Blog by Deanna Vaughn, PT, DPT who practices at Core and Pelvic Physical Therapy Clinic in Conway, Arkansas, this article was originally located at https://whatsupdownthere.info/colorectal-cancer-the-gut-and-the-butt/.

Colorectal cancer refers to cancerous cells within the colon or rectum. Need a quick anatomy review? Keep reading then!

The colon is another name for the large intestine, which is the long tube (nearly 5 FEET!) surrounding the small intestines (that snaky, jumbled tube in the middle of our bodies, which you can see below in the picture). It’s comprised of segments: the cecum (the little pouch that joins the small intestine to the large intestine) in the right lower abdomen, the ascending colon starting at the right lower part of your abdomen (coming off the cecum), and up to about the right side of your ribcage; the transverse colon that loops underneath the stomach and ribcage from right to left; the descending colon that extends down from the left side of your ribcage to the lower part of your left abdomen; and then the sigmoid colon that loops (in an s-shape) along the lower abdomen to the center of the body. At the end of the colon is the rectum, which pretty much connects the colon to the actual anus/anal opening for wastes to leave the body.

That being said, colorectal cancer can affect any part or segment of the colon and the rectum. If you have a family history of colorectal cancer, or if you have an inflammatory bowel disease (like Crohn’s disease or ulcerative colitis), then you may be at a higher risk for colorectal cancer. Other risk factors are the same for virtually any other health condition – genetics, no regular physical activity, poor diet, tobacco use, high alcohol consumption, etc.

So how would we know if it’s colorectal cancer – or precancerous cells, and how do we decrease our risk?

That’s where screening comes into play! Just like how someone may see their gynecologist annually and undergo the PAP smear every 1-3 years to check for any gynecological cancer (like cervical or labial cancer), someone may see their colorectal or gastrointestinal (GI) provider to check for colorectal cancer or disorders. Regular screening takes place around age 45 (although a person may be screened earlier if they are at higher risk or had a previous history of cancer).

What does screening look like?

There are a few tests that screen for colorectal cancer. These tests include stool tests, flexible sigmoidoscopy, and colonoscopy.

Stool tests – This pretty much involves you taking a sample of your stool via test kit provided to you, and returning it to your doctor/lab, where your stool is checked for any blood or other abnormal findings.

Flexible sigmoidoscopy – A thin, short tube with a light is inserted into the rectum. This allows your doctor to see any polyps or cancer within the rectum and lower part of the colon.

Colonoscopy – This is like the sigmoidoscopy, but with a longer tube. The longer tube allows your doctor to check for polyps/cancer inside the rectum and the entire length of the colon. Your doctor can also remove some polyps during this procedure if indicated.

Most people without any symptoms, abnormal findings or outstanding personal or family history of colorectal cancer will have these screening tests performed anywhere from 5-10 years.

What are the symptoms? 

This is not an exhaustive list, but some symptoms may include:

• Bleeding, pain, and/or discomfort within the rectum/anus
• Blood in stool
• Abdominal pain and bloating
• Nausea/vomiting
• Difficulty or incomplete bowel evacuation
• Hemorrhoids
• Altered bowel habits (such as sudden constipation, diarrhea, change in stool consistency)

Now what are our treatment options?

Besides preventative measures – such as getting regular physical activity, improving our diet, etc., treatment looks similar to any other cancer treatment. This may look like chemotherapy, radiation therapy, immunotherapy, and/or surgery. Surgery may be indicated to remove polyps/tumors, or parts of the colon or rectum to eliminate cancerous growths. Thankfully though, regular screening of the colorectal region can find precancerous/cancerous cells early. Oftentimes, such as during a colonoscopy, your colorectal provider may go ahead and remove polyps that are abnormal or deemed precancerous at that time!

Now what about pelvic physical therapy? Can it possibly help?

Well, this is another condition (like Pelvic Congestion Syndrome in the previous blog post), where pelvic physical therapy is not the initial go-to or main treatment option. Individuals with colorectal cancer vary in several ways depending on staging/severity and overall health. Once again, pelvic therapy is a nice resource to utilize if you’re needing or wanting ways to manage your bowel symptoms.

Ways that pelvic PT CAN help may include: Teaching appropriate toileting – positioning to straighten out the anorectal angle and allow stool to pass more easily from the rectum; mechanics, such as exhaling smoothly when pushing for a bowel movement to prevent straining; Improving pelvic floor muscle function (strength, endurance, coordination) so that your body can delay defecation as needed and calm down bowel urges; and overall promoting health bowel habits by supporting your nutrition and keeping bowel movements regular.

Whether or not you (or someone you know) have colorectal cancer, developing healthy and safe bowel habits is key to a better quality of life. Working with your doctor and/or your team of providers is important in making sure your needs are addressed, but feel free to reach out to your local pelvic PT if you want more resources or guidance – even things like, “So, how SHOULD I be pooping??”

References & Resources

Brenner H, Chen C. The colorectal cancer epidemic: challenges and opportunities for primary, secondary and tertiary prevention. Br J Cancer. 2018;119(7):785-792. doi:10.1038/s41416-018-0264-x

https://www.cancer.org/cancer/colon-rectal-cancer.html

https://my.clevelandclinic.org/health/diseases/14501-colorectal-colon-cancer

Kuipers EJ, Grady WM, Lieberman D, et al. Colorectal cancer. Nat Rev Dis Primers. 2015;1:15065. Published 2015 Nov 5. doi:10.1038/nrdp.2015.65

Leslie A, Steele RJC. Management of colorectal cancerPostgraduate Medical Journal 2002;78:473-478. http://dx.doi.org/10.1136/pmj.78.922.473

Mármol I, Sánchez-de-Diego C, Pradilla Dieste A, Cerrada E, Rodriguez Yoldi MJ. Colorectal Carcinoma: A General Overview and Future Perspectives in Colorectal Cancer. Int J Mol Sci. 2017;18(1):197. Published 2017 Jan 19. doi:10.3390/ijms18010197

You YN, Lee LD, Deschner BW, Shibata D. Colorectal Cancer in the Adolescent and Young Adult Population. JCO Oncol Pract. 2020;16(1):19-27. doi:10.1200/JOP.19.00153

Tara Sullivan, PT, DPT, PRPC, WCS, IF is on faculty with Herman & Wallace. She created Sexual Medicine in Pelvic Rehab and co-created Pain Science for the Chronic Pelvic Pain Population which she instructs alongside co-creator Alyson N Lowrey, PT, DPT, OCS. Tara started in the healthcare field as a massage therapist, practicing over ten years including three years of teaching massage and anatomy and physiology. Tara has specialized exclusively in Pelvic Floor Dysfunction treating bowel, bladder, sexual dysfunctions, and pelvic pain since 2012. She is adjunct faculty speaking at the annual conference for the International Society for the Study of Women’s Sexual Health (ISSWSH) and teaches an elective course at Northern Arizona University (NAU) and Franklin Pierce University on Pelvic Health. Tara is very passionate about creating awareness on Pelvic Floor Dysfunction and recently launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

You may have heard of Jessica Pin. She’s been making headlines lately with the unconventional ways she is going about changing what medical texts and schools teach about the clitoris…..which is currently very little. According to Pin, who has a bachelor’s degree in biomedical engineering, the average textbook has over 50 pages more dedicated to the penis than compared to the clitoris. Jessica Pin started her journey to create awareness of clitoral anatomy because at 17 years old she had a labiaplasty leaving her with sensory loss. Jessica’s activism has so far changed 8 medical texts to include detailed anatomy of the clitoris in hopes knowledge of this anatomy is understood well, as it is critical prior to performing surgery near the clitoris.

Loss of clitoral function can also occur after labiaplasty, biopsies, cosmetic surgeries, and repair. As pelvic rehab providers, there is a level of responsibility we have to help shift the narrative. How often have we seen or heard similar stories of young patients undergoing cosmetic surgeries to try to ‘look normal’ or apologize for the way they look? We have such a unique position to spend time educating our patients and treating sexual dysfunctions across the spectrum.

The clitoris is analogous to the penis so what is the cause of this disparity? It could be that, traditionally, the focus has been on penetrative intercourse which largely overlooks that the clitoris is the primary sexual organ of the female sexual response and that 81.6% of women don’t orgasm from intercourse alone (without additional clitoral stimulation). Only 18.4% of women report that intercourse alone is sufficient to orgasm (Herbenick, et al. 2018).

The clitoris has historically been omitted from anatomical textbooks and then ‘rediscovered’ throughout medical history (O’connell, 1998). If you look at the 1948 Grey’s Anatomy textbook you will see that the clitoris was left out. Anatomical information centralized around the medical field has been historically male-dominated, affecting how the world discusses and understands anatomy and their bodies even in the current day. In 2005 Wade, Kremer and Brown ran a study on college students and found that 29% of women and 25% of men could not identify the clitoris on a diagram of the vulva. We need to revolutionize female sexuality in general, change the focus from the linear model where penetrative sex and orgasm are the focus as it’s been traditionally taught. 

The full clitoris goes far beyond the crown which is the external tip. The clitoris actually extends several inches into the body where it branches into a shape similar to a wishbone. A description that I love is from Latham Thomas, “It’s all this amazing erectile tissue that wraps around, and it all engorges when it’s stimulated. Pound for pound, if you have a vulva, you actually have the same amount of erectile tissue that people with penises have, but it’s just internal.” These clitoral legs are responsible for the sensations where the front wall of the vagina connects to the paraurethral glands (the G-spot) and for female ejaculation.

I authored the Herman & Wallace Sexual Medicine in Pelvic Rehab course for practitioners to have a platform to learn proper anatomy, identify misconceptions, and understand that sexuality is circular with satisfaction as the focus. With the understanding of ‘normal’ anatomy and function, we can help our patients with sexual dysfunctions return to a healthy sexual lifestyle.

To sign the petition to get the nerves of the clitoris into the American College of OB/GYN curriculum go to:

https://www.change.org/p/american-college-of-ob-gyns-get-nerves-of-the-clitoris-into-american-college-of-ob-gyn-curriculum?utm_content=cl_sharecopy_26277604_en-US%3A3&recruiter=955693637&utm_source=share_petition&utm_medium=copylink&utm_campaign=share_petition

Sexual Medicine in Pelvic Rehab is a two-day, remote continuing education course 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 the gender and sexual spectrum, 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, and 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. As well as the 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.

Course dates in 2022 include:

• April 9-10
• July 16-17
• October 15-16

Top Homogenous Image: Internal genitalia depicting homology (Carrellas, B. and Sprinkle, A., 2017).

Bottom Clitoral Anatomy Image: Jessica Pin, https://drive.google.com/file/d/1fS1HfBWYqXAEBu_jnAPuiulTE3nqIYYQ/view

O'Connell, H.E., Hutson, J.M., Anderson, C.R. and Plenter, R.J., 1998. Anatomical relationship between urethra and clitoris. The Journal of Urology, 159(6), pp.1892–1897.

Herbenick, D., Tsung, Chieh F., Arter, J. Women's Experiences With Genital Touching, Sexual Pleasure, and Orgasm: Results From a U.S. Probability Sample of Women Ages 18 to 94. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2017.1346530

Wade, L.D., Kremer, E.C. and Brown, J., 2005. The incidental orgasm: The presence of clitoral knowledge and the absence of orgasm for women. Women & Health, 42(1), pp.117–138.

Megan Kranenburg, PT, DPT, WCS created the course Doula Services and Pelvic Rehab Therapy to present the unique challenges of merging a rehab practice with Doula services. Megan is a physical therapist who has balanced her solo outpatient pelvic health practice and Doula work since 2016. She lives and works in the nexus of Doula training near Seattle, Washington - which has provided plenty of opportunities to observe and participate in birth conversations and process the experience through the Physical Therapist's mind and heart.

As a pelvic floor practitioner, you may know that nearly 24% of women in the United States have pelvic floor dysfunction (as reported by the National Institutes of Health) and that this frequency increases with age. Childbirth can contribute to pelvic floor dysfunction, and it can be beneficial for pelvic therapists to know the doula's toolkit

So what is a doula? Doulas are often the first and sometimes the only people with whom a birthing person will feel comfortable discussing pelvic floor-related issues. Dona International defines a doula as a trained professional who provides continuous physical, emotional, and informational support to a mother before, during, and shortly after childbirth to help her achieve the healthiest, most satisfying experience possible.

Doulas can offer position ideas for comfort and labor progression, while their skilled hands can assist a mispositioned baby find its way through the pelvis. They can also support the birthing parent in learning how to push safely, effectively and protect the pelvic floor for birth. Doulas may hear several different symptoms of pelvic floor conditions from their clients through the perinatal experience. Two examples of natural birth/ pushing that a doula and pelvic therapist can spot or assist with include:

• Long hours of pushing can contribute to long-term muscle weakness and damage as well as lead to incontinence and pelvic organ prolapse.
• Uncoordinated pushing can result in weaker pelvic floor muscles that can last for several months postpartum. This weakness can also contribute to incontinence.

Similarly, Sara Reardon shared in a blog for Doula Trainings International a few symptoms of pelvic floor conditions that doulas may hear from their clients and can be looking out for throughout the birthing experience (1):

• Pain above the vagina that is sharp or achy and is exacerbated when rolling over in bed, or standing on while leg while getting dressed. This can be pubic symphysis dysfunction due to ligament relaxation.
• Pain in the back or lower back on one side that is sharp and is felt with a deep lunge, or when standing for a long time. This can be sacroiliac joint dysfunction due to ligament relaxation.
• Heaviness or pressure in the vagina that is worse at the end of the day, after exercise, or when standing. This can be a prolapse of pelvic laxity/varicose veins/swelling.
• Leakage of urine or poop, constipation, hemorrhoids and straining with bowel movements, incomplete bladder emptying, urinary urgency.

During vaginal birth, the baby passes through the ‘levator hiatus’ in the pelvic floor. This process can damage the fascia, muscles, connective tissues, and nerves. The levator muscles are stretched by 1.5 to more than 3 times their normal length as the baby passes through, depending on the size of both baby and pelvic floor muscle opening. (2) After this fascia is stretched, or torn, it doesn't heal like before. This fascia is attached to the bone and supports the urethra, vagina, and rectum.

Pelvic therapists and doulas can both make a big difference in the health of their clients. The following simple list is a very basic list that can be shared with clients that can make a difference in their healing.

• Breath - Inhale for the count of 2. Exhale for the count of 4. Repeat. Allow the exhale to be longer than your inhale.
• Nutrition - Choose nourishing whole foods. Collagen and mineral-rich foods, good quality protein, zinc, vitamin C are critical for tissue integrity and supporting new connective tissue repair.
• Hydrate - Easy & often. Don't wait until the end of the day to hydrate. Manage fluids throughout the day.
• Movement - Start with a good walk and build up from there. Spend time sitting on the floor with your baby and practice getting up from there.
• Sleep when the baby sleeps. Regular sleep and deep restorative rest are important for healing, recovery, and supporting mental energy.
• Each birth story is important and valid.

Doula Services and Pelvic Rehab Therapy is scheduled for April 3rd, August 6th, and December 10th this year. This is a four-hour, beginner-level course. Practitioner's who register are recommended to have completed Pelvic Floor Level 1, and the following reading:

• Preparing for A Gentle Birth, Calais-Germaine
• Reviving your Sex Life After Childbirth, Wallace
• The Birth Partner, Penny Simkin

1. 5 Pelvic Health Lessons For Doulas From The Vagina Whisperer. The DTI Team. Doula Trainings International. Nov 5, 2018. https://doulatrainingsinternational.com/5-pelvic-health-lessons-for-doulas-from-the-vagina-whisperer/
2. Pelvic Floor Muscle Damage. Australasian Birth Trauma Association. https://www.birthtrauma.org.au/physical-birth-trauma/pelvic-floor-muscle-damage/#:~:text=The%20levator%20muscles%20are%20stretched,and%20pelvic%20floor%20muscle%20opening.&text=In%20many%20women%2C%20these%20muscles,sometimes%20torn%20off%20the%20bone.

In a 2018 article by Holly Tanner, she explains how managing a medical crisis such as a cancer diagnosis can be overwhelming for an individual. ‘Faced with choices about medical options, dealing with disruptions in work, home, and family life often leaves little energy left to consider sexual health and intimacy. Maintaining closeness, however, is often a goal within a partnership and can aid in sustaining a relationship through such a crisis.” Research shows that cancer treatment is disruptive to sexual health. Intimacy is a larger concept that may be fostered even when sexual activity is impaired or interrupted.

Prostate cancer treatment can change relational roles, finances, work-life, independence, and other factors including hormone levels. (1) Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido, and performance anxiety can create further challenges. (1, 3, 4) Recovery of intimacy is possible, and reframing of sexual health may need to take place. Most importantly, these issues need to be talked about, as a renegotiation of intimacy may need to take place after a diagnosis or treatment of prostate cancer. (2)

If a patient brings up sexual health, or the practitioner encourages the conversation, many research-based suggestions can be provided to encourage recovery of intimacy including:

• Redefining sex to include other sexual practices beyond penetration, such as massage or touching, cuddling, talking, use of vibrators, medication, aids such as pumps (5)
• Participation in couples therapy to understand their partner’s needs, address loss, be educated about sexual function (7)
• Participation in “sensate focus” activities (developed by Masters & Johnson in the 1970s as “touch opportunities”) with appropriate guidance (6)

Holly continues to share that “Within the context of this information, there is an opportunity to refer the patient to a provider who specializes in sexual health and function. While some rehabilitation professionals are taking additional training to be able to provide a level of sexual health education and counseling, most pelvic health providers do not have the breadth and depth of training required to provide counseling techniques related to sexual health - we can, however, get the conversation started, which in the end may be most important.”

Courses of Interest:

Oncology of the Pelvic Floor Level 2A Remote Course - Male Pelvic and Colorectal Cancers - April 2-3, 2022

• A colorectal or male pelvic cancer diagnosis has multiple systems that are affected by cancer treatment. The rehabilitation professional that works with the pelvic oncology patient needs to competently navigate treatment techniques for all of these systems, as well as be confident in treating a patient in a personal area. This two-day course will address specific cancer types including prostate cancer, penile cancer, and testicular cancer. Additional cancer types covered include colorectal cancer and anal cancer.

Trauma Awareness for the Pelvic Therapist - Remote Course - Apr 9-10, 2022

• Bring their increased awareness of trauma to the successful, holistic treatment of patients with pelvic pain, sexual dysfunction, bowel dysfunction, and bladder dysfunction.

Sexual Medicine in Pelvic Rehab - Remote Course - Apr 9-10, 2022

• This course provides a thorough introduction to pelvic floor sexual function, dysfunction and treatment interventions for males and females of all 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, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Male Pelvic Floor Function, Dysfunction, and Treatment - Satellite Lab Course - April 23-24 2022

• Discuss sexual anatomy and physiology, prostate issues, and look at the research describing models of intimacy and what worked for couples who did learn to renegotiate intimacy after prostate cancer. Participants will be able to describe the relationships between pelvic muscle function and men’s sexual health, including the evidence that demonstrates pelvic muscle rehabilitation's positive impact on erectile function.

1. Beck, A. M., Robinson, J. W., & Carlson, L. E. (2009, April). Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. In Urologic oncology: seminars and original investigations (Vol. 27, No. 2, pp. 137-143). Elsevier.
2. Gilbert, E., Ussher, J. M., & Perz, J. (2010). Renegotiating sexuality and intimacy in the context of cancer: the experiences of carers. Archives of Sexual Behavior, 39(4), 998-1009.
3. Hawkins, Y., Ussher, J., Gilbert, E., Perz, J., Sandoval, M., & Sundquist, K. (2009). Changes in sexuality and intimacy after the diagnosis and treatment of cancer: the experience of partners in a sexual relationship with a person with cancer. Cancer Nursing, 32(4), 271-280.
4. Higano, C. S. (2012). Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology, 30(30), 3720-3725.
5. Ussher, J. M., Perz, J., Gilbert, E., Wong, W. T., & Hobbs, K. (2013). Renegotiating sex and intimacy after cancer: resisting the coital imperative. Cancer Nursing, 36(6), 454-462.
6. Weiner, L., Avery-Clark, C. (2017). Sensate Focus in Sex Therapy: The Illustrated Manual. Routledge, New York.
7. Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., An, L., Palapattu, G., & Montie, J. E. (2014). Exploring the role of the partner in couples’ sexual recovery after surgery for prostate cancer. Supportive Care in Cancer, 22(9), 2509-2515.

Faculty member Christine Stewart, PT, CMPT began her career specializing in orthopedics and manual therapy and became interested in women’s health after the birth of her second child.  Christine joined Olathe Health in 2010 to further focus on women’s health and obtain her CMPT from the North American Institute of Manual Therapy. She also went through Diane Lee's integrated systems model in 2018. Her course, Menopause Transitions and Pelvic Rehab is designed for the clinician that wants to understand the multitude of changes that are experienced in the menopause transition and how they affect the aging process. 

Menopause. The M-word, the second puberty, is the final frontier of a hormonal roller coaster when there are twelve consecutive months with no menstruation. A time of celebration, right? No more cramps, hygiene products, menstrual cups, or moodiness – FREEDOM! Not so fast my fellow clinician!

The body goes through some serious, hormonal loop-the-loops leading up to the cessation of ovulation. Perimenopause is the stretch leading up to the final cycle and this stretch can feel like yoga on steroids. It can last TEN years, not including symptoms experienced after the transition takes place. Changes in cycle length, flow, anovulation, and yes, even ovulating twice are all stages of perimenopause. (Hale et al., 2009). These changes translate into symptoms: sleeplessness, brain fog, anxiety, palpitations, fatigue, painful intercourse, and joint stiffness are just a few things that can be experienced during this time (Lewis, 2021).

This transition can begin for patients during their mid-thirties, more commonly it begins during their forties, but eventually, all people that ovulate will experience it. For some, perimenopause can be much more challenging than after menopause. The perimenopause hormone guessing game begins. Some months, progesterone makes an appearance. The next month, mostly estrogen, and some months - neither are around very much at all. If there is an abrupt change in ovulation, such as with a complete hysterectomy, the symptoms will most likely be intensified due to the abrupt loss of hormones. (Gunter, 2020). Dealing with the changes of menopause can be challenging in a variety of ways (like a two-year-old wailing for a candy bar in the checkout line), but many things can help ease this transition.

With fluctuating hormones also comes changes to many systems in the body. Estrogen receptors are everywhere, and when hormone levels are changing, so does the body’s internal workings. Glucose metabolism, bone physiology, brain, and urogenital function are just some of the systems affected (Shifren et al., 2014). Perimenopause is not just a time of altered periods. It is also a critical time in a person’s health where an increased incidence of heart disease, diabetes, and bone loss can begin (Lewis 2021).

Preparing for menopause should be on our radar for patients in their twenties, thirties, and early forties before the process starts. Establishing healthy habits earlier instead of later can help for a more successful transition, however, it is never too late! Knowing the signs and symptoms of this phase can help us guide patients and ourselves to a better understanding of what is happening with the body in this adaptation. We can make recommendations on lifestyle, exercise, and meditation, as well as refer them to other knowledgeable providers when needed.

I have had countless patients sent to me for urinary frequency, incontinence, or painful intercourse who are in this transition, but no one has talked to them about what is happening to their bodies. You may be thinking to yourself, these patients have doctors. Why aren’t they getting the information from their physician? After all, these providers have had years of training. The reality is sometimes doctors do not receive the necessary education to treat menopausal patients. 

In a survey of postgraduate trainees in internal medicine, family medicine, and obstetrics/gynecology, 90% felt unprepared to manage women experiencing menopause (Reid, 2021). Insert jaw drop here. As pelvic health providers, we can help to fill this knowledge gap and be a conduit to explaining the process. We can empower patients with education, treatments, and recommendations to flourish in this critical phase of life.

The menopause transition can be a time of great uncertainty. Not only are patients’ lives transforming as their children grow and their parents age, but their bodies are changing as well. We can ease their burden in this period of adaptation. By calming their fears through education, we can assure them that indeed, they are not losing their minds.

Knowledge is power, and I am all in when it comes to empowering patients. They can learn that menopause is a phase and does not define who they are as a person. It is possible to survive and come out on the other side still thriving, while learning how to cope during the process. There is hope! 

Menopause Transitions and Pelvic Rehab is an excellent opportunity to understand the physiological consequences to the body as hormones decline, in order to assist our patients in lifestyle habits for successful aging. Lecture topics include cardiovascular changes, metabolic syndrome, bone loss and sarcopenia, neurological changes (headache, brain fog, sleeplessness), Alzheimer’s risk, urogenital changes, as well as symptoms and treatment options. These include hormone replacement, non-hormonal options, dietary choices, and exercise considerations. 

Manual Therapy for the Abdominal Wall allows practitioners to review how everything interplays within the myofascial system and apply specific techniques. These techniques include how to assess the tissue for mobility, how to treat tissues that are restricted in the abdominal wall, and how to treat scar tissue. How do we help somebody who can’t lay flat because their abdominal wall has become restricted for so long because of possible pain? Possibly due to surgery. Possibly due to fear. How do we help those patients get back to function?

Over the past 10 plus years of teaching the pelvic series with Herman & Wallace, Tina Allen noticed that for some of the participants there was a gap in confidence in palpation skills and treatment techniques applied to the pelvic floor region. For most, it’s confidence in where they are and what they are feeling on the patient. Manual Therapy for the Abdominal Wall came out of wanting to fill that gap. This course is really about taking some of those skills and then applying them to the abdominal wall.

Abdominal pain can arise from many origins including abdominal scars, endometriosis, IC/PBS, and abdominal wall restrictions that impact pelvic girdle dysfunction. An older study, back in 2007 by Geoff Harding focused on back, chest, and abdominal pain and whether it was spinal referred pain and employed manual therapy as part of his treatments for his case studies. Harding found that “More specific treatment of the origin of the pain may then include manual therapy, including mobilization (gentle rhythmic movement), …  applied to the affected segment can be very effective in reducing movement restriction – and pain. These simple treatments were used in all three case studies to good effect.” (1)

This research was supported by Rice et al. in 2013 when their research on non-surgical treatment of adhesion-related small bowel obstructions showed that “those patients who underwent the manual therapy demonstrated increased range of motion … and an early return to normal activities of daily living simply enhanced the benefits.” (2) Manual therapy has no recovery time and allows patients to recover and participate in daily activities while promoting the return of normal tissue function, range of motion, and increased blood flow.

Tina Allen explains that manual therapy is about “asking for permission to touch and using our hands to help the patient integrate into their system again. The patient may not realize that they’ve been holding, that there is tension or rigidity in the tissues.” Tina continues to share that “for me, manual therapy fits in to help folks realize, or feel, what’s happening in their body again. And then allowing them to make that change. I use manual therapy to allow a patient to move better. To become more aware in their body.” The full interview with Tina can be viewed below or on the Herman & Wallace YouTube Channel.

Manual Therapy for the Abdominal Wall is a beginner-level class and is filled with practitioners just beginning their pelvic floor journey through experienced clinicians taking the course to learn something new. The techniques instructed by Tina Allen are immediately applicable in the clinic. Course dates for 2022 include:

• March 19
• June 5
• October 14

References:

1. Harding G, Yelland M (2007). Back, chest, and abdominal pain. Australian Family Physician, 36(6), 422-429.
2. Rice, A. D., King, R., Reed, E. D., Patterson, K., Wurn, B. F., & Wurn, L. J. (2013). Manual Physical Therapy for Non-Surgical Treatment of Adhesion-Related Small Bowel Obstructions: Two Case Reports. Journal of clinical medicine, 2(1), 1–12. 
   

Dustienne Miller, CYT, PT, MS, WCS instructed the H&W remote course Yoga for Pelvic Pain. Dustienne passionately believes in the integration of physical therapy and yoga in a holistic model of care, helping individuals navigate through pelvic pain and incontinence to live a healthy and pain-free life.  You can find Dustienne Miller on Instagram at @yourpaceyoga

Research demonstrates multiple benefits of a yoga practice that extend beyond the musculoskeletal system. These benefits 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.

Do the brains of yoga practitioners vs non-practitioners look different?

A study by Villemure et al looked at the role the insular cortex plays in mediating pain in the brains of yoga practitioners. They included various styles of yoga to capture the essence of yoga across multiple styles - Vinyasa, Ashtanga, Kripalu, Sivananda, and Iyengar.

Rewind back to neuroanatomy class - remember the insular cortex? The insular cortex is responsible for sensory processing, decision-making, and motor control by communicating between the cortical and subcortical aspects of the brain. The outside inputs include auditory, somatosensory, olfactory, gustatory, and visual. The internal inputs are interoceptive (Gogolla).

Villemure et al found several interesting objective differences. The practitioners had increased grey matter volume in several areas of the brain. This increase in grey matter specifically in the insula correlated with increased pain tolerance. The length of time practiced correlated with increased grey matter volume of the left insular cortex. Additionally, white matter in the left intrainsular region demonstrated more connectivity in the yoga group.

Other differences were seen in strategies utilized to manage pain. Most folks in the yoga group expected their practice would decrease reactivity to pain, which it did. The yoga group used parasympathetic nervous system accessing strategies and interoceptive awareness. These strategies were breathwork, noticing and being with the sensation, encouraging the mind and body to relax, and acceptance of the pain. The control group strategies were distraction techniques and ignoring the pain.

The authors determine that the insula-related interoceptive awareness strategies of the yoga practitioners being used during the experiment correlated with the greater intra-insular connectivity. Therefore, the authors conclude that the insular cortex can act as a pain mediator for yoga practitioners.

The more strategies our patients have for pain management, the better! Yoga is one of several non-invasive modalities our patients can add to their healing toolbox.

Yoga for Pelvic Pain was developed by Dustienne Miller to offer participants an evidence-based perspective on the value of yoga for patients with chronic pelvic pain. This course focuses 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 are discussed including interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia. Other lectures discuss 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.

References:

Gogolla N. The insular cortex. Current Biology. 2017; 27(12): R580-R586.

Villemure C, Ceko M, Cotton VA, Bushnell MC. Insular cortex mediates increased pain tolerance in yoga practitioners. Cereb Cortex. 2014 Oct;24(10):2732-40. doi: 10.1093/cercor/bht124. Epub 2013 May 21. PMID: 23696275; PMCID: PMC4153807.

Rachna Mehta, PT, DPT, CIMT, OCS, PRPC is the author and instructor of the Acupressure for Optimal Pelvic Health course. Rachna brings a wealth of experience to her physical therapy practice and has a personal interest in various eastern holistic healing traditions. 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.

What is Acupressure

According to the National Center for Complementary and Integrative Health (NCCIH), a branch of the National Institute of Health (NIH), a recent study by Feldman et al¹ in the Journal of Pain showed that patients with newly diagnosed chronic musculoskeletal pain are prescribed opioids more often than physical therapy, counseling, and other nonpharmacologic approaches. A study² by Elizabeth Monson and colleagues noted that the use of effective nonpharmacologic options is now mandated by Joint Commission Guidelines³ per updated pain management recommendations. The study also noted that there has been a growing clinical interest in Acupressure as a therapeutic modality for symptom management in Western health care.

The scientific literature presents robust 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 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.

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 anxiety².

The Sanyinjiao (SP6) Acupoint

Sanyinjiao (SP6) acupoint is one of the most extensively researched points in the literature. It is located four finger-widths above the tip of the medial malleolus. Studies have found Sp 6 to be effective in relieving pain associated with primary dysmenorrhea, premenstrual syndrome (PMS), labor pain as well as symptoms of menopause. Ancient and modern acupuncture charts map the Spleen meridian as part of the principal 12 meridians which are connected to the physiological functions of key organs.

A recent systematic review published by Abarogu et al⁴ reviewed the available evidence for SP6 (Sanyinjiao) acupressure for the relief of primary dysmenorrhea symptoms, as well as patients' experiences of this intervention. The review included six studies with a total of 461 participants. The primary outcome was pain intensity. They found that:

• SP6 acupressure delivered by trained personnel significantly decreased pain intensity immediately after the intervention (effect size = -0.718; CI = -0.951 to -0.585; p = 0.000)
• Pain relief remained up to 3 h after the intervention (effect size = -0.979; CI = -1.296 to 0.662; p = 0.000)

The review concluded that SP6 acupressure appears to be effective when delivered by trained personnel for Primary Dysmenorrhea symptoms.

Acupressure has also been used with various types of mindfulness and breathing practices including Qigong and Yoga. Yin Yoga, a derivative of Hath Yoga is a wonderful complimentary practice to Acupressure. Yin Yoga is a calm meditative practice that uses seated and supine poses, held for three to five minutes with deep breathing. Yin poses supportively align the body to stress connective tissues along specific meridian lines thereby activating potent acupressure points that lie along those meridians. Mindfulness-based holistic interventions are the key to empowering our patients by giving them the tools and self-care regimens to lead healthier pain-free lives.

The course Acupressure for Optimal Pelvic Health brings a unique evidence-based perspective by integrating Acupressure and Yin Yoga into traditional rehabilitation interventions. It is curated and taught by Rachna Mehta. To learn how to integrate Acupressure into your practice, join the next scheduled remote course on March 19-20, 2022.

 References

1. Feldman DE, Carlesso LC, Nahin RL. Management of Patients with a Musculoskeletal Pain Condition that is Likely Chronic: Results from a National Cross-Sectional Survey. J Pain. 2020;21(7-8):869-880.
2. 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.
3. Pain assessment and management standards for hospitals. Online document at: https://www.jointcommission.org/standards/r3-report/r3-report-issue-11-pain-assessment-and-management-standards-for-hospitals/
4. 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.
5. Chen MN, Chien LW, Liu CF. Acupuncture or Acupressure at the Sanyinjiao (SP6) Acupoint for the Treatment of Primary Dysmenorrhea: A Meta-Analysis. Evid Based Complement Alternat Med. 2013;2013:493038.
6. Mehta P, Dhapte V, Kadam S, Dhapte V. Contemporary acupressure therapy: Adroit cure for painless recovery of therapeutic ailments. J Tradit Complement Med. 2016;7(2):251-263.

Part 1: Burnout

Let’s get real for a minute.

You are a highly educated professional.  If you are reading this blog, I can assume you are invested in your career and your continued education.  You are probably pretty skillful, and you help a lot of people.

BUT

How are you doing once you leave work?

Does your life outside of work give you joy and fulfillment?

Or do you leave your work setting completely drained, snippy with your loved ones, and too tired to care for yourself?

You have at least one advanced degree, probably some certifications, but did anyone ever teach you how to get your paperwork done on time? 

Or how to leave work at work and not have your patients popping into your head day and night?

What about energy conservation?  In fact, we may have been taught to give our ALL to work, to our patients, to strive for productivity and accomplishment.  But where does that leave us?

BURNED OUT.

Part 2:  Mindset

Taking continuing education classes was my pathway to becoming a better physical therapist.

But I had to go to therapy to learn how to survive as a physical therapist.

There were struggles.

Paperwork.  I could NEVER finish in a timely way.

Timeliness.  I was OFTEN running behind for patients.

Discharge. I had some patients for YEARS because I did not know how to discharge them even though they weren’t getting better.  They depended on me, and I also depended on them.

Boundaries.  I had none. 

And here’s something that surprised me. 

I had to change the way I THOUGHT before I could change my BEHAVIOURS.

I had to change my mindset.

I used to show up at work with the idea of Helping People.  I felt responsible for their outcomes.  If they weren’t doing well, I assumed I was missing something.

The shift looked like this:

I can show up at work to coach people who are responsible for their own outcomes.  If they aren’t doing well, we can have honest communication about next steps (medical or otherwise), discharge, or resistance.

My patients are not my family, they are not my friends.  I show up as a coach who is very interested in understanding their story and helping them reach their goals through a shared responsibility model of care.

My free time is sacred.  I need to protect it for my mental, physical, spiritual, and emotional health.  Because I am a priority, I will use 5 minutes of each treatment session to complete the patient’s treatment by doing paperwork.

Now, therapy is INVALUABLE.  Don’t get me wrong, but paperwork, timeliness, discharge, and healthy boundaries are things MANY of us struggle with.  So Nari Clemons and I designed a Continuing Education COURSE.  We believe that therapists deserve to learn skills to preserve our wellbeing and strengthen our resilience against burnout. 

Especially since the pandemic, more and more health care workers are reporting very high levels of burnout.  Nari Clemons and I went through a period of burnout earlier in our careers.  The tools and techniques we learned to heal ourselves and develop new patterns of delivering care are powerful.  We know you might also be struggling and we want to help.  So we developed a course to equip you.  We would love to learn with you at Boundaries, Self-Care, and Meditation.  A two-part, online journey toward experiencing a practice you enjoy and a life you love.

Boundaries, Self-Care, and Meditation is a two-part series intended to be completed in order. Participants should register for Part 1 and Part 2 at the same time, or complete Part 1 and wait to complete Part 2 at a later date. This course was developed by Nari Clemons, PT, PRPC, and Jennafer Vande Vegte, PT, PRPC and was "born out of our own personal and professional struggles and our journey to having a life and a practice that we love and can sustain." The intention of this class is deep, personal, and professional transformation through evidence-based information and practices. Both Part One and Part Two have a significant amount of pre-work to digest and practice before meeting via Zoom. Nari shares that "This sets the stage for you to find your path to experiencing more joy, energy, and balance."

Boundaries, Self-Care, and Meditation - Part 1 - Remote Course

In Part One, participants begin their process of study, meditation, and self-reflection in the weeks prior to the start of the class. Pre-work includes focusing on the neuroscience of pain, trauma, PTSD, and meditation. Participants will learn about the powerful influence both negative and positive experiences have on our nervous system’s structure and function. Personal meditation practice and instruction will create changes in the participant's own nervous system. Participants will also learn how to prescribe meditation for various patient personalities and needs, as well as analyze yourself through inventories on coping, self-care, empathy, burnout, values as well as track how you spend your time. Commitment to pre-work will facilitate rich discussion as we put what you have learned into practice around building a shared responsibility model of patient care, language to support difficult patients, and both visualizing and planning steps to create new, healthier patterns in your life and in your practice.

Boundaries, Self-Care, and Meditation - Part 2 - Remote Course

Part Two continues the focus on personal and professional growth for the participant, with a deeper dive into meditation and self-care practices. Yoga 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". Course 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. 

The hip flexor muscles include the Iliopsoas group (Psoas Major, Psoas Minor, and Iliacus), Rectus Femoris, Pectineus, Gracillis, Tensor Fascia Latae, and Sartorius. When the hip flexors are tight it can cause tension on the pelvic floor. This can pull on the lower back and pelvis as well as change the orientation of the hip socket, lead to knee pain, foot pain, bladder leakage, prolapse, and so much more. The ramifications of iliacus and iliopsoas dysfunctions are discussed in a contemporary and evidence-based model with Steve Dischiavi in the Athletes & Pelvic Rehabilitation remote course.

A common issue with the iliacus and hip flexors is that they can shorten over time due to a lack of stretching or a sedentary lifestyle. When this happens, the muscle adapts by becoming short, dense, and inflexible and can have trouble returning to its previous resting length. A muscle that resides in this chronic contraction can become ischemic, develop trigger points, and distort movement in the body.

If you are treating patients with pain in their lower abdomen, sacroiliac joint, or that wraps around the lower back and buttocks, it could be because the hip flexors are tight. Traditional testing performed by medical practitioners tends to come back negative as many tests do not evaluate soft tissue issues. The best way to diagnose these concerns is through assessment with skilled palpation and structural evaluation.

One assessment test, the Thomas Test used for measuring the flexibility of the hip flexors, is discussed in the Athletes & Pelvic Rehabilitation course. In this test, the patient is supine while flexing the unaffected, contralateral leg at the hip until lumbar lordosis disappears. The length of the iliopsoas is determined by the angle of hip flexion displayed by the patient. The test is positive when the patient is unable to keep their lower back and sacrum against the table, the hip has a posterior tilt (or hip extension) greater than 15°, or the knee is unable to meet more than 80° flexion. A positive test indicates a decrease in flexibility iliopsoas muscles.

Treatment plans for the iliacus and hip flexors include stretching. An example includes the hip extension stretch or other active isolated stretches. Manual therapy, including trigger point release, can be used in conjunction with stretching to help muscle adhesion and release muscle tension. As with all treatment, the practitioner should discuss the risks, benefits, and treatment options, and obtain consent with patients. Prior to proceeding with manual therapy treatment make sure to establish a pain scale, assess the patient's range of motion and strength, and (if needed) perform the appropriate neurologic testing.

To learn more about treatment philosophies for the pelvis and pelvic floor and global considerations of how these structures contribute to human movement you can join Steve Dischiavi in the Athletes & Pelvic RehabilitationRemote Course.

You may be interested in attending this course if you have taken:
Yoga for Pelvic Pain
Sacroiliac Joint Current Concepts
Mobilization of the Myofascial Layer: Pelvis and Lower Extremity
Weightlifting and Functional Fitness Athletes