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Herman & Wallace Blog

Supporting the use of yoga for urge urinary incontinence symptom management


Urinary incontinence (UI) can be problematic for both men and women, however, is more prevalent in women.  Incontinence can contribute to poor quality of life for multiple reasons including psychological distress from stigma, isolation, and failure to seek treatment. Patients enduring incontinence often have chronic fear of leakage in public and anxiety about their condition.  There are two main types of urinary leakage, stress urinary incontinence (SUI) and urge urinary incontinence (UUI).

SUI is involuntary loss of urine with physical exertion such as coughing, sneezing, and laughing.   UUI is a form of incontinence in which there is a sudden and strong need to urinate, and leakage occurs, commonly referred to as “overactive bladder”.  Currently, SUI is treated effectively with physical therapy and/or surgery.  Due to underlying etiology, UUI however, can be more difficult to treat than SUI.  Often, physical therapy consisting of pelvic floor muscle training can help, however, women with UUI may require behavioral retraining and techniques to relax and suppress bladder urgency symptoms.  Commonly, UUI is treated with medication.  Unfortunately, medications can have multiple adverse effects and tend to have decreasing efficacy over time.  Therefore, there is a need for additional modes of treatment for patients suffering from UUI other than mainstream medications. 

An interesting article published in The Journal of Alternative and Complimentary Medicine reviews the potential benefits of yoga to improve the quality of life in women with UUI. The article details proposed concepts to support yoga as a biobehavioral approach for self-management and stress reduction for patients suffering with UUI.  The article proposes that inflammation contributes to UUI symptoms and that yoga can help to reduce inflammation.

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Breast Cancer Survivorship


A diagnosis of breast cancer means many different things to many different people. Regardless, receiving this diagnosis means some sort of treatment will likely follow. The types of treatment and outcomes are largely dependent on individual patient scenarios, however, one thing is for certain: A patient’s life will be forever changed after having received this diagnosis.Historically, comprehensive care for a patient with breast cancer has focused on treatment and prevention. However, more and more women are surviving breast cancer every year. Therefore, more attention needs to be paid to survivorship. Once someone has survived cancer, comprehensive, quality care should obviously focus on preventing recurrence, however, it may also include guidance and counseling on maintaining a healthy lifestyle and addressing physical and psychosocial changes.

A very recent 2016 article published in the Annals of Surgical Oncology discusses the subject of survivorship in breast cancer patients. This article suggests that the key to achieving successful outcomes for management of a breast cancer survivor is a multidisciplinary approach to help these survivors deal with the physical and psychosocial sequela resulting from their diagnosis.

As a pelvic rehabilitation provider, this is a very thought-provoking article as it outlines several areas in which I feel breast cancer survivors could benefit from physical therapy. A pelvic rehabilitation provider can be a valuable part of the multidisciplinary team that helps manage a breast cancer survivor towards positive and meaningful outcomes, ultimately enhancing their quality of life. The following are some areas addressed in the article in which a breast cancer survivor may need assistance to improve and support a meaningful quality of life.

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Sensing the Body from the Inside Out


In the 16th century, a theory called Preformationism claimed that sperm contained a preformed, exceedingly minute body referred to as a homunculus, which eventually became a person. This idea of a tiny man had staying power, as today the homunculus is a “body map” based on how much of the cerebral cortex is devoted to sensing each part of the body. Although the idea of a 16th alchemist placing little bodies into a flask conjures a variety of tantalizing images, our program focuses on the mundane, contemporary version of the homunculus. So…what does this have to do with a course that addresses pelvic floor dysfunction? Everything.

Emerging evidence indicates that therapies that include work to enhance body awareness/kinesthetic sense are potent and effective. Our professional training unfortunately, tends to over-emphasize a structural approach. The good news is that manual therapy, to some degree, enhances a client’s body awareness; but when we have more “tools” to capitalize on this synergy between manual therapy and improved body awareness, we have a potent “elixir” to promote change. To quote Deane Juhan, “touching hands are not like pharmaceuticals or scalpels…they are like flashlights in a darkened room.” By using the “flashlight”, we not only contribute to structural change, but neurological change – meaning the more we pay attention to a particular part of our body, the more “real estate” the brain devotes to that part of the body. Increasing the pelvic floor’s “footprint” on the brain can enhance function of the pelvic floor dramatically and quickly. Therefore, rehabilitation to address pelvic floor dysfunction benefits from weaving orthopedic, neurologic and mindfulness practices together.

This program is designed to add a new dimension for the skilled pelvic floor practitioner and to also serve practitioners new to this area of practice. There is no internal manual work; rather we draw from our deep knowledge of Yoga, Tai Chi, along with other Chinese internal martial arts (that put lots of emphasis on the pelvic floor for performance) and Feldenkrais to address pelvic floor dysfunction. Some lessons focus directly on the pelvic region and others on integrating the pelvic floor with full body movement. Ultimately, our goal is to help you connect the dots between structural, functional movement and mindfulness practices, as this powerful triad offers practitioners a comprehensive, approach for treating pelvic floor dysfunction.

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Hip and Pelvis Biomechanics: Assessing Baby’s First “Crib”


You wouldn't place a newborn in a crib without knowing the legs were firmly attached at the right angle to the base. You wouldn't jump on a hammock if the poles or trees were not firmly intact and upright to support the sling. Why would you treat a pregnant woman without checking if her hips were working optimally in proper alignment to support the pelvis, inside which a new life is developing? Let's hope higher level clinicians spend the extra effort to learn about the surrounding areas that affect our specialty, whether it is pelvic floor or spine or sports medicine.

In 2015, Branco et al., published a study entitled, “Three-Dimensional Kinetic Adaptations of Gait throughout Pregnancy and Postpartum.” Eleven pregnant women voluntarily participated in this descriptive longitudinal study. Ground reaction forces (GRF), joint moments of force in the sagittal, frontal, and transverse planes, and joint power in those same 3 planes were measured and assessed during gait over the course of the first, second, and third trimesters as well as 6 months post-partum. The authors found pregnancy does influence the kinetic variables of all the lower extremity joints; however, the hip joint experiences the most notable changes. As pregnancy progressed, a decrease in the mechanical load was found, with a decrease in the GRF and sagittal plane joint moments and joint powers. The vertical GRF showed the peaks of braking propulsion decreases from late pregnancy to the postpartum period. A significant reduction of hip extensor activity during loading response was detected in the sagittal plane. Ultimately, throughout pregnancy, physical activity needs to be performed in order to develop or maintain stability of the body via the lower quarter, particularly the hips.

The same authors, in 2013, studied gait analysis in the second and third trimesters of pregnancy. Branco et al., performed a 3-dimensional gait analysis of 22 pregnant women and 12 non-pregnant women to discern kinetic differences in the groups. Nineteen dependent variables were measured, and no change was noted between 2nd and 3rd trimesters or the control group for walking speed, stride width, right-/left-step time, cycle time and time of support, or flight phases. Comparing the 2nd versus 3rd trimester, a decrease in stride and right-/left-step lengths decreased. The 2nd and 3rd trimesters both showed a significant decrease in right hip extension and adduction during the stance phase when compared to the control group. In this study, the authors also noted increased left knee flexion and decreased right ankle plantar flexion during gait from the 2nd to the 3rd trimester. The bottom line in this study, just as the more recent one suggests, pregnant women need a higher degree of lower quarter stability to ambulate efficiently throughout pregnancy.

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Pelvic Floor: Does Posture Matter?


Posture is a concept that rehab clinicians have long hung our hats on, and yet updated models of evaluation and care take into account the truth that there are plenty of humans functioning in poor postures who do not complain of musculoskeletal pain or other dysfunctions. Is postural dysfunction always, or never, causative? As with many things in life, the answer is likely somewhere in between. If our patient arrives at the clinic with a dysfunctional posture and improving their alignment eases discomfort and improves function, we have provided help with addressing posture. It is also likely that we have spent a bit too much time lecturing on the elusive “ideal” posture, when in fact dynamic and adaptive postures are more often occurring throughout a person’s day. Certainly computer postures add to a patient’s movement challenge, and we continue to learn more about the best ways for patients to manage the otherwise potentially static and unhealthy positions that add to many of our patients’ issues.

In regards to the pelvic floor, does changing standing lumbopelvic posture affect pelvic floor muscle (PFM) activation? This is the question asked by researchers from Queen’s University in Canada. (Capson et al., 2011) Sixteen women ages 22-41 who had never given birth and who were continent participated in the study. They were assessed completing five tasks in three different postures: normal lumbopelvic posture, hyperlordosis, and hypolordosis. The tasks included quiet standing, maximal effort cough, Valsalva maneuver, pelvic floor maximal voluntary contraction, and a load-catching activity. A vaginal sensor was to use to collect electromyographic activity of the pelvic floor, and sensors were placed on trunk muscles including the rectus abdominus, external and internal obliques, and erector spinae. A perineometer was utilized separately to record manometry measures, and 3D motion analysis was used to position women in the appropriate lumbopelvic angles. Key results of the investigation are summarized below:

Baseline EMG activity of the PFMs and the trunk muscles was significantly lower in supine versus standingPFM EMG activity in standing hypolordotic was higher than normal or typical postureTrunk muscle EMG activity did not significantly change during the 3 quiet standing postures For maximal PFM contraction and for cough, Valsalva, and load-catching, lower EMG activity was measured in standing in hyperlordotic or hypolordotic postures compared to “normal” or habitual postureWith cough, all muscles except the erector muscles demonstrated increased activityIn general, EMG activity was increased in trunk muscles when the subjects were in their habitual postureRelated to timing of the rectus abdominus (RA) muscles, the RA were activated 106 ms before the PFMIn standing, the intravaginal pressure was significantly higher in the hypolordotic posture compared to hyperlordotic posture

How can we put this valuable research to work in the clinic? This study validates a typical EMG activity finding of increased activity during standing versus lying, which makes sense given the pelvic tasks of working against gravity. In addition, it may be the case that our patients can generate an optimal amount of pelvic muscle contraction (when strengthening) in a more neutral posture. It may also be worth considering that for our patients who are chronically holding, perhaps a tendency for them to be in a hypolordotic posture is perpetuating their dysfunction. The data on timing of trunk and pelvic floor muscles was less consistent, although not less interesting. This research can also be implemented as an evaluation and intervention in the clinic- let’s be sure that we are using methods of feedback such as EMG, real-time ultrasound, or pressure biofeedback in various and functional positions. Then we can find out what seems to work best for our patient, whether the goal is to increase or decrease muscle activity and function.

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Central Sensitization: The Core of Chronic Pelvic Pain


Assuring patients with chronic pain they are not crazy by explaining the neurophysiology behind what is happening in their brain and body can be life changing. Increasing our patients’ knowledge about physical conditions can reduce anxiety and provide hope. As a healthcare provider, being confident in your differential diagnosis skills can help narrow down the physical source of pain, weed out the psychological components, and connect the dots to the neurological influence on the patient’s persistent symptoms.

A 2015 article in Pain Medicine (Gurian et al) found a direct association between pain sensitivity and treatment of chronic pelvic pain. The study involved 58 women with at least 6 months of pelvic pain, and they were evaluated on pain threshold using transcutaneous electrical nerve stimulation before treatment and 6 months after a multidisciplinary approach to treatment of the pelvic pain. Pain intensity was also evaluated using the visual analog scale and the McGill questionnaire. Depending on the specific condition, treatment included manual therapy, physical therapy, pain medications, laparoscopy, oral contraceptives, nutrition intervention, or psychological support. After receiving treatment for 6 months, the pain threshold mean improved from 14.2 to 17.4. The effect sizes of 0.86 in the group with pain reduction and 0.53 in the group not achieving pain reduction were both within the 95% confidence interval. The authors concluded in this study that central sensitization does occur in patients with chronic pelvic pain, and treatment can reduce the general pain sensitivity of the patient.

Kutch et al., (2015) performed a study regarding the change in men’s resting state of neuromotor connectivity as affected by chronic prostatitis or chronic pelvic pain syndrome (CP/CPPS), showing men are also subject to central sensitization. Fifty-five men (28 males with pelvic pain for at least 3 months and 27 healthy males) completed the study, with resting state functional magnetic resonance imaging detecting the functional connectivity of the pelvis with the motor cortex (pelvic-motor). The right posterior insula and pelvic-motor functional connectivity was found to be significantly different in men with chronic pelvic pain and prostatitis versus the healthy control group. Contraction of the pelvic floor corresponded with activation of the medial aspect of the motor cortex, while the left motor cortex was more associated with contraction of the right hand. The authors concluded this relationship may explain the viscerosensory and motor processing changes that occur in men with CP/CPPS and could be the most important marker of brain function alteration in this group of patients.

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Personal Pregnancy Series: 3 - Postpartum


III. PostpartumNourishing my baby and myself, a complicated dichotomy

The care I received from the doctors, nurses, and hospital staff during labor, delivery, and postpartum period was excellent. I felt all the staff members explained all procedures for myself and the baby. The labor and delivery nurses were helpful and compassionate. They showed me how to breastfeed the baby, assisted me with skin to skin contact, and taught my husband and I how to care for the baby when we took her home. The birth center site at the hospital was amazing. I had an individual birthing suite with a bathroom, a television, a bathtub and a place for my husband to sleep. Health care for the baby and I following delivery continued to be excellent. I had a surgical follow up one week later with my doctor and another postpartum visit at 6 weeks. At each visit I was given The Edinburgh Postnatal Depression Scale (a scale to help identify postpartum depression) as well as educational pamphlets on self-care following a cesarean delivery. The only complaints I had that required assistance from a health care provider was with getting baby to latch with breast feeding and neck and shoulder pain from breast feeding the baby. I took it upon myself to work on core and hip exercises I would give a postpartum patient who had undergone a cesarean delivery and was working on my scar tissue to prevent problems with bladder, bowel, abdomen, and uterus. I sought some massage for my neck and shoulders and did my physical therapy exercises for my neck and shoulders. I sought a lactation consultant for the latching issues with breast feeding. Seeking care helped resolve these issues which reduced my neck and shoulder pain and helping me enjoy breastfeeding my baby.

I have always felt that women in our country need better post-partum care and I am happy to see improvements being made

Before having my daughter, I had preconceived notions about postpartum care. For the last ten years since I started working with women’s health patients I have heard repeatedly from my patients that they felt they did not receive comprehensive postpartum care. Many of these women hopped from health care provider to health care provider, sometimes taking years to resolve orthopedic or pelvic floor problems from their pregnancy or labor and delivery experience. Quality postpartum care was my soap box issue and still is. That being said, I was very satisfied with my postpartum health care experience. My experience revealed that support and education about postpartum problems as well as proactive healthcare for theses challenges is becoming mainstream. I have always felt that women in our country need better post-partum care and I am happy to see improvements being made. We may forget between the constant baby changing, soothing, and feedings that mom needs some care too. I am not sure that we always remember that there have been 9 months of physiologic changes occurring to a woman’s body. Additionally, physical trauma that occurs with caesarean or vaginal delivery. A mother may need physical therapy for exercises to strength abdominals or back, help for bowel or bladder problems, manual therapy for painful intercourse, or scar tissue work for abdominals or pelvic floor.

I think as a society we are getting more aware of the influence of hormones, crying babies, sleep deprivation, and a heavy work load can overwhelm a postpartum mother. Based on my experience only, I think we are doing a better job of monitoring postpartum depression, pain management, and pelvic floor problems. I was so pleased at the availability of information and counseling opportunities presented to me during my birthing and postpartum experience. I received so much encouragement and permission to seek help from others during my postpartum healing.

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Personal Pregnancy Series: 2 - Labor & Delivery


II. Labor and DeliveryThe Baby Always Has a Different Plan

Towards the end of my pregnancy, my doctor ordered an ultrasound to make sure the baby was growing appropriately. This was precautionary as the baby had measured small the last couple appointments. The ultrasound gave us some important information. Baby K was growing appropriately, however, she was breech. At this point, she should have already flipped into the cephalic (head down) position, and it was unlikely that she would turn further along in my pregnancy. I knew what this meant… “C-section” (cesarean). Like so many women before me, this was not what I wanted for my birth plan. Having a planned cesarean had not really crossed my mind. I figured it would only be some kind of emergency that would result in this outcome. Instantly I thought of all the patients I have treated over the years who had cesarean delivery. I thought of abdominal adhesions and scar tissue mobility work that would need to be done postpartum. Naturally, as a physical therapist, I also thought of all the mobility challenges this would bring after baby. Having a cesarean would change my post-partum recovery; I would need more help with lifting, carrying, and we have so many stairs in our house! I know this may sound crazy… but what saddened me the most about cesarean delivery was that I was not going to experience what labor felt like. I felt cheated, in a weird way, I was looking forward to it, almost like a rite of passage. I wanted to analyze labor and delivery from a patient’s standpoint, not just as a therapist. I thought it would help me relate to patients and friends who have experienced labor. All that being said, a scheduled C-section was happening unless that baby miraculously flipped.

My doctor suggested a version, which is a procedure where your doctor tries to manually turn your baby using an external technique. I had heard it is painful, but I pride myself on being a pretty tough woman who has dealt with some pain, I can do this! Needless to say, the version was painful… Very painful! As a matter of fact, the most painful procedure I have ever encountered. After trying about four times to turn the baby, my doctor asked me if we should try one more time. Although I was miserable, I asked if they thought the baby was close to being in the right position. The looks on my husband’s and doctor’s faces told me that she hadn’t moved at all. We gave it one more try, but that stubborn baby really liked the spot she was in. The plan was to proceed with the scheduled C-section at 39 weeks, unless I went into labor first, then it would be an emergency cesarean delivery.

At 39 weeks, I woke up the morning of the planned cesarean and thought, “it’s a good day to have a baby”. I was excited to finally meet this little princess, but a little nervous about the cesarean delivery. I was trying not to think about what was going to happen to my abdomen and uterus. I was hoping Baby K would handle all of this safely, and she would be well. My plan for the procedure was distraction, not to think about what was happening, as I knew too much. Sometimes ignorance is bliss. I did not want to think of every unfortunate story I had heard about “spinals”, and “cesareans gone wrong”, so I kept telling myself to trust my doctors and relax. After all, this is what they do every day, and they are good at it. I wasn’t the biggest fan of the numbness and tingling I felt in my legs, as well as the lack of motor control in the lower half of my body once they administered the spinal, but it did the trick.

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Personal Pregnancy Series: 1 - Pregnancy


The following is the first in a three-part blog series which chronicles the peripartum journey of Rachel Kilgore.

I. Pregnancy

In April, I had my first child, a sweet and healthy baby girl. Reflecting on the last year, what a ride! I have had many of my friends, family members, patients, and acquaintances discuss the journey and challenges of motherhood with me, however, experiencing it first hand was a memorable voyage. I thought I was very prepared and knew what I was getting into, but as usual, nothing compares to first-hand knowledge and experience. From an academic standpoint, I had done my research on everything from conception, what to expect each trimester of pregnancy, and reviewed the many options for labor and delivery. I even was lucky enough to assist in the Herman and Wallace Care for the Post-Partum Patient course with Holly Tanner while I was pregnant! As a practitioner, I love treating pregnant and post-partum patients, it is one of my favorite populations to treat. I love helping these strong, motivated women with pain relief and to teach them management skills to adapt to a new lifestyle and a changed body that has unique musculoskeletal needs.

First Trimester: Information, Nausea, and Fatigue

I had always had a preconceived notion that I would exercise diligently and eat super healthy through my pregnancy. After all, that was how my lifestyle was before pregnancy, why should it change? That lasted about 6 weeks, until 24-hour episodes of nausea and vomiting overwhelmed me, which continued until the start of the second trimester. I basically just tried to make it through the day without vomiting at work, and would go straight to bed whenever I had the chance. I even had to miss several days of work! I thought it was termed “morning sickness” implying that it went away after morning, but apparently it should be renamed to “forever nausea” as that is what it felt like at the time. Because of the nausea, I wanted nothing to do with food, which in turn lead to constant concern about the baby not getting enough nourishment. Of course, my regular activity levels plummeted. In addition to nausea was constant fear of miscarriage and whether my regular activities were somehow harmful to my baby. Instead of ice cream and pickles, I craved information. What should I be doing, and what should I not be doing?

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Latissimus Dorsi Reconstruction and Functional Implications of the Shoulder

CC BY-SA 3.0

Susannah Haarmann, PT, CLT, WCS is the author and instructor of Physical Therapy Treatment for the Breast Oncology Patient. Join her this September 24-25 in Stockton, CA to learn about the various diagnostic tests, medical and surgical interventions to provide appropriate and optimal therapeutic interventions for breast cancer patients.

I turned to the literature and found prominent articles discussing breast reconstruction and giving minimal consequence to shoulder function after resection of the latissimus dorsi muscle. As a physical therapist, this left me in a quandary, “Really? Harvesting a portion of the broadest muscle of the back then threading it through the axilla to recreate the breast mound won’t have an impact on shoulder function or back pain? Impressive!” However, this did not correlate with my clinical findings. Often, scapulohumeral rhythm was altered, range of motion restricted and activities limited due to pain and fatigue. Scrutinizing the literature, I found that those articles were mostly unsubstantiated. Here is a quick summary of two systematic reviews published in 2014 addressing what the research really found pertaining to shoulder function after ‘lat flap’ reconstruction:

Patient impressions: - Reported incidence of overall functional impairment is 41%. 8 - Overhead activities, lifting and pushing objects and high-level activities such as sport and housework were the most cumbersome. 1,7 - Subjective deficits did not resolve based on length of follow-up. 1

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Upcoming Continuing Education Courses

Feb 25, 2018 - Feb 27, 2018
Location: Touro College: Bayshore

Mar 2, 2018 - Mar 4, 2018
Location: Texas Children’s Hospital

Mar 2, 2018 - Mar 3, 2018
Location: Texas Children’s Hospital

Mar 2, 2018 - Mar 4, 2018
Location: Marathon Physical Therapy

Mar 3, 2018 - Mar 4, 2018
Location: Florida Hospital - Wesley Chapel

Mar 3, 2018 - Mar 4, 2018
Location: Loyola University Stritch School of Medicine

Mar 9, 2018 - Mar 11, 2018
Location: Mount Saint Mary’s University

Mar 9, 2018 - Mar 11, 2018
Location: Northern Arizona Healthcare

Mar 9, 2018 - Mar 11, 2018
Location: Core 3 Physical Therapy

Mar 9, 2018 - Mar 11, 2018
Location: Bella Physical Therapy

Mar 16, 2018 - Mar 18, 2018
Location: Middlesex Hospital

Mar 17, 2018 - Mar 18, 2018
Location: DeKalb Medical Atlanta Hospital and Medical Center

Mar 17, 2018 - Mar 19, 2018
Location: The Sage Colleges

Mar 23, 2018 - Mar 25, 2018
Location: University of Central Arkansas

Mar 23, 2018 - Mar 25, 2018
Location: Henry Ford Macomb Hospital

Mar 23, 2018 - Mar 25, 2018
Location: Robert Wood Johnson Medical Associates

Mar 24, 2018 - Mar 25, 2018
Location: St. Francis Physical Therapy

Apr 6, 2018 - Apr 8, 2018
Location: WakeMed Health & Hospitals

Apr 6, 2018 - Apr 8, 2018
Location: Aurora Medical Center

Apr 7, 2018 - Apr 8, 2018
Location: Florida Hospital - Wesley Chapel

Apr 7, 2018 - Apr 8, 2018
Location: Saint Luke\'s Health System

Apr 13, 2018 - Apr 15, 2018
Location: St. Joseph Hospital Rehabilitative Services

Apr 13, 2018 - Apr 15, 2018
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Apr 13, 2018 - Apr 15, 2018
Location: Highline Medical Center

Apr 14, 2018 - Apr 15, 2018
Location: University Hospitals

Apr 15, 2018 - Apr 17, 2018
Location: Touro College: Bayshore

Apr 20, 2018 - Apr 22, 2018
Location: The George Washington University

Apr 20, 2018 - Apr 22, 2018
Location: Marathon Physical Therapy

Apr 21, 2018 - Apr 22, 2018
Location: Core 3 Physical Therapy

Apr 21, 2018 - Apr 22, 2018
Location: The Everett Clinic