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Pessary Use and Defecatory Dysfunction

After completing an intake on a patient and learning that her history of constipation started about 3 years ago with insidious onset, the story wasn’t really making any sense of how or why this started. Yes, she was menopausal. Yes, she seemed to be eating fiber and drinking water. Yes, she got a bowel movement urge daily, but her bowel movements felt incomplete. Yes, she was a little older, using Estrace cream, and her mobility had slowed down, but nothing seemed to make sense in the story that was leading me to believe it was an emptying problem or a stool consistency issue. She had a bowel movement urge, she could empty, but it was incomplete.

So, after explaining about physical therapy, the muscle problems involved and what we do here, it led us to the physical examination portion. I explained that we check both the vaginal and rectal pelvic floor muscle compartments to determine rectal fullness internally, check for a rectocele, check for muscle lengthening (excursion) and shortening (contraction). She was on board and desperate to find an answer. She was eager for me to help her find an answer to her emptying problem that she had for the last 3 years.

Upon entering her vaginal canal slowly, I start to move around and felt a ring of plastic. “Are you wearing a pessary?” I asked. “Pessary? Oh, yes, I forgot to tell you about that!”, she exclaimed. “How long have you been using it?” I asked. “About 3 years…” she answered.

I sent her back to the urogynecologist to get fit for another type of pessary as her muscle examination proved to be negative. Since that time, I have added the question “Do you wear a pessary?” as part of the constipation intake questions. Pessary use creates the ability for a patient to forgo or to extend their time for a surgical intervention due to pelvic organ prolapse.

Looking at the dynamics of the pessary, it may block bowel movement emptying. The recent study by Dengle, et al, published in the October 2018 in the International Urogynecological Journal confirms this anecdotal, clinical finding. The article, Defecatory Dysfunction and Other Clinical Variables Are Predictors of Pessary Discontinuation, looked at reasons for discontinuation of pessary use from April 2014 to January 2017 and did a retrospective chart review on a selected 1071 women. Incomplete defecation had the largest association with pessary discontinuation.

While there are over 20 sizes of pessaries on the market, patients will discontinue use without having a better conversation with their practitioner. From a PT perspective, when the patient comes in with bowel emptying issues, if no muscle dysfunction is found, it needs to be brought to the provider’s attention. Our role in educating the patient on the options that are available and creating this dialogue can prove to be very helpful in those suffering from pelvic organ prolapse and defecatory dysfunction.


Dengler, EG et al. "Defecatory dysfunction and other clinical variables are predictors of pessary discontinuation." Int Urogynecol J. 2018 Oct 20. doi: 10.1007/s00192-018-3777-1. https://www.ncbi.nlm.nih.gov/pubmed/30343377

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Osteoporosis and Multiple Sclerosis: Patient Study Part 3

The following is part three in a series documenting Deb Gulbrandson, PT, DPT's journey treating a 72 year old patient who has been living with multiple sclerosis (MS) since age 18. Catch up with Part One and Part Two of the patient case study on the Pelvic Rehab Report. Dr. Gulbrandson is a certified Osteoporosis Exercise Specialist and instructor of the Meeks Method, and she helps teach The Meeks Method for Osteoporosis course.

On Maryanne’s third visit, after reviewing her home exercises I told her that today our focus was on alignment. “In dealing with osteoporosis we want the forces that act upon our bodies to line up as optimally as possible. We have gravity providing a downward force from above and we have ground reaction forces coming up from below. Remember back to your first visit when we did the Foot Press in sitting and talked about Newton’s 3rd Law? For every action there’s an opposite and equal reaction and, how by pressing your feet down it helped you to sit straighter and gave more support to your back?” She nodded in agreement.

“Well, there’s another important component to that- one that we call optimal alignment. When we sit or stand in a flexed posture, those two opposing forces do not line up well and can put undue stress and pressure on our body, particularly the vertebral bodies.” I showed her the spine again with an increased flexion (hyper-kyphosis) in the thoracic area. “It’s normal to have a kyphosis in the thoracic spine. What we don’t want is a hyper-kyphosis. We often see the apex of the increased curve around T-7, 8, 9 levels near the bra line. We also call it the “slouch line” because from the front, that’s where we slouch in sitting. A thoracic hyper-kyphosis can lead to hyper-lordosis in the lumbar spine as the body tries to counteract the flexion forces above with extension or arching in the low back. We know that Wolff’s Law states that bone in a healthy person will adapt to the loads under which it is placed.1 But we want those loads to be optimally transmitted; otherwise the adaptation can be problematic.”

With Maryanne sitting in a Perch Posture position on the side of the low mat table, I placed a 4 foot dowel rod alongside her back, touching her sacrum and apex of her thoracic curve. I instructed her to bring her occiput back toward the dowel without extending her neck. I wanted her to do more of a cervical retraction move. She was a good 3+ inches away. Previously I had measured her using the WOD (Wall to Occiput Distance).2 This helps patients understand when they are forward flexed in the upper thoracic and cervical area and becomes an exercise as well. Since Maryanne was not safe in a standing position, we used an armless chair against the wall. I turned it sideways so the side of the chair was snugged up to the wall and transferred her to the chair, sitting so that her sacrum was flush against the wall. “Bring your upper back against the wall without allowing your low back to arch forward”, I told her as I placed a folded towel behind her head. “Now you’re going to press the back of your head into the towel, just as you do when lying down in the Re-alignment routine. Before you perform the Head Press, inhale to prepare, start your exhale, then do the head press. Hold for 3 -5 seconds as you continue to exhale, then relax as you inhale. Do 3-5 reps.”

The Head Press in standing, (or in Maryanne’s case, sitting) is a convenient way to not only strengthen the back muscles isometrically, but also increase awareness of body in space and relationship of head to trunk positioning. For any individual who has developed a forward head position over a period of years, there is a loss of the proprioceptive feedback necessary to know when we’re not in alignment, even if we have the ROM to achieve it. And often a lack of strength and especially muscle endurance to maintain that optimally aligned position is problematic. Using the wall several times a day can assist in building strength and awareness. In Maryanne’s case we needed a folded towel behind her occiput to give her something to press into and prevented her from going into increased cervical extension.

“I still want you to do the Head Press in supine as part of the Re-alignment routine everyday”, I told her. “But also practice it in sitting against a wall, making sure your sacrum is right up against it. Do this several times a day for several minutes, holding 3-5 seconds each. And be sure to use your breath to maintain neutral alignment of your lumbar spine.”
And with that, our work for the day was done.


1. Wolff's Law and bone's structural adaptations to mechanical usage: an ... https://www.ncbi.nlm.nih.gov/pubmed/8060014
2. Concurrent Validity of Occiput-Wall Distance to Measure Kyphosis in Communities. Journal of Clinical Trials. May 18, 2012 Sawitree Wongsa1,4, Pipatana Amatachaya2,4, Jeamjit Saengsuwan3,4 and Sugalya Amatachaya1,4*

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Transabdominal Ultrasound In The Assessment Of Abdominal And Pelvic Floor Muscles

Authors: Tamara Rial, PhD, CSPS, Kathleen Doyle-Elmer, PT, DPT and Rebecca Keller, PT, MSPT, PRPC

Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care Level 2 and 3 in Princeton, New Jersey in September, 2019. Rebecca Keller and Kathleen Doyle-Elmer are certified Low-Pressure Fitness specialists with training in rehabilitative ultrasound imaging. In this article, the authors discuss and explore the use of transabdominal ultrasound during Low Pressure Fitness on the abdominal and pelvic floor structures.

Real-time ultrasound imaging is a reliable and valid method to evaluate muscle structure, activity and mobility. Over the past few years, there has been increasing interest in the use of transabdominal ultrasound in the field of rehabilitation. The additional value of ultrasound imaging is that it allows for real-time analysis and visual feedback during the performance of pelvic floor and abdominal exercises (Hides et al., 1998). In the field of pelvic health, this is of notable importance when assessing proper movement of the deep abdominal and pelvic muscles during voluntary muscle actions. Transabdominal ultrasound has been found to be a safe, noninvasive, and accurate method to assess and observe muscular and fascial activity (Khorasani et al., 2012). When therapists learn how to properly use and apply ultrasound imaging, this technique can be a comprehensive tool for the clinician and a comfortable procedure for the patient. Moreover, it may be the method of choice for some patients who don’t want to have an internal pelvic examination (Van Delft, Thakar & Sultan, 2015). In this regard, a cross-sectional study found a moderate-to-strong correlation between ultrasound measurements and both digital examination and perineometry for the assessment of pelvic floor muscle actions (Volløyhaug et al., 2016).

Recently, Low Pressure Fitness has gained popularity as a pelvic floor training program aimed at reducing pressure on the pelvic structures while engaging the stabilizing muscles through postural and breathing exercises. In order to evaluate proper execution of Low-Pressure Fitness exercises as well as abdomino-pelvic muscle function during this type of training, real-time transabdominal ultrasound can be a clinically relevant tool.

Sagittal and Transverse Pelvic Floor/Urinary Bladder Assessment

The amount of movement of the bladder base on transabdominal ultrasound is considered an indicator of pelvic floor muscle mobility during pelvic floor muscle exercises (Khorasani et al., 2012). When properly executed, the Low-Pressure Fitness technique will allow the bladder to lift and the pelvic floor muscles to contract. These observed actions can be cued and progressed due to the real-time imaging biofeedback of the ultrasound. Because of the postural activation and diaphragm lift occurring during Low Pressure Fitness, the bladder fascial support system is tensioned resulting in a desirable bladder lift.

For example, we used a Pathway® Musculoskeletal Rehabilitative Ultrasound Imaging unit with a curvilinear transducer and Prometheus Pathway® rehabilitative ultrasound software utilizing the pre-set parameters (Abdominal Wall 7.5MHz and Bladder 5.0MHz) during a Low-Pressure Fitness basic supine posture. A standardized bladder filling protocol was used before imaging to ensure sufficient bladder filling to allow clear imaging of the base of the bladder and pelvic floor muscles.

For the transverse view, radiologic standards were used, and the ultrasound transducer was placed in the transverse plane suprapubically and angled in a caudal/ posterior direction to obtain a clear image of the inferior-posterior aspect of the bladder. The participant was asked to perform the Low-Pressure Fitness Demeter exercise in the supine position with a neutral pelvis and knees flexed (Figure 1).

Demeter exercise with postural technique and with postural and abdominal vacuum technique combined
Figure 1. Demeter exercise with postural technique and with postural and abdominal vacuum technique combined.

The following video illustrates the pelvic floor/urinary bladder during: a) resting position; b) active pelvic floor contraction; c) Low Pressure Fitness Demeter exercise and; d) Low Pressure Fitness Demeter exercise combined with a voluntary pelvic floor muscle contraction. It is noticeable a greater bladder lift and pelvic floor activation with the postural and breathing cueing added to an active pelvic floor contraction than with the pelvic floor contraction alone.


Video of the behavior of the pelvic floor muscles in a sagital and transversal view during the supine position of Low Pressure Fitness and with the combination of an active pelvic floor muscle contraction.

 

Lateral Abdominal Wall Assessment

The lateral abdominal muscle ultrasound assessment allows us to observe the structural changes produced in the transversal section of the abdominal muscles in the midpoint between the anterior iliac crest and the costal angle. At low levels of contraction, the extent of transverse abdominis thickening measured using ultrasound is reported to be a valid method of assessment compared with either fine wire electromyographic measures of transverse activity (McMeeken et al., 2004). It is well established in the scientific literature that the lateral abdominal muscles provide stability to the trunk in different functional activities. Therefore, the assessment of the size, thickness and sliding of the abdominal wall is important for patients who present with lumbo-pelvic and/or pelvic floor dysfunctions. In this regard, patients with low back pain show different abdominal wall muscle activation patterns (i.e. less slide of the abdominal fascia and muscle thickness) than those without low back pain (Gildea et al., 2014; Unsgaard-Tondel et al., 2012).

Figure 2 shows the three muscle layers of the lateral wall in the resting position. The superficial layer corresponds to the external oblique, the middle layer to the internal oblique and the deep layer to the transverse abdominal muscle.

View of the right lateral abdominal wall at rest
Figure 2. View of the right lateral abdominal wall at rest.

A key breathing component of the Low-Pressure Fitness program is the abdominal vacuum which manipulates intra-abdominal, intra-thoracic and intra-pelvic pressures during the breath-holding phase. Another key aspect of Low-Pressure Fitness is the shoulder girdle activation, spine elongation and ankle-dorsiflexion (Rial & Pinsach, 2017). Of note, previous studies have demonstrated greater transverse abdominis activation when performing ankle dorsi-flexion (Chon et al., 2010). We used transabdominal ultrasound to assess the lateral abdominal wall response during ankle dorsiflexion, shoulder girdle activation and the abdominal vacuum during Low Pressure Fitness.

In the following video, a voluntary (active) abdominal contraction is performed in order to distinguish this action from the involuntary abdominal contractions during Low Pressure Fitness. Afterwards, the postural technique of ankle dorsiflexion and shoulder girdle activation are performed in the Demeter exercise with arms in middle position (Figure 1). Lastly, an abdominal vacuum maneuver is added to the postural technique. If the exercises are properly executed, the progressive sliding and thickness of the abdominal muscles throughout exercise sequence should be observable (Figure 3).

Ultrasound imaging at rest and during the complete LPF technique
Figure 3. Ultrasound imaging at rest and during the complete LPF technique.

 

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Video of a voluntary (active) abdominal contraction or draw-in maneuver is performed in order to distinguish this action from the involuntary abdominal contractions that occur during Low Pressure Fitness in a supine position

Muscle thickness of the transverse and internal oblique as well as a noticeable slide of the anterior abdominal fascia are observable during the Demeter exercise of Low-Pressure Fitness. This exercise pattern reflects an abdominal draw-in maneuver and a “corseting effect”. In this regard, notice the lateral pull or displacement of the edge of the anterior fascial insertion of the transverse the internal oblique muscle.

Navarro et al., (2017) used transabdominal ultrasound to assess the muscular responses of the pelvic floor and abdominal muscles in a group of women who underwent pelvic physiotherapy over two months. They found a significant increase in the transversal section of the transverse abdominis, external oblique, and internal oblique muscles when compared to resting in the supine position. Similar to the position assessed by Navarro et al. (2017), we also assessed the pelvic floor and abdominal muscle responses during a Low-Pressure Fitness supine exercise.

Transabdominal ultrasound can provide a noninvasive and informative visual biofeedback when training patients with Low Pressure Fitness. This ultrasound imaging can be a valuable tool to both the client and the clinician to objectify progress, assist with validating correct Low-Pressure Fitness form with positioning and vacuum/hypopressive maneuver as well as a motivational technique for the client. As demonstrated during our rehabilitative ultrasound imaging, observable bladder lift, pelvic floor activation and desirable lateral abdominal muscular corseting (slide and thicking) occurs during Low Pressure Fitness postural exercises and breathing. Since Low Pressure Fitness is a progressive exercise program, qualified instruction, technique driven progression and understanding pelvic floor health are needed to optimize patient outcomes.


Chon SC, Chang KY, You JS. Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study. Physiotherapy 96: 130-6, 2017.
Gildea JE, Hides JA, Hodges PW. Morphology of the abdominal muscles in ballet dancers with and without low back pain: a magnetic resonance imaging study. J Sci Med Sport. 17(5): 452-6, 2014.
Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology, 80: 673-7, 2012.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19: 337–342, 2004.
Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther. 3:125-131,1998.
Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia 39: 187-94, 2017.
Rial T, Pinsach P. Practical Manual Low Pressure Fitness Level 1. International Hypopressive & Physical Therapy Institute, Vigo, 2017.
Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen J, Vasseljen O. Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up. Br J Sports Med, 46(10): 729-34, 2012.
Van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol, 45: 217-22, 2015. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. Ultrasound Obstet Gynecol 47: 768-73, 2016.

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Post-prostatectomy Penile Rehabilitation

Erectile dysfunction (ED) is a debilitation complication of radical prostatectomy, which is a treatment for prostate cancer. ED is caused by a variety of causes, diabetic vasculopathy, smoking, high blood pressure, high cholesterol, psychological issues, peripheral vascular disease and medication; we will focus on post-prostatectomy ED and the role of penile rehabilitation in its management.

Post-prostatectomy-related Erectile dysfunction

Radical prostatectomy can result in nerve injury to the penis. Moreover, significant fibrotic changes take place in the corpus cavernosum of the penis postoperatively. It takes approximately 1-2 years for erectile function to return after radical prostatectomy. This is a period of “neuropraxia,” during which there is transient cavernosal nerve dysfunction. However, a prolonged “flaccid state” might lead to irreversible damage to the cavernous tissue 1.

Research on penile hemodynamics in these patients have shown that venous leakage is also implicated in its pathophysiology. An injury to the neurovascular bundles likely leads to smooth muscle cell death, which then leads to irreversible veno-occlusive disease.

There is a potential role of hypoxia in stimulating growth factors (TGF-beta) that stimulate collagen synthesis in cavernosal smooth muscle. Prostaglandin E1 (PGE1) was found to suppress the effect of TGF-β1 on collagen synthesis.

Role of Penile Rehabilitation

The goal of Penile Rehabilitation is to limit and reverse ED in post-prostatectomy patients. The idea is to minimize fibrotic changes during the period of “penile quiescence” after nerve-sparing radical prostatectomy. Several approaches have been tried, including PGE1 injection, vacuum devices, and phosphodiesterase type 5 (PDE-5) inhibitors.

Mulhall and coworkers followed 132 patients through an 18-month period after they were placed in “rehabilitation” or “no rehabilitation” groups after radical prostatectomy, and 52% of those undergoing rehabilitation (sildenafil + alprostadil) reported spontaneous functional erections, compared with 19% of the men in the no-rehabilitation group 2.

Prostaglandin E1 (PGE1)

Alprostadil is a vasodilatory prostaglandin E1 that can be injected into the penis or placement in the urethra in order to treat ED. Montorsi, et al. studied the use of intracorporeal injections of alprostadil starting at 1 month after bilateral nerve-sparing radical prostatectomy and reported a higher rate of spontaneous erections after 6 months compared with no treatment 3. Gontero, et al. investigated alprostadil injections at various time points after non–nerve-sparing radical prostatectomy and found that 70% of patients receiving injections within the first 3 months were able to achieve erections sufficient for intercourse, compared with 40% of patients receiving injections after the first 3 months 4.

Vacuum constriction device (VCD)

VCD is an external pump that is used to get and maintain an erection. Raina, et al evaluated the daily use of a VCD beginning within two months after radical prostatectomy, and reported that after 9 months of treatment, 17% of patients using the device had return of natural erections sufficient for intercourse, compared with 11% of patients in the nontreatment group 4.

PDE-5 Inhibitors

PDE-5 inhibitors (such as Sildenafil) are the first-line treatment for ED of many etiologies. Several studies have shown that the use of PDE-5 inhibitors might lead to an overall improvement in endothelial cell function in the corpus cavernosum. Chronic use of oral PDE-5 inhibitors suggest a beneficial effect on endothelial cell function. Desouza, et al. concluded that daily sildenafil improves overall vascular endothelial cell function. However, Zagaja, et al. found that men taking oral sildenafil within the first 9 months of a nerve-sparing procedure did not have any erectogenic response 4.

Overall, accumulating scientific literature is suggesting that penile rehabilitation therapies have a positive impact on the sexual function outcome in post-prostatectomy patients. It must be noted that these methods do not cure ED and should be used with caution.


1Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study. J Urol. 2005;173:1701-1705.
2Mulhall J, Land S, Parker M, et al. The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med. 2005; 2:532-540.
3Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomised trial. J Urol. 1997;158:1408-1410.
4Gontero P, Fontana F, Bagnasacco A, et al. Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following non- nerve sparing radical prostatectomy? Results from a hemodynamic prospective study. J Urol. 2003;169:2166-2169.

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Simple Screening Questionnaire for Pelvic Floor Dysfunction

Earlier diagnosis is clearly a huge need for patients with pelvic floor dysfunction. Many patients suffer with their symptoms for years before even hearing the words “pelvic floor,” or realizing that a pelvic floor physical therapist may be able to help. For interstitial cystitis, one large survey article found fewer than 10% of patients with the condition had been correctly diagnosed with IC, even after years of symptoms and visits with multiple doctors.

Even after being diagnosed, patients still don’t learn about how the pelvic floor can be causing or exacerbating their symptoms. In one study of our interstitial cystitis patients, 46% learned about the importance of the pelvic floor on their own and sought out treatment independently, while nearly half felt they were referred by their physician to physical therapy far too late, as a ‘last resort.’ This is despite the fact that many of these patients had seen five or more physicians and physical therapy is considered the most proven treatment for IC by the American Urological Association.

Physicians, orthopedic physical therapists, other practitioners, and patients themselves need a simple, proven way to identify pelvic floor dysfunction to help patients find pelvic floor physical therapy earlier in their medical journey.

In a large survey of our patients with confirmed pelvic floor dysfunction, we examined what symptoms and medical history was most closely correlated with pelvic floor dysfunction. Any screening questionnaire would ideally be able to identify a wide variety of pelvic floor dysfunction, including patients with chronic pelvic pain, pelvic organ prolapse, orthopedic pain with a pelvic floor component (low back, hip, groin), urinary urgency/frequency, and/or bowel dysfunction.

While these patients all had different medical diagnoses, many symptoms were common across the patient population. The most common were pelvic pain (84%), urinary urgency, frequency, or incontinence (81%), orthopedic pelvic pain (71%) and symptoms that worsen with prolonged sitting (68%).

Based on the survey results, we created the Cozean Pelvic Dysfunction Screening Protocol to screen for pelvic floor dysfunction and published the results in the International Pelvic Pain Society (2017). The goal was to correctly identify more than 80% of the patients with pelvic floor dysfunction (sensitivity). For ease of use by both practitioners and patients, the questions were phrased so they could be answered with a simple ‘yes/no’ (as a check box). If patients answers ‘yes’ to 3 or more of the questions, pelvic floor dysfunction is highly likely.

 

Testing the Model

In a model like this, we would expect a normal (bell-shaped) distribution curve of answers from patients with pelvic floor dysfunction. Some patients will score on the high end, others on the low, and the majority would be clustered in the middle. This is what we observe with use of the questionnaire, as seen by the trendline in the blow graph. Most patients with confirmed pelvic floor dysfunction cluster in scores between 3 and 7, with a few scoring at 8 or higher. Less than one out of ten patients with pelvic floor dysfunction score below a 2 on the questionnaire and would not be captured by this measure.

Specificity: 91%. More than 90% of patients with confirmed pelvic floor dysfunction were correctly identified by this screening protocol. Additional testing is required on a general population without PFD to determine the specificity of the questionnaire.

Average: 5.2. Of patients with confirmed PFD, the average score according to this screening protocol was 5.2 with a median score of 5 and a mode of 6. This is in line with what would be expected with a normal distribution curve.

We hope this 10-question survey is able to help patients with pelvic floor dysfunction be diagnosed earlier - whether by their physician, other physical therapists, or themselves – and seek pelvic floor physical therapy earlier in their medical journey. Please feel free to use the printable version of this protocol with your patients or in working with local practitioners.

Nicole Cozean will be teaching the course Interstitial Cystitis: Holistic Evaluation and Treatment in Princeton, NJ from April 6-7, 2019.

Nicole CozeanNicole Cozean is the founder of PelvicSanity physical therapy, in Orange County, California. Nicole was named the 2017 PT of the Year, is the first physical therapist to serve on the ICA Board of Directors, and is the award-winning and best-selling book The Interstitial Cystitis Solution (2016). She is an adjunct professor at her alma mater, Chapman University and teaches continuing education courses through the prestigious Herman & Wallace Institute.

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An Interview with Featured Practitioner Adina Leifer, PT, DPT, PRPC

Adina Leifer, PT, DPT, PRPC recently passed the Pelvic Rehabilitation Practitioner Certification exam and was kind enough to discuss her career with us. Adina Leifer, PT, DPT, PRPC practices at ABLe Pelvic Physical Therapy in Atlanta, GA. Thank you for the interview, Dr. Leifer, and congratulations on earning your certification!

Adina Leifer, PT, DPT, PRPCHow did you get involved in the pelvic rehabilitation field?
After graduating from Touro College, and receiving my Doctorate of Physical Therapy. I began to work in an outpatient sports rehab setting. While looking for continuing education courses, I happened upon Herman and Wallace through the Touro College website. They were hosting PF1 at their New York City campus. I knew nothing about pelvic health and rehabilitation at that time. Holly Herman and Tracy Sher taught that first class, after 3 days of class, I was hooked. I knew that pelvic health and wellness was my calling. It has been 9 years since I took that first course and I could not be happier.

What patient population do you find most rewarding in treating and why?
Not sure I can pick one diagnosis or patient population as my favorite. I feel that with each patient that comes to see me, they have either lost ability or do not have normal function of their bladder, bowel or sexual functioning. When I can treat them successfully and educate patients in proper strength and mobility of their pelvic muscles. When I can provide them with the tools so that they can function in their lives, there is nothing more rewarding then that.

Describe your clinical practice:
I currently have my own outpatient practice in Atlanta, GA. I treat adult men and women with any and all pelvic muscle dysfunction and diagnoses.

What has been your favorite Herman & Wallace Course and why?
My favorite course from Herman & Wallace was the capstone course given by Nari Clemons and Jennafer Vande Vegte. I felt this course was informative with practical hands on information for everyday patient treatment. As well as, really helping me to prepare for the PRPC exam.

What motivated you to earn PRPC?
Having practiced for over 9 years and taken many courses through Herman & Wallace, I felt my knowledge and experience made me a specialist. As I was building my own practice, I felt that I wanted the credentials and letters after my name to prove that I was truly a specialist in this field.

What advice would you give to physical therapists interested in earning PRPC?
Go for it! Study the coursework and anatomy. Trust in the knowledge that you have and take the test! You will be very happy that you did.

Certified Pelvic Rehabilitation Practitioners have experience treating a wide variety of pelvic floor dysfunction conditions in men and women throughout the lifecycle. Each certified practitioner has passed a comprehensive exam, and has directly treated pelvic patients for more than 2,000 hours. To learn more about the Pelvic Rehabilitation Practitioner Certification, visit our certification page.

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Effects of Exercise on Polycystic Ovary Syndrome

Few patients discuss polycystic ovary syndrome (PCOS) in orthopedic manual therapy, but one lady left a lasting impression. She was adopted and did not know her family’s medical history or her genetics. At 18, she had a baby as a result of rape. At 34, she was married and diagnosed with POCS. She struggled with infertility, anxiety, obesity, and hypertension. Although I saw her for cervicalgia, the exercise aspect of her therapy had potential to impact her overall well-being and possibly improve her PCOS symptoms.

Polycystic Ovary SyndromePericleous & Stephanides (2018) reviewed 10 studies that considered the effects of resistance training on PCOS symptoms. Some of these symptoms include the absence of or a significant decrease in ovulation and menstruation, which can lead to infertility; obesity, which in turn can affect cardiovascular health and increase the risk of diabetes, insulin resistance, and metabolic syndrome; and, mental health problems. Research has shown resistance training benefits include lowering body fat, improving insulin resistance and glucose metabolism, and increasing insulin sensitivity in type II diabetes. Although it has been documented that obesity and insulin resistance can exacerbate PCOS symptoms, resistance training is not a common recommendation in healthcare settings for patients with PCOS . Studies have shown diet and exercise are essential to improve cardiac and respiratory health and body makeup in patients with PCOS, as the combination improves the Follicle-stimulating hormone (FSH), sex hormone-binding globulin (SHBG), ovulation, testosterone levels, and weight loss. One systematic review found that weight loss can improve PCOS symptoms without consideration of diet; however, most other studies find intake of various macronutrients (protein, fat, carbohydrates) may lead to different results, and the effects of resistance training can only be optimized with appropriate dietary changes. These authors concluded caloric consumption and macronutrient habits must be considered in conjunction with resistance training to determine the greatest impact on improving PCOS symptoms.

Benham et al., (2018) also performed a recent systematic review to assess the role exercise can have on PCOS. Fourteen trials involving 617 females of reproductive age with PCOS evaluated the effect of exercise training on reproductive outcomes. The data published did not allow the authors to quantitatively assess the impact of exercise of reproductive in PCOS patients; however, their semi-quantitative analysis allowed them to propose exercise may improve regularity of menstruation, the rate of ovulation, and pregnancy rates in these women. Via meta-analysis, secondary outcomes of body measurement and metabolic parameters significantly improved after women with PCOS underwent exercise training; however, symptoms such as acne and hirsutism (excessive, abnormal body hair growth) were not changed with exercise. The authors concluded exercise does improve the metabolic health (ie, insulin resistance) in women with PCOS, but evidence is insufficient to measure the exact impact on the function of the reproductive system.

Increasing our knowledge about comorbidities such as PCOS, regardless of our practice setting, can help us provide better education to the patients we treat. Perhaps exercise compliance can increase when patients are told multiple long-term benefits, not just immediate symptom relief. More often than not, a patient’s 4-6 week interaction with us could motivate and promote healthy lifestyle changes.


Pericleous, P., & Stephanides, S. (2018). Can resistance training improve the symptoms of polycystic ovary syndrome? BMJ Open Sport — Exercise Medicine, 4(1), e000372. http://doi.org/10.1136/bmjsem-2018-000372
Benham, J. L., Yamamoto, J. M., Friedenreich, C. M., Rabi, D. M. and Sigal, R. J. (2018), Role of exercise training in polycystic ovary syndrome: a systematic review and meta‐analysis. Clin Obes, 8: 275-284. doi:10.1111/cob.12258

Suggested newly published resource for readers…
Teede, H. J., Misso, M. L., Costello, M. F., Dokras, A., Laven, J., Moran, L., … Yildiz, B. O. (2018). Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Human Reproduction (Oxford, England), 33(9), 1602–1618. http://doi.org/10.1093/humrep/dey256

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Updates to the Sacral and Lumbar Nerve Courses

Faculty member Nari Clemons, PT, PRPC recently created a two-course series on the manual assessment and treatment of nerves. The two courses, Lumbar Nerve Manual Assessment and Treatment and Sacral Nerve Manual Assessment and Treatment, are a comprehensive look at the nervous system and the various nerve dysfunctions that can impact pelvic health. The Pelvic Rehab Report caught up with Nari to discuss these new courses and how they will benefit pelvic rehab practitioners.

Nari Clemons

What is "new" in our understanding of nerves? Are there any recent exciting studies that will be incorporated into this course?

The course is loaded with a potpourri of research regarding nerves and histological and morphological studies. There are some fascinating correlations we see with nerve restrictions, wherever they are in the body. Frequently the nerves are compressed in fascial tunnels or areas of muscular overlap, then the nerve, wherever the location, frequently has local vascular axonal change, which increases the diameter of the nerve and prohibits gliding without pain. This causes local guarding and protective mechanisms. Changing pressure on the nerve can change that axonal swelling and allow gliding without pain.

New pain theory also supports that much of pain perception is the body perceiving danger or injury to a nerve. By clearing up the path of the nerve and mobilizing it, we can decrease the body's perception of nerve entrapment and thus create change in pain levels.

What do you hope practitioners will get out of this series that they can't find anywhere else?

I hope they will leave the course able to treat the nerves of the region, which is essentially the transmission pathway for most pelvic pain. I don't know of other courses that have this emphasis.

You've recently split your nerve course in two. Why the split?

I didn't want this class to be a bunch of nerve theory without the manual intervention to make change. After running the labs in local study groups, we found it took more time for people's hands to learn the language, art, and techniques of nerve work. To truly do the work justice and for participants to have a firm grasp of the manual techniques without being rushed, we found it takes time, and I wanted to honor that, as well as treating enough of the related factors and anatomy to make real and lasting change for patients.

How did you decide to divide up content?

Basically, we divided them up by anatomical origin:

The lumbar course covers the nerves of the lumbar plexus, the abdominal wall when treating diastasis, and treatment of the inguinal canal (obturator nerve, femoral nerve, iliohypogastric, ilioinguinal, genitofemoral nerves). Also, the lumbar nerves have more effect in the anterior hip, anterior pelvis, and abdominal wall.

The sacral nerve course covers all the nerves of the sacral plexus (pudendal, sciatic, gluteal/cluneal, posterior femoral cutaneous, sciatic, and coccygeal nerves), as well as subtle issues in the sacral base and subtle coccyx derangement work as well as the relationship with the uterus and sacrum, to take pressure off the sacral plexus. The sacral nerves have more effect in the posterior and inferior pelvis and into the posterior leg and gluteals.

What are the main stories that either course tells?

Both courses tell the story of getting closer to the root of the pain to make more change in less time.  Muscles generally just respond to the message the nerve is sending.  Yet, by treating the nerve compression directly, we are getting much closer to the root of the issue and have more lasting results by changing the source of abnormal muscle tone. Rather than an intellectual exercise of discourse on nerves, we devote ourselves to the art of manual therapy to change the restrictions on the pathway of the nerve and in the nerve itself.

If someone went to the old nerve course, what's the next best step for them?

The first course was initially all the lumbar nerves with a dip into the pudendal nerve. They would want to take the sacral nerve course, as those nerves were not covered in the first round.

Anything else you would like to share about these courses?

Sure. Essentially, we will take each nerve and do the following:

  1. Thoroughly learn the path of the nerve
  2. Fascially clear the path of the nerve
  3. Manually lengthen supportive structures and tunnels that surround the nerve.
  4. Directly mobilize the nerve
  5. Glide the nerve
  6. Learn manual local regional integration techniques for the nerve after treatment
  7. Receive handouts for and practice home program for strengthening and increasing mobility in the path of the nerve

Join Nari at one of the following events to learn valuable evaluation and treatment techniques for sacral and lumbar nerves

Upcoming sacral nerve courses:
Sacral Nerve Manual Assessment and Treatment - Winfield, IL
Oct 11, 2019 - Oct 13, 2019

Sacral Nerve Manual Assessment and Treatment - Tampa, FL
Dec 6, 2019 - Dec 8, 2019

Upcoming lumbar nerve courses:
Lumbar Nerve Manual Assessment and Treatment - Phoenix, AZ
Jan 11, 2019 - Jan 13, 2019

Lumbar Nerve Manual Assessment and Treatment - San Diego, CA
May 3, 2019 - May 5, 2019

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September is Gynae Cancer Awareness Month

September is Gynae Cancer Awareness Month – but how aware are we as clinicians of the signs and symptoms, the epidemiology and the sequalae of treatment afterwards? As pelvic rehab specialists, we have the privilege of helping women live well after cancer treatment ends, both on a ‘local’ pelvic area (bladder, bowel, sexual and pelvic pain management strategies) but also on a more ‘global’ level – dealing with issues such as cancer related fatigue, bone health and cardiovascular concerns.

We know that women who are diagnosed with cancer of the vulva, vagina, cervix, endometrium or ovaries are treated with a combination of surgery, radiation or chemotherapy. However, with improving treatment and better survival rates, there is evidence that a variety of pelvic health concerns may arise for these women, both during and after treatment. (Hazewinkel et al 2010). For example, urinary incontinence is reported in 80% of women treated for endometrial cancer, with more severe symptoms and impact on quality of life in those who had adjuvant radiation (Erekson et al 2009) In Malone’s 2017 paper, ‘The patient’s voice: What are the views of women on living with pelvic floor problems following successful treatment for pelvic cancers?’, the author notes that ‘…there is currently a lack of knowledge regarding the effects of PFD on QoL in this cohort. Patients do not always report these problems to their health care providers and clinicians may underestimate symptoms…In the context of having survived cancer, PFD may be seen as relatively trivial. However, in the context of resuming normal living, the symptoms experienced by the survivors may be significant’.

This can present a clinical conundrum – often pelvic rehab therapists are nervous when working with a patient who has a current or previous gynecologic cancer diagnosis, but similarly oncology rehab specialists may have qualms about dealing with pelvic health issues, with the result that these women fall through the cracks and do not have their pelvic health issues managed properly (or at all). Theodore Roosevelt once said ‘No one cares how much you know, until they know how much you care’ and this is especially relevant for oncology pelvic rehab. Often you may be the first clinician to ask about bladder, bowel or sexual function or dysfunction. An understanding of the effects of cancer treatments on the pelvis is important but so too is the wealth of information you may already have about bladder, bowel and sexual health as well as neuroscience and pain education.

The most important thing is to ask these women about their pelvic health concerns – the National Coalition for Cancer Survivorship defined cancer survivorship as extending from ‘the time of diagnosis and for the balance of life’. An emphasis on quality of life has been emphasised – if we know that cancer survivors may not independently volunteer information about their pelvic floor dysfunction, it is our responsibility to ask the questions and comprehensively treat and advocate for these women, in order to help them live well after cancer treatment ends.


  1. Hazewinkel MH. Sprangers MA, Velden Jvd, Vaart CH, Stalpers LJ, Burger MP ‘Longterm cervical cancer survivors suffer from pelvic floor dysfunction symptoms: A cross-sectional matched cohort study’ Gynecol Oncol 2010;117(2):381-6
  2. Erekson EA, Sung VW, Disilvestro PA, Myers DL ‘Urinary symptoms and impact on quality of life in women after treatment for endometrial cancer’ Int Urogynecol J 2009;20(2):159-63
  3. Malone P, Danaher D, Galvin R, Cusack T ‘The patient’s voice: What are the views of women on living with pelvic floor problems following successful treatment for pelvic cancers?’ Physiotherapy Practice and Research 38(2017)93-102
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Osteoporosis and Multiple Sclerosis: Patient Study Part 2

The following is part two in a series documenting Deb Gulbrandson, PT, DPT's journey treating a 72 year old patient who has been living with multiple sclerosis (MS) since age 18. Catch up with Part one of the patient case study on the Pelvic Rehab Report here. Dr. Gulbrandson is a certified Osteoporosis Exercise Specialist and instructor of the Meeks Method, and she helps teach The Meeks Method for Osteoporosis course.

On Maryanne’s second visit, she reported she had been doing her “homework” and didn’t have any questions. Just to be sure, we reviewed them and I had her demonstrate. In Decompression position, she was lying supine with her hands on her abdomen, a common mistake I see. Usually this is due to tightness in pec minor with protracted scapulae. Patients unknowingly resort to the path of least resistance to take the strain off of the muscles. I explained to her that we want to use gravity to gently lengthen those muscles and “widen” the collarbones to allow for improved alignment. With her shoulders abducted to approximately 30 degrees and palms up, I propped a couple of small towels under her forearms which allowed her shoulders to relax into a more posterior and correct position.Osteoporosis Evaluation

“Today we begin the Re-alignment routine,” I said, “starting with the Shoulder Press.” I showed her how to gently press the back of her shoulders down into the mat without arching her lumbar spine. “As you press your shoulders down, exhale through your mouth as if you’re fogging a mirror. This will help activate your core muscles to keep your back in good alignment. Hold for 2-3 seconds, and then relax. Repeat 3 times.” Maryanne looked at me as if I’d lost my mind. “Did you say do 3 reps?” she asked. “I do 2 sets of 20 reps at the gym,” she said with obvious pride in her voice. “Yes, that’s where we start, and there are a couple of reasons. First, these are very site specific exercises which focus on the exact areas that need strengthening. Exercises done in a gym setting are often more general and usually involve compensation.  We are minimizing any compensation such as allowing your low back to arch. There is probably weakness in those upper back muscles as well as the tightness seen in your anterior chest muscles and we need to go slowly. Also, we are simultaneously stretching while we strengthen. Our society is so forward biased (we work on computers, drive cars, make beds, eat- it’s all forward, forward, forward), that the anterior muscles get tight and the upper back muscles get overstretched and weak. We need to reverse that pattern. Take a look at our younger population and their texting postures. Yikes! We will be layering on more exercises as your technique improves so you’ll be doing more than just 3 reps, I promise.”

After the Shoulder Press we proceeded with the Head Press, Leg Lengthener and Arm Lengthener, spending time to make sure her cervical spine stayed in neutral as she pressed her head down into the mat. Head Press (cervical retraction) performed in supine allow patients to have something to press against and helps inhibit the tendency to move into cervical extension. It can also be done standing against the wall with a small pillow or folded towels between the occiput and the wall.

We ended with Maryanne in standing at the kitchen sink to promote functional activities and weight bearing positions.  I reminded her to do the Foot Press through the floor using the Triangle of Foot Support visual. This helped to elongate her spine. “Imagine a bungie cord running from the top back of your head to the ceiling” I said which further increased her standing height. “Now I want you to imagine a shelf running straight out from your breastbone with a glass of some very expensive fine drink sitting on it. Do not spill your libation! Oh, and one last thing Maryanne. Breathe!!!” At which point she collapsed into laughter and our session was over. “Busted”, she said.

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Upcoming Continuing Education Courses

Aug 23, 2019 - Aug 25, 2019
Location: PeaceHealth Southwest Medical Center

Aug 23, 2019 - Aug 25, 2019
Location: Inova Physical Therapy Center

Aug 23, 2019 - Aug 25, 2019
Location: The Sage Colleges

Aug 23, 2019 - Aug 25, 2019
Location: Loyola University Stritch School of Medicine

Aug 23, 2019 - Aug 24, 2019
Location: Mizzou University of Missouri

Aug 23, 2019 - Aug 25, 2019
Location: Mizzou University of Missouri

Sep 6, 2019 - Sep 8, 2019
Location: Advanced Physical Therapy of Little Rock

Sep 6, 2019 - Sep 8, 2019
Location: Bon Secours St. Francis Health System

Sep 7, 2019 - Sep 8, 2019
Location: Franklin Pierce University

Sep 7, 2019 - Sep 8, 2019
Location: Spooner Physical Therapy

Sep 13, 2019 - Sep 15, 2019
Location: Huntington Hospital

Sep 13, 2019 - Sep 15, 2019
Location: Mary Free Bed Rehabilitation Hospital

Sep 13, 2019 - Sep 15, 2019
Location: Loyola University Stritch School of Medicine

Sep 13, 2019 - Sep 15, 2019
Location: Lee's Summit Medical Center

Sep 13, 2019 - Sep 15, 2019
Location: Princeton Healthcare System

Sep 14, 2019 - Sep 15, 2019
Location: Aurora Medical Center

Sep 20, 2019 - Sep 22, 2019
Location: Marathon Physical Therapy

Sep 20, 2019 - Sep 22, 2019
Location: Viverant

Sep 21, 2019 - Sep 22, 2019
Location: Carolinas Healthcare System - Union

Sep 27, 2019 - Sep 29, 2019
Location: Catholic Health Administrative and Training Center

Sep 27, 2019 - Sep 28, 2019
Location: Fort HealthCare

Sep 27, 2019 - Sep 29, 2019
Location: Fort HealthCare

Sep 27, 2019 - Sep 29, 2019
Location: Good Shepherd Penn Partners

Sep 28, 2019 - Sep 29, 2019
Location: Regions Hospital

Oct 4, 2019 - Oct 6, 2019
Location: Thomas Jefferson University

Oct 4, 2019 - Oct 6, 2019
Location: Olathe Medical Center

Oct 4, 2019 - Oct 6, 2019
Location: Tri-City Medical Center

Oct 5, 2019 - Oct 6, 2019
Location: The Fountain WNY

Oct 5, 2019 - Oct 6, 2019
Location: Advantage Physical Therapy

Oct 11, 2019 - Oct 13, 2019
Location: Houston Methodist