the course is to make a lot of tables, a lot of charts, and a lot of drawings, that we can reference (we don’t have to memorize it) and look at as needed. We can look at a chart and a drawing right next to it in the manual. I spent a lot of time just putting it all down in words, what I’m saying, so you don’t have to take a lot of notes. I think this has really helped practitioners as we get into the course and learn about the details of Parkinson’s and pelvic health.


What is it that makes you so passionate about working with these patients and continuing to learn and share your knowledge?

It is so heartwarming and feels so good to help these individuals. The motor symptoms of PD are really the ones recognized by physicians or even outwardly noticed even by other individuals. These private conditions of pelvic health that we are helping with are things that they might not even mention to their physician. Maybe we find out when we are doing other physical rehab or when colleagues refer them to us because they know what we do, and to help them with something of this magnitude that affects their everyday life - when they have trouble just walking, or moving or transferring. 

Their caregiver burden for these individuals is so high because their loved one - now turned caregiver - is helping them do everything. We can make such an impact on these individuals. I mean, we do on other people too, but when you have a progressive neurologic condition and we can make an effect on shaping techniques they can use to improve their day-to-day. It’s just so great to be able to help them. 

Sometimes these patients with PD can have cognitive impairments, they can have difficulties learning, and that can be helpful for the care partner. It can be a significant reduction in their burdon. I do talk a lot in the course about cognitive impairment and I give a lot of tips about how we can train and some ideas. People with Parkinson’s muscles and minds are a little different so there are some great tips that I can provide and lots of clinical experience. 

I’ve been an occupational therapist for over 20 years, so I have a ton of clinical experience with this population. It’s been the population I’ve worked with my entire career. I hope I can provide the passion that I have for working with these individuals as well as the individuals who take my class.


I’m sure you would agree that we need more folks knowledgeable about Parkinson’s and combine that with pelvic health knowledge as well.

There are over a million people in the United States alone that have Parkinson disease. It’s the second most common neuro-degenerative disorder just behind Alzheimer’s disease. So there are so many individuals dealing with this and I think we can really expand our practices. I don’t think a lot of individuals that work in pelvic health market themselves to neurologists. There is an opening there for additional referrals and more people that we can help.


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References:

  1. SVT Global is an organization that develops innovative treatments that improve the speech and movement of people with Parkinson’s disease and other neurological conditions. They train speech, physical and occupational therapists around the world in these treatments so that they can positively impact the lives of their patients.
  2. LSVT BIG®: Physical Therapy for Parkinson’s Disease and Similar Conditions. LSVT BIG trains people with Parkinson disease to use their body more normally.
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Acupressure: Holistic care for Pregnancy, Labor, and Postpartum

Acupuncture

Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200 has a personal interest in various eastern holistic healing traditions, and she noticed that many of her chronic pain patients were using complementary health care approaches including acupuncture and yoga. 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.

rachna linked in post 25 june 26 june

There is worldwide concern over the increasing rates of pharmacologically induced labor, opioid use, and operative birth. Women are seeking holistic non-pharmacologic options to avoid medical and surgical interventions in childbirth which has led to the popularity of Complementary and Alternative Medicine (CAM) therapies. Despite CAM existing outside of conventional heath systems, a substantial number of women have been found to use CAM to manage their health during pregnancy1.

Among CAM therapies, Acupuncture and Acupressure have been found to be helpful for pregnancy-related symptoms such as nausea, breech presentation, and labor induction with post-partum recovery considerations as well. Acupressure has roots in Acupuncture and is based on more than 3000 years of Traditional Chinese Medicine (TCM). TCM supports Meridian theory and meridians are believed to be energy channels that are connected to the function of the visceral organs. Acupoints located along these meridians transmit Qi or the bio-electric energy through a vast network of interstitial connective tissue connecting the peripheral nervous system to the central viscera.

A systematic review published by Smith et al2 looked at the use of Acupuncture or Acupressure for pain management during labor. They noted that the pain women experience during labor can be intense, with body tension, anxiety, and fear making it worse. The data included a total of 3960 women and found that Acupressure may reduce pain intensity in women experiencing labor pain.

Another RCT published by Levett et al included 176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics. They incorporated six evidence-based complementary medicine techniques: Acupressure, visualization and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomization occurred at 24–36 weeks’ gestation, and participants attended a 2-day antenatal education program plus standard care, or standard care alone.

The study found a significant difference between the two groups with the study group having decreased epidural use (23.9%) compared to the standard care group (68.7%). The study group participants also reported a reduced rate of cesarean section and length of the second stage among other measures.

An article published by Debra Betts3 discusses several key considerations for promoting physiological Labor with Acupuncture. Multiple studies have cited the effectiveness of Acupressure by stimulating these powerful Acupoints as well. The author states that the suggestion of Acupoints cited below are based on both her clinical practice and midwifery feedback and are by no means an exhaustive list. The practitioner is encouraged to explore Traditional Chinese Medicine to promote efficient physiological labor in women.

Key considerations for promoting natural physiological labor include:

Is the baby in an optimal anterior position? The author states “Women can become involved in their own treatment by learning proactive positioning. This involves a woman keeping her knees lower than her hips when sitting, in order to assist gravity in moving her baby into the best possible position. Bucket‑type seats such as car seats and comfy sofas, therefore, need to be abandoned in favor of birthing balls, sitting astride chairs (with the arms resting on the back).” Key acupuncture points that can be stimulated include Bladder 60 ( BL 60), Spleen 6 (Sp 6), and Bladder 67 (BL 67). Bladder 60 (BL 60) is considered an empirical induction point. Midwifery feedback suggests that this is a useful point for promoting an optimal position of the baby for birth. Bladder 67 (BL 67) is considered an extremely important point if the baby is not in an anterior position.

Is the woman emotionally prepared for labor? While most women have some level of underlying anxiety or fear about the approaching birth, it is essential to address any significant emotional disharmony. The hormone oxytocin is released several weeks prior to labor, initially stimulating uterine contractions at night, with increasing production then aiding the transition into labor. Stress hormones such as adrenaline and noradrenaline have a direct inhibiting effect on natural oxytocin release, and therefore play a very significant role in inhibiting contractions2. Key acupuncture points that can be stimulated include Kidney 1 (KD 1), Liver 3 (Liv 3), and Pericardium 6 (P6) among others. Kidney 1 (K1) is useful for women who are experiencing fear of induction or childbirth itself. Liver 3 (Lv 3) is helps in improving Liver chi. Pericardium 6 (P6) is helpful for nausea, regulating the heart and calming.

Is the woman physically prepared for labor? Women may be physically exhausted or have pre-existing physical conditions that, once addressed, will help to promote physiological labor2. Key acupuncture points that can be stimulated include Bladder 43 (BL 43) and Stomach 36 (St 36). Bladder 43 ( BL 43) is A point that tonifies and nourishes the Lung, Heart, Kidneys, Spleen, and Stomach. Stomach 36 (ST 36) is a useful point to reinforce if the woman is exhausted, due to its qi-tonifying and blood-nourishing properties.

Stimulating contractions:  Debra Betts also notes that key points of the Bladder meridian that are located on the sacrum are crucial in initiating contractions. While Traditional Chinese Medicine (TCM) does consider some Acupuncture points like Large Intestine 4 (LI 4), Gall Bladder 21 (GB 21), and Spleen 6 (Sp 6) should not be stimulated in pregnant women, the opposite is true when we want to initiate labor and these points can be additionally used to assist in stimulating contractions.

Acupressure can also be used in the post-partum period for overall generalized well-being, promoting a sense of bonding with the baby, calm, and relaxation.

Acupressure can be used to stimulate key energy points also known as Acupoints in various meridians and as hands-on musculoskeletal specialists, we can use and teach this modality to our patients. Acupressure requires no equipment, is easy for clinicians to teach and for patients to self-administer when taught correctly, and is an empowering self-care tool to promote optimal health outcomes.

The course Acupressure for Optimal Pelvic Health focuses on powerful Acupressure points in key Meridians including the Kidney, Bladder, Spleen, and Stomach meridians. It also explores Yin Yoga as an integrative intervention with Acupressure. Yin Yoga, a derivative of Hath Yoga is a wonderful complimentary practice to Acupressure. Yin Yoga is a slow and calm meditative practice that uses seated and supine poses that are held for three to five minutes with deep breathing. It stimulates the energy flow through the meridian channels by creating tension along specific meridian lines.

This course is curated and taught by Rachna Mehta. To learn how to integrate Acupressure into your clinical practice, join the next scheduled remote course on June 25- 26, 2022.


rachna linked in post 25 june 26 june 2

References

  1. Steel A, Adams J, Sibbritt D, Broom A. The Outcomes of Complementary and Alternative Medicine Use among Pregnant and Birthing Women: Current Trends and Future Directions. Women’s Health. May 2015:309-323. doi:10.2217/WHE.14.84.
  2. Smith CA, Collins CT, Levett KM, et al. Acupuncture or acupressure for pain management during labour. Cochrane Database Syst Rev. 2020;2(2): CD009232.
  3. Betts, Debra. Inducing Labour with Acupuncture–Crucial Considerations. Journal of Chinese Medicine. 2009;90: 20-25.
  4. Atkins KL, Fogarty S, Feigel ML. Acupressure and Acupuncture Use in the Peripartum Period. Clin Obstet Gynecol. 2021;64(3):558-571. doi:10.1097/GRF.0000000000000636.
  5. Levett, Kate M., Smith, C.A., Bensoussan, A. & Dahlen, H.G. Complementary therapies for labour and birth study: a randomized controlled trial of antenatal integrative medicine for pain management in labour.  BMJ Open, 2016 Jul 12;6(7):e010691. DOI: 10.1136/bmjopen-2015-010691.
  6. Schlaeger JM, Gabzdyl EM, Bussell JL, et al. Acupuncture and Acupressure in Labor. J Midwifery Women's Health. 2017;62(1):12-28. doi:10.1111/jmwh.12545.

Acupressure for Optimal Pelvic Health 
Instructor: Rachna Mehta PT, DPT, CIMT, OCS, PRPC, RYT 200

Price: $450
Experience Level: Beginner
Contact Hours: 12.5

Course Dates: June 25-26, 2022 and October 15-16, 2022

Course Description:
This continuing education course is a two-day seminar that offers participants an evidence-based perspective on the application of Acupressure for evaluating and treating a host of pelvic health conditions including bowel, bladder, and pelvic pain issues. The course explores a brief history of Acupressure, its roots in Acupuncture and Traditional Chinese Medicine (TCM), and presents current evidence that supports the use of complementary and alternative medicine as an adjunct to western medicine. TCM concepts of Meridian theory and energy channels are presented with scientific evidence of Acupoints transmitting energy through interstitial connective tissue with potentially powerful integrative applications through multiple systems.

Lectures will present evidence on the use of potent Acupressure points and combinations of points for treating a variety of pelvic health conditions including chronic pelvic pain, dysmenorrhea, constipation, digestive disturbances, and urinary dysfunctions to name a few. Key acupoints for decreasing anxiety, and stress and bringing the body back to a state of physiological balance are integrated throughout the course.

Participants will be instructed through live lectures and demonstrations on the anatomic location and mapping of acupressure points along five major meridians including the spleen, stomach, kidney, urinary bladder, and gall bladder meridians. Key associated points in the pericardium, large intestine, small intestine, lung and liver meridians as well as the governing and conception vessels will also be introduced. The course offers a brief introduction to Yin yoga and explores Yin poses within each meridian to channel energy through neurodynamic pathways to promote healing across multiple systems. Participants will learn how to create home programs and exercise sequences and will be able to integrate acupressure and Yin yoga into their orthopedic and pelvic health interventions.

Special Considerations and Lab materials
The labs for this course will involve external whole-body palpation and mapping of acupressure points. Please wear fitted t-shirt and leggings or yoga pants for acupressure point mapping. Participants should buy a pack of 1-inch diameter white circle stickers to be used in Labs for mapping acupressure points.

Participants are encouraged to use a Yoga mat if available and any other props they may have at home including yoga blocks, small blankets, towels and pillows to be used in the guided Yin Yoga Lab portion of the course.

Recommended resources: It is recommended that participants purchase an Acupressure Point Chart for ease of following the course work and labs in this course. Since the accuracy of points and content may vary on different charts, it is recommended to buy a copy at https://acupressure.com/products/acupressure-charts/

Target Audience:
This continuing education seminar is targeted to rehabilitation professionals who use manual therapy as a treatment modality. Knowledge of acupressure points with specific anatomical landmarks will enable clinicians to add to their toolbox skills for treating a variety of pelvic health conditions related to the bowel, and bladder and treatment of pelvic pain.

Prerequisites:
It is recommended that the participants have a working knowledge of the functional anatomy of pelvic floor muscles as well as various associated pelvic health conditions. Pelvic Floor 1 through Herman & Wallace is strongly recommended.

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Got 30 Minutes? 4 Underestimated Daily Practices to Make Your Lunch Break More Life-Giving

Amanda

Amanda Davis, PT, DPT, PRPC can be found online at https://www.makeandmanifest.com/. She has generously shared her recent blog with The Pelvic Rehab Report. "Got 30 Minutes? 4 Underestimated Daily Practices to Make Your Lunch Break More Life-Giving" can be found in its original post on her website here: http://www.makeandmanifest.com/blog-lunchbreak/.

 

Hey there, I'm Amanda. Pelvic rehab therapist, endo warrior, girl mama (despite that whole endo thing), and creator of this space where I'm sharing the story of practicing what I preach and the wins and losses I gather along the way. I love early morning espresso, podcast binging, yoga pants, and scrolling Pinterest for my next obsession (heyyyy fellow libras!). My mission is to help women see the difference between "common" and "normal" and to take their physical, mental, and emotional health beyond the "that's just the way it is" mentality.

Hats off to my fellow 9-5ers who head home after a long day to jump right into their 5-9. If you’re like me, that second “career” includes (but definitely is not limited to) caregiver, dog walker, master gardener, professional organizer, chef, and housekeeper to name a few. Add in friendships that need energy, relationships that need time, those hobbies you swore you’d keep alive, and self-care you promised yourself you’d do…aaaaand the whole multi-passionate, multi-talented, multi-hyphenate thing can get overwhelming quick.

After a glorious five-month maternity leave, I’ve officially been a working mom for a year. I love my job and I love my girl, and while trying to fit both in a 24 day is challenging and exhausting, it’s what’s right for me in the season I’m in. Plus there’s something about pursuing my calling outside of the home and knowing Sloan’s watching me do it.

RELATED POST: 9 Ways to Practice Self-Love as a New Mom on Maternity Leave

We’ve all chased that ultimate goal of a *perfect* balance and ~seamless~ blend between work and home, but in full disclosure, I’ve gotta tell ya— it’s hard for me to do. I’ve found myself coming home drained, dying for a break, wishing I could just lock myself in a quiet room, and feeling guilty for all of the above.  Being with my daughter is the best part of my day, but I’m often just too depleted to enjoy it.

Maybe you can relate? Maybe you’re also trying to work to live but find those words flipping themselves around more than you care to admit.

I recently took an online course called Boundaries, Self-Care, and Meditation for the Pelvic Rehab Therapist, Part 1 (part 2 is on June 12). As a PT I’m required to take continuing education to keep my skillset relevant and knowledge fresh, but the pending burnout I shared with you above led me to [this] course instead. To put it simply, it was [insert explosion sound here] mind-blowing; and call me dramatic, but I consider my practice, my patients, and myself as a person and professional forever changed because of it.

While I could write at least ten posts on all the things I learned in this class, the concept that’s been most life-altering for me was how I spend my lunchtime. Yep!…just a few tweaks to those 30 minutes mid-day and not only are my afternoons more pleasant and productive, but I’m going home refreshed, renewed, and ready to spend my time and energy on alllllllllll the other people and things that mean the most to me.

RELATED POST: Your Day Starts at Bedtime: 25 Easy Habits for a Better Night’s Sleep

RELATED POST: Promote Health + Prevent Burnout: A Pelvic Rehab Therapist’s Guide to the ~Perfect~ Self-Care Day

What you’ll find next is how I structure my lunchtime for life-giving success— a strategy that serves me most. We all have different work environments, different physical and mental needs, and different priorities. As long as your cup feels full(er) at the end of your break, I can confirm you’re doin’ it right.

SHUT YOUR DOOR
I fully realize that not everyone has an office door they can shut during lunchtime, but as long as you can get somewhere semi-quiet and remotely alone, that should do the trick (heck…I’ve been known to go out to my car in a pinch). Creating a calm and centered environment has proven paramount to taking a true “break” from the day and will make all of my recommendations to follow that much more enjoyable.

If you’re worried about appearing “selfish” or “standoffish”…I was too. But after a week’s worth of lunches behind a closed door, I realize the positives of this practice far outweigh the negatives I was creating in my head. I’m still a team player. My coworkers still know where I am if they need me. But I’m a better colleague the other eight hours of the day when I take these 30 minutes to myself, and to my knowledge, there have been no complaints so far.

STOP TO EAT
To my fellow multi-tasking queens— if you only read one part of this post, let [this] be it as I believe this one change has made the biggest difference.

I used to spend my lunch catching up on paperwork, tending to emails, paying bills, online shopping, and then resort to scrolling social media if all of that was done. But I was eating during all of it and realized that not only was it taking me twice as long to complete tasks, but I wasn’t tasting, appreciating, or ultimately enjoying my food, all huge components of appetite, digestion, and ultimately nutrition and health.

My lunches aren’t anything fancy; in fact, 99% of the time they’re leftovers from earlier in the week (helloooooooo my trusty 3-day-old grilled chicken). But stopping to eat with intention and nothing other than a little music or podcast playing in the background has surprisingly, but positively, affected how much I consume, how my gut feels afterward, and the amount of energy I have for the rest of the day.

PS- What you eat can make a huge impact here too. I aim for whole, quality foods full of healthy fats and filling proteins to set me up for success. I’m someone who can eat the same thing again and again, so you’ll typically find my lunchbox full of that good ol’ grilled chicken, boiled eggs, fruit, cheese, and rice noodles if I’m feelin’ feisty.

LEARN
On top of that podcast I have playing while I eat, I’ve started spending ten to fifteen minutes learning during lunch. I literally set a timer, pull out a book, and read about something that fuels my brain.

In order to make these minutes a 10/10, here’s a few tips to uplevel the experience:

  • Get comfortable. Find a place to prop your feet up or lean that car seat back (this is in part why I set a timer…juuuuuuuust in case I fall asleep). Have water nearby, a blanket tucked away if it’s cold, and don’t hesitate to indulge in all the ways even if for just a short period of time.
  • Read about something unrelated to your occupation. For instance…I’m a pelvic rehab therapist but you won’t see me catching up on the latest research in anatomy and physiology. I typically grab a book on self-improvement, business and marketing, or homesteading, and my brain feels so much more recharged when it gets to focus on something that builds me up as a passionate person outside of my profession.
  • Use a physical book. Seriously…no kindle, no phone apps, no audiobooks. Chances are you’re looking at a screen, listening to people talk, or a combo of the two all day long. Digging into an actual hard copy will access other parts of your brain that you may not be tapping into as regularly and result in faaaaaaaar more feel-good-ness.

When I became a mom I went from devouring a few books a month to being able to count my yearly reads on one hand. Reading on my lunch break has made me excited to learn again and reminded me of who I am outside of motherhood too (in turn making me a better mama). Even if reading isn’t your “thing”, at least give this one a try. Bonus if you utilize your local library because their books just smell better and we’re going for indulgent here…remember?

MOVE
Eat…ten minutes. Learn…ten minutes. If you’re like me and have ten more minutes to spare, then I encourage you to move your body with that time. While the options are endless, I try to avoid sweating too much in the middle of the work day, so walking, stretching, and even deep breathing exercises are more my speed. Whatever you decide to do, make sure you have the shoes, yoga mat, or whatever it is you need ready to go.

RELATED POST: Easy + Impactful Ways to Use Your Time Confetti to Improve Your Pelvic Floor Health

Not only does research show that movement improves your mood and elevates your energy, but there are also the physical benefits (duh!) and mental resilience that comes with knowing you’re taking care of yourself when you could be doing something else. Once fearful of wasting precious energy, I now consider my mid-day movement the boost I need to ensure I’m ready to go when I get home because let me tell ya…one year olds don’t quit.

One look at my Pinterest boards and you’ll see I’m a girl who has a lot she wants to accomplish (I see you dream house, list of must-reads, vacation itineraries, and yummy recipes just dyyyyyying to be made). But with a 24-hour day divided in thirds between work, sleep, and “other”, I have to use my time wisely to see success in a life where I’m more often than not choosing the option of (D) ALL OF THE ABOVE.

I don’t mean to be dramatic, but hacking my 30-minute lunch has ~literally~ changed my life and I’m a better physical therapist, caregiver, dog walker, master gardener, professional organizer, chef, and housekeeper (to name a few) because of it. There’s a saying that if you can’t go big, go home, but this is an instance where you can’t underestimate the power of a few minutes spent intentionally where it counts.

I’d love to hear in the comments what you do for work, if these strategies work for you, and ways you’ve made them your own. And don’t hesitate to share this one with a coworker who could use these strategies too! Nothing makes me happier than picturing us all spending half an hour in that 11-2 time frame-filling our cups for full-day success. I have a feeling you’ll be surprised at the impact this can have, and I can’t wait to watch you grow one lunchtime at a time.


Boundaries, Self-Care, and Meditation - Part 2 - Remote Course - June 12, 2022

This course focuses on personal and professional growth for the participant, with a deeper dive into meditation and self-care practicesYoga is introduced as a means of mindful movement and energy balance. Participants will learn to identify unhealthy relational patterns in patients and others, and skills on how to use language and boundaries to create shifts that keep the clinician grounded and prevent excessive energic and emotional disruptions. There is a lecture on using essential oils for self-care and possibly patient care. Learning new strategies to preserve energy, wellness, and passion while practicing appropriate self-care and boundaries will lead to helpful relationships with complex patients. This course also includes a discussion of energetic relationships with others as well as the concept of a "Higher Power". The discussion will also include refining life purpose, mission, and joy potential, unique to the individual participant. The goal is that the participating clinician will walk away from this experience equipped with strategies to address both oneself and one's patients with a mind, body, and spirit approach. 

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What Are Your Core Values in Pelvic Health

Ethics

Mora Pluchino, PT, DPT, PRPC sat down this week with Holly Tanner in an interview to discuss her new courses, Ethical Concerns for Pelvic Health Professionals and Ethical Considerations from a Legal Lens. She is a pelvic therapist who works in an outpatient clinic, has her own side company (Practically Perfect PT), has written 2 books available on Amazon, and is a senior TA and faculty member with Herman & Wallace. Mora joins the Herman & Wallace faculty with her new course series in ethics: Ethical Concerns for Pelvic Health Professionals and Ethical Considerations from a Legal Lens

What are your core values as a pelvic health practitioner? Depending on your practitioner license these may include (1):

  • Accountability - Active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist and physical therapist assistant including self‐regulation and other behaviors that positively influence patient and client outcomes, the profession, and the health needs of society.
  • Altruism - The primary regard for or devotion to the interest of patients and clients, thus assuming the responsibility of placing the needs of patients and clients ahead of the physical therapist’s or physical therapist assistant’s self‐interest.
  • Collaboration - Working together with patients and clients, families, communities, and professionals in health and other fields to achieve shared goals. Collaboration within the physical therapist‐physical therapist assistant team is working together, within each partner’s respective role, to achieve optimal physical therapist services and outcomes for patients and clients.
  • Compassion and Caring - Compassion is the desire to identify with or sense something of another’s experience; a precursor of caring. Caring is the concern, empathy, and consideration for the needs and values of others.
  • Duty - The commitment to meeting one’s obligations to provide effective physical therapy services to patients and clients, to serve the profession, and to positively influence the health of society.
  • Excellence - The provision of physical therapist services occurs when the physical therapist and physical therapist assistant consistently use current knowledge and skills while understanding personal limits, integrating the patient or client's perspective, embracing advancement, and challenging mediocrity.
  • Integrity - Steadfast adherence to high ethical principles or standards, being truthful, ensuring fairness, following through on commitments, and verbalizing to others the rationale for actions.
  • Social Responsibility - The promotion of mutual trust between the profession and the larger public that necessitates responding to societal needs for health and wellness.
 

Annual CEU requirements for license renewals don’t just look at hands-on skills. Many states also require a number of ethics credits including California, Georgia, Illinois, New Jersey, and Utah (2).  In her interview, Mora Pluchino explains that one day she and her colleague were at lunch talking about course options for their ethics CEU requirement. They had taken the same course over and over at Stockton University and wanted to do something different this time. This led to Mora reaching out to Herman & Wallace and Holly Tanner who helped her start writing the course. Mora’s new courses focus on this ethics requirement, provide 6 contact hours, and registration is $175.00 for each: 

What should you expect from an ethics course? Mora breaks down the Ethical Concerns for Pelvic Health Professionals course and shares that there is about an hour of pre-course video lectures to watch, then the live course involves “a little bit of lecture in relation to pelvic health and ethics, and then there will be some case studies and group work. After this, an ethical expert will come in and do live question/answers with us.”

These courses are to really make practitioners comfortable with these ethical and moral issues. Mora explains, “I really want practitioners who take this course to understand and know where to find information about those issues that come up with their boss, their organization, their patients, or themselves. A lot of times, ethical situations just make us just know instinctively that something doesn’t feel right.” Holly follows up with “Sometimes these situations can make us feel embarrassed, and maybe we contributed or didn’t contribute in the right way to a scenario. We don’t always bring them up to other people out of this embarrassment, or we just don’t know which pathway to take.”

A lot of common questions have an ethical component such as “How do I bill for this,” “How do I tell my boss I can’t do this,” or even “Can I reuse a biofeedback sensor?” Mora shares, “Sometimes, as a practitioner you can feel pressured to do (or not do) something, and you don’t know how to say no. With these courses, you will be able to give clear reasons such as it’s in my guidelines, in my practice act, and core values as being a PT or OT.” She further expands on this, “We have all of these people working for us in the APTA and AOTA that are creating all of these ethical guidelines and all of this information to give us the support.”

The ethics topics are broken down into two courses, with the first course Ethical Concerns for Pelvic Health Professionals focused specifically on people who treat pelvises scheduled for June 18, 2022. The second course, Ethical Considerations from a Legal Lens, is scheduled for December 10, 2022, and deals with the legalities and rights of health care providers. Some questions that are touched on during lectures include abandonment of care and discrimination.  Mora also shares that a lot of the ethics courses she has taken are “from the perspective of therapists that are abusing their patients, but when you work in pelvic health world you realize it can go the other way too, or it can be a back and forth kind of thing.”

To learn more, and fulfill that ethics CEU requirement, join H&W and Mora Pluchino this summer in Ethical Concerns for Pelvic Health Professionals on June 18th or this winter in Ethical Considerations from a Legal Lens scheduled for December 10th.


Resources:

  1. APTA. Core Values for the Physical Therapist and Physical Therapist. HOD P06‐19‐48‐55. 9/20/2019. https://www.apta.org/siteassets/pdfs/policies/core-values-endorsement.pdf. Accessed 5/30/2022.
  2. Fraticelli, T. PT Progress. Physical Therapy Continuing Education: PT CEU Requirements by State. October 8, 2018. https://www.ptprogress.com/physical-therapy-continuing-education-requirements-by-state/. Accessed 5/30/2022.

Additional Resources:

• Core Values of Your Profession:
• The Core Values Self Assessment.
o This measure was created for Physical Therapists/ Physical Therapy Assistants but it has value for all health care professionals. If you are another type of health care professional, please just imagine the questions apply to your profession. https://www.apta.org/your-practice/ethics-and-professionalism/professionalism-in-physical-therapy-core-values-self-assessment
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Dry Needling and Pelvic Floor Dysfunction

DNPH1 Blog

Kelly Sammis, PT, OCS, CLT, AFDN-S is a physical therapist, educator of dry needling and all things pelvic, Pilates instructor, wife, and mama living and working in Parker, Colorado. She specializes in the treatment of male and female pelvic floor dysfunction, athletic injury/return to sport, sports performance, and persistent pain. Her formal education took place at Ohio University (2007) and The University of St Augustine for Health Sciences (2010). Kelly serves as the lead faculty developing and teaching dry needling and pelvic health courses nationwide. Kelly co-instructs the Herman & Wallace Dry Needling courses along with fellow faculty member Tina Anderson, MS PT.

Pelvic floor dysfunction (PFD) is a common and relevant condition that affects many patients worldwide.  According to our evidence, PFD can affect approximately 20-25% of women and men in the United States1, contributing to decreased participation in preferred daily, work and recreational activities due to high incidences of lumbopelvic pain, abdominopelvic pain, incontinence, prolapse, and/or other urologic and urogynecologic symptoms.2  These symptoms have a significant impact on a person’s quality of life and mental health status.2

While PFD is common, the general public has not been fully educated that these dysfunctions are not normal.  As clinicians, we have a duty to educate our patient population that PFD is not a normal, nor acceptable, part of the postpartum experience or aging process.  These dysfunctions are very debilitating but are also very treatable.

Common, not normal.  Common, but treatable.

Pelvic floor pathology comes to us as clinicians in a variety of diagnoses, etiologies, and presentations2. Patients are often referred to physical therapy with medical diagnoses such as chronic pelvic pain syndrome (CPPS), interstitial cystitis, irritable bowel syndrome, endometriosis, dyspareunia, pudendal neuralgia, bowel and urinary incontinence, and chronic prostatitis.3-5 Symptom presentation is quite varied but often will include bowel, bladder, and sexual dysfunctions. That being said, a multidisciplinary approach is crucial to tailor treatment specific to each patient’s pathology, symptomatology, and clinical presentation.6  Many of these patients have seen a variety of gynecologists, urologists, and gastroenterologists without successful symptom mitigation and are being referred to pelvic health practitioners as a last resort. This is unfortunate, as a primary contributor to these symptoms is the neuromusculoskeletal system…and who better to treat the neuromusculoskeletal system than rehabilitative clinicians?!

Multimodal practice is key.

A well-rounded, multimodal treatment approach that is tailored to meet the patient’s specific goals is an important step in successfully treating PFD.  Patient education can be a very powerful modality, which many clinicians tend to overlook. Research suggests education may help to address central nervous system upregulation and may help to retrain the brain in how it is processing input.7,8 While it is incredibly powerful to be able to influence pain processing, it doesn't stop with education.  As clinicians, we also need to provide non-threatening, nourishing input to the tissues.

Manual therapies may help to desensitize the peripheral nervous system and surrounding soft tissues by providing neural input to alter the source of the pain and disruption.9,10 These techniques, including joint mobilization, soft tissue release, myofascial techniques, tool-assisted therapies, or any other manual approach, are likely addressing local tissue issues that may be perpetuating chronic pain or tissue dysfunction.

Dry needling is another effective and efficient technique that pelvic health practitioners can utilize to modulate the central nervous system, peripheral nervous systems and local tissues, including the pelvic floor directly.10  Dry needling encompasses the insertion of solid filament, non-injectate needles into, alongside or around muscles, nerves or connective tissues with or without mechanical and/or electrical stimulation for the management of pain and dysfunction in neuromusculoskeletal conditions.

While the detailed mechanisms of dry needling are not well known, we have seen more and more evidence that has provided us with an understanding on how to best utilize this technique in our clinical practice. Overall, it is thought that dry needling may address hypersensitive neural structures and spinal segments5, enhance treatment of myofascial pain and trigger points in the pelvic floor and surrounding musculature, and assist in the facilitation and/or inhibition of abnormal muscle tone and motor recruitment patterns.10-23 Dry needling has the ability to assist in addressing bladder, bowel, and sexual dysfunction alongside addressing pain syndromes in our patient population that is impacted by PFD.

Dry needling is one of the most effective tools we have as rehabilitative practitioners to reset dysfunctional tissue, providing effective and efficient functional changes for our patients.  Ultimately, we are able to facilitate a more balanced resting tone, healthy motor recruitment patterns, and optimal neuromuscular utility to re-establish ideal function in our patients. The power of the tissue reset that dry needling provides has changed my clinical outcomes for the better and has also positively impacted and changed the lives of many of my clients. Want to add this tool to your clinical practice? Check out our course offerings with Herman & Wallace:


References:

  1. Hallock JK. The epidemiology of pelvic floor disorders and childbirth: an update. Obstet Gynecol Clin North Am. 2016 March;43(1):1-13
  1. Messelink et al. Standardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report from the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurology and Urodynamics. 2005;24:374-380
  1. Anderson R, Sawyer T, Wise D, Morey A and Nathanson B. Painful Myofascial Trigger Points and Pain Sites in Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome. The Journal of Urology. 2009;182:2753-2758
  1. Hahn L. Chronic Pelvic Pain in Women. Lakartidningen. 2001;98:1780-5
  1. Kotarinos R. Myofascial Pelvic Pain. Curr Pain Headache Rep. 2012;16:433.438
  1. Srinivasan A, Kaye J, Moldwin R. Myofascial Dysfunction Associated with Chronic Pelvic Floor Pain: Management Strategies. Current Pain and Headache Reports. 2007;11:359-364
  1. Moseley G. Widespread Brain Activity During An Abdominal Task Markedly Reduced After Pain Physiology Eduction: fMRI Evaluation of a Single Patient with Chronic Low Back Pain. Australian Journal of Physiotherapy. 2005;51(1):49-52
  1. Moseley G. A Pain Neuromatrix Approach to Patients with Chronic Pain. Manual Therapy. Aug 2003;8(3):130-140
  1. Baron et al. Peripheral Input and Its Importance for Central Sensitization. Ann Neurol. 2013;74(5):630-6
  2. Chou L, Kao M, Lin J. Probably Mechanisms of Needling Therapies for Myofascial Pain Control. Evidence-Based Complimentary and Alternative Medicine. 2012;11
  1. Chen J, Chen S, Kuan T, et al. Phentolamine Effect on the Spontaneous Electrical Activity of Active Loci in a Myofascial Trigger Spot of Rabbit Skeletal Muscle. Archives of Physical Medicine and Rehabilitation. 1998;79(7):790-4
  1. Cummings T and White A. Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Archives of Physical Medicine and Rehabilitation. 2001;82(7):986-992
  1. Gerber L, Shah J, Rosenberger W et al. Dry Needling Alters Triggers Points in the Upper Trapezius Muscle and Reduces Pain in Subjects with Chronic Myofascial Pain. Physical Medicine and Rehabilitation. 2015;7(7):711-718
  1. Gunn C, Milbrandt W, Little A et al. Dry Needling of Muscle Motor Points for Chronic Low Back Pain: A Randomized Clinical Trial with Long-Term Follow-Up. Spine. 1980;5(3):279-291
  1. Hsieh Y et al. Dry Needling to a Key Myofascial Trigger Point May Reduce Irritability of Satellite MTrPs. American Journal of Physical Medicine and Rehabilitation. 2007;86(5):397-403
  1. Lewit K. The Needle Effect in the Relief of Myofascial Pain. Pain. 1979;6(1):83-90
  1. Shah J. Uncovering the Biochemical Milieu of Myofascial Trigger Points Using In Vivo Microdialysis. Journal of Musculoskeletal Pain. 2008;16(1-2):17-20
  1. Shah J, Danoff J, Desai M et al. Biochemicals Associated with Pain and Inflammation are Elevated in Sites Near to and Remote from Active Myofascial Trigger Points. Archives of Physical Medicine and Rehabilitation. 2008;89(1):16-23
  1. Sterling M, Valentin S, Vicenzino B, et al. Dry Needling and Exercise for Chronic Whiplash - A Randomized Controlled Trial. BMC Musculskeletal Disorders. 2009;10:160
  1. Tough E, White A, Cummings T, et al. Acupuncture and Dry Needling in the Management of Myofascial Trigger Point Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. European Journal of Pain. 2009;13(1):3-10
  1. Tuzun E, Gildir S, Angın E, et al. Effectiveness of Dry Needling Versus a Classical Physiotherapy Program in Patients with Chronic Low-Back Pain: A Single-Blind, Randomized, Controlled Trial. Journal of Physical Therapy Science. 2017;29(9):1502-1509
  1. Hong C and Torigoe Y. Electrophysiological Characteristics of Localized Twitch Responses in Responsive Taut Bands of Rabbit Skeletal Muscle Fibers. Journal of Musculoskeletal Pain. 1994;2(2):17-43
  1. Puentedura E, Buckingham S, Morton D, et al. Immediate Changes in Resting and Contracted Thickness of Transversus Abdominis After Dry Needling of Lumbar Multifidus in Healthy Participants: A Randomized Controlled Crossover Trial. Journal of Manipulative and Physiological Therapeutics. 2017;40(8):615-623
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How I Went from Ortho to Pelvic Floor PT

Sarah Clampett, PT, DPT, is Head of Clinical Operations at Origin, a leading provider of pelvic floor and whole-body physical therapy with a special focus on pregnancy and postpartum. After studying Kinesiology and Psychology at the University of California, Sarah stayed on to earn her Doctorate of Physical Therapy. As a clinical leader at Origin, she’s as passionate about helping PTs love the work they do as she is helping patients feel good in their bodies.

 

Sarah Clampett, PT, DPT

Shortly after I started physical therapy school, I realized that being a physical therapist is a fantastic conversation starter. People’s eyes tend to light up when they hear I’m a PT because almost everyone has had an experience with physical therapy — and even if they haven’t, they’ve had an injury. They want to tell me about the physical therapy they did in high school for their scoliosis or that time they tore their ACL skiing. They even seek advice for that pesky low back pain that hasn’t fully resolved since throwing their back out six months ago. 

I love to hear people’s stories and genuinely enjoy engaging in casual conversations about injuries. When I’m done explaining that core strength is important when dealing with back pain, I go on to say that while I started my career in ortho, I’m now a pelvic floor PT. That’s when one of two things happens: 1) They stare at me blankly, then quickly change the subject, or 2) Their eyes light up even brighter and they start asking questions. That’s when the conversation gets really fun. “What exactly do you do?” “What do you treat?” and “How did you get into that?”

Where My Passion for Ortho Started
I decided to go to PT school for a couple of reasons. I’ve always loved sports and consider sports a large part of my upbringing. (Fun fact: I only listened to AM sports radio until I was about 13). And, like many PTs, I discovered physical therapy as a patient. In my case, it was after injuring myself in high school playing volleyball.

I loved going to PT, not only because I was getting better — I loved seeing all the other patients getting better around me. It was a very sports-oriented PT clinic and my first and only experience with PT, so when I declared Kinesiology as my major and started my pre-PT coursework in college, I had my heart set on being a sports/ortho PT. It felt like the perfect fit at the time. I was a student athletic trainer for 2.5 years in college to learn as much as I could about the sports rehab world before heading into PT school.

Fast forward to my final semester and clinical rotation at PT school: I was at an ortho clinic with a large population of athletes. I loved it. After I graduated, I was hired as a PT at that same clinic and started my career as a working PT. I began working a few days a week to build my caseload with the plan to transition to full-time as my schedule filled. That clinic happened to also own a women’s health clinic that treated primarily prenatal and postpartum patients. A few weeks after starting, I was asked if I wanted to work additional days by filling in at the women’s health clinic. As a new grad who needed to pay rent, I said yes because more days meant more money. It was supposed to be temporary.

My Journey to Becoming a Pelvic Floor PT
As soon as I walked into the women’s health clinic, something clicked. I fell in love with the patient population and helping them feel better. I remember early on, a patient with such severe pelvic pain that they could barely walk to the bathroom. At their next visit, they said they could walk without pain again. The ability to help people going through pregnancy and postpartum felt especially meaningful. I spent a year and a half working in both clinics and then transitioned to treating women’s health full time.

After working in women’s health for a couple of years, I eventually got tired of referring my patients with pelvic floor conditions to colleagues who treated pelvic floor and decided it was time to start treating it myself. To be honest, I was hesitant at first and definitely nervous about taking my first course. But as soon as I started treating the pelvic floor, something clicked again.

Even more so than in the past, I connected deeply with my patients and their goals. Giving someone the confidence to leave the house without wearing a maxi-pad or carrying extra underwear because they’re no longer worried about leaking was amazing. So many people suffer in silence from pelvic floor disorders and are resolved to just live with them. I’m lucky enough to provide a safe space to talk about it and assure them that it can get better. How cool is that?  

Advice for an Ortho PT Curious About Pelvic floor
Take a course! Just because you take the course does not mean you are committing to a career change. Even if you decide it’s not the right time to switch or you didn’t enjoy it as much as you thought you would, you’ll still learn valuable information that you can immediately incorporate into your practice. That overworked, stressed patient with lingering hip pain might need pelvic floor lengthening to get that last bit of pain to resolve.

Most ortho PTs who make the shift are nervous they won’t be able to use their ortho skills when treating the pelvic floor, and that simply isn’t true. My time in ortho has definitely shaped the pelvic floor PT I am today.

In ortho, you treat the whole body. If your foot hurts, you look at the knee, the hip, the low back, and how everything works together to figure out what’s causing the foot pain. Pelvic floor PT is no different. You must look at the whole body and figure out how all the parts are working together to get the results you need. I continue to use many of the same exercises now that I used back when I was working as an ortho PT.

Lastly, the pelvic floor is a group of muscles. If it’s weak, it needs to strengthen. If it’s overactive, it needs to lengthen. If it’s uncoordinated, it needs to be retrained. Yes, treating pelvic floor dysfunction requires special training, but at the end of the day, muscles are muscles.

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Interventions for the Postpartum Patient

Rachel Kilgore Banner 1

I have always enjoyed working with the peripartum population. However, the longer I worked in pelvic rehabilitation the more I heard the same story over and over when interviewing patients. For example, when working with a patient with urinary incontinence or prolapse, I would say: “when did this start” and some of my elderly patients would laugh and say “when Johnny was born” and I would say “how old is Johnny” they would reply “40!” Many of the pelvic patients I was treating had symptoms originating around the time of childbirth and they had been suffering for decades. So, I figured, let’s get to the root of the problem and focus on earlier intervention.    

Rachel Kilgore

What is the root of the problem? In my opinion, it is the lack of postpartum care. Pregnant patients are often inundated with birth education programs and information about pregnancy and childbirth. Additionally, there is a battery of prenatal visits, prenatal testing, and preparations for birth. All of which are wonderful to help prepare for birth. Conversely, the resources and guidance to help with physiological and musculoskeletal healing postpartum are lacking. Patients are counseled about serious signs and symptoms, but clear guidance to help to return to daily functional activities including recreation and exercise is often not provided. As musculoskeletal and exercises experts we are in a wonderful position to help patients reduce pain and improve function following the birth of a child.

Prior to 2018, the first post-partum checkup was six weeks following birth. Barring any severe problems, this was often the last contact with a medical provider for the parent. Patients were not provided specific guidance on how to return to daily activities, let alone higher-level activities such as running, exercising, and/or lifting weights.

In 2018, the American College of Obstetrics and Gynecology (ACOG) revised its guidelines, which now support earlier and more frequent postpartum visits. It is recommended that the first contact between patient and obstetric care provider occur in the first three weeks following birth and that subsequent visits are scheduled as needed in an ongoing fashion1. This is important, as many consider the patient is still healing from birth up to 12 weeks (definitions vary). Depending on their knowledge and experience, a patient may not immediately realize they have a musculoskeletal problem. A new parent is busy adapting to their role as a care provider and may not be thinking about themselves. Additionally, they may not know what “normal” is for their body postpartum, including vaginal, abdominals, and/or bowel, and bladder functions. For example, the patient may be experiencing urinary incontinence (UI) which they “think” is normal postpartum, therefore, they may not bring it up to their provider. Patients often seek advice from family and friends who may even joke about peeing their pants when they sneeze or laugh or play with their children. Urinary incontinence is not ever “normal”, however, is it common in the postpartum period. Availability of vetted resources and a relationship with a healthcare provider are essential to cure these misconceptions.       

According to a systematic review, the prevalence of urinary incontinence is 33% at three months postpartum2 and remains at 29% four years postpartum3. This means about one-third of women have urinary incontinence postpartum and remain that way without intervention. We also know the prevalence of urinary incontinence is strongly related to increasing age and underreported. This example highlights a common misconception: pelvic dysfunction is a normal part of the after-birth stage. However, with intervention, these problems can be alleviated, and we can improve the quality of life for these patients. 

According to the American College of Physicians (ACP) clinical practice guidelines for non-surgical management of UI there is high-quality evidence that strongly recommends pelvic floor muscle training as the first-line treatment for stress incontinence.4

So why isn’t pelvic assessment and rehabilitation recommended for all people who birth in our country? In several European countries, pelvic rehab is standard postpartum care for anyone who births. Over the last two decades, I do see more postpartum patients referred for rehabilitation for their musculoskeletal impairments. However, I still think we need more skilled providers assisting these patients and spreading the word about the interventions rehabilitation professionals provide. These can range from common orthopedic complaints (e.g neck or back pain from repetitive baby care) to specific bladder and/or bowel dysfunction, such as leakage and/or constipation, abdominal separation (Diastasis Rectus Abdominus-DRA), prolapse, pelvic pain, perineal tearing, and/or pain with intercourse.    

When developing this four-course postpartum series, I wanted rehabilitation providers to have more advanced skills to provide examination and treatment to this special population. This includes techniques to assess and treat the abdominals and pelvis, as these areas are physiologically impacted by pregnancy and birth over a relatively short amount of time. To effectively treat this population, one needs to be familiar with physiological changes from pregnancy, and stages of labor and birth to understand the journey of your patient. There is so much we can do to help these patients over a range of complaints, from acute breast and perineal care to DRA and pelvic dysfunctions.  As with any special population, postpartum patients have unique red flags and concerns to monitor, and due to our more frequent patient contact, it is imperative to be proficient in screening for these conditions. These topics and more are included in the course series. 

I am grateful and appreciative of this collaboration between Herman & Wallace and Medbridge to provide a platform for clinicians to progress their knowledge. Hopefully, this improves access to postpartum care and increases referrals for rehabilitation services to improve the function and quality of life for parents. Together we can reduce chronic impairments stemming from the childbirth period.


Resources:

  1. Accessed on 5/9/2022: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
  2. Thom, D. H., & Rortveit, G. (2010). Prevalence of postpartum urinary incontinence: a systematic review. Acta obstetricia et gynecologica Scandinavica89(12), 1511-1522.
  3. Gartland, D., MacArthur, C., Woolhouse, H., McDonald, E., & Brown, S. J. (2016). Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG: An International Journal of Obstetrics & Gynaecology, 123(7), 1203-1211.
  1. Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., Denberg, T. D., Shekelle, P., & Clinical Guidelines Committee of the American College of Physicians*. (2014). Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Annals of internal medicine161(6), 429-440.

MedBridge

Postpartum Patient: General Examination

Instructor: Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES

Functions and Dysfunctions of the Pelvic Girdle and Pelvic Floor

Postpartum Patient: General Treatment

Instructor: Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES

Abdominals in the Postpartum Patient: Evaluation and Treatment

Abdominals in the Postpartum Patient: Evaluation and Treatment

Instructor: Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES

Pelvic Floor in the Postpartum Patient: Evaluation and Treatment

Pelvic Floor in the Postpartum Patient: Evaluation and Treatment

Instructor: Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES

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Health Benefits of Yoga

The health benefits of yoga 600 600 px 1640 600 px

The popularity of yoga continues to rise with over 36 million yogis living in the United States of America and over 300 million practitioners worldwide. Yoga has several therapeutic effects that make it a beneficial addition to home exercise programs for practitioners and personal practice.

Dustienne Miller discussed some of the benefits of yoga in her March blog (March 8, 2022 - A yoga practice can change your neuroanatomy!). These benefits extend beyond the musculoskeletal system and include improved mood and depression, changes in pain perception, improved mindfulness and associated improved pain tolerance, and the ability to observe situations with emotional detachment.

The physical benefits are well documented in several research studies and include improved flexibility, strength, and stability as well as enhanced respiratory and cardiovascular function. Supporting documentation also shows that yoga can help alleviate the symptoms of chronic pain. Dustienne Miller shared that in a study by Villemure et al, they determined “that the insula-related interoceptive awareness strategies of the yoga practitioners being used during the experiment correlated with the greater intra-insular connectivity...concluding that the insular cortex can act as a pain mediator for yoga practitioners.”

Restorative yoga shares the many benefits seen in other styles of yoga and can also be a great addition to home programs for pelvic rehab practitioners. Kate Bailey shared in her interview with The Pelvic Rehab Report (August 31, 2021 – Faculty Interview: Kate Bailey) that restorative yoga “focuses on the lesser-known aspects of the yoga platform: breath, restorative practice, and a bit of meditation. I have clients all the time who struggle with meditation because their nervous systems aren’t ready for it. So we look at breathing and restorative yoga both as independent alternatives, but also as a way to get closer to meditation.. giving the clinicians another skill for their own rest practice can be useful when feeling tired, overwhelmed, or burned out. “

But what does this mean? Let’s look at some of these aspects a bit closer:

Improving mood and sleep: This includes depression, anxiety, and even stress or other mood disorders. Consistent yoga practice can lead to significant increases in serotonin levels coupled with decreases in the levels of monoamine oxidase, an enzyme that breaks down neurotransmitters and cortisol(1). Yoga can inhibit the areas in the brain responsible for fear, aggressiveness, and rage (posterior or sympathetic area of the hypothalamus) – while simultaneously stimulating the rewarding pleasure centers in the median forebrain and other areas leading to a state of bliss and pleasure. This inhibition results in lower anxiety, heart rate, respiratory rate, blood pressure, and cardiac output (2).

Think about it. Deep breathing calms the nervous system. This promotes relaxation. The more relaxed you are then the better the chance of having a good night’s sleep. Consistent yoga practice can also assist sleep quality by increasing melatonin and reducing hyperarousal (3). Pratyahara, or a turning inward of the senses, allows downtime for the nervous system and can be encouraged by yoga poses such as savasana (corpse pose) and pranayama (breathing exercises/control.

Reduced Chronic Pain: Asana and meditation have been shown to reduce chronic pain including reduced pain from arthritis, back pain, and other chronic conditions while also improving balance and increasing proprioception(1). Yoga sessions can take our joints through a full range of motion. This squeezes and soaks areas of cartilage not often used and provides fresh nutrients, oxygen, and blook to the joints. Otherwise neglected areas of cartilage in the joints would wear out, exposing bone, which can lead to arthritis and chronic pain. At the same time, yoga is gentle on the body and consistent practice can strengthen the connective tissues that surround the bones and joints.

Effects on Cancer Patients: Yoga cannot cure cancer, but it can reduce stress and improve physical, emotional, and spiritual wellness. There is supporting research that the growth of cancerous tumors can be exacerbated by stress(4). This same study found that consistent yoga practice could decrease post-chemotherapy-induced frequency and intensity of nausea and the intensity of anticipatory nausea and vomiting. In 2018 Lin et al provided new research showing that restorative yoga can decrease depression in cancer survivors; improve symptoms of anxiety, depression, and pain symptoms in cancer patients; and help patients manage the toxicity of cancer treatments (5). In addition, yoga has a fundamental emphasis placed on mindfulness and acceptance of your body and its limitations.

Kate Bailey likes to joke about lying on the floor, but really, it is not a joke at all. Lying on the floor for 15 minutes is savasana. She shares that “Savasana is a wakeful resting and a practice of relaxation response. It seems easy: you always have access to a floor. You don’t need anything fancy. Aside from the neuroregulatory benefits of rest, savasana also gives the postural muscles a break. It allows the hip flexors to re-lengthen and the cervicothoracic junction to realign.”

Let’s take a moment to close with a savasana (did you know that a 5-minute savasana is recommended for every 30 minutes of yoga?). This pose can calm the central nervous system, aid the digestive and immune systems, reduce headaches, fatigue, and anxiety while lowering blood pressure and calming the mind, and reducing stress.

Take a moment and lay on the floor with your arms and legs open wide and relaxed (starfish style), supported by a bolster, or you may want to place your hands gently over your chest or your stomach. Now gently still your body. Release your breath and be present. Be completely aware of the moment. Let your mind and body go for a few moments.

Namaste.


References:

  1. McCall T. New York: Bantam Dell a division of Random House Inc; 2007. Yoga as Medicine.
  2. Woodyard C. Exploring the therapeutic effects of yoga and its ability to increase quality of life. International journal of yoga4(2), 49–54. 2011. doi: 10.4103/0973-6131.85485
  3. Wang W-L, Chen K-H, Pan Y-C, Yang S-N, Chan Y-Y. The effect of yoga on sleep quality and insomnia in women with sleep problems: A systematic review and meta-analysis. BMC Psychiatry. 2020;20(1):195. doi:10.1186/s12888-020-02566-4
  4. Carson, J. W., Carson, K. M., Porter, L. S., Keefe, F. J., Shaw, H., & Miller, J. M. (2007). Yoga for women with metastatic breast cancer: results from a pilot study. Journal of pain and symptom management33(3), 331–341.
  5. Lin P-J, Peppone LJ, Janelsins MC, et al. Yoga for the management of cancer treatment-related toxicities. Curr Oncol Rep. 2018;20:5. doi:10.1007/s11912-018-0657-2

RYPT600 600 px 1600 400 px 2Restorative Yoga for Physical Therapists with instructor Kate Bailey

This course will provide the basis for experiencing and integrating restorative yoga into physical therapy practice. Restorative yoga is an accessible practice that can teach patients (and practitioners) how to rest systematically, for short periods of time, on a regular basis to encourage the parasympathetic nervous system to balance with the sympathetic nervous system for improved neuroregulation. Topics include the difference between meditation and restorative yoga, and how they can support each other in order to support the ability to drop into relaxation. Restorative postures, each taking 20-30 minutes are offered prior to the live meeting so that participants can experience what a patient might experience when restorative yoga is a component of their home program. Then in the live course participant experiences, questions, and strategies on how to reduce barriers to relaxation so that patients can integrate this practice into their lifestyle will be discussed. There will also be live labs for breathing techniques and specific meditations that may be helpful to patients working with an unregulated nervous system.

RYPT600 600 px 1600 400 pxYoga for Pelvic Pain with instructor Dustienne Miller

This course offers an evidence-based perspective on the value of yoga for patients with chronic pelvic pain by focusing on two of the eight limbs of Patanjali’s eightfold path: pranayama (breathing) and asana (postures) - and how they can be applied for patients who have hip, back and pelvic pain. A variety of pelvic conditions will be discussed including interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Lecture topics include the role of yoga within the medical model, contraindicated postures, and how to incorporate yoga home programs as therapeutic exercise and neuromuscular re-education both between visits and after discharge. 

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