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Herman & Wallace Blog

Seeing is Believing

Using sEMG biofeedback to get real-time results

Tiffany Lee, MA, OTR, BCB-PMD and Jane Kaufman, PT, BCB-PMD are internationally board-certified clinicians in the treatment of pelvic floor muscle dysfunction through the Biofeedback Certification International Alliance. Combined, they have over fifty years of treatment experience using sEMG biofeedback. Their new course, “Biofeedback for Pelvic Floor Muscle Dysfunction”, will provide the nuts and bolts of this powerful tool so that clinicians can return to the clinic after this course with another component to their toolbox of treatment strategies.

As a clinician treating patients with pelvic floor muscle dysfunction, have you gone away from a treatment session and asked yourself ‘what else can I do for this patient?’. Have you considered adding surface EMG, often referred to as biofeedback, to your treatment plan, but aren’t sure how to go about it correctly or effectively? Perhaps you think you can’t use the sensor because the patient has pain. Maybe you think biofeedback only helps with up-training or strengthening.

So exactly what is biofeedback? Why should I consider this modality? Biofeedback provides a non-invasive opportunity for patients to see muscle function visualized on a computer screen in a way that allows for immediate feedback, simple representation of muscle function, and allows the patient and the clinician the opportunity to alter the physiological process of the muscle through basic learning strategies and skilled cues. Many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation is what helps patients really hone in on body awareness and connect all the dots. Here are a few comments that our patients have made; “I can now pay attention to my muscle while at work thanks to the visual of my muscle when sitting and standing”; “I needed to see my muscle to fully understand how to release the tension in it “; “I totally get what I need to do now that I have a clear picture of what you want”; “Seeing is believing”.

A 2017 study by Moretti, E., et al. is a great article that helps support the concept that measuring the pelvic floor electrical activity through a standard vaginal sensor is not always an option. For many patients, use of surface electrodes with peri-anal electrodes will provide the same reading and offer a more comfortable alternative for those patients who cannot use an internal sensor. This allows the clinician more opportunities to use this treatment modality with ease and assurance that the patient can learn from the visual representation of the muscle without fear of penetration from a sensor, and get great results!

In another study by Aysun Ozlu MD, et al. the authors conclude that biofeedback assisted pelvic floor muscle training, in addition to a home exercise program, improves stress urinary incontinence rates more than home exercise program alone.

Herman & Wallace is offering a course for clinicians in Alexandria, Virginia this June that will answer all of your questions and concerns about this fabulous treatment tool: biofeedback! This course enables the clinician to learn and practice this valuable tool and gain knowledge about the benefits of this modality, so that treatment can begin immediately with ample opportunity for patient’s positive feedback and awareness of muscle function. Participants will experience being a biofeedback practitioner and patient (using a self-inserted vaginal or rectal sensor). Participants will be administering biofeedback assessments, analyzing and interpreting sEMG signals, conducting treatment sessions, and role-playing patient instruction/education for each diagnosis presented during the many hands-on lab experiences. Biofeedback is a powerful tool that can benefit your patient population, and add to your skill-set.


Moretti, E., Galvao de moura Filho, A., Correia de Almedia, J., Araaujo, C., Lemos, C. “Electromyographic assessment of women’s pelvic floor: What is the best place for a superficial sensor?” Neurology and Urodynamics; 2017; 9999:1-7.;
Aysun Ozlu MD, Neemettin Yildiz MD, Ozer Oztekin MD, “Comparison of the efficacy of perineal and intravaginal biofeedback assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence

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Bugs, Gut, and Glial

Advancing Understanding of Nutrition’s Role in…..Well….Everything

Gratitude filled my heart after being able to take part in the pre-conference course sponsored by the APTA Orthopedic Section’s Pain Management Special Interest Group this past February. For two days, participants heard from leaders in the field of progressive pain management with integrative topics including neuroscience, cognitive behavioral therapy, motivational interviewing, sleep, yoga, and mindfulness to name a few. It’s exciting to witness and participate in the evolution of integrative thinking in physical therapy. When it was my turn to deliver the presentation, I had prepared about nutrition and pain, I could hardly contain my passion. While so much of our pain-related focus is placed on the brain, I realized acutely the stone yet unturned is the involvement of the enteric nervous system (aka the gut) on pain and….well…everything.

Much appreciation is due to those on the forefront of pain sciences for their research, their insight, their tireless work to fill our tool boxes with pain education concepts. Neuroscience has made tremendous leaps and bounds as has corresponding digital media to help explain pain to our patients. One such brilliant 5-minute tool can be found on the Live Active YouTube channel.

What I love about this video is how intelligently (and artistically!) it puts into accessible language some incredibly complex processes. It even mentions lifestyle and nutrition as playing a role in what is commonly referred to as a maladaptive central nervous system.

"Maladaptive central nervous system"

Ok. I’ll admit, I struggle with the implications of this term. However, what doesn’t sit right with me is the concept of chronic or persistent pain being entirely in the brain as though the brain is a static entity. We know the brain to be plastic but often do not identify just how this is so.

Glial Cells found in Nervous SystemWhat about the role of our second brain…. the one with 200-600 million neurons that live in that middle part of our body (right next to / inside our pelvis)? Termed the enteric nervous system, this second brain both stores and produces neurotransmittersTurna, et.al., 2016, serves as the scaffolding of interplay between the ENS, SNS, and CNS. This ENS is home to the interface of “bugs, gut, and glial” which are “not only in anatomical proximity, but also influence and regulate each other…interconnected for mutual homeostasis.”Lerner, et.al., 2017 In fact, part of this process then directly impacts the brain. “Healthy brain function and modulation are dependent upon the microbiota’s [gut bugs] activity of the vagus nerve.”Turna, et.al., 2016. Further, “by direct routes or indirectly, through the gut mucosal system and its local immune system, microbial factors, cytokines, and gut hormones find their ways to the brain, thus impacting cognition, emotion, mood, stress resilience, recovery, appetite, metabolic balance, interoception and PAIN.”Lerner, et.al., 2017

So, by process of logic, it requires little convincing to conclude that the food we eat or fail to eat directly impacts the health or dysfunction of this magnificently orchestrated system. One that directly and profoundly impacts our brain, our body, our being. And it’s a concept that our patients, our clients, ourselves, know in our gut to be true.

And it’s thanks to all the hard work of those who have come before us that we can share in the advancing understanding for the benefit of thousands who need your help, expertise and guidance. Please join me for Nutrition Perspectives for the Pelvic Rehab Therapist. The next course will be in Springfield, MO on June 23-24, 2018. Vital and clarifying information awaits you!


Live Active. (2013, Jan) Understanding Pain in less than 5 minutes, and what to do about it! https://www.youtube.com/watch?v=C_3phB93rvI Retrieved March 28, 2018.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Turna, J., Grosman Kaplan, K., Anglin, R., & Van Ameringen, M. (2016). "What's Bugging the Gut in Ocd?" a Review of the Gut Microbiome in Obsessive-Compulsive Disorder. Depress Anxiety, 33(3), 171-178. doi:10.1002/da.22454

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Really…. a New Organ…it’s Called Fascia

There has been a bit of buzz on the various news outlets and social media feeds about the “new organ” the interstitium. On March 27th an article appeared in Scientific Reports, an online peer-reviewed journal from the publishers of Nature. This work was presented by a team of researchers that utilized a new in vivo laser endomicroscopy technique that demonstrated this tissue is a matrix of collagen bundles and elastic fibers surrounded by fluid rather than the tightly packed layers of connective tissue that was previously observed on fixed slides . This submucosal layer was observed in the entire gastrointestinal tract, the urinary bladder, bronchus, dermis, bronchus and peri-arterial soft tissue and fascia. The authors state, “In sum, we describe the anatomy and histology of a previously unrecognized, though widespread, macroscopic, fluid-filled space within and between tissues, a novel expansion and specification of the concept of the human interstitium” Benias et al., 2018.

The only thing ‘new’ is the way that this group of scientists observed the tissue that until now has primarily been studied ex vivo. I find it rather humorous to note that it is mainstream news that histologists in the 21st century just realized that there is a difference in the architecture of living versus dead tissue. They noted a significant change in the appearance of tissue slides that were chemically fixed in the traditional manner when compared to studies of in vivo structures as well as fresh frozen samples. The researchers noted this tissue in the dermis as well as urinary system, gastrointestinal system and respiratory system. This further supports one of my favorite talking points presented in the visceral mobilization courses “fascia is fascia is fascia is fascia.”

As an instructor that presents entire courses around the importance of the fascial system within all structures of the body including the dermis, epimysium, all organs, and the adventitia of vessels, I am thrilled to see this layer of the fascial system receive recognition and garner the attention it deserves. However, to refer to the interstitium as a new undiscovered organ is to ignore the work of the International Fascia Research Congress as well as many other notable scientists. These researchers see the fascial system as the dynamic mesenchymal tissue that unites every cell in the body and allows for fluid and tissue movement.

French hand surgeon Dr. Jean-Claude Guimrberteau has documented this tissue utilizing microendoscopy on living subjects for the past 20 years. Dr Guimberteau created a brilliant DVD called Strolling Under the Skin, you can view an excerpt available on YouTube. Following the success of several videos, he went on to co-author the book Architecture of Human Living Fascia: The extracellular matrix and cells revealed through endoscopy.

Another brilliant researcher is Orthopedic Surgeon Dr. Carla Stecco. Her paper The Fascia: the forgotten structure is an excellent review of the three-dimensional continuity of the myofascia. Following multiple publications, she also authored the book The Functional Atlas of the Human Fascial System. Her work is limited to the myofascial layer and does not include the visceral fascia although she notes its presence in her published works. For those that would like to know more about this tissue, I highly recommend both of these authors. If you wish to explore how a physical therapist can utilize this information in clinical practice, join me for one of my courses on fascial manipulation. The fascial based treatment for pelvic dysfunction series includes:


Benias, P. C., Wells, R. G., Sackey-Aboagye, B., Klavan, H., Reidy, J., Buonocore, D., ... & Theise, N. D. (2018). Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Scientific Reports, 8(1), 4947. https://:doi.org/10.1038/s41598-018-23062-6, 2018.

Stecco, C., Macchi, V., Porzionato, A., Duparc, F., & De Caro, R. (2011). The fascia: the forgotten structure. Italian journal of anatomy and embryology, 116(3), 127.

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Do pelvic floor exercises improve sexual arousal and orgasm in women?

Sagira Vora, PT, MPT, WCS, PRPC practices in Bellevue, WA at the Overlake Hospital Medical Center, and she played a pivotal role in creating the Pelvic Rehabilitation Practitioner Certification examination. Today's post is part one of a multi-part series on pelvic rehabilitation and sexual health. Stay tuned for part two!

“Have mind-blowing sex: learn how to do your Kegels.” “Amazing orgasms, ladies do your Kegels!” These were just some of the headlines that greeted me as I researched what was being said in the popular media regarding pelvic floor exercises and improving sexual function in women. Some other wisdom from popular women’s magazines included advice on, “stopping the flow of urine,” to do your Kegels. We know how much we pelvic floor therapists love hearing that phrase!

How about taking a slightly more scientific view and really finding what helps women improve sexual function?

I found a few recent and past studies that have tried to study pelvic floor exercises and sexual function in women.

In 1984, Chambless et.al. studied a small group of women who were able to achieve orgasm through intercourse less than 30% of time. Strength gains in the pubococcygeus muscles were noted in the exercise group but neither the exercise nor control group achieved increased orgasmic frequency.

In a more recent study, Lara et. al. studied 32 sexually active post-menopausal women, who had the ability to contract their pelvic floor muscles, tested the hypothesis that 3 months of physical exercises including pelvic floor muscle training with biweekly physical therapy visits and exercise performed at home three times a week, would enhance sexual function. Pelvic floor muscle strength was significantly improved post-test, but this study found no effect on sexual function.

Forty years after Dr. Kegel’s assertion about sexual arousal enhancing properties of pubococcygeus muscle exercises, Messe and Geer tested Kegel’s hypothesis in their psychophysiological study, in which they asked women to perform vaginal contractions while engaging in sexual fantasy. A second group was asked to engage in sexual fantasy without the contractions, and yet a third group was given the task of vaginal contractions but no sexual fantasy. The results indicated that performing vaginal contractions with sexual fantasy improved arousal and orgasmic ability. Initially, this group made better gains than vaginal contractions alone and fantasizing alone. However, with a second test session one week later, no further gains were noted in the ability of this group to improve sexual arousal or orgasm. Messe and Geer speculated that increased muscle tone may result in increased stimulation of stretch and pressure receptors during intercourse, leading to enhanced arousal and orgasmic potential.

The most interesting finding was reported by an older study done by Roughan, who reported no differences in the groups he studied. Roughan et. al. expected women with orgasm difficulties to improve after 12-week period of pelvic floor strengthening exercises, compared to a group that practiced relaxation and an attention control group. No difference was found between the orgasmic ability of the two groups.

The majority of women studied here had no reported pelvic floor dysfunction. Perhaps, contrary to popular opinion and against the advice of women’s magazines, women with healthy pelvic floors may not benefit from pelvic floor exercises any more than they would from relaxation training, or mindful attention to sexual stimuli.

So, what then, will increase our mojo in bed, you ask? Stay tuned for the next blogs…


Chambless D, Sultan FE, Stern TE, O’Neill C, Garrison S. Jackson A. Effect of pubococcygeal exercise on coital orgasm in women. J Consult Clin Psychol. 1984; 52:114-8
Laan E. Rellini AH. Can we treat anorgasmia in women? The challenge to experiencing pleasure: Sex Relation Ther. 2011:26:329-41
Messe MR, Geer JH. Voluntary vaginal musculature contractions as an enhancer of sexual arousal. Arch Sex Behav. 1985; 14:13-28
Padoa, Anna. Rosenbaum, Talli. 1st edition. 2016. The Overactive Pelvic Floor.
Roughan PA, Kunst L. Do pelvic floor exercises really improve orgasmic potential? J Sex Marital Ther. 1984;7:223-9

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Narrowing the Inter-Rectus Distance of the Transverse Abdominus

Today's guest post comes to us from Kelly Feddema, PT, PRPC. Kelly practices pelvic floor physical therapy in the Mayo Clinic Health System in Mankato, MN, and she became a Certified Pelvic Rehabilitation Practitioner in February of 2014. To learn more about diastasis recti abdominis, consider attending Care of the Postpartum Patient!

It can be a struggle to treat patients with diastasis recti if they don't seek treatment early after giving birth. Many therapists may often find themselves thinking “if I only could have started them sooner.” Why does this condition often get missed at postpartum examinations? I personally deal with symptoms from an undiagnosed diastasis, and I'm a therapist! I didn’t really pay attention to it until I started down the road of becoming a pelvic floor therapist.

Diastasis recti can be a difficult diagnosis to treat, as the patient may come to us when they are already one year postpartum, and not everyone agrees on the what are the best treatments. To crunch or not crunch? To use a brace or not to brace? It would be great if we had a similar healthcare system to France, where the norm is to have 10-20 postpartum rehabilitation visits with women after child birth. While therapy is available in the United States, women must ask for it.

There are many programs out there from the more well-known Tupler Technique and Mutu programs to others that come up when searching for exercise ideas. The American Physical Therapy Association (APTA) has a basic program to work on isolating the transverse abdominis (TrA) muscle and then progressing movements in the legs while keeping the TrA activated.

Some research by Paul Hodges and Diane Lee from 2016 in the Journal of Orthopedic Sports Physical Therapy indicates that narrowing the inter-rectus distance with a TrA contraction might improve force transfer between the sides of the abdominals and in turn, improve abdominal mechanics.

Another study in Physiotherapy from December of 2014 by AG Pascoal, et.al. utilized ultrasound to determine the effect of isometric contraction of the abdominal muscles on inter-rectus distance in postpartum women. They found that the while the inter-rectus distance in postpartum women was understandably higher than controls, it significantly lowered during an isometric contraction of the abdominal muscles.

One year later, a study in the same journal by MF Sancho, et.al. had similar findings when studying women who had a vaginal delivery and women who had Cesarean deliveries. They found that abdominal crunch exercises were successful in reducing inter-rectus distance, but drawing-in exercises were not.

As with a lot of research, the findings lead to more questions and ideas to explore. I think it is safe to say that starting safe re-education of the muscles as early as possible is going to provide women the most benefit in reducing diastasis recti, and that will help to prevent further issues in the abdominal and pelvic region.

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Prenatal Yoga - What’s the Evidence?

As practitioners, we understand the value of a yoga practice for multiple systems. Yoga improves cardiovascular function, pulmonary function, improves flexibility, builds strength, improves balance, and cultivates resiliency. Prenatal yoga is deemed safe and widely practiced. Beyond not laying prone after the first trimester, what are modifications for practicing yoga while pregnant? Is there any evidence to demonstrate if specific yoga postures are safe from both the maternal and fetal perspective?

Polis et al set out to determine the safety of specific yoga postures using vital signs, pulse oximetry, tacometry, and fetal heart rate monitoring. The patients were diverse in age, race, BMI, gestational age, parity, and yoga experience. Exclusionary criteria included preeclampsia, placenta previa, bleeding in the 2nd or 3rd trimester, gestational diabetes, BMI greater than 35 and other medical conditions that presented contraindications.

The maternal and fetal responses were tested in 26 yoga postures. The selected postures, much like most yoga classes, offered a variety of physical positions. The standing, seated, twists and balancing postures chosen were: Easy Pose, Seated Forward Bend, Cat Pose, Cow Pose, Mountain Pose, Warrior 1, Standing Forward Bend, Warrior 2, Chair Pose, Extended Side Angle Pose, Extended Triangle Pose, Warrior 3, Upward Salute, Tree Pose, Garland Pose, Eagle Pose, Downward Facing Dog, Child’s Pose, Half Moon Pose, Bound Angle Pose, Hero Pose, Camel Pose, Legs up the Wall Pose, Happy Baby Pose, Lord of the Fishes Pose and Corpse Pose.

Balancing postures were modified to decrease fall risk. Warrior 3, Tree Pose, Eagle Pose, and Half Moon Pose were performed at the wall or using a chair for support. The addition of a yoga block to bring the floor closer to the practitioner was used for Extended Side Angle Pose, Extended Triangle Pose, and Garland Pose.

Four poses that have previously been theorized to be contraindicated were studied in this group. These postures are Child’s Pose, Corpse Pose, Downward Facing Dog, and Happy Baby. No adverse reactions were discovered for this specific population during the intervention or in the 24 hour follow-up as reported by email.

Now that we have this data, what do we do with it?

We have the opportunity to educate our non-high-risk patients that the previously theorized contraindicated postures listed above were safe for the self-selected group in this study. Those who are in high-risk categories should understand that even though yoga is not a high impact activity, there should be clearance from the OB team to ensure expectant mothers are moving as safely as possible. With proper guidance, yoga is a safe form of exercise and stress reduction which can optimize physical and mental health during the prenatal period and prepare for birth.

Dustienne Miller is the author and instructor of Yoga for Pelvic Pain. Join her in Kansas City, MO on April 7, 2018 - April 8, 2018 to learn about treating interstitial cystitis/painful bladder syndrome, vulvar pain, coccydynia, hip pain, and pudendal neuralgia with a yoga approach.


Polis RL, Gussman D, Kuo YH. Yoga in Pregnancy. Obstet Gynecol 2015;126:1237–41

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An Orthopedic Approach to Coccyx Pain

Most of us spend our day sitting and do not think about the position of our ilia, sacrum or coccyx during the change from standing to sitting. Weightbearing through a tripod of bilateral ischial tuberosities and a sacrum that should have normalized form closure should be easy and pain free. The coccyx typically has minimal weight bearing in sitting, about 10%, just like the fibula, however, it can be a major pain generator, if the biomechanics of the ilia, sacrum and femoral head positions are not quite right.

Coccydynia and Painful Sitting is a course that can be related to all populations that physical therapists treat. A lot of patients will state “my pain is worse with sitting” which can mean thoracic pain, low back/sacral pain and even lower extremity radicular pain. Women’s health providers treat anything regarding the pelvis, so we are seeing a lot of complicated histories and symptoms.

Scanning the literature for coccyx treatment does not always yield the best results for physical therapists. Most literature states what the medical interventions can be, and physical therapy is never at the forefront. However, as we are musculoskeletal and neuromuscular specialists, this is no different on our thinking patterns relating to coccyx pain or painful sitting.

During sitting, the coccyx has a normal flexion and extension moments that will change or become dysfunctional once mechanics above and below that joint change. A simple ankle sprain from 2 years ago can result in chronic knee pain, sacroiliac pain, and can lead to coccyx pain over time. Even the patient who has long standing TMJ (temporomandibular joint) and cervical dysfunction, now has a thoracic rotation and your correction of their coccyx deviation cannot maintain correction.

This course sparks your orthopedic mindset, encouraging the clinician to evaluate the coccyx more holistically. What are the joints doing? How does it change from sitting to standing? Standing to sitting? What is the difference from sitting upright to slump activities? Working through the basics and the obvious with failed results, takes you to the next step of critical thinking within this course. How does the patient present, what seems to be lacking and how to correct them biomechanically to achieve pain free sitting?

Related coccyx musculature and nerve dysfunction can seem like the easiest to treat, but what happens when those techniques fail? This course looks at the entire body, from cranium to feet, to determine the driver of coccyx pain and dysfunction. A better understanding of ilial motion, with accompanied spring tests (Hesch Method), normalizing spinal mechanics and lower extremity function is highlighted in this course. Internal vaginal and rectal release of pelvic floor muscles can lead to normalized coccyx muscle tension that are supported via coccyx taping.

Join me for "Coccydynia and Painful Sitting: Orthopedic and Pelvic Floor Muscle Implications", taking place May 6-7 in Dayton, OH and October 13-14 in Houston, TX.

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Perineal Stimulation for Nocturia and Overactive Bladder in Elderly Women

A 2016 study by Kaori et al examined the effect of self administered perineal stimulation for nocturia in elderly women. A prior study using rodents found a soft roller used decreased overactive bladder syndrome (OAB), but a hard roller did not produce the same results. Kaori et al performed a similar study for elderly women in a randomized, placebo controlled, double blind crossover. Participants were 79-89 years old women who applied simulation to perineal skin for 1 minute at bedtime, using either active (soft, sticky elastomer) roller or a placebo (hard polylestrene roller). Participants did a 3-day baseline, followed by 3-day stimulation, then 4 days rest, then other stimuli for 3 days. There were 24 participants, 22 completed the study: 9 with OAB, 13 without OAB. The placement of the roller was not on the skin of the perineal body, but rather on the general peri-anal area with the diagram from the study showing an area just medial to the gluteal crease—where one would find the ischial tuberosity-- and anterior and lateral to the anal sphincter.

Across the subjects with OAB, change with the elastomer roller (soft and sticky feel) was more statistically significant than with the hard roller. Baseline micturition for the participants was 3.2+/- 1.2 times per night, measured as the number of urination between going to bed and arising. The group as a whole did not have a statistically significant difference, measured by at least one less time arising per night. However, in the OAB group, the difference was significant. The researchers theorized that the soft and sticky texture may induce more firing of somatic afferents nerve fibers.

The most commonly prescribed treatment for overactive bladder is anticholinergic therapy, but the side effects, including cognitive changes and lack of significant difference from controls, as well as the drying effect of these drugs in a post-menopausal-low-estrogen-pelvis, bring up questions of whether this is the best option in the elderly.(6)

In anesthetized animals, electrical stimulation and noxious stimuli decrease frequency of bladder contractions when applied to the perineal area (3-5). Somatic, afferent nerve stimuli (those theorized to be active with the soft roller) are used to treat OAB by modalities such as acupuncture and transcutaneous electrical stimulation to the perineum (2). So, stimulation of somatic visceral afferent nerves in the perineal region seems to have an effect on the bladder. However, with manual therapies, it seems we can also affect the somatic or visceral afferents. Essentially, visceral afferents convey information to the central nervous system about local changes in chemical and mechanical environments of a number of organ systems(7). Doing manual therapy between the urethral and bladder fascia would also theoretically cause stimulation of the visceral afferents to the central nervous system about that organ (bladder).

In our pelvic floor intro class (Pelvic Floor Level 1) at Herman Wallace, we discuss the role of Bradley’s neurology loop 3 and the inverse relationship between pelvic floor contraction (lifting the perineal area) and the bladder. One suppression technique we discuss is the contraction of the pelvic floor to quiet or inhibit bladder activity in the bladder retraining program. Bladder retraining has evidence level A (strong) for improving urgency and frequency with overactive bladder.

Clinicians who are ready to raise their manual game may try using the skills of prior series courses and adding the sophistication of manual techniques in the abdomen and pelvis to increase afferent firing in patients with OAB, as well as freeing up any fascial restrictions that may be interfering with full bladder excursion.

In the newly written Capstone course, we combine the prior level of education from the pelvic series (bladder strategies) with manual techniques to address the endopelvic fascia at the bladder base, in the fascial articulations along the perineum, and along its attachments to the coccyx, as well as combining internal work with sacral techniques to facilitate S234 afferents for bladder control. We discuss studies, such as this one, to explore advanced concepts of bladder and urethral fascial mechanics and neural entrapment affecting the bladder. We move out of the pelvic muscle and into the fascial contents of the abdominopelvic region, to allow such firing of the somatic afferents. And the perineal stimulation? We have an entire lab for perineal tissue and its effect on pelvic function. Physical therapists can manually address the perineum, urethral and bladder fascia with Capstone techniques. With such intervention, we get more CNS communication.

So, what about the roller? Well, the soft roller created change in rodents in a couple of studies. (Sato 2010). In this human study, it helped with OAB. Certainly, manual therapies in the region of the endopelvic fascia and suprapubic region may be of help for also stimulating the visceral afferents. Also, it could be worth it to have a high fall risk elderly patient with OAB type nocturia follow up your treatments with one minute of soft washcloth stroking in the area of the perineum for one minute at bedtime to see if it helps decrease the number of voids on a night time bladder diary.

Nari Clemons, PT, PRPC is a Herman & Wallace faculty member who helped author the Pelvic Floor Series Capstone: Advanced Topics in Pelvic Rehab course. She is also the creator and instructor of Pelvic Nerve Manual Assessment and Treatment.


Main study: PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial.Iimura K1,2, Watanabe N2, Masunaga K3, Miyazaki S1,2,4, Hotta H2, Kim H5, Hisajima T1,4, Takahashi H1,4, Kasuya Y3.
2. Exp Ther Med. 2013 Sep;6(3):773-780. Epub 2013 Jul 9., Acupuncture for the treatment of urinary incontinence: A review of randomized controlled trials.Paik SH1, Han SR, Kwon OJ, Ahn YM, Lee BC, Ahn SY.
3. Guo ZF. Transcutaneious electrical nerve stimulation in the treatment of patients with poststroke urinary incontinence. Clin Interv Aging. 2014; 851-6.
4. Sato A, The impact of somatosensory input on autonomic functions. Reve Physiol Biochem Pharmacol. 1997;130;1-328
5. Sato A. Mechanism of the reflex inhibition of micturition conractions of the urinary bladder elicited by acupuncture-like stimulation in anesthetized rats. Neurosci res. 1992 15:189-98
6). Effects of a Gentle, Self-Administered Stimulation of Perineal Skin for Nocturia in Elderly Women: A Randomized, Placebo-Controlled, Double-Blind Crossover Trial. Iimura K, Watanabe N, Masunaga K, Miyazaki S, Hotta H, Kim H, Hisajima T, Takahashi H, Kasuya Y. PLoS One. 2016 Mar 22;11(3):e0151726. doi: 10.1371/journal.pone.0151726. eCollection 2016.
7) John C. Longhurst, Liang-Wu Fu, in Primer on the Autonomic Nervous System (Third Edition), 2012

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Reflections on course design and development: Neuroanatomy

In an effort to provide the best possible educational experience for clinical rehabilitation application of neuroanatomy, I was on a mission. Having a core, base knowledge review of the nervous system is essential when leading into talking about dysfunction and disease of that system. I went on a search for anatomical depictions that could clearly identify the structures and processes I was trying to portray. New books from the library and books I own from when I was in college serve as great resources when trying to get back into studying the specifics, but do not offer the opportunity to easily get these images into a powerpoint. Online resources are also challenging. I am learning how time consuming the process can be to determine who owns the online image, if it is free to copy, save and utilize for my own teaching purposes, or if I need to go through the process of requesting permissions for use.Nervous System

Through my employer, where I treat patients in the clinic, I have access to a program called Primal Pictures. I had used this in the past for clinic related marketing presentations and educational materials for patients and other clinicians I have mentored. Looking into the product further, I came to find out that there is a newer version of the program which offered so many more options. A truly unlimited amount of images which can be manipulated into an optimal position depicting the most clear neuroanatomical views I have ever been able to find. Not only does it provide me with the images I need in order to depict the treacherous pathways of the nerves in our body, but it also provides some amazing depictions of the physiological processes that occur within our nervous system to allow for healthy day to day functioning and protection of our bodies.

I also came across the title of a journal article that I was sure would provide some excellent depictions of neuroanatomy. The article titled, Sectional Neuroanatomy of the Pelvic Floor, provides cross sectional views of both the male and female pelvises. I obtained the article which has an excellent color-coded system, each nerve colored the same as the muscles and skin surface it innervates, going from superior to inferior cross sections. This makes for a clear understanding of each structures anatomical position. It is a great reference when looking at the anatomical relationships to adjacent structures and can help guide palpation skills. The article was more specifically written for physicians to best direct needle procedures/injections in the most accurate location possible when targeting nerves and structures. Neuroanatomy and physiology can be essential to understanding certain patient populations we encounter as we practice pelvic floor rehabilitation. Having clear depictions to refer to can help you provide the best possible base knowledge to your patients as you help them understand the challenges they face and how to overcome them.


Kass, J. S., Chiou-Tan, F. Y., Harrell, J. S., Zhang, H., & Taber, K. H. (2010). Sectional neuroanatomy of the pelvic floor. Journal of computer assisted tomography, 34(3), 473-477.

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Flaxseed: Improving Prostate Health

I love adding flax seed to my recipes when I bake. I even hide it in yogurt with crushed graham crackers for my kids. It is a powerful nutrient that can be consumed without knowing it! Although the specific mechanism for its efficacy on prostate health continues to be researched, studies over the last several years applaud flax seed for its benefits and encourage me to keep sneaking it in my family’s diet.

In 2008, Denmark-Wahnefried et al. performed a study to see if flax seed supplementation alone (rather than in combination with restricting dietary fat) could decrease the proliferation rate of prostate cancer prior to surgery. Basically, flax seed is a potent source of lignan, which is a phytoestrogen that acts like an antioxidant and can reduce testosterone and its conversion to dihydrotestosterone. It is also rich in plant-based omega-3 fatty acids. In this study, 161 prostate cancer patients, at least 3 weeks prior to prostatectomy, were divided into 4 groups: 1) normal diet (control); 2) 30g/day of flax seed supplementation; 3) low-fat diet; and 4) flax seed supplementation combined with low-fat diet. Results showed the rate of tumor proliferation was significantly lower in the flax seed supplemented group. The low-fat diet was proven to reduce serum lipids, consistent with previous research for cardiovascular health. The authors concluded, considering limitations in their study, flax seed is at least safe and cost-effective and warrants further research on its protective role in prostate cancer.

In 2017, de Amorim et al. investigated the effect of flax seed on epithelial proliferation in rats with induced benign prostatic hyperplasia (BPH). The 4 experimental groups consisting of 10 Wistar (outbred albino rats) rats each were as follows: 1) control group of healthy rats fed a casein-based diet (protein in milk); 2) healthy rats fed a flax seed-based diet; 3) hyperplasia-induced rats fed a casein diet; and 4) hyperplasia-induced rats fed a flax seed diet. Silicone pellets full of testosterone propionate were implanted subcutaneously in the rats to induce hyperplasia. Once euthanized at 20 weeks, the prostate tissue was examined for thickness and area of epithelium, individual luminal area, and total prostatic alveoli area. Results showed the hyperplasia induced rats fed a flax seed-based diet had smaller epithelial thickness as well as a reduced proportion of papillary projections found in the prostatic alveoli. These authors determined flax seed exhibits a protective role for the epithelium of the prostate in animals induced with BPH.

Bisson, Hidalgo, Simons, and Verbruggen2014 hypothesized a lignan-fortified diet could decrease the risk of BPH. The authors used an extract rich in lignan obtained from flax seed hulls. Four groups of 12 Wistar rats were used, with 1 negative control group and 3 groups with testosterone propionate (TP)-induced BPH (1 positive control, and 2 with diets containing 0.5% or 1.0% of the extract). Over a 5 week period, the 2 BPH-induced groups consuming the lignan extract starting 2 weeks prior to the BPH induction demonstrated a significant inhibition of prostate growth from the TP compared to the positive control group. These authors concluded the lignan-rich flax seed hull extract prevented BPH induction.

From BPH to prostate cancer, flax seed has proven a noteworthy supplement for preventative health. A tablespoon of flax seed in a muffin recipe is likely not a life-changing dose, but it’s a start. Nutrition Perspectives for the Pelvic Rehab Therapist enlightens practitioners with even more healthy choices, and Post-Prostatectomy Patient Rehabilitation gives you the necessary tools to help patients recover from prostate cancer.


Demark-Wahnefried, W., Polascik, T. J., George, S. L., Switzer, B. R., Madden, J. F., Ruffin, M. T., … Vollmer, R. T. (2008). Flax seed Supplementation (not Dietary Fat Restriction) Reduces Prostate Cancer Proliferation Rates in Men Presurgery. Cancer Epidemiology, Biomarkers & Prevention : A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 17(12), 3577–3587. http://doi.org/10.1158/1055-9965.EPI-08-0008
de Amorim Ribeiro, I.C., da Costa, C.A.S., da Silva, V.A.P. et al. (2017). Flax seed reduces epithelial proliferation but does not affect basal cells in induced benign prostatic hyperplasia in rats. European Journal of Nutrition. 56: 1201. https://doi.org/10.1007/s00394-016-1169-1
Bisson JF, Hidalgo S, Simons R, Verbruggen M. 2014. Preventive effects of lignan extract from flax hulls on experimentally induced benign prostate hyperplasia. Journal of Medicinal Food. 17(6): 650-656. http://doi.org/10.1089/jmf.2013.0046

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