Carolyn McManus, PT, MS, MA is the author and instructor of "Mindfulness Based Pain Treatment: A Biopsychosocial Approach to the Treatment of Chronic Pain". Carolyn is a specialist in managing chronic pain, and has incorporated mindfulness meditation into her practice for more than 2 decades. Today she is sharing her experience by analyzing some of the most foundational research in the field of mindfulness and meditation.

Mindfulness awareness has been described as the sustained attention to present moment awareness while adopting attitudes of acceptance, friendliness and curiosity. (1,2) In patients with persistent pain, mindfulness has shown to reduce pain intensity, anxiety and depression and in improve quality of life. (3,4) Researchers suggest that mindful awareness may work through 4 mechanisms: attention regulation, increased body awareness, enhanced emotional regulation and changes in perspective on self. (5)

1. Attention Regulation: In chronic pan populations, improved attention regulation has been suggested to result in less negative appraisal of pain, greater pain acceptance and reduced pain anticipation. (6)

2. Body Awareness: Improved body awareness has been shown to help patients with chronic pain recognize the difference between muscle tension and relaxation, identify early warning signs that precede a pain flare and reduce maladaptive reactions to pain. (7)

3. Emotional regulation: Training in mindful awareness has been shown to enhance emotional regulation, improve mood and reduce anxiety and depression in patients with chronic pain. (6, 7, 8)

4. Changes in Perspective on Self: In a qualitative study, participants with chronic pain reported becoming less identified with their pain condition or diagnostic label. (7) They felt less “fragmented, experienced a greater integration of mind any body and described the experience of wellness even though they had a persistent pain condition.

I constantly see these changes in my patients who learn to be mindful. Empowered with a skillful way to pay attention, they have greater control over the direction of their mind and thoughts and an increase in body awareness that promotes the ability to relax and the self-regulation of their stress reaction. They avoid escalating distressing emotions and experience a renewed feeling of wholeness and well-being. I am delighted to share my training and experience in mindfulness and years of teaching mindfulness to patients in persistent pain through Herman and Wallace continuing education programs.

1. Kabat Zinn, J., 2013. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. 2nd ed. New York: Bantam.
2. Bishop, S.R., Lau, M., Shapiro, S., et al., 2004. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11(3), pp. 230–41.
3. Lakhan, S.E., Schofield, K.L., 2013. Mindfulness-based therapies in the treatment of somatization disorders: a systematic review and meta-analysis. PLoS One, 8(8), e71834.
4. Reiner, K., Tibi, L., Lipsitz, J.D., 2013. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med, 14(2), pp. 230-42.
5. Holzel, B.K., Lazar, S.W., Guard, T., et al., 2011. How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Science, 6, pp. 537–59.
6. Brown, C.A., Jones, A.K., 2013. Psychobiological correlates of improved mental health in patients with musculoskeletal pain after a mindfulness based pain management program. Clin J Pain, 29(3), pp. 233-44.
7. Doran, N.J., 2014. Experiencing wellness within illness: Exploring a mindfulness-based approach to chronic back pain. Qual Health Res, 24(6), pp. 749-60.
8. Song, Y., Lu H., Chen H., et al. Mindfulness intervention in the management of chronic pain and psychological comorbidity: A meta-analysis. Int J Nurs Sci, 1(2), pp.215-23.

An interesting study aimed to objectively answer the following question: Does applying kinesiotape to promote a posterior pelvic tilt improve an active straight leg raise (ASLR) test in women who have sacroiliac joint pain and who habitually wear high-heeled shoes? To explain some of the rationale for the chosen technique and target population, the authors first describe prior research pointing out that use of high heels can lead to an anterior pelvic tilt position and increased lumbar lordosis. This position can slacken the sacrotuberous ligament and therefore reduce the ability of the ligament to create proper form closure, according to the article.

The research included 16 women with a mean age of 23.63. Inclusion criteria is as follows: having a habit of wearing high-heeled shoes (at least 4 times/week for 4 consecutive hours over at least 1 year), and having pain in both sacroiliac joints with the active straight leg raise test (ASLR). Additionally, having symptoms for at least 3 months, no proximal SIJ pain referral to the lumbar spine, and at least 3 of 5 positive SIJ tests (posterior shear test, pelvic torsion test, sacral thrust test, distraction and compression test) were needed for inclusion in the study.

Anterior pelvic tilt was measured using a palpation meter (PALM) before, immediately after application, 1 day after tape application, and immediately after removal of tape. ASLR was measured at same time points. The ASLR was self-scored on a 6-point scale ranging from “not difficult at all”” to unable to perform”. Kinesiotape was applied for a posterior pelvic tilt taping, and the tape was applied in the target position. I-type strips with ~50% of available tension were applied over the rectus abdominis and external oblique muscles. I-type strips with ~75% tension were placed from ASIS to PSIS aiming for mechanical correction of the anterior tilt.

Results of the study indicated a decrease inanterior pelvic tilt, both during and after tape application, and an improved active straight leg raise test. As this was a preliminary study, the results cannot be extrapolated to SIJ pain and dysfunction with other activities than the ASLR test. The degree of anterior pelvic tilt cannot also directly be correlated to sacroiliac joint pain and dysfunction, yet this research is very interesting, and demonstrates a simple method for affecting in the short term a patient’s mechanics as well as reports of function on the ASLR test, a very clinically simple and useful exam.

If you would like to learn more about evaluating and treating dysfunctions related to the sacroiliac joint, join Peter Philip at Sacroiliac Joint Evaluation and Treatment - New Orleans, LA this Sep 12, 2015 - Sep 13, 2015.

Today we are so fortunate to hear from Diane Hubbard, PT, who is this week's Featured Pelvic Rehab Practitioner! Diane has completed the full Pelvic Floor Series and puts her skills to use every day. Thank you, Diane for your contributions to the field of pelvic rehabilitation, and for sharing your thoughts with us!

Tell us about your clinical practice
I am working in inpatient rehabilitation. However, I am increasing my time in pelvic rehab, as the caseload increases, in an outpatient rehab setting.

How did you get involved in the pelvic rehabilitation field?
Our hospital system was negotiating with a urology group of physicians to come and serve in our area. One of the requests of the urology group was that the hospital have a pelvic floor trained physical therapist to work with their patients as needed. Our rehab director asked if any of the PTs were interested in working with a urinary incontinence program. I said that I was very interested and was eventually given the opportunity to become trained to work with pelvic floor patients.

I will admit that I had no idea how involved the training would actually be! I really had to contemplate if I was willing to commit to all areas of the training, most especially internal exams. I finally realized that if I was not willing to learn to do internal exams, it would be like trying to perform gait training on someone if I had never seen them walk. I would be doing my patients a disservice if I was not willing to learn to do internal exams. Then I thought, when you go to a gynecologist, you know what to expect and it is fine since they are helping you. So, that is how I looked at it for pelvic floor patients.
It was worth all of the training the first time that my pelvic floor patient said to me that she was so glad that I got trained in this since no one else has been able to help her!

What/who inspired you to become involved in pelvic rehabilitation?
I was working in a SNF and I got a referral from the DON regarding a patient with incontinence. I did not know much about kegels but said that I would try. The patient said that for 40 years, she had used a pad an hour for incontinence of urine but that she was willing to try. We did 15 minutes of kegels 3 x week, then she eventually got down to 3 pads in a 24 hour period for incontinence. We were all surprised and pleased with the results!. That piqued my interest in pelvic rehabilitation.

What patient population do you find most rewarding in treating and why?
I really enjoy helping people who are willing to work hard to help themselves. It is so awesome to see them understand the concepts and perform the exercises and continue them on their own. It is inspirational to see them improve the quality of their own lives!!!

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
No ?JICING? (just in case) from Holly Herman, as she stood with her hands out and repeated that phrase several times. My co-workers now understand that phrase too!

What is in store for you in the future?
There were no other pelvic floor therapists in my geographic area when I started this training. I had to travel and was mentored by a few pelvic floor therapists who let me observe and shared some paperwork with me. I was glad to learn from the many helpful and experienced people that I met in the H&W education classes. I got my first patient in the same month that I completed the last of the 4 classes in the H&W pelvic floor series. My first patient was coccydynia and the second patient that I had was a male. I was so grateful that I had taken all 4 classes in the series before I started treating or else I would not have had experience in knowing what to do to help those first 2 patients! I am learning as I go, that is for sure! I had to start this program from the ground up, using the resources that I had available. I have been able to secure handouts, learn g-codes, formulate documentation forms and do some marketing. I have been lucky enough to be able to increase my caseload almost every month this year. It is so worth it as I have heard more than 1 patient tell me that they can do this program and that I have given them some hope!

Is there a consensus among physical therapists about the use and perceived effectiveness of Pilates exercise for low back pain? 30 Australian physiotherapists experienced with Pilates exercise were surveyed and asked about Pilates as an indication for low back pain. The results were published in Physical Therapy. Consensus at 100% was reached for benefits, indications, and precautions of Pilates exercise, and only 50-56% for risks and contraindications, respectively. Therapists agreed on indications such as maladaptive movement patterns, poor body awareness, poor flexibility, decreased lumbar spine mobility, poor breathing and postural control.

The contraindications that were agreed on (but not as strong an agreement as the indications) included pre-eclampsia and unstable fractures. Agreement was reached that participation in Pilates exercise requires caution in the presence of unstable spondylolisthesis or significant lower extremity radiculopathy. The contraindications that were no agreed upon included cancer, severe osteoporosis, significant hypertension, and yellow psychosocial flags.

The physiotherapists did all agree that Pilates may help patients who have chronic low back pain by increasing function and confidence with movement, exercise, and activities, and additionally, that body awareness, postural control, and movement patterns may improve. Potential adverse events that may occur following Pilates exercise (and that were agreed upon) included aggravation of low back pain, or increased muscle tension. In relation to other potential risks of participating in Pilates exercise, inadequate training of instructors and inappropriate exercise prescription was listed. If you would like to learn more about Pilates exercise prescription for specific women’s health issues such as pelvic floor dysfunction, peripartum issues, and perimenopausal issues such as osteoporosis, check out the Institute’s new course on Pilates.

Does prior training in pelvic floor muscle exercises contribute to a woman’s ability to contract the pelvic floor shortly after childbirth? Researchers aimed to study this question and other variables in a prospective observational study involving 958 women. Within one week of childbirth, and in the hospital setting, participants were instructed by a physiotherapist (specializing in pelvic floor) to contract the pelvic floor in a supine position. Confirmation of a contraction was determined by visual observation of the perineum moving inward. The women were also asked by a physiotherapist if they had prior knowledge or experience with pelvic floor muscle training, and if not, the women were briefly instructed in the location and function of the pelvic floor muscles. The women who had some knowledge of the pelvic floor muscles including exercise experience “…were asked if they considered themselves able to perform correct…” pelvic muscle contractions.

All women was asked to complete three pelvic muscle contractions in a row and were assessed visually using a score of 0 (no movement of the perineum), 1 (weak movement), or 2 (strong inward displacement/lift of perineum). The physiotherapist gave feedback if the women completed a correct, insufficient, or incorrect contraction. Further verbal instruction was provided to those who could not adequately contract, and a re-assessment was completed with a quantification of any change in ability to contract. After providing feedback on pelvic muscle contractions, 73.6% of the women were able to perform a better contraction. In 500 of the 958 women, no inward displacement of the perineum was observed. Additionally, a significant number of the women (33%), believed that they were doing a contraction correctly but in fact were not. Another interesting point is that women with urinary incontinence before or during pregnancy had more knowledge about pelvic floor function and training.

Although in this study, 47.8% of the participants were able to perform a pelvic floor muscle contraction shortly after giving birth, “Knowing about the function and location of the pelvic floor was a positive predictor for being able to complete a pelvic floor muscle contraction.” Interestingly, having prior training in pelvic muscle exercises was not predictive of being able to complete a contraction. The value of assessing the ability to contract the pelvic floor is evident in this study, and with methods that are quick, easy, and non-invasive, women can be empowered with an improved ability to improve performance of a pelvic muscle contraction which is necessary for an effective pelvic muscle training program.

Megan Pribyl, MSPT is the author and instructor for Nutrition Perspectives for the Pelvic Rehab Therapist. Megan is passionate about nutritional science and manual therapy. Megan holds a dual-degree in Nutrition and Exercise Sciences (B.S. Foods & Nutrition, B.S. Kinesiology) from Kansas State University, and has actively sought to fill in missing links between orthopedics and nutrition.

APTA Landmark Motion Passes
RC 12-15: The Role of the Physical Therapist in Diet and Nutrition
Is nutrition within our scope of practice? As the instructor for “Nutrition Perspectives for the Pelvic Rehab Therapist” offered through Herman & Wallace, I hear this question frequently! To me, the answer has always been a clear “yes*!”; now the APTA is endorsing this view. It’s an exciting time to be a rehab professional, especially for those looking to broaden clinical perspectives and scope of services to include basic nutrition and lifestyle information.

At the APTA House of Delegates in early June 2015, a landmark motion passed - RC 12-15: The Role of the Physical Therapist in Diet and Nutrition. As our profession advances towards a more integrative model, this motion symbolizes an acknowledgement of the rehab professional’s broader role as a health care provider. We, as physical therapists, are uniquely positioned to offer patients more comprehensive lifestyle-related education including discussion of nutrition. Both the World Health Organization (WHO, 2008) and the Physical Therapy Summit on Global Health (Dean, et.al, 2014) have called upon all health care providers to stand in unity to help the public with epidemics of lifestyle-related diseases; the APTA has given it’s nod of approval as well.

The motion states: “as diet and nutrition are key components of primary, secondary, and tertiary prevention of many conditions managed by physical therapists, it is the role of the physical therapist to evaluate for and provide information on diet and nutritional issues to patient, clients, and the community within the scope of physical therapist practice. This includes appropriate referrals to nutrition and dietary medical professionals when the required advice and education lie outside the education level of the physical therapist*.” Further, “this motion clearly incorporates the intent of the new Vision Statement for the Physical Therapy Profession by transforming society and improving the human experience.” (APTA, 2015)

This powerful development provides us with both challenge and opportunity. How can we, as pelvic rehab professionals, be armed with the most cutting edge nutritional information available? What nutrition information lies within our scope of practice? How can we apply this information to our pelvic rehab patient population? For the answer to these pressing questions and much more, plan now to attend Nutrition Perspectives for the Pelvic Rehab Therapist” March 5 & 6, 2016 in Kansas City, MO. It is my passion to share this information and I welcome you to join me for this timely CEU opportunity. It is designed to help you obtain the skills needed to confidently identify nutritional correlates in pelvic rehabilitation.

References:

ATPA (2015) http://www.apta.org/uploadedFiles/2015PacketI.pdf

Dean, E., de Andrade, A. D., O'Donoghue, G., Skinner, M., Umereh, G., Beenen, P., . . . Wong, W. P. (2014). The Second Physical Therapy Summit on Global Health: developing an action plan to promote health in daily practice and reduce the burden of non-communicable diseases. Physiother Theory Pract, 30(4), 261-275. (http://www.ncbi.nlm.nih.gov/pubmed/24252072)

World Health Organization. (2008). 2008-2013 Action plan for the global strategy for the prevention and control of non communicable diseases. Geneva, Switzerland: WHO. (http://www.who.int/mediacentre/news/releases/2015/noncommunicable-diseases/en/)

photo credit: Walmart’s locally grown produce via photopin (license)

Today we get to hear from Mitch Owens, MsPT, COMT who is the author and instructor of "Neck Pain, Headaches, Dizziness, and Vertigo: Integrating Vestibular and Orthopedic Treatment". Join Mitch in Rockville, MD on November 14-15 in order to learn more about treating patients with head trauma.

Following a whiplash injury, concussion or vestibulopathy patients will complain of the same cluster of symptoms: neck pain, dizziness, and headache. In order to properly treat patients complaining of these symptoms a clinician must first be able to determine the source and understand the physiology at work to reason out the best plan of care.

Treating individuals for dizziness, neck pain and headaches requires a refined understanding of the systems involved, the clinical tests that can be used to differentiate symptom generation and then finally which evidence based interventions should be deployed.

A patient who presents with a complaint of dizziness or vertigo following a trauma to the head or neck will challenge the examination skills of even the best practitioners. The list of differential diagnosis includes a number of conditions that could prove to be quite threatening to the patient with or without intervention. These conditions include: vertebral basilar insufficiency, cervical fracture, dislocation or instability, stroke, traumatic brain injury, concussion, and peripheral vestibulopathy to name a few. The ability to clinically reason and properly assess these individuals is crucial to the effective management of any orthopedic or neurologic case load.

Clinicians treating either population need skill sets that bridge the orthopedic and neurologic expertise gap that often exist if clinicians. The need to close this gap is highlighted the following facts:

- 15-20% of Benign Paroxysmal Positional Vertigo is caused by trauma (Gordon, Carlos et al. 2004).
- 19% of cases of whiplash demonstrated vestibulopathy with videonystagmography (VNG) testing within 15 days of their accident (Nacci, A. et al 2011).
- 60% of cases of whiplash with head trauma demonstrated vestibulopathy (Nacci, A. et al. 2011).
- Dizziness is reported 20-58% of whiplash patients (Wrisley DM et al. 2000).
- Between 40%-70% of individuals with persistent whiplash associated disorders complain of dizziness (Treleaven, Julia et al. 2003).
- The incidence of cervicogenic dizziness has been reported to be 7.5% of all dizziness (Ardic FN, et al. 2006)

Recent evidence has shown that sensory dysfunction is as much a part of dizziness as it is a component of chronic neck pain (Treleaven, Julia et al. 2003).

Interventions directed at training cervical proprioception have been show to significantly reduce pain and has improved function in patients with chronic neck pain (Revel, Michel, et al 1994). Manual therapy techniques directed at the upper cervical spine have also been shown to effectively treat dizziness in randomized control trials (Reid, Susan A., et al. 2013).

Thus we are learning the ability to effectively measure and treat neurologic dysfunction is an important part of address cervical spine issues. It is equally true that being able to assess and treat cervical spine dysfunction is an important part of treating patients who complain of dizziness.

Enhancing your neurologic and orthopedic skill set is clearly useful for any clinician and will help improve your outcomes across all patient populations. Continued training in these areas will expand what patients you can see, add to your clinical tool belt, and improve your confidence within your current caseload.

References:
Ardic FN, Topuz B, Kara CO. Impact of multiple etiology on dizziness handicap. Otol Neurotol. 2006;27:676 – 680.
Gordon, Carlos R., et al. "Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?." Archives of Neurology 61.10 (2004): 1590-1593.
Nacci, A., et al. "Vestibular and stabilometric findings in whiplash injury and minor head trauma." Acta Otorhinolaryngologica Italica 31.6 (2011): 378.
Reid, Susan A., et al. "Comparison of Mulligan Sustained Natural Apophyseal Glides and Maitland Mobilizations for Treatment of Cervicogenic Dizziness: A Randomized Controlled Trial." Physical therapy (2013).
Revel, Michel, et al. "Changes in cervicocephalic kinesthesia after a proprioceptive rehabilitation program in patients with neck pain: a randomized controlled study." Archives of physical medicine and rehabilitation 75.8 (1994): 895-899.
Treleaven, Julia, Gwendolen Jull, and Michele Sterling. "Dizziness and unsteadiness following whiplash injury: characteristic features and relationship with cervical joint position error." Journal of Rehabilitation Medicine 35.1 (2003): 36-43.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM: Cervicogenic dizziness: a review of diagnosis and treatment. Journal of Orthopaedic & Sports Physical Therapy 2000, 30(12):755-766.

The Pelvic Rehab Report had an opportunity to interview Dawn Sandalcidi, the creator and instructor of "Pediatric Incontinence and Pelvic Floor Dysfunction". Dawn has developed a pediatric dysfunctional voiding treatment program in which she lectures on nationally. Dawn has published articles in the Journal of Urologic Nursing, the Journal of Manual and Manipulative Therapy, and the Journal of Women’s Health Physical Therapy. Let's hear more from Dawn about her Pediatric Incontinence and Pelvic Floor Dysfunction course!

What essential skill does your course add to a practitioner’s toolkit?

Adding pediatrics to your practice truly allows you to treat the pelvic floor through the lifespan. If you are a pediatric therapist adding this most important specialty will complete the picture of your entire patient.

Will your course allow practitioners to see new/more patients?

There are so many therapists who tell me that while treating a parent they share a story about their child being a bed wetter or having incontinence. That has opened up many doors for including this population into my practice. Be careful though! Once the pediatricians, school nurses, pediatric urologists and GI docs know there is someone out there that can take care of kids you will be flooded with patients!!

Why did you develop this course?

I began treating pediatrics after having success with adult patients in a large urology practice over 25 years ago. One of the urologists called me and asked me to take care of this little girl who had already been operated on twice and was headed toward kidney transplants. My reply was "what is wrong with kids?????" So my journey began- observing surgery and learning how children developed pelvic floor dysfunction. This kiddo had vesicoureteral reflux or a back flow of urine form the bladder to the kidneys causing frequent infections and kidney damage. My goal in this course is to take the basic knowledge we have as therapists and apply it to a population of children who suffer terribly with urinary and fecal incontinence. The psychological side effects from incontinence are significant and we now have the tools to help!!

What are the attributes and barriers to care for college-aged women who have pelvic pain? This is a question asked by researchers who published an original article on the topic in the Journal of Minimally Invasive Gynecology. To complete the study, a random sample of 2000 female students at the University of Florida were sent an online questionnaire. Included in the questionnaire was basic demographic data, general health and health behavior questions, psychosocial factors, measures assessing different types of pelvic pain such as dyspareunia, dysmenorrhea, urinary, bowel, or vulvar pain, and information about barriers to care for pelvic pain and quality of life measures. A total of 390 women completed the survey, and the mean age was 23 years old. Most of the women in the sample identified as white, with 9.6% identifying as black or African-American. Most of the respondents had never been pregnant. The chart below lists some of the data.

Barriers to receiving care included difficulty with insurance coverage and providers’ “…lack of time and knowledge or interest in chronic pelvic pain conditions.” An interesting finding was that among the women who had pelvic pain, those who were sexually active reported lower scores on physical and mental health. Even among the women without pelvic pain, those who were sexually active reported lower mental health scores.

How can this study encourage us as pelvic rehabilitation providers? Can we reach out to providers and share the potential benefits of pelvic rehab care to decrease the burden on the patient in finding services? It seems that in addition to continually spreading the word that pelvic pain can be eased with rehabilitation efforts, we can provide the interest and knowledge in the subject so that the patient can feel validated and can be instructed in self-management tools.

Over the past 28 years, my pelvic floor has endured at least 20,000 miles of running, including racing on the collegiate level and then completing 10 marathons. Add to the high-impact sport two 8.1 pound natural childbirth deliveries 26 months apart, and you can imagine why I accepted the invitation to blog for this well-respected institute. One of my elderly patients once told me my uterus was going to drop out from so much running (which, thankfully, has NOT happened); however, I have to admit, urinary stress incontinence and frequent urination were unwelcome enough consequences! On the positive side, it all initiated my journey to understanding the pelvic floor.

In 2014, Poswiata et al used the Urogenital Distress Inventory (UDI-6) to assess how prevalent stress urinary incontinence may be among elite female skiers and runners. Of the 112 female athletes in the study, 50% reported leaking a small amount of urine. Coughing and sneezing provoked leakage for 45.54% of those women, indicating stress incontinence, and 58.04% of the women in the study reported frequent urination. Are those acceptable statistics? I would have to say no.

Research results can be comforting so athletes can be told they are not alone regarding a quite personal aspect of their lives. When I could supposedly empty my bladder, stand to wash my hands and have to go again, walk down the hall to put on my sneakers and go once again before heading out the door for a run, it was nice to know someone else was probably experiencing the same issue that morning. Just because it is common, though, does not make it “normal.” We are not meant to leak just because we stress our bodies beyond normal ADLs.

A very recent study by Luginbuehl et al (2015 July 21), just published online, attempted to explore the electromyography (EMG) activity of pelvic floor muscles with variable running speeds (7, 9, and 11km/h) over 10 steps. The highest pelvic floor muscle activity was recorded at 11km/h, which would sensibly suggest the muscles produce a greater contraction the faster someone runs. If a runner has developed a decreased ability to activate the pelvic floor muscles, stress urinary incontinence will likely become a highly irritating problem with fast running speeds over time. But how do they know, and where do they go?

Without health practitioners trained in rehabilitation of pelvic floor dysfunctions, consider how chronic an issue urinary stress incontinence would be for a large athletic population. So many women (and men) do not even recognize their leakage or frequent urination as treatable “issues” and never mention them to anyone. Often times, we are treating an athlete for a hip or lumbar injury and purposefully yet discretely have to ask the right questions and then educate the patient how some of their symptoms are secondary to pelvic floor deficits. Someone has to explain what is normal, and, better yet, someone HAS to make an effort to fix what is “broken” and restore the pelvic floor to a higher level of function. With the proper training, perhaps that someone can be you.

References:
1. Poświata, A., Socha, T., & Opara, J. (2014). Prevalence of Stress Urinary Incontinence in Elite Female Endurance Athletes. Journal of Human Kinetics,44, 91–96. doi:10.2478/hukin-2014-0114.
2. Helena Luginbuehl, Rebecca Naeff, Anna Zahnd, Jean-Pierre Baeyens, Annette Kuhn, Lorenz Radlinger (2015 July 21). Pelvic floor muscle electromyography during different running speeds: an exploratory and reliability study. Archives of Gynecology and Obstetrics. doi: 10.1007/s00404-015-3816-9.