Appropriate sun exposure and/or daily supplements provide our bodies with sufficient amounts of Vitamin D. I would venture to guess almost every one of the patients I treated in Seattle had a deficiency of Vitamin D if they were not taking a supplement. Running outside year round has always kept my skin slightly tan and my levels of Vitamin D healthy; however, when I was pregnant in the Pacific Northwest, I had to supplement my diet with Vitamin D, which was a first for this East Coast beach girl. The benefit of Vitamin D has spread beyond just bone health, with studies showing its impact on pelvic floor function.

Parker-Autry et al., (2012) published a study discerning the Vitamin D levels in women who already presented with pelvic floor dysfunction versus “normal” gynecological patients. The retrospective study involved a chart review of 394 women who completed the Colorectal Anal Distress Inventory (CRADI)-8 and the Incontinence Impact Questionnaire (IIQ-7). These women all had a total serum 25-hydroxy Vitamin D [25(OH)D] drawn within one year of their gynecological visit. The authors defined a serum 25(OH)D of <15ng/ml as Vitamin D deficient, between 15-29ng/ml as Vitamin D insufficient, and >30ng/ml as Vitamin D sufficient. In the pelvic floor disorder group comprised of 268 women, 51% were found Vitamin D insufficient, 13% of whom were deficient. The CRADI-8 and IIQ-7 scores were noted as higher among the Vitamin D insufficient women. Overall, the mean 25(OH)D levels in the women without pelvic floor issues were higher than those who presented with pelvic floor disorder symptoms.

Another case-control study in 2014 by Parker-Autry et al., focused on the association between Vitamin D deficiency and fecal incontinence. They considered 31 women with fecal incontinence versus a control group of 81 women without any pelvic floor symptoms, looking at serum Vitamin D levels. The women with fecal incontinence had a mean serum Vitamin D level of 29.2±12.3 ng/ml (insufficient/deficient), while the control group had a higher mean level of 35±14.1 ng/ml (sufficient). The women completed the Modified Manchester Health Questionnaire and the Fecal Incontinence Severity Index, and women with deficient Vitamin D scored higher on the questionnaire, indicating fecal incontinence as a burden on quality of life. The severity scores were higher for Vitamin D deficient women, but there was not a statistically significant difference between the groups.  Once again, the pelvic floor disorder and Vitamin D deficiency correlation prevailed in this study.

An even more recent study looked at postmenopausal women and Vitamin D deficiency (Navaneethan et al., 2015). This prospective case control study involved 120 postmenopausal women, 51 of whom had pelvic floor disorders. The serum 25-hydroxy Vitamin D levels were obtained, and the results revealed a deficiency in those women with pelvic floor dysfunction. Vitamin D levels were found to be significantly lower in women who were 5 years or more into menopause. Overall, Vitamin D was deemed a worthy factor to consider in the pelvic floor disorder population as well as in postmenopausal women.

Taking time to talk to patients about their lifestyle, daily supplements, and diet can often shed light on their ability to benefit from our treatments. If a Vitamin D deficiency sounds possible, discuss current research with them and suggest they get their serum Vitamin D levels checked. Don’t underestimate the power of a little sunshine – it just might have a positive impact on pelvic floor health.

Parker-Autry, C. Y., Markland, A. D., Ballard, A. C., Downs-Gunn, D., & Richter, H. E. (2012). Vitamin D Status in Women with Pelvic Floor Disorder Symptoms. International Urogynecology Journal, 23(12), 1699–1705. http://doi.org/10.1007/s00192-012-1700-8
Parker-Autry, C. Y., Gleason, J. L., Griffin, R. L., Markland, A., & Richter, H. E. (2014). VITAMIN D DEFICIENCY IS ASSOCIATED WITH INCREASED FECAL INCONTINENCE SYMPTOMS. International Urogynecology Journal, 25(11), 1483–1489. http://doi.org/10.1007/s00192-014-2389-7
Navaneethan, P. R., Kekre, A., Jacob, K. S., & Varghese, L. (2015). Vitamin D deficiency in postmenopausal women with pelvic floor disorders. Journal of Mid-Life Health, 6(2), 66–69. http://doi.org/10.4103/0976-7800.158948

The American Society of Clinical Oncology convened their 2016 annual meeting over the weekend, and several of the presentations suggest new methods of preventing breast cancer recurrence.

Extended Hormone Therapy Reduces Recurrence of Breast Cancer

Breast cancer patients who are treated with aromatase inhibitor therapy are generally prescribed the the estrogen drugs for a five year course. A new study has suggested that by doubling the length of hormone therapy, the recurrence rate for breast cancer survivors drops by 34%. The study included 1,918 women who underwent five years of hormone therapy with the drug letrozole. After five years, half of the group switched to a placebo while the other half were given an additional five year treatment.

Drug Used to Treat Type 2 Diabetes May Increase Breast Cancer Survivability

The Univerisity of Pennsylvania School of Medicine has published results from two recent studies which document the effects of Metformin, a drug commonly used to treat type 2 diabetes, on breast cancer and endometrial hyperplasia. The study tracked outcomes for 1,215 patients who were diagnosed and surgically treated for breast cancer. Patients who began to use metformin after their diagnosis were found to have a 50% higher survivability rate than those who did not use metformin.

The timing of metformin use is extremely important when it comes to breast cancer survivability rates. The study also found that patients who used metformin prior to their diagnosis were more than twice as likely to die than those who never used the drug.

Research Suggests a "Mediterranian Diet" May Reduce Breast Cancer Recurrence

A study has indicated that a diet rich in vegetables, fish, and olive oil may decrease the odds of a breast cancer survivor experiencing a relapse or recurrence of their cancer. The study tracked 300 women with early-stage cancer and found that those who ate a normal diet were more likely to experience a breast cancer recurrence. The findings build upon previous research which indicated that a Mediterranean diet, and especially extra virgin olive oil, could reduce breast cancer risk by 68%.

Want to Learn More?

Susannah Haarmann, PT, CLT, WCS is the author and instructor of Physical Therapy Treatment for the Breast Oncology Patient, a course offered through the Herman & Wallace Institute. This continuing education course for medical practitioners offers a rehabilitation perspective for providers who work with oncology rehabilitation patients. Join Dr. Haarmann this in Stockton, CA on September 24-25 to learn evaluation and treatment techniques necessary to make an outpatient therapist an essential member of any oncology team.

1) Paul E. Goss, et al. J Clin Oncol 34, 2016 (suppl; abstr LBA1)
https://www.asco.org/about-asco/press-center/news-releases/ten-years-hormone-therapy-reduces-breast-cancer-recurrence
2) Yun Rose Li. University of Pennsylvania, American Society of Clinical Oncology Annual Meeting 2016
http://www.eurekalert.org/pub_releases/2016-06/uops-ddm060316.php
3) http://www.scienceworldreport.com/articles/41404/20160606/mediterranean-diet-prevent-breast-cancer-recurring.htm

When a 472 pound gentleman recently arrived for an evaluation for low back pain, he came to the clinic for me to help him, not deride him about his weight (which he complained all his doctors have already done). He claimed he had lost 120 pounds but gained back 50, and his low back was extremely painful with transitional movements and daily function. Undoubtedly, this man’s body was a battlefield for inflammation, and no matter how much manual therapy or exercise I implemented, nutrition education seemed vital. Instead of just chatting about baseball or the weather, competently sharing what we’ve studied and learned in continuing education courses is warranted in our practice.

In a 2016 review Klek reveals the most current evidence regarding Omega-3 Fatty Acids in nutrition delivered intravenously. Although physical therapists do not decide the ingredients for patients’ parenteral nutrition, the article thoroughly explains the essential benefits of fatty acids. Aside from being important structural components of cell membranes and precursors of prostaglandins and cholesterol, fatty acids regulate gene expression and adjust pathways of cells regarding inflammation and cell-mediated immune responses. Ultimately, fatty acids modulate metabolic processes in the body, whether locally, in a particular region, or at remote sites. Omega-3 fatty acids have been shown to inhibit synthesis of triglycerides by the liver, prevent cardiovascular disease, reduce cancerous cell growth, and even affect the development of rheumatoid arthritis and Chrohn’s disease. This article not only sheds light on parenteral nutrition for post-surgical, oncology, critically ill, and even pediatric patients but also educates the healthcare professional on the impact fatty acids have on the patients we treat.

In 2015, Haghiac et al. performed a randomized double-blind controlled clinical trial to determine if Omega-3 fatty acid supplementation could reduce inflammation in pregnant woman who are obese. Although the study began with 36 subjects in each group, only 24 women in the experimental group receiving 4 capsules a day of Omega-3 fatty acid (total of 2000mg) and 25 of the women taking 4 placebo capsules a day completed the supplementation over the 25 weeks up until delivery. The authors referenced the findings that low grade inflammation becomes exacerbated in obese pregnant women. While an excess of Omega-6 fatty acids practically promotes inflammation via eicosanoid (hormone) production, a healthy balance of Omega-3 fatty acids lessens inflammatory and immunosuppressive eicosanoid production. This study demonstrated an improvement in inflammation in the women who took the Omega-3 fatty acid as evidenced by a decrease in the expression of inflammatory genes in adipose tissue and placenta as well as reduced plasma C-reactive protein (CRP) at delivery.

Being able to control or reduce inflammation on a cellular level through nutrition could promote an exciting cycle of positive events for obese patients. Decreased inflammation in the body could decrease pain, which could allow and even promote increased activity and likely boost metabolism to equip them to battle obesity. The “Nutrition Perspectives for the Pelvic Rehab Therapist” course should spark the interest of any therapist wanting to guide patients not only on movement and function but also on the appropriate nutrition that best facilitates the body’s ability to heal and perform.

To learn more about nutrition and it's effects on pelvic rehabilitation, check out Nutrition Perspectives for the Pelvic Rehab Therapist this month in Lodi, CA.

Klek, S. (2016). Omega-3 Fatty Acids in Modern Parenteral Nutrition: A Review of the Current Evidence. Journal of Clinical Medicine, 5(3), 34. http://doi.org/10.3390/jcm5030034
Haghiac, M., Yang, X., Presley, L., Smith, S., Dettelback, S., Minium, J., … Hauguel-de Mouzon, S. (2015). Dietary Omega-3 Fatty Acid Supplementation Reduces Inflammation in Obese Pregnant Women: A Randomized Double-Blind Controlled Clinical Trial. PLoS ONE, 10(9), e0137309. http://doi.org/10.1371/journal.pone.0137309

Congratulations to Jane Blair Johe, PT, PRPC on becoming one of the newest Certified Pelvic Rehabilitation Practitioners! Read our interview with Blair below.

Tell us about your clinical practice
I work in a free standing outpatient PT center of a large 4 hospital affiliation. 70% lymphedema 30% pelvic floor rehab.

How did you get involved in the pelvic rehabilitation field?
I was already the lymphedema PT (LANA cert.) when I moved to WV. The women's health PT was moving to another state and asked me to please pick up her bladder incontinence patients.

What patient population do you find most rewarding in treating and why?
I do like pelvic pain clients as I can work with other PT’s on staff to problem solve . Both patients and their doctors are so grateful.

If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
That you cannot ignore a very important group of muscles (PF) whether you are treating backs, hips etc. or pain and weakness or balance issues…. it plays such a vital role in wellbeing. Any of these clients should be questioned about bowel and bladder issues.

What has been your favorite Herman & Wallace Course and why?
I took my first course from them in September and was so impressed (compared to other courses)

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
the PT pelvic floor assessment. Correct postures , breathing and “safe” effort of bowel movements.

What do you find is the most useful resource for your practice?
MedBridge Courses

What motivated you to earn PRPC?
If I only had one pelvic floor referral, I would like to give the best service possible to that client. My referring MD’s are very happy too.

What makes you the most proud to have earned PRPC?
I thought it was a many faceted subject and combined many aspects of my 45 years of physical therapy practice. It made me feel that I do know my profession that I love.

What advice would you give to physical therapists interested in earning PRPC?
Have a broad back ground in multiple areas of PT then I highly recommend Herman and Wallace courses as the best path.

What is in store for you in the future?
A urologist in town contacted me today to set up referring for pre surgery PT (prostate surgery).

The following guest post comes to us from Angie Johnson, a physical therapist with Kaiser Permanente in Portland, OR.

Did you know that the pelvic floor muscles are actually quite thin? “Pelvic floor muscles are able to produce enough force to overcome changes in intra-abdominal pressure during less rigorous activities of daily living,“ but in activities such as coughing and jumping, “intra-abdominal pressure clearly exceeds the maximum force generated by pelvic floor muscles alone.”¹ But we know that people are continent of urine during these activities, so it begs to question what structures help support the pelvic floor during high force events?

In our journey of pelvic rehabilitation and evidence-based medicine, researchers have determined that contributors to pelvic floor function include trunk stabilization² and co-contraction of the abdominal wall (especially transverse abdominus)^3,4. But this is only the beginning of the story. To add to this picture, new research, recently published in the Journal of Women’s Health Physical Therapy (January/April 2016) validates what we as practitioners already know; hip muscles play a crucial role in optimal pelvic floor functioning.

Knowledge of the anatomy of the pelvic floor and hip musculature helps to give us more understanding of the continence mechanism during high force activity. Obturator internus, which can be easily palpated through the vaginal wall “acts to externally rotate the hip. Interesting, this muscle actually shares a fascial attachment with the pelvic floor muscles.”

Researchers from a team at San Diego State University asked the very pertinent question: If you strengthen obturator internus do you strengthen the pelvic floor muscles too? To answer this question, they conducted a randomized control trial of 40 nulliparous women, aged 18-35, who were assigned to a hip exercise or control group. Both hip external rotator strength and pelvic floor muscle strength (via the Peritron™ perineometer) were measured in all of the women. The exercise group was then asked to perform clamshell exercises, isometric wall external rotation and “monster walks” as their specific hip exercises. The prescription of the exercises were 3 sets of 10 repetitions 3 days per week for 12 weeks. One session each week was supervised in the laboratory to ensure proper execution.

After the 12 weeks, the exercise group had an increase in hip external rotation strength, but also in pelvic floor muscle peak pressure. That was without any specific pelvic floor strengthening exercises at all. Strengthen the hips by doing these three exercises, and pelvic floor strength increases!! This is exciting and fantastic news for us as pelvic floor therapists and a good message to convey to our patients.

The results of this study are preliminary, but if you are treating pelvic floor weakness, hip external rotation strengthening exercises in addition to the traditional kegel strengthening exercises are a must. Go ahead – let’s all get hippie!

Tuttle LJ, DeLozier ER, Harter KA et al. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 2016; 40, 1 pg 15-19
Sapsford R. Rehabilitation of pelvic floor muscles utilizing trunk stabilization. Man Ther 2004;9(1):31-42
Sapsford RR, Hodges PW, Ricahrdson CA, Cooper DH, Markwell SJ, Jull GA. Co-activation of the abdominal and pelvic floor muscles during voluntary exercises. Neruourol Urodyn 2001;20(1):3-12
Sapsord RR, Hodges PW. Contraction of the pelvic floor muscles during abdominal maneuvers. Arch Phys Med REhabil. 2001;82(8):1081-1088

“…visceral manual therapy can produce immediate hypoalgesia in somatic structures segmentally related to the organ being mobilized…”

This statement is taken from an article written by MCSweeney and colleagues published in the Journal of Bodywork and Movement Therapies in 2012. The authors, who state that there is a lack of research that explains underlying mechanisms for visceral mobilization, aimed to determine if visceral mobilization could produce local and/or systemic effects towards hypoalgesia. The measurement of hypoalgesia, defined by the IASP as “diminished pain in response to a normally painful stimulus,” was assessed by use of a hand-held manual digital pressure algometer for pressure pain threshold (PPT). Sixteen asymptomatic subjects were recruited from an osteopathic school and were treated on separate occasions with a visceral mobilization of the sigmoid colon, a sham intervention of manual contact on the abdomen, and a control of no intervention. Six females (mean age 23.7) and ten males (mean age 27.7) completed the single-blinded, randomized study.

The visceral manipulation technique was administered in the supine position by contacting the left sigmoid colon and drawing it superomedially for one minute, and repeated at a frequency and duration determined by the therapist base on each individual’s tissue response. The sham treatment included one minute of light tough contact over the umbilical area, and no position of ease or tissue barrier was engaged. The algometer was placed 1 centimeter to the left of the L1 spinous process, a location known to correspond to the segmental level equal to the colon. A site on the hand was used as a distant area for comparison. The authors concluded that visceral mobilization of the sigmoid colon was found to produce analgesia in tissue that is related segmentally.

The clinical practice relevance was difficult to determine, however, this study used new techniques to determine that there is an immediate and measurable effect on the body. While therapists who treat with visceral mobilization and other soft tissue techniques know that the interventions have helped their patients, having further experimental and clinical validation of the value of these techniques is critical. If you are interested in learning more about fascial approaches to easing pain and improving function in your patients, check out the courses offered by faculty member Ramona Horton.

Ramona will be teaching her Mobilization of the Myofascial Layer: Pelvis and Lower Extremities course three times this year, with the next event in Nashua, NH June 3-5. Her Mobilization of Visceral Fascia: The Urinary System course is available three times as well, next in Kirkland, WA on June 24-26. If you're ready for the advanced course, and some wine tasting(!), check out Mobilization of Visceral Fascia: The Reproductive System of Men and Women on October 14-16 in Medford, OR.

McSweeney, T. P., Thomson, O. P., & Johnston, R. (2012). The immediate effects of sigmoid colon manipulation on pressure pain thresholds in the lumbar spine. Journal of bodywork and movement therapies, 16(4), 416-423.

In Megan Pribyl’s course on Nutrition Perspectives for the Pelvic Rehab Therapist, she discusses a wide variety of useful topics specific to nutrition and pelvic health. In her lecture on “Nutritional Homeostasis”, Megan counsels against missing an underlying eating disorder when working with a patient who has bowel issues. Work by Abraham and Kellow (2013) is cited, and in their article published in BMC Gastroenterology, the authors concur that many patients who have functional gastrointestinal complaints may also have disordered eating. How then, can we tell these patients apart, and get patients the most appropriate care? First let’s look at their research.

Patients who were admitted to a specialty unit for those with eating disorders in Australia were studied and were found to have conditions such as anorexia nervosa, bulimia nervosa, polycystic ovarian syndrome, treated celiac disease, and treated bipolar depression. All of the 185 patients completed the Rome II Modular Questionnaire to identify symptoms consistent with functional gastrointestinal (GI) dysfunction. They also completed the Eating and Exercise Examination which collected data about behaviors including objective binge eating, self-induced vomiting, laxative use and excessive exercise.

Esophageal discomfort (heartburn and chest pain of non cardiac origin) was associated with excess exercise (more than 5 days/week). Self-induced vomiting was identified primarily in the patients diagnosed with bulimia. One interesting finding the researchers noted is that for patients who have disorder eating, pelvic floor symptoms that are not associated with functional constipation are a prominent feature. This data begs the question, how can we best screen for disordered eating in patients who present with bowel dysfunction that otherwise may fit with the symptoms and presentation of patients who do not have disordered eating?

Our first step may be to include important conditions and symptoms on our written or computer-based intake forms. Is “disordered eating” or bulimia, anorexia-nervosa included on your intake forms for patients? What about symptoms like heartburn, laxative use, or vomiting? (As an important aside, I always remember being surprised by a patient who had urinary incontinence when she told me that she leaked with vomiting. She had gone through a gastric bypass surgery and would vomit several times per week as a reaction to difficulty digesting food. There may be a few good reason therefore to include vomiting on a checklist.) As pelvic rehab providers, we can understand how frequent vomiting may lead to dehydration, intrabdominal and intrapelvic pressure, potential pelvic floor dysfunction, or how disordered eating may lead to other bowel dysfunctions such as constipation and/or fecal incontinence. If we also hold space for eating issues to be a concern, we may find that asking some valuable questions provides more information.

If you would like to learn more about nutrition and the pelvic health connections, you still have time to sign up for Megan Pribyl’s nutrition course which takes place in Lodi, California this June!.

Abraham, S., & Kellow, J. E. (2013) "Do the digestive tract symptoms in eating disorder patients represent functional gastrointestinal disorders?" BMC gastroenterology, 13(1), 1.

If an infomercial played in pre-op waiting rooms explaining all the possible side effects or problems a patient may encounter after surgery, I wonder how many people would abort their scheduled mission. As if having an abdominal or pelvic surgery were not enough for a patient to handle, some unfortunate folks wind up with small bowel obstruction as a consequence of scar tissue forming after the procedure. Instead of having yet another surgery to get rid of the obstruction, which, in turn, could cause more scar tissue issues, studies are showing manual therapy, including visceral manipulation, to be effective in treating adhesion-induced small bowel obstruction.

Amanda Rice and colleagues published a paper in 2013 on the non-surgical, manual therapy approach to resolve small bowel obstruction (SBO) caused by adhesions as evidenced in two case reports. One patient was a 69 year old male who had 3 hernia repairs and a laparotomy for SBO with resultant abdominal scarring and 10/10 pain on the visual analog scale. The other patient was a 49 year old female who endured 7 abdominopelvic surgeries for various issues over the course of 30 months and presented with 7/10 pain and did not want more surgical intervention for SBO. Both patients received 20 hours of intensive manual physical therapy over a period of 5 days. The primary focus was to reduce adhesions in the bowel and abdominal wall for improved visceral mobility, but treatment also addressed range of motion, flexibility, and postural strength. The female patient reported 90% improvement in symptoms, with significant decreases in pain during bowel movements or sexual intercourse, and the therapist noted increased visceral and myofascial mobility. Both patients were able to avoid further abdominopelvic surgery for SBO, and both patients were still doing well at a one year follow up.

In 2016, a prospective, controlled survey based study by Rice et al., determined the efficacy of treating SBO with a manual therapy approach referred to as Clear Passage Approach (CPA). The 27 subjects enrolled in the study received this manual therapy treatment for 4 hours, 5 days per week. The CPA includes techniques to increase tissue and organ mobility and release adhesions. The therapist applied varying degrees of pressure across adhered bands of tissue, including myofascial release, the Wurn Technique for interstitial spaces, and visceral manipulation. The force used and the time spent on each area were based on patient tolerance. The SBO Questionnaire considered 6 domains (diet, pain, gastrointestinal symptoms, medication, quality of life, and pain severity) and was completed by 26 of the subjects pre-treatment and 90 days after treatment. The results revealed significant improvements in pain severity, overall pain, and quality of life. Suggestive improvements were noted in gastrointestinal symptoms as well as tissue and organ mobility via improvement in trunk extension, rotation, and side bending after treatment. Overall, the authors conclude the manual therapy treatment of SBO is a safe and effective non-invasive approach to use, even for the pediatric population with SBO.

Myofascial release and visceral manipulation can disrupt the vicious cycle of adhesions causing small bowel obstruction after abdominopelvic surgical “invasion.” Learning specific techniques we may never have thought of can make a huge impact on certain patient populations. Quality of life for our patients often depends on how willing we are to increase our own knowledge and skill base.

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. PubMed Link
Rice, A. D., Patterson, K., Reed, E. D., Wurn, B. F., Klingenberg, B., King, C. R., & Wurn, L. J. (2016). Treating Small Bowel Obstruction with a Manual Physical Therapy: A Prospective Efficacy Study. BioMed Research International, 2016, 7610387. http://doi.org/10.1155/2016/7610387

Dr. Peter Philip, a faculty member with the Herman & Wallace Institute, has published a new book! "Pelvic Pain and Dysfunction: A Differential Diagnosis Manual" is available now through Thieme Medical Publishers. We caught up with Dr. Philip to learn a bit more about his project.
Peter is also the author and instructor of two courses offered through Herman & Wallace. Sacroiliac Joint Evaluation and Treatment is an opportunity to learn an exercise and stabilization approach to pelvic girdle, sacroiliac joint, and pelvic ring dysfunction. This course is available twice in 2016; May 21-22 in Austin, TX and later on November 6-7 in Bayshore, NY. Peter's other course, Differential Diagnostics of Chronic Pelvic Pain: Interconnections of the Spine, Neurology and the Hips, expands the practitioner's diagnostic toolkit for complicated chronic pelvic pain patients. This course is available on August 19-21 in Nashville, TN. Don't miss out!

H&W: Thanks for doing this interview, Peter! What's new?
Dr. Philip: After years of research, and writing, my textbook has been published and is ready for the public.

H&W: That's great! What can you tell us about the book?
Dr. Philip: It's called Pelvic Pain and Dysfunction; a Differential Diagnosis Manual, and it has been published by Thieme. Thieme is based out of Stuttgart Germany and is the world’s largest distributor of medical textbooks and journals! The purpose of the book is to answer the questions that so many clinicians have as it relates to their patient’s pain, such as:

• Why are there muscle spasms?
• How can the pain seemingly spread from one organ to the next? Or even from one system to another?
• How can I effectively and efficiently evaluate my patients who suffer with pelvic, bladder, bowel, or visceral pain and dysfunction?
• And so much more

The textbook also outlines a revolutionary strategy that immediately provides the patient with a reduction in their pain, and often immediate resolution of tight “spasms” or “trigger points”. The mysteries of how and why our patients' pain changes and progresses are outlined in a clear, linear fashion that integrates into a practitioner's current practice. The purpose of the textbook is to provide a means of understanding where pain originates and how to isolate it to a specific region. Once isolated, the book instructs how to treat that region effectively.

H&W: you mean to tell me that you’ve created a method which allows a suffering patient to experience “immediate relief”?
Dr. Philip: Yes! And it's actually quite simple once you understand the anatomy, and the integration of the central nervous system, the peripheral nervous system, psychology, viscera, muscles, tendons, ligaments, and nerves.

H&W: Who is this textbook written for?
Dr. Philip: the textbook is written for all my colleagues who treat patients with pelvic pain. Medical Doctors and Doctors of Science in both the United States and Germany have reviewed the material and found the information, concepts and strategies to be useful.

H&W: how did you put this all together?
Dr. Philip: I realized years ago that the field of pelvic health did not take into consideration the multiple facets that may be involved in a patient’s pain. Many strategies employed simply address restrictions in tissue mobility by “stretching” or “massaging” without taking into consideration the reason these structures are limited in mobility, or have spasms. Knowing why a structure is limited in its mobility or is spastic will allow the clinician to immediately address the suffering patient's needs and promote healing, even if the patient has been suffering for decades.

H&W: but how did you come up with this process?

Dr. Philip: my background is in non-surgical orthopedic medicine. Having three degrees in orthopedic physical therapy, and a certification by the International Academy of Orthopedic Medicine, I applied the differential diagnostic concepts of orthopedic medicine to the pelvic pain population with great success! Using the principles found within this textbook the clinician will have the opportunity to address the exact tissue at fault, provide a near immediate resolution of their pain, and provide a means for the patient to completely regain their wellness and move forward in their life.

H&W: I can see why you are so excited. Is this textbook available yet?
Dr. Philip: yes it is. It can be found at http://www.thieme.com/books-main/obstetrics-and-gynecology/product/3517-pelvic-pain-and-dysfunction. I put in a lot of effort to keep the book comfortably priced at $99.00! I know how tight cash can be for students and the working professional, so keeping it affordable was paramount to me.

H&W: What a fantastic project. Thank you so very much for taking the time to share it with us!

Dr. Philip: It's been a pleasure. Thank you to the Herman and Wallace Institute for allowing me to introduce my textbook and to teach these concepts and strategies.

I lived in Seattle during my pregnancies, where practicing yoga is almost as common as drinking coffee. I never accepted my friends’ invitations to partake in a perinatal yoga classes, mostly because I do not know how to do it, and I simply ran instead. My friends reaped the benefits of the meditation and strengthening involved when it came to delivering their babies. Researchers have been trying to measure the physical benefits from performing yoga during pregnancy, both for the mother and the fetus, and scientifically support the efficacy of participating in peripartum yoga.

In a systematic review of studies regarding yoga for pregnant women, Curtis, Weinrib, and Katz (2012) explored the literature on yoga for pregnancy. Six studies were included in the review, only 3 of which were randomized controlled trials. The aspects of yoga included in the trials were postures, breathing practices, meditation, deep relaxation, counseling on lifestyle change, and chanting and anatomy information. The programs in the trials began either between 18-20 weeks gestation or between 26-28 weeks. The yoga was practiced either 3 times per week for 30-60 minutes or 60 minutes daily. Control groups included walking, standard prenatal exercise, or general nursing care. The literature review suggested improvements were noted regarding quality of life and self-efficacy, discomfort and pain during labor, and birth weight and preterm births. Due to the limited number of trials, only a general positive commendation of yoga during pregnancy could be made from this research.

In 2015, Jiang et al. looked at 10 randomized controlled trials from 2004 to 2014 regarding yoga and pregnancy. The authors found consistent evidence showing a positive correlation between yoga intervention and lower incidence of prenatal disorders and small gestational age. Lower levels of stress and pain as well as higher relationship scores were noted with yoga. The studies showed yoga to be a safe and effective means of exercise during pregnancy, but the authors agreed further randomized controlled studies still need to be performed.

A 2015 randomized control trial by Rakhshani et al. examined the effect of yoga on utero-fetal-placental circulation during pregnancy considered high-risk. The yoga group consisted of 27 women who received standard care plus 60 minute yoga sessions 3 times per week and practice at home. The control group included 32 women who received standard care and walked 30 minutes in the morning and evening. The intervention began at the 13th week of gestation and concluded at the end of the 28th week. Yoga intervention involved yoga postures, relaxation and breathing exercises, and visualization with guided imagery. The authors conceded larger studies need to be performed to confirm the results of their randomized controlled trial; however, they concluded yoga visualization and guided imagery can significantly improve uteroplacental and fetoplacental circulation.

Although further studies are needed to make evidence-based claims regarding yoga during pregnancy, the general consensus deems yoga appropriate and safe. As with any exercise program, a tailored approach for each individual is prudent. Yoga includes many components, and current trials consistently indicate the visualization/imagery aspect is safe and beneficial during pregnancy, even when high risk. In retrospect, when I had placenta previa, perhaps I should’ve traded my running shorts for yoga pants!

Curtis, K., Weinrib, A., & Katz, J. (2012). Systematic Review of Yoga for Pregnant Women: Current Status and Future Directions. Evidence-Based Complementary and Alternative Medicine : eCAM, 2012, 715942.
Jiang Q, Wu Z, Zhou L, Dunlop J, Chen P. (2015). Effects of yoga intervention during pregnancy: a review for current status. American Journal of Perinatology. 32(6):503-14..
Rakhshani, A., Nagarathna, R., Mhaskar, R., Mhaskar, A., Thomas, A., & Gunasheela, S. (2015). Effects of Yoga on Utero-Fetal-Placental Circulation in High-Risk Pregnancy: A Randomized Controlled Trial. Advances in Preventive Medicine, 2015, 373041.