Can patients successfully perform a pelvic muscle contraction following verbal instruction? This question was asked by Bump and colleagues in the often-cited research article published in 1991. Urethral pressure profiles were assessed in forty-seven women at rest and during a pelvic muscle contraction following brief, standardized verbal instruction. In the article, the authors found that nearly half of the women performed with "an ideal effort" leading to urethral closure without a Valsalva effort. 25% of the women, unfortunately, demonstrated an effort at muscular contraction that could promote incontinence. The authors' conclusion is that simple verbal or written instruction is not the best approach for a patient engaging in a pelvic floor muscle training program.

The limitations of the above study (small number of subjects, arbitrary definition of "effective Kegel," and inability to predict patient outcomes based on urethral profile) are made very clear throughout the article, yet how do we see this apply to our patient population? How often do we complete a perineal observation during an examination and identify that the patient is not generating any perineal movement, demonstrating a bearing down maneuver rather than a shortening, protective contraction, or creating such force through the abdomen that even a well-contracted pelvic floor would struggle against the strain from above? The value of the Bump study reminds us that not all patients respond positively to verbal or written instruction only.

What about men? A recent study aimed to assess the ability of 52 healthy men (mean age of 22.6 years with a standard deviation of 4.42 years) to complete a pelvic muscle contraction in standing or crook lying following brief, standardized instruction. Real-time transabdominal ultrasound was used to measure bladder base elevation. 6 participants were unable to contract the pelvic floor muscles in either position, 17 were unable to contract the muscles in crook lying, and 14 could not contract the muscles in standing. While many of the men we instruct in pelvic muscle rehabilitation strategies are significantly older than the men in this study, the major point matches that of the Bump article: it is not safe to assume that a patient (even a young, healthy patient) can contract the pelvic floor muscles following verbal instruction. The authors suggest that transabdominal ultrasound may be a useful clinical tool for measuring bladder base elevation and therefore pelvic muscle activity.

To be fair, more people in general need to be educated about the pelvic floor muscles;we can likely agree that the lack of awareness and discussion about the roles the PFM play in daily life leads to persisting dysfunction. There are people within the population who can activate the pelvic muscles appropriately with verbal instruction, and for this portion of the population, verbal or written instruction may be better than no instruction. Group education in community or institutional settings may benefit patients who are unwilling, unable or uninterested in acquiring a referral to a pelvic rehab provider. But for the group of patients who is either not contracting the muscles or bearing down rather than lifting, the consequences of doing pelvic muscle strengthening incorrectly may be significant. Do we need to change how we are instructing the patient verbally? Should we offer assessment of pelvic muscle contraction ability in varied positions? Must we include other functional applications of the coordinating muscles such as the respiratory diaphragm? At this time, there is not one answer. If we can ask the questions, read the research, and participate in our own way to the research, or at a minimum, apply these questions to clinical care, we may find the best answer for each individual patient.

Since launching the application for our Pelvic Therapy Practitioner Certification (PTPC) exam, we've had a lot of questions about the difference between a course certificate - like the CAPA certificates awarded to participants at our courses - and a certification, which is what PTPC is.

At our Pelvic Floor series, Pregnancy and Postpartum series, Visceral, Movement Systems, and other specialty courses, there are Certificates of Academic Profficiency Achievement (CAPA) that are given out at the end of the courses after participants complete a CAPA pre- and post-test. These are certificates of completion, not a certification. A certificate like this attests to attendance at a given continuing education course and passage of a short test that is not developed to any psychometric standards.

A certificate that recognizes completion of a course is different than a professional designation awarded based on passage of an exam developed with rigorous psychometric standards, like PTPC. A certificate is usually based on a short pre and post test created by the course instructor. While these test are an important part of a course, such tests are not developed to "legally definsible" exam developmet standards. A properly designed certificaiton process, followed to legally definsible standards, is created to scienficially measure a candidates' knowledge relative to a "minimally acceptable candidate" - as defined by the exam developers. Certifying bodies, offering certifications developed to such stanards, often empower earners of a certification to ammend their professional title with an abbeviation to denote their demonstrated expertise. Without having completed all the steps (of which there are many) in a legally definsible exam development process, entities empowering others to ammend their professional titles through any other process do so under potential legal liability.

By definition, all Herman & Wallace continuing education courses are designed to instruct in immediately-applicable, evidence-based knowledge and skills so that therapists will be welll-trained to treat patients in the clinic. It is not required that one earn this certification to be an excellent therapist or to practice pelvic rehabilitation. Therapists should complete continuing education courses wilh the goal of growing his or her knowledge and clinical skill set.

PTPC is an exam for experienced pelvic therapists to validate their skill set and knowledge. We created this certification so the rehabilitation professionals who do want to distinguish themselves by ammeding their professional title with "PTPC" have an option to sit for a test that covers pelvic dysfunction, for men and women, throughout the life cycle. Prior to Herman & Wallace launching this certification, no specialty certification recognizing rehabilitional professionals treating women AND men of all ages experiencing pelvic dysfunction.

Some therapists value certifications more than others, so it's entirely up to the individual whether to pursue PTPC, or any other certification. Our goal is that PTPC becomes the gold standard of quality in the field of pelvic rehabilitation, and that it helps spread awareness about the important work pelvic rehabiltation professionals do. If you would like more information about the Pelvic Therapy Practitioner Certification or would like to download the application, please see our Certification Page.

H&W instructor Dustienne Miller, CYT, PT, MS, WCS wrote this post.

As specialists in pelvic health, we have the honor of being trusted with very private information. Our patients trust us with their secrets, their emotions, and their bodies. Sometimes patients reveal traumatic personal stories, both past and present. Even if our patients have not suffered emotional, physical, or sexual abuse, we can assume that the diagnosis of pelvic floor dysfunction is traumatic itself. Bouncing from clinician to clinician and inability to share their pain and experience with coworkers and friends is enough to increase baseline anxiety and depression levels. Yoga has proven to be an effective method in helping to heal Post Traumatic Stress Disorder and other mental comorbidities associated with pelvic floor dysfunction. But where do you start? How do you make your patient feel safe?

In David Emerson and Elizabeth Hopper?s book Overcoming Trauma through Yoga, there is guidance on how to appropriately guide your patient or yourself through a yoga program that feels safe and appropriate. As clinicians, we are very aware of monitoring patient response in the treatment room. If we notice guarding or dissociation we do not continue the session according to the goals we have set for the patient, rather we meet the patient where they are at that time on that day and work accordingly. I recommend we utilize the same sensitivity with our patients when creating a home program and working with our patients in open gym areas. What might feel great for us (ie: downward facing dog) may trigger trauma for another. Be mindful of the transition from the emotionally charged manual treatment to a less contained room like an open gym. Instructing a patient in pelvic tilts and bridging with other people around could trigger an emotional response, especially if their emotions were primed after myofascial release in the pelvis and abdomen. Bottom line: take the sensitivity you have at the plinth and carry it over into the exercise component of your treatments. Your patient will lead the way.

Dustienne Miller is a board certified women?s health clinical specialist and Kripalu Yoga teacher. She is the creator of the DVD Your Pace Yoga: Relieving Pelvic Pain, a musical theatre performer, and a terrible cook. Her two day class offered through Herman and Wallace, Yoga for Pelvic Pain, is being offered in San Diego next March.

The new PTPC exam, the first certification that recognizes specialized skills for

providers of pelvic rehabilitation, is available to the following activelylicensed practitioners:

• Physical Therapists (PT)
• Occupational Therapists (OT)
• Physician (MD, DO, ND)
• Registered Nurse (RN)
• Advanced Registered Nurse Practitioner (ARNP)
• Physician's Assistant (PA-C)

Applications from other providers will be reviewed for approval on a case by case basis to determine eligibility. The basic premise is that a provider must have a license that allows a provider to complete the appropriate examination and intervention techniques in order to sit for the PTPC exam. In addition to being a licensed provider, documentation of clinic hours must be included on the application. A minimum of 2,000 hours of clinical experience with pelvic therapy patients must have occurred over the last 8 years, with 500 of those hours occurring within the last 2 years. This patient care experience must be "direct" meaning that the provider is involved in processes that will have a direct influence on the patient such as examination, evaluation, designing or modifying plans of care, and interventions for pelvic conditions.

Conditions that relate to pelvic dysfunction may include, but are not necessarily limited to, the following conditions:

• Pelvic pain (dysfunctions of ligaments, bones, joints, connective tissues, organs)
• Pelvic girdle dysfunction
• Bowel dysfunction
• Bladder dysfunction
• Sexual dysfunction
• Abdominal dysfunction
• Thoracolumbar dysfunction
• Lumbo-pelvic-hip dysfunctions

The hours of direct patient care may include time spent with patients of various ages (elderly, adult, pediatric) or with patients of any gender. Please check out our page on the website that lists other frequently asked questions, and contact the Institute with additional questions. You can download the PTPC application here. The first exam will be given at the start of 2014!

The Herman & Wallace Pelvic Rehabilitation Institute is pleased to introduce pelvic rehab providers to the Pelvic Therapy Practitioner Certification (PTPC) application process that is now available on-line. The PTPC is the only certification that addresses specific knowledge and skills in the field of pelvic rehabilitation of men and women. The Institute has been working with Kryterion, an expert in exam development, since 2011 to accomplish the detailed and rigorous steps that go into a certification test. First, a job task analysis (JTA) survey was created with the work of subject matter experts (SME's) over a long planning weekend together. Many of you (403 to be exact) completed the lengthy survey to complete the development of this step. Through the JTA the Test Blueprint was created, upon which the test will be based.

Items on the exam were written by physical therapists who are clinicians and educators. Knowledge of patient care scenarios is integrated into the exam along with evidence based practice. Once all of the items were written, each was examined by a team of experts to be sure that the question meets the high standards of psychometrics and best practices.

This exam will allow a pelvic rehabilitation provider to achieve recognition for the years of study and practice required to develop his or her expertise. In the coming weeks we will continue to update our community about the PTPC application and testing process. As always, contact the Institute with any questions.

Janna Trottier, PT, DPT, CSCS recently attended our Biomechanical Assessment of the Hip and Pelvis in Tampa, FL, taught by Steve Dischiavi, MPT, DPT, ATC, COMT, CSCS. Here's what she had to say about this course:

Last month I attended the course “Biomechanical Assessment of the Hip and Pelvis.” It was created and instructed by Steve Dischiavi, MPT, DPT, ATC, COMT, CSCS. I was drawn to the program because I was looking for an SI course that was comprehensive including evaluation and treatment as well as a functional application for treatments. It was advertised through Herman and Wallace.

I have been an orthopedic/sports physical therapist for 15 years and have been specializing in OB physical therapy for 6 years. I was interested in expanding my knowledge of core stability into functional movements. I was also intrigued that this “Women’s Health” course was going to be taught by a male who was a Sports Physical Therapist/Athletic Trainer for the Florida Panthers NHL Hockey Team as well as a private practice owner. There are also very few Women’s Health courses available in South Florida where I practice.

Immediately from his introduction, Steve drew the connection between myofasical stability and pelvic pain. All of the other course participants were female pelvic therapists with the exception of my husband who is an orthopedic sports physical therapist. This was fantastic because it allowed for great discussion about treatment techniques specific to Women’s Health.

I have been to many great SI and Women’s Health courses over the years and usually the goal is to take home 1-2 clinical pearls to use in your practice. However after this course with Steve, I felt as though I came away with an entire day full of “pearls”. I enjoyed that this course was not entirely pelvic floor based, butstill completely relevant to the Women’s Health population. He really focused on functional movement and evaluation for SI instability and lumbar core stability as well as incorporating many different treatment philosophies while blending his own.

The day after the course, I returned to my clinic and used his techniques on a 75 year old male patient with LE strength and stability dysfunction. Within the first treatment, there was marked improvement in his gait stability. After 2 treatments, he was able to leave his cane at home! It was really fantastic that I was able to utilize Steve’s techniques immediately in the clinic with rapid results. This was especially exciting since clinicians are encouraged to make fast improvement with declining visit limits. I have since been using Steve’s theories with many different patient populations – but especially our Women’s Health population. I would highly recommend Steve’s course to any practicing Women’s Health therapist as well as any orthopedic physical therapist.

Are the healthcare needs of patients who identify as lesbian, gay, bisexual and transgender (LGBT)different than those of patients who identify as heterosexual? Are we asking the important questions, providing the appropriate education in our treatment environments? Fortunately, these questions have been asked by researchers and medical providers, and there are increased resources to provide excellent educational content for those of us working in pelvic rehabilitation. There are some important distinctions among definitions and health care issues for lesbian, gay, bisexual and transgender (LGBT) individuals, and the references and resources are helpful in describing those differences. The following points represent some common health issues in the LGBT community:

• Screening for cervical cancer occurs less often in women who identify as lesbian, thereby increasing the risk of missing an early diagnosis. In a survey of more than 1000 women, only 62% were routinely screened according to Tracy et al., 2013, with participants citing lack of primary care physician or lack of physician referral for screening as barriers

• Healthy People 2020 cites health disparities of those in the LGBT community to include the following: societal stigma, discrimination, denial of basic human rights, having high rates of psychiatric disorders, substance abuse, violence, victimization, and suicide

• Medical providers assume heterosexuality, this is often referred to as "heteronormative" behavior, and this is not conducive to useful communication. In a summary of a large survey of men and women in the UK, Fish & Bewley describe homophobic behaviors or lack of knowledge (about societal marginalization or sexual practices, for example) in healthcare providers. The referenced article emphasizes improving access to healthcare for all and improving knowledge of GLBT needs among providers

Now for the excellent and convenient resources we have that can assist our own educational process:

• Heck & colleagues describe positive intake interview techniques and the importance of "starting from a place of positive affirmation" as many patients who have experienced discrimination or bias will not open up about personal health history unless the interviewer establishes an unbiased approach. While the article is written from the psychotherapy approach, the information is relevant for any health provider

• ACOG May 2012 Bulletin titled "Health Care for Lesbians and Bisexual Women" is an excellent tool and states that women should be provided with quality care regardless of sexual orientation. Understanding the barriers as well as the importance of routine care and providing a patient with an overall positive clinic experience are outlined.

• The Center of Excellence for Transgender Health has an excellent "Learning Center" complete with guidelines for patient care

• Womenshealth.gov has a page devoted to lesbian and bisexual health issues, and there is a link to a PDF that you can freely download and use in patient education (or peer and community education) about the topics

In the world of pelvic rehab, fiber is a big deal. Regardless of the diagnosis that brings the patient in to our clinic, bowel dysfunction is often a complaint that can aggravate or complicate any other diagnosis. Most of us are familiar with dietary fiber basics, but what do we know beyond those basics?

Put simply, there are 2 types of fiber: soluble and insoluble. According to Medline Plus, the average American eats 10-15 grams of fiber per day, when the recommended intake for older children, adolescents, and adults is 20-35 grams. (A high fiber fruit, a medium apple has 4.4 grams of fiber, just for perspective.) Soluble fiber, such as oat bran, nuts, seeds, beans, attract water and turn to gel during digestion. This helps to slow digestion, whereas insoluble fiber, found in wheat bran, vegetables, and while grains, speeds passage of food through the stomach and adds bulk to stools.

According to Eswaran & colleagues (2012), fiber is a crucial part of the digestive process. Any undigested carbohydrate that reaches the colon can be completely or partially fermented by the gut bacteria. Fiber fermentation can indirectly increase fecal bulking, and water retention (influenced by fiber type) can also affect bulk of stool. A potential negative aspect of fermentation is gas production that can cause bloating, discomfort, and flatus.The level of fermentation and solubility of different types of fiber varies based on chemical composition. For more details about the benefits of fiber related to fermenting and non-fermenting properties, click here for a full text article describing these processes.

In the article by Eswaran et al., the authors describe how insoluble fiber can have a laxative effect through mechanical stimulation/irritation if the fiber particles are sufficiently course and large. Soluble, viscous fibers can soften hard stool OR firm loose stool via its water-holding and gel-forming capabilities. While the authors point out varied types of fiber and the research about potential risks and benefits of each in patients with irritable bowel syndrome (IBS), the results of the research are often "mixed." This same phenomena can be seen in our patient populations: each person may need to tailor the amount and type of dietary fiber to her own body.

In relation to dietary fiber supplements, the highest level evidence(Level IIB)cited in the same article is for psyllium/ispaghula. While some patients consume psyllium that is recommended by a medical provider such as Metamucil, many patients choose to purchase the same product (minus the added preservatives) and add psyllium to their diet. While there are many studies that examine the effects of adding a fiber supplement, few actually study the effects of whole foods as the treatment.

One of the most important concepts to teach patients when they are adding fiber to their diet is to do so gradually, as a sudden increase can cause bloating, abdominal gas, and discomfort. If you are interested in learning more about pelvic rehabilitation for functional gastrointestinal disorders, come to PF2A, or attend the new-this-year Bowel Course happening next in November in California. Sign up early for the next 2A course, as the remaining 2013 courses have sold out!

H&W is thrilled to announce that we have completed one more giant step in the process of developing our certification exam, the Pelvic Therapy Practitioner Certification (PTPC) exam.

Over the past few weekends, our team of Subject Matter Experts met in Seattle to painstakingly go through all 450 items (exam questions) for clarity, correctness and other conventions. This was a massive project and we are thrilled to have gotten over this hurdle.

Now that all items have been reviewed, we are only a few steps away from beta testing the first offering of the exam.

Stay tuned - as we will be making the application for beta testers available shortly!

The Pelvic Therapy Subject Matter Experts enjoy the Seattle sunshine!

Many therapists who are interested in the use of dry needling for patients who have pelvic pain are faced with the following questions:

• is dry needling in my scope of practice?
• how do I get trained in the technique?
• how do I bill for the intervention?
• is there research to support use of dry needling?