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?

Our own Holly Herman, DPT PT MS OCS WCS BCB-PMD, is adding two more initials to her credentials.

She has met the criteria for the International Society for the Study of Women's Sexual Health (ISSWSH) Fellowship and is approved to use the designation IF after her name, making her one of only three PTs in the world to hold this title (the others are H&W friends Amy Stein and Talli Rosenbaum).

Congrats to Holly for this achievement!

We are glad to report that Institute founder Holly Herman arrived safe and sound in Santiago, Chile and just finished teaching Day One of our intensive Pregnancy and Postpartum course we are offering to therapists in the region.

This course is being offered in partnership with Francisco Eduardo Ubilla Benghi, PT, COMT, MOMT, a local therapist who worked with Herman & Wallace to put on this event.

Holly will be teaching the coures in English to an audience of Chileans (and a few participants from other South American countries) with the help of a translator. In Chile, people speak Spanish with a castellano dialect, which is wholly unique from the Spanish which Americans learn in high school (in addition to being a brilliant PT, Holly speaks Spanish).

It is thrilling to bring our Pregnancy and Postpartum series of courses to other parts of the world. In December, we will be returning to the country to offer a follow up course covering Male Pelvic Floor topics.

Stay tuned for updates on H&W's many travels!

This blog was written by Pelvic Rehab Report guest blogger, Richard Sabel MA, MPH, OTR, GCFP, who - along with Bill Gallagher PT, CMT, CYT - teaches the H&W course, Integrative Techniques for Pelvic Floor & Core Function: Weaving Yoga, Tai Chi, Qigong, Feldenkrais and Conventional Therapies as well as an online series of courses on the same topic.

RS: When considering the broad range of health issues that fall under the umbrella of pelvic dysfunction, we’ve observed that too many of our clients have PPA - poor pelvic awareness. Sure they’re cognizant of the pain, discomfort or distress associated with their particular issue, but in reality the pelvic region is, as Imgard Bartenieff described it, “the dead seven inches in most Americans’ bodies.” We’ve taken creative license here and call it “the dead zone.”

A lot happens “down there,” yet how many clients are attuned to the unique contribution this region has in terms of functioning? Most would identify elimination and sexual function (definitely biggies), but what about other key “happenings” such as the pelvis is home to our center of balance and femoral joints; or connect the intimate relationship of the tailbone and head in terms of mobility and flexibility; or realize that key muscles for postural alignment originate or pass through the pelvis? Not many.

How can we resurrect the dead zone? The antidote is awareness. We often think about strengthening weak muscles, stretching tight muscles and improving the coordination among muscles, however a missing component is helping our clients’ develop a better kinesthetic sense. This ingredient, added to the rehab elixir, is integral to lasting change. We live in our bodies, but most of us have major holes in our sensory awareness – what we call the “Swiss Cheese Effect.”

What about therapist? We have an excellent knowledge of anatomy and kinesiology, but how many of us embody this knowledge? It’s hard to say, but we suspect not enough. A few years ago, we observed a therapist teaching students transfers. He described the body mechanics perfectly, but when he demonstrated the transfer, his lower back was rounded. Intellectually he understood what to do, but he could not sense the awkward position of his back. Frederick Alexander would describe this as debauched kinesthesia. It’s not surprising this therapist often complained about back pain.

That’s why the intention of our touch and the cues we give clients are so important. As Deane Juhan said, “Touching hands are not like pharmaceuticals or scalpels, they are like flashlights in a dark room.” When our touch and cues are clear, we guide clients toward a new sensory experience, which may alter how they feel and in time may influence how they think and act. This last sentence is a tweaked quote from Moshe Feldenkrais. He referred to his clients as students, which changes the dynamic of the therapeutic relationship and emphasizes learning over curing.

Our webinars and on-site workshops are designed to provide participants opportunities to embody the work. Some lessons focus directly on the pelvic region and others on integrated full body movement. Once we better understand the kinematic chain or kinetic melody, we have more options: we can focus on the structure to address underlying issues contributing to dysfunction, or we can use our knowledge of integrated movement to bring about change in the structure. In other words, we go both ways.

Just for fun, try the following lesson, which we call the Ferris wheel. You’ll need a chair with a solid seat and no armrests.

Be mindful of the following rules: 1) keep the movements small, 2) move slowly, and 3) rest briefly after each movement.

Start with a body scan

Sit toward the front edge of your chair, with your feet flat on the floor, hands resting comfortably on your lap. Observe your breathing. Where do you notice the movement as you breathe in and out? Observe the way a cat watches a bird outside the window. Shift your attention to the souls of the feet. Without moving, sense how each foot makes contact with the floor. Compare both feet and notice the differences. Be as specific as possible. Now bring your attention to the buttock. Is there more weight on one side? What about the lower back, is it rounded, arched or flat? Sense the shoulders. Is one shoulder higher than the other? Finally, notice the position of the head. Is the chin pointing up or down? Is the head turned to the right or left? Keep a “sensory snap shot” of the body scan, which will help clarify changes that might occur as you progress through the lesson..

Scoot left, allowing the left sit bone to come off the chair. If you need to, place the right hand on the chair for balance. Lower the left sit bone just below the seat of the chair, then gently raise it back to the starting position. This movement will create a gentle stretch in the muscles and ligaments of pelvic floor. Repeat the movement again, this time noticing as the sit bone is lowered, how the ribs may broaden on the left side and close on the right side. Repeat the movement and this time observe the head and neck. Do they move as the sit bone is lowered? Did the right ear, tilt toward the right shoulder? If not, the next time the sit bone is lowered, in a synchronized movement, allow the head to tilt slightly to the right. As the left sit bone rises, bring the head back to midline. Did this make the movement easier? Repeat this pattern 4 more times. Keep the movement slow and small. Breathe throughout the movement. Rest.

Lower the left sit bone and begin making small circles in the sagittal plane - like a Ferris Wheel. Make 6-8 circles and rest for a moment. Observe the movement in the ribs, neck and head. Repeat this sequence going in the opposite direction. Rest.

Imagine a pen is attached to the bottom of the sit bone. Begin writing your name on an imaginary piece of paper just below the sit bone. Play. If writing your name is too hard, make any pattern that comes to mind. Just keep the movement slow and easy. Rest.

Scoot to the right allowing the left sit bone to rest on the chair. Notice how the left side of the body feels compared to the right side. What differences do you notice? Be specific. Has your breathing changed? After the body scan, repeat this sequence on the right side.

After completing the right side, repeat the body scan done prior to the lesson . How have the points of contact and position of the body changed? Is the body more symmetrical? Are there any differences in the breathing? Stand. How does the body feel in standing? What differences do you notice in this position? Take a short walk. Does your walking feel different? Be specific about any changes you observe.

There’s a second version of this lesson in which the pelvic breath is coordinated with the movements. For that experience, you’ll have to join us at an on-site workshop or view our webinar.

In a follow-up blog, we’ll discuss the rationale for the lesson. In the mean time, before we bias your thinking, it would be great to hear from you. Post a response to your experience with the lesson and how you might consider using it with a client.

Most pelvic rehabilitation providers begin working with female patients. Regardless of a therapist's interest in or comfort level with working with male pelvic rehabilitation issues, these same therapists find themselves sitting across from a male patient who is desperate for relief from symptoms. What happens next? The therapist extrapolates what she has learned about female pelvic floor dysfunction, applies that information, and is often successful in offering effective solutions. The concern with that approach is this: while there are similarities in anatomy and function, the differences require knowledge and skills specific to the male population.

Most pelvic rehab providers have taken several courses specific to female pelvic dysfunction, and can easily discuss diagnoses such as vaginismus, dyspareunia, dysmenorrhea, or surgeries for prolapse. Thinking back to our schooling, we commonly had not learned evaluation or intervention strategies specific to those conditions. If we apply the same thinking to male patients, what were you taught about hernia repair, scrotal pain, ejaculatory dysfunction? While applying what we know about female conditions when treating men is a good start, filling in the gaps in knowledge and adding tools to our ever-growing toolbox is critical in providing expert care.

One way to fill in the gaps is to attend the Male Pelvic Floor course offered by the Pelvic Rehabilitation Institute. The course offers detailed information about urinary incontinence (including post-prostatectomy rehabilitation), sexual dysfunction, and many topics related to male pelvic pain. Conditions you can learn about include epididymitis, testalgia, benign prostatic hypertrophy, transurethral resection of the prostate, erectile dysfunction, and many more. The lectures include several anatomy lectures to help providers understand the functional relationships of the structures to urinary, bowel, and sexual health. The next opportunity to take the course is next month in Minneapolis. I just noticed the leaves starting to change this morning- September in Minnesota is beautiful, and we would love to see you there!

This fall, Herman & Wallace is proud to again offer the course Harnessing the Diaphragm and Pelvic Floor Piston for Rehab and Fitness, instructed by Julie Wiebe. The course will be offered November 2-3 in San Diego, CA

Our pelvic rehab report blogger sat down with Julie to hear more about her course.

PRR: What can you tell us about this continuing education course that is not mentioned in the “course description” and “objectives” that are posted online?

JW: The biggest thing to understand is that this is not just a course for traditional women’s health practitioners, nor is it simply about the pelvic floor, or incontinence. The course as a great introduction for all specialties to the pelvic floor, it is a “gateway drug” to a mysterious muscle group that many have held at arms length. A neuromuscular approach is presented, not a pure strengthening model, with the intention of linking the brain, sensory, motor and IAP systems again to create a coordinated central stability system that is responsive versus statically held. Finally, the course material links that powerful and responsive central foundation to the rest of musculoskeletal system for optimized movement, function, and performance.

The course has practical, manageable, and external intervention strategies to help non-women’s health practitioners integrate the pelvic floor linked with the diaphragm into current programming. For traditional women’s health therapists the course offers integrative ideas to expand their clinical tools and external options for patients that are reticent about or can’t tolerate internal therapies.

PRR: What inspired you to create this course?

JW: Initially, my goals were to share with my ortho and sports med colleagues how incredible the pelvic floor muscle group is, and how to integrate it as a powerful ally in their programming. The pelvic floor really needs new PR, and many practitioners just assume that ‘typical” women’s health issues and anything pelvic floor related aren’t their department. But the evidence is clear that the pelvic floor is a player in the “core” and in all of our movements. The pelvis, and pelvic stability are part of both the upper and lower extremity kinetic chain. So adding pelvic floor integrative tools to the skill set of all practitioners is critical.

Along the way I found traditional women’s health practitioners who were hoping to link their specific pelvic floor interventions to the rest of the musculoskeletal system, with an eye on fitness. So I saw the course as a way to bring both specialties to the middle. Now more and more neuro therapists are coming to the course in search of alternative approaches for creating central stability and continence solutions for their patient populations, which is exciting!

What resources and research were used when writing this course?

The course presents an integrative approach sourced from research, books, articles, and interaction/coursework with top practitioners in multiple fields: sports med, orthopedics, womens health, pediatrics, neuro, cardio pulm, and pain science. A bibliography is available upon request.

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

First the course introduces the evidence and thought process behind a new way of thinking about how the pelvic floor and its functional partners work together. Then step-by-step, it builds on that understanding to advance a clinical model that adheres to the evidence. This involves identification of the pelvic floor and each of its teammates, using that team integratively to provide a dynamic, responsive central stability system, then linking that deep system from the inside out to the rest of the postural system and extremities in movement and function. This builds a powerful foundation for exercise progressions and return to fitness. The treatment progression is experienced and internalized by each participant and applied in a live demonstration throughout the course. The treatment progressions are experienced and internalized by each participant and applied in a live demonstration throughout the course. Case studies and small group learning opportunities are provided to assist with information synthesis and prep for return to the clinic on Monday morning.

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

To an ortho or sports med practitioner : The pelvic floor is an essential part of the core, come learn external techniques to integrate it into your programming.

To a neuro therapist: The pelvic floor and diaphragm are part of the postural control system, and this approach accesses central stability system through breath, which allows a natural access point for your patients not provided by traditional core programs.

To the women’s health practitioner: This is an opportunity to learn to move the pelvic floor from isolation to integration with its functional, postural, and performance partners.

Don't miss the chance to learn more from Julie - register for the November course today!

Earlier this week, everyone here at the Institute was thrilled to see pelvic rehabilitation and the important role of the physical therapist in addressing pelvic floor dysfunction highlighted in an article in Elle magazine.

This morning, we were equally excited to see pelvic physical therapy mentioned on The Today Show's "Gross Anatomy" segment, during which a gynocologist from Norwalk, CT answered a woman from the audience's question about her weak bladder with advice to seek out a good pelvic physical therapist.

It's wonderful to see pelvic PT getting mainstream attention in women's glossy magazines and morning talk shows. We hope these will be venues to get the word out to patients: "You are not alone and we can help you!"

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