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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This fall, Herman & Wallace is thrilled to be offering two brand new courses instructed by Ginger Garner, MPT, ATC. The first, Yoga as Medicine for Pregnancy, will be offered in Greenville, SC on September 21-22.

Our Pelvic Rehab Report blogger sat down with Ginger to talk about this course. Here's what Ginger had to say:

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?

Ginger: First I want to say how excited I am about this opportunity to be able to write and teach this landmark integrative maternal health course for Herman and Wallace (H&W). H&W’s progressive philosophy in educational programming has made it possible for me to pen (and teach) a course that can directly affect our poor maternal health outcomes in the US.

Second, what isn’t discussed in the online description is that the core of the Yoga for Pregnancy, Labor & Delivery, and Postpartum coursework (32 CE/hours) is built upon the Institute of Medicine’s (IOM) 2011 “Blueprint for Transforming Prevention, Care, Education, and Research” in medicine, in which the Institute puts its full support behind the biopsychosocial model of integrative care. This is important because the June 2011 reports efficacy in health care could be improved through adoption of the model, since it is found to be the most effective and proven method for patient-centered care, especially when managing pain. Both the prenatal and postpartum course are built on utilization of the biopsychosocial approach.

Third, American mothers deserve a better birth and right now there are definitive measures we can take to influence those outcomes. Combining conventional rehabilitation and therapy with integrative methods, based on the evidence-base and a review of systemic changes during prenatal and postpartum, can be a major tool in empowering mothers and improving care.

Lastly, clinicians who attend either the prenatal and/or labor & delivery/postpartum course will be equipped to be agents of change in improving maternal health, since they will be prepared to apply conventional therapy and integrative yoga methods with their patients. In this way, clinicians who attend the courses will able to offer the best of both worlds.

PRR: What inspired you to create this course?

Ginger: I have two sources of inspiration in creating this coursework. Both are equally important and have prepared me to teach coursework that is both integrative and conventional.

The chief source of my inspiration is my activism in maternal health. Since 2009 I have been blogging, through Breathing In This Life (www.gingergarner.com), and other mediums, on behalf of mothers. Two of my posts, How America’s Broken Health Care System Affects Women and Why Childbirth Needs to Change are both favorites because they establish the urgent need to improve women and maternal health care in America. My inspiration for creating the coursework can be found in these two posts.

The second but equally important source of inspiration for me is infant well-being. I have three sons of my own, and I feel very strongly that there is no greater satisfaction than helping a woman through what is the most transforming and miraculous time of her life: becoming a mother. If we can strive to better support mothers, all American families will be healthier and happier. Caring Economics theory also posits that egalitarian care for mothers would vastly improve American health and wealth (www.caringeconomy.org)

The National Association of Mothers’ Centers recently asked for my input on motherhood in a series entitled, “Researching Motherhood.” The interview really crystallizes my motivation and inspiration for creating this course. Read the interview here

PRR What resources and research were used when writing this course?

Ginger: As I mentioned above, maternal health is very important to me, both personally and professionally. For that reason, I sourced over 250 research articles, from sources like Cochrane database reviews, systematic reviews, and randomized controlled trials. The World Health Organization, ACOG, State of the World’s Mothers report, and the latest perinatal and midwifery recommendations and bulletin updates are also included, which discuss the latest evidence for maternal health and well-being, systemic changes during pregnancy, and the intervention clinicians should consider. All of the intervention techniques I teach utilize the evidence and provide the clinician with an integrative biopsychosocial model of assessment combining physical therapy and yoga as its chief modality. I also draw on the first generation course I wrote for integrative yoga prenatal and postpartum intervention back in 2005. So actually this course has been in the making for almost 10 years.

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

Ginger: The coursework (both prenatal and labor/delivery/postpartum) cover intervention in maternal health using the biopsychosocial model. The model has five facets and covers physical, psycho-emotional-social, intellectual, energetic, and spiritual well-being.

The model acknowledges that individual health and well-being of the mother means more than just an absence of disease, as the World Health Organization also supports, and is made up these five facets which depend on integral balanced intervention. Clinical intervention in these five facets happens through assessment and prescription of physical yoga postures (asana) which also includes some Pilates, breath techniques (pranayama), guided meditation and imagery, physical therapy, manual therapy and soft tissue mobilization, myofascial release, neural mobilization, and specific yoga and physical therapy based plans of care for each trimester, including specific intervention for common diagnoses and conditions, as well as labor & delivery and the phases of postpartum.

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

Ginger: The US spends more money than any other country on both overall health care and maternal health care, yet, we have some of the poorest outcomes in the world. America’s healthcare shortcomings in particular include maternal (and infant) health outcomes, pain management, and chronic disease management. What this coursework does is uniquely enable the clinician to change these outcomes and engage mothers on a level that conventional care is unable to accomplish.

What’s more is clinicians who have training in integrative medicine are among the most marketable and sought after by employers. Additionally, this course is interdisciplinary, meaning nurses, midwives, and other maternal health professionals can engage in a dialogue that has not yet happened in the US in maternal health. Interdisciplinary education is also well supported as a means for improving patient satisfaction and patient care.

This course gives clinicians a distinct and measurable advantage because it provides both interdisciplinary interaction and integrative education in maternal health. This is good news for everyone – both patient and provider - because this coursework provides a medical model that empowers everyone. It works because it can improve healthcare and its delivery, and at the same time, reduce clinician burnout. Through its multi-faceted integrative approach, the coursework provides a long-overdue full circle return to holistic healing in an evidence-based container; and that creates a win-win situation for us all.

The Institute is thrilled to be offering these new courses taught by Ginger. Don't miss your chance to learn more about this approach - register today!

Recently, Elle magazine did a feature story on a woman suffering from pelvic pain who ultimately found relief from her debilitating and excrutiating symptoms through pelvic-floor physical therapy.

The article mentions Herman & Wallace, our founders Kathe and Holly, and H&W-trained therapists Amy Stein (of Heal Pelvic Pain fame) and Sarah Emmanuel.

We appreciate the shout-out, but - more importantly - we think it's wonderful to see in-depth and awareness-raising articles about pelvic floor dysfunction and the role of the physical therapist in a widely-read women's glossy like Elle.

Kudos to Amy and Sarah and to the writers of Elle for continuing to spread the word on the important role of Pelvic Rehab!

Herman & Wallace instructors Bill Gallagher PT, CMT, CYT and Richard Sabel MA, MPH, OTR, GCFP are currently leading a four-session workshop for men who recently underwent prostate surgery. They recently completed the second two sessions and shared their story and experience with Pelvic Rehab Report:

You can read their dispatch from Sessions 1-2 here.

The group was a rousing success. In fact, the opening narration to Star Trek, with some modification, can be used here: The pelvic floor program was, for many, the final frontier. It’s 4-week mission: to explore strange and unusual sensations, to boldly go where man has never gone before, works well. Everyone had fun. There were lots of laughs, but some cognitive dissonance too - especially the first week when we were learning the pelvic breath. However, by the end, most were smiling as they felt the dance between their respiratory and pelvic diaphragms.

In fact, the pelvic breath led to some interesting discoveries. Everyone found it relaxing, and a majority, for the first time, could sense the movement and dimensionality of pelvic floor, thereby making it easier to differentiate the front, back, left and right quadrants. Some additional discoveries were 1) only noticing movement on one side, 2) feeling the whole pelvic floor move, but discerning differences among the quadrants, 3) those with pelvic pain found it easier to pinpoint and release, 4) one participant discovered he was breathing paradoxically and 5) several of the participants were surprised to hear that the front quadrant is where the “action is” for improving urinary incontinence and sexual function. Everyone agreed that the pelvic breath lesson helped fine-tune their practice.

Prior to our workshop, Kegels was the exercise of choice, or rather lack of choice. Most were given a piece of paper with the instructions. A couple were actually taught the exercise, but not always given good information. One member was told by the urologist to squeeze his anus during the exercises. Learning that there were other exercises - or lessons, as we like to call them - surprised some participants who thought Kegels was their only option.

The Tai Chi lesson also created some cognitive dissonance as participants tried to maintain the pelvic breath in Standing Stake. There were also some unprintable comments on what some felt in their quadriceps after being in the form for a minute, but by the end, 2-3 minutes was, as one participant said, “no problem.” All of the participants could sense how softening the knees and dropping the tailbone - key elements of Standing Stake - reduced the stress in their lower back, freed the pelvic region and made it easier to breathe and sense the pelvic hammock.

The final session, which focused on learning to use the pelvic floor in everyday activities such as lifting, standing, bridging in bed, was met with pleasant surprise. Sensing how engaging the pelvic floor made each of these movements easier, clarified the contribution these muscles make in day-to-day activities. As one participant said, “although it felt funny at first, using my pelvic muscles added a little propulsion to helping me stand.” After four weeks, although the stress incontinence had not resolved, most noticed an improvement, meaning less leakage and pads. Everyone felt more hopeful now that they had more tools at their disposal.

We plan to meet with the group for 2 follow-up sessions late in the fall. At that time we’ll have a “check –in” to see how everyone is doing, review the lessons and based upon the needs of the group, teach 1-2 new lessons.

Eight weeks after the program we bumped into “Jack” - he was the paradoxal breather and, at 82, he was the oldest participant. “Jack” shared:

“I’ve been practicing your program and didn’t force my breathing to change. I kept working gently like you recommended, and after 4 weeks it changed (his breathing) and hasn’t come back. By the way I’m no longer incontinent. That went away too.”

When we asked Jack how often he practiced, he said everyday, which obviously was the key to his success. Unfortunately, too many give up too soon.

All of the lessons came from our “Integrative Techniques for the Pelvic Floor & Core Function: Weaving Yoga, Qigong, Feldenkrais & Conventional Therapies” online courses and live program. As mentioned in our previous blog, the lessons can be used one-to-one or in groups. From our experience, the group format is extremely effective for pelvic floor work. Participants learn from each other as much as they learn from us. Most of all, groups lend themselves to everyone having fun, which keeps the work light and playful. Not a bad thing when focusing on the “down under.”

Herman & Wallace is excited to announce that we will be offering a Pelvic Floor Level One course this year in Birmingham, UK!

This course will be hosted at Coventry University and taught by Michelle Lyons, PT, MISCP.? Unlike our usual PF1 courses, the Birmingham course will be a two-day event, starting on November 30^th.

Michelle, who is based in Ireland, had this to say about the course ?[Pelvic Floor Level One is] is of the highest quality and the clinical usefulness is immediately applicable?I worked with Siv on teaching PF1 in Belfast in February of this year - it was a big success and there is nothing of comparable quality being taught in England so we thought the time was right. ?Gerard Greene, who will be organising the course, is a fantastic clinician himself, and recognises the importance of assessment and treatment of pelvic floor dysfunction in promoting women's health.?

H&W has made an effort to offer courses outside the U.S.? As we discussed in a previous Pelvic Rehab Report, this September, Founder Holly Herman will be teaching a course in Chile.

Michelle frequently teaches around the world.? About the prospect of teaching this course, she had this to say:

?I love teaching! ?I am very passionate about women's health, especially pelvic health, and to share this information with other clinicians and see them get excited about this work is such a reward for me. ?I have taught all over the world - Europe, the US, Canada and the Middle East, but I am especially happy to bring this work to England. ?I have been a PT for twenty years, working in a variety of clinical settings and I really believe the PT'?s in the UK will appreciate the magnitude with which we can help women with pelvic floor dysfunction - we really do change people's lives with our work.?

Personally, we want to thank Michelle for all her hard work in organizing and teaching this course.? Thanks so much for all your hard work Michelle!

France has it right when it comes to treating the pelvic floor of postpartum women.

On Monday, The New York Times published an article, ?The Re-Education of My Perineum.?? In it, author Ruth Foxe Blader tells the story of her experience in France after giving birth.? As she tells it, her experience in France is close to ideal.? Her physical therapist, Aude, handles the reality of pelvic rehab with the professionalism that is needed:

?Aude politely suggested that I insert the sonde, a tampon-like metal-and-plastic contraption with a long wire she would hook up to the computer. When I flinched, she reiterated the importance of perineal re-education. She delivered this practiced discourse with an air of utter professionalism, flicking through computer exercises with a mouse, her back pin straight. Thankfully. Because had she so much as cracked a smile, I wouldn?t have survived the ensuing psychic trauma.?

Physical therapists play a key role in pelvic rehabilitation.? More often than not, ignoring the role of a therapist in treatment can cause more problems for a patient in the long run.

Blader puts the significance of the therapist brilliantly: ?Four years later, I can say with confidence that the exercises, far more extensive than the standard Kegels that American gynecologists mention offhandedly, worked. Unlike in the United States, where a hypermedicalized pregnancy is followed by a perfunctory six-week follow-up, in France women aren?t left treading water in a sea of untold postnatal soreness.?

Considering Beyond Kegels was published more than fifteen years ago, it is amazing that there is a persistent attitude that pelvic rehab professionals are just Kegel doctors.

Herman & Wallace offers a series on treating pregnant and postpartum patients, a time at which injury to the pelvic floor is common.? Care of the Pregnant Patient, Care of the Postpartum Patient, and Peripartum Special Topics each focus on the special considerations a therapist must have for patients during these distinct times surrounding motherhood.

For those interested in learning more about treating this population, each of these courses has at least one course-event between the now and the end of the year.? Sign up today!

It is a reality in the world of pelvic rehab that too few patients are comfortable discussing their genitalia, anus, or the functions of any pelvic organ when things are going smoothly, much less when something goes amiss.? Often, questions about them are more likely to give blushes than honest answers.

Role/Reboot, a blog that focuses on gender roles and relations, published a blog this July titled ?The Sex Education I Wish I Had.?? In it, author Marianne Cassidy catalogues some of the main problems with sexual education.? While much of the piece is a litany of ?I wishes? for sexual education, Cassidy?s piece reminds me of the wonderful ?Camp Gyno? video Pelvic Rehab Report discussed two weeks ago. ?It?s refreshing to read a blog that is both honest and to the point about perfectly normal things like menstruation and masturbation.

At the end of her litany of ?I wishes,? Cassidy drives home the ultimate point of this blog, ?Most of all, I wish I?d grown up in an environment where my peers and I felt comfortable discussing sex and asking questions, because then maybe none of the above would ever have been scary or mysterious. ?I wish we had classroom discussions about sex and exams on sex and reflective essays on sex and it was all as normal and interesting and important as algebra or poetry.?

Truly, a medical professional?s duty is to treat patients.? Therefore it?s vital for pelvic therapists to be able to speak frankly to their patients.? However, it is equally important to do so without passing judgment about the gender, sex life, or sexuality of a patient.

Herman & Wallace offers a course that focuses on treating sexual concerns for pelvic wellness patients, titled Sexual Health Clinical Toolkit.? This course was last offered in June 2013 in San Diego, California and is currently being planned for 2014.? Keep your eyes peeled for our 2014 calendar (coming this September)!

The Las Vegas Guardian published an article yesterday titled, ?Pregnancy Yoga Magic,? that articulates the benefits of yoga for pregnant patients.? Yoga, the article explains, ?can be the perfect choice for helping to increase endurance little by little, as well as improving muscle strength and honing one pointed focus ? important for birth preparation.?

This article does an excellent job illustrating that, while exercise is important for everyone, pregnant women must find exercise that is effective without being harmful: ?Pre-natal yoga practices are often geared to tune women into their pelvis and the flexibility therein as well as breath control and leg strength ? all critical tools to have during labor and delivery.? Unlike walking, weight-lifting or other ?regular? exercise, pre-natal yoga is fine-tuned to specifically prepare women for the birthing experience and to empower them into the knowledge that they can do this.?

However, few moms-to-be get as much exercise as they should: ?as many as 75% of pregnant women don?t do any type of exercise.?? This means that it is critical for anyone working with pregnant patients to emphasize the how crucial of a role exercise takes for both their health and the health of the child.

This September Herman & Wallace will be offering a course on Yoga for Pregnancy.? This course is geared toward therapists who wish to utilize yoga to treat patients with both complicated and healthy pregnancies.? Yoga for Pregnancy is less than two months away so register today, before the Early Bird Discount expires!

The Border Mail, an Australian newspaper, published an article today following Brian Costello, a man who underwent a prostatectomy.? Surgery for prostate cancer often leaves patients suffering with erectile dysfunction and incontinence.? However, Brian?s physicians did not send him into outpatient rehab, leaving him and his wife Jill, ?on their own.?

The piece titled ?Sex and Secret Men?s Business,? outlines how important pelvic floor and penile rehabilitation is, as well as how few hospitals are prepared to treat outpatients who survive prostate cancer.

Brian?s wife and daughter Leah started ManUp!, an advocacy organization meant to promote better prostate care in Australia.? All too often they hear stories like Brian?s; physicians who show ?no interest in what happens to their patients after prostate cancer treatment.? One man left impotent and incontinent after his robotic surgery[, and] was told the doctor?s job was simply to deal with the cancer.?

One of the many reasons that erectile dysfunction and incontinence are under-serviced conditions though is that patients frequently do not bring it up: ?it?s hard for busy practitioners to keep up to date with the recently developed erection treatments.? It?s also a two-way street, with some men finding it difficult to talk about these issues,? says Prem Rashid, a urologist and associate professor at the University of NSW.? ?Issues surrounding erectile dysfunction following prostate cancer treatment are complex and multi-factorial and often require the help of a multidisciplinary team,? - a team in which pelvic PTs play an important role.

Herman & Wallace will be offering a course on The Male Pelvic Floor in Minneapolis this September.? Participants in this two-day course will learn how to treat conditions such as sexual dysfunction, pelvic pain, and incontinence.

A recent article examines the relationship between sexual dysfunction and body image. The authors note that little is known about the relationship between dyspareunia (painful intercourse) and body image and genital self-image. Could it be that body image issues link to the fact that women who report dyspareunia also complain of overall sexual impairment, anxiety, and feelings of sexual inadequacy?

The research included an on-line survey of 330 premenopausal women, and 58% reported dyspareunia, 42% were pain-free controls. The women with dyspareunia reported more distress about their body image and more negative genital self-image. This study presents an excellent literature review related to the myriad of challenges a woman faces when dealing with pain limiting intercourse. Such examples include decreased sexual desire, feelings of guilt, shame, failure, and a sense of being incomplete. Women will frequently describe their genital area as a "dead" part of the body. These intense thoughts and feelings are rarely addressed in studies of dyspareunia, and in the treatment of the condition, according to the authors. In studies using the Female Genital Self-Image Scale (FGSIS) in a sample of young college women, women reporting impaired sexual function also reported negative genital self image.

How do we help? In addition to providing caring pelvic rehabilitation, how can the medical community offer a more comprehensive approach that encompasses body image? As discussed in the article, if health care providers view dyspareunia as a chronic pain syndrome rather than only as a sexual dysfunction, patients may benefit from addressing how their "sense of self" becomes negative in relation to the pain. Interestingly, body image and sexuality are intertwined, as a positive body image may "...facilitate the subjective experience of sexuality..." while a negative body image can inhibit sexual health.

In our role as pelvic rehabilitation providers, we can discuss the potentially negative relationship between a woman's sexual dysfunction and her body image. As a minimal level of intervention, instructing in awareness of the problem, in use of positive self-talk, and in ways to evaluate self-worth as a "whole" person despite sexual health issues. Ideally, rehabilitation and medical management can alleviate sexual dysfunction, yet the patient may continue to struggle with anxiety, fears, and self-doubt. Through education, encouragement, rehabilitation, and further research, patients may continue to address issues of sexual health as well as body image. We may not know if decreased genital self-image causes decreased sexual dysfunction, or if having sexual dysfunction causes the poor body image, but this research creates an excellent, well-cited platform from which we can launch meaningful discussions with our patients. Referring providers can also be consulted when the patient may benefit from a consult with an expert in psychological health or counseling.