Modalities: Ur Doin it Wrong?

Ice Pack

So, when did you last really think about the modalities you applied to your patient?

As I sat through the last few lectures in a physical therapy "Interventions" class that includes training in various modalities, I am reminded that there is quite a lot of science behind the modalities we have in the clinic. What I am also reminded of is the fact that it is easy to get in a groove and do what is easy in the clinic versus process the sometimes painful clinical reasoning that is required for electromodalities. Today's lecture at the College of St. Scholastica, from where I graduated and now am honored to assist in an adjunct role, given brilliantly by faculty member Karen Swanson, consisted of terminology that frankly gets a bit mind-boggling unless you have some lecture material in front of you. There is direct current, alternating current, microcurrent, interfering current that happens before leaving the machine, interfering current that happens in the body, and specific ranges of current that produce specific effects.

Regarding electrical stimulation, have you ever made the following errors?

1. Applied premodulated bipolar interferential current and used 4 electrodes instead of 2?

2. Applied a TENS unit, using the 4 electrodes in an "x" fashion thinking the treatment area is between all 4 electrodes?

3. Kept the electrodes closer together to allow the current to be applied more deeply?

4. Applied Russian stimulation, telling the patient (as it was described by its inventor) that it is "painless?"

The title of this post, in the current mode of LOL cats and "Ur Doin' It Wrong" humor is not meant to point fingers, rather my goal is to stimulate some thought about why we are doing what we are doing in the clinic.A clinical approach I hear that astounds me is the complete dismissal of all modalities that require a plug-in. "There's no research..." is one of the more common excuses that I hear. When was that information last confirmed? Ultrasound in particular has received a bad rap in the clinic, however, the articles that were relied upon to conclude that ultrasound has no merit were later found to not be considered worthy research articles. Also of note is the updated information that unless you are treating a scar or trigger point in the muscle, applying ultrasound over a muscle belly is not recommended. Rather, the tissue heating effects of ultrasound are best applied over tendons and ligaments.

How do we stay current in the clinic when it comes to modalities? Attending a session at a national conference, or a continuing education course is a great place to start. Another option is to rely upon the students or new graduates who are hopefully making their way into your workplace. Ask them to give an inservice, or invite your local modalities representative in and request recent research. The next time that you apply a modality that has optional settings, ask yourself why you are applying the modality at those settings? You can also invest in an updated copy (5th Edition!) of Michlovitz's Modalities for Therapeutic Intervention (just updated this year.) In our profession, there are few situations that rely upon a cookbook approach, and we must rely upon clinical reasoning skills rather than habits. And if you are a new graduate, don't allow a more experienced therapist to enforce upon you his or her bad habits, and be sure to share all the updated, good bits you have learned in your extensive training!

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1st Annual Multi-Disciplinary Pelvic Health Symposium!

Grab your passports, colleagues, and head up (or down as it may be) for the 1st Pelvic Health Symposium to be offered in Toronto, Canada. The symposium will feature expert lecturers and topics that are relevant for pelvic health practitioners. The symposium is titled Beyond The Basics: Pelvic Pain and Incontinence, and topics include pudendal neuralgia, interstitial cystitis/painful bladder syndrome, vulvodynia, mindfulness, hormone therapy, and compounded medications for pelvic pain. In this one day symposium you can hear from a neurologist, urologist, gynecologist, psychiatrist, staff physician at a clinic for menopause, and a compounding pharmacist. You can access the program brochure, information about the speakers, as well as registration at the Pelvic Health Solutions website.

Pelvic Health Solutions is a practice created by Nelly Faghani and Carolyn Vandyken, two physiotherapists who are committed to providing excellent rehabilitation for pelvic dysfunctions through continuous learning, mentoring and teaching. In addition to creating practice environments that support patients with pelvic dysfunction, their website serves as an excellent resource for both clinicians and patients. Check out one of their pages here.

Because the drive to learn is so strong among pelvic health practitioners, we seem to be constantly traveling to attend workshops and increase our level of knowledge to share with our patients. Take advantage of this one-day symposium and then enjoy the beautiful and culturally diverse city of Toronto!

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Surf the Wave - Visceral Mobilzation of the Reproductive System

Pelvic Rehab Report from Guest Blogger, Jillian Beaulieu, DPT, CYT

Jillian Beaulieu

OK, before I discuss the inspiration for the title of this blog, a brief anatomy and physiology lesson:

In terms of anatomical location, the ovary is deeply embedded and protected within the ovarian fossa in the crowded lateral wall of the pelvis on either side. Each ovary is fairly small, each one being only approximately 3-5 cm during childbearing years. Female ovaries are analogous to male testes in that they are both gonads and endocrine glands that play a big role in reproductive function. Several paired ligaments support the ovaries. The ovarian ligament on either side connects the uterus directly to the ovary. The posterior portion of the broad ligament forms the mesovarium, which supports the ovary and houses its arterial and venous supply. The suspensory ligament of the ovary (infundibular pelvic ligament) attaches the ovary to the pelvic sidewall. Nerve supply to the ovaries runs via the suspensory ligament of the ovary provided through the ovarian, hypogastric, and aortic plexuses. Superior to the ovary lies the small intestine and cecum (right) or sigmoid (left). The bladder and round ligament reside anterior to each ovary. Inferiorly there is the broad ligament and parametrium. The rectum and ureters are behind each ovary. Laterally, the suspensory ligament, obturator nerve, ureters, iliac vessels are found and medially the fundus of the uterus. Wow!

Physiologically, the two small ovaries have a big job to accomplish every month in two phases, follicular and luteal. The follicular phase involves follicle development and growth with the goal of releasing a mature follicle to be fertilized within the uterine tube. Additionally, the ovaries are responsible for the production of female sex hormones estrogen and progesterone. They are busy factories that are constantly in movement and require a significant amount of organ mobility within the pelvic cavity. Given the latter information and without discussion of the many possible underlying causes of ovarian pain, there is no wonder that connective tissue and mechanical tightness or adhesion in the periovarian and surrounding structures may cause ovarian pain and dysfunction.

Thank goodness Ramona Horton, MPT recently taught me how to address these issues through Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction: Level II!

Recently I found myself with quite a few patients with diagnoses involving ovarian pain and dysfunction that led to an endless list of other concerns for them. For three of my patients I have found the techniques that I learned in this course to be particularly valuable, and that is only in the three weeks since I took the course! For the patients I first ruled out kidney, bladder, small intestine, and large intestine involvement and treated with techniques such as pubovesical ligament mobilization and ileocecal valve induction as appropriate. I also looked at the kidneys, obturator nerve, and uterus/cervix due to their direct connections. I found techniques such as broad ligament mobilization and cervical-ovarian mobilization profound for freeing the periovarian structures. Finally, I have been concluding each treatment with tubo-ovarian induction for establishing motility of the periovarian structures by “surfing the wave.” Interested and intrigued? I cannot recommend taking this course enough!

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Education Opportunity- for Patients!

Have you ever wished that you could impart all that you have learned about pelvic pain to your female patients? Starting from simple concepts such as how one insult or injury to the tissues can start a cascade of events over time, and progressing to the amazing knowledge that keeps pouring in about the brain's involvement in chronic pain states? And don't we always hear from patients how difficult it can be to establish a team of professionals who are all on the same page related to treatment options discussed in a compassionate manner?

The Institute recently heard from such a team of experts who have joined together to offer a weekend program for women who have chronic pelvic, sexual and genital pain. Diagnoses included in the above categories can include Interstitial Cystitis (IC), vulvodynia, vestibulitis, Irritable Bowel Syndrome (IBS), pelvic floor dysfunction, pudendal neuralgia, lichen sclerosis, endometriosis, and other pelvic and genital pain disorders. The experts who will provide an entire weekend of education for patients (and interested partners) consists of two physicians, Dr. Robert Echenberg, Dr. Deborah Coady, a physical therapist, Amy Stein, and two counselors, Nancy Fish and Alexandra Milspaw.

The weekend goals are to provide a safe environment in which a person can learn skills that can be immediately applied for self-care. You can be assured that with the group of practitioners involved your patients will be addressed in a holistic manner, and that the knowledge gained can be used in conjunction with a patient's current home program or concurrent therapies. The workshop is scheduled for April 27-28 of 2013, and located in Bethlehem, Pennsylvania. Participants can register at the website

The cost of the retreat itself including several meals is only $450 if registered prior to December 1st of this year (price increases to $475 after December 1st.) What a reasonable price for a patient who can travel (or perhaps lives nearby) and who is interested in expanding her knowledge of how to live with and heal her chronic pelvic pain.

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Watch a Free Chapter of our Online course!

Our partners at Medbridge Education are offering the chance to watch one chapter of our course on pelvic floor exercise cueing for free.

In this clip, Institute founder Kathe Wallace demonstrates techniques and instructs on how to confidently cue exercises for your next pelvic rehabilitation patient. Each cue helps patients identify where they need to contract or relax their pelvic musculature.

Click HERE to watch this chapter for free and learn more about the full list of online offerings available through Herman & Wallace and Medbridge Education.

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Pain, the Brain, and Rehabilitation

Last night as I spoke to an arthritis support group about myofascial and chronic pain, I was able to share information about the research that has taken place over the last decade that describes associations between the brain and pain. The simple idea that being "distracted" by a task eases the perception of pain brought about a story from an attendee about how riding a horse, because it required focused, unwavering attention and because it was immensely enjoyable, was an activity that reduced the rider's pain dramatically. Mentioning that playing with grandchildren or pets could be a wonderful distraction brought about smiles and nods of agreement.

Within the realm of pelvic rehabilitation, we face many patient scenarios that include chronic pain and the need for education about the brain's ever-present role in pain. A recent literature review for a pharmacology course confirmed that research continues to present fascinating advances in imaging and brain changes in response to such pain. Here is a link to a full text article about distraction and pain and the response to functional MRI (neurofeedback) with attempts to modify pain.

According to Apkarian and colleagues (who have completed pioneering work in this field) some of the topics that have been studied in relation to brain structural changes include back pain, fibromyalgia, chronic regional pain syndrome, knee pain, irritable bowel syndrome, headaches, female and chronic pelvic pain. Here is a terrific article by Apkarian that summarizes much of the development of the evolving theories about pain and the brain. The basic summary of the article includes the thought that chronic pain causes abnormal changes in the gray and white mater, and in the relationship between the two. Lorimer Mosely wrote an interesting post about Dr. Apkarian back in May, you can access it here.

Different types of chronic pain will shape the pain uniquely, and the changes can take place rather quickly or over a period of several years. In women who have endometriosis, As-Sanie and colleagues demonstrated that women with chronic pelvic pain have brain changes in multiple areas associated with pain processing, and that women with chronic pelvic pain (and not endometriosis) have changes in a separate site. The exciting news is also that within the research, reducing the pain also appears to positively affect the brain changes.

As professionals involved in helping our patients understand the complex and remarkable experience that is healing, we have a responsibility to continue to learn ourselves and to figure out how to include the brain in our approaches to pain. The Neuro Orthopaedic Institute ( has supplied various educational opportunities and resources that assist in accomplishing this type of education. There is a new resource from NOI about graded motor imaging, worth checking out in addition to the patient education book titled "Explain Pain" with which many of you are already familiar. While teaching in Seattle over the weekend, experienced course participants generously shared their strategies for educating patients in concepts of pain and healing. Here is a highly recommended video available on YouTube that explains common pain concepts while using great visual sketches to get the ideas across.

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PTPC- One Step Closer!

The Herman & Wallace Pelvic Rehabilitation Institute is excited to announce that we have completed the "blueprint" for the Pelvic Therapy Practitioner certification (PTPC). In this post I will share the components of the examination and the anticipated date for launch of the exam. What I am unable to share yet (you will be updated each step of the way over the coming months) are specifics about the when, where, and how of test administration. We do know that we will offer two opportunities per year to take the test and the test will be administered at testing sites in the areas where test takers live. The Institute is also working on details such as examination fees, study guide information, and those important factors, and you will be made aware of all updates as they are finalized. The tentative launch date for the computer-based examination is Spring of 2013.

What I can tell you is this: there are 8 domains on the certification examination and the test will be based on 150 questions. The chart below lists the domains, the general percentage of content in the exam for that domain, and the approximate number of test questions pertaining to the given domain.

Category # of Questions
Anatomy (15%)
22 or 23
Physiology (20%)
Pathophysiology (20%)
Pharmacology (5%)
7 or 8
Medical Intervention & Tests (5%)
7 or 8
Tests & Measures (10%)
Interventions (20%)
Professional & Legal (5%)
7 or 8

The next step in the process is item writing. The Institute's Subject Matter Experts (SME's) will be busy writing questions that are specific to pelvic rehabilitation and the above categories. Questions will be based in evidence, in best practices, and will be about conditions or situations that are common to the pelvic rehabilitation provider. It is not necessary to take any particular courses, as you will be provided with a detailed list of the content areas of the exam, and the manner in which you satisfy the knowledge of material can vary. We will create a list of resources and recommended materials as we get closer to the application date of the examination.

The PTPC credentials that will appear after your name once you have passed the examination will allow you to identify yourself as a certified pelvic therapy practitioner who has worked towards advanced knowledge and skills in pelvic rehabilitation. The process to achieve the ability to utilize the professional designation of PTPC has been extensive and rigorous, and many faculty members as well as the Institute founders have already invested significant time and energy in devotion to this endeavor. We look forward to providing you with more information about the details of the examination and the process. Keep your eye on the blog and the newsletter for such updates!

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Emotional disclosure

While recently researching the topic of fibromyalgia, I came across literature related to the phrase "emotional disclosure." I thought that the phrase is a perfect way of describing what often happens when we are in the clinic working with patients. I know that all of you, regardless of your caseload in pelvic rehabilitation, have worked with patients who have symptoms of fibromyalgia or chronic fatigue syndrome (I mean them as separate entities although research questions if they are one and the same.) And regardless of the patient having a diagnosis of fibromyalgia, the fact that so many of our patients emotionally break down in our presence once they recognize that first, we believe them, and second, we have some strategies to offer towards healing, makes this an interesting topic.

Back to the research. One article describes the relationship between depression, anxiety, and the tendency to "engage in diminished emotional disclosure." The authors found that in the college students who participated in the study, depression was tied to the tendency to avoid emotional disclosure. From a psychological stance, increased disclosure in a counseling session was found to lead to a "deeper" session. Interestingly, not all patients benefit from emotional disclosure, and there is limited evidence in randomized, controlled trials to know which patients should be encouraged to share.

While most pelvic rehabilitation providers are not licensed psychologists or other mental health and behavioral specialists, disclosure happens. We should not be engaged in trying to get a patient to discuss prior trauma or emotional issues unless he or she initiates the dialog or unless we are screening the patient for adverse events so that we can be sensitive to the patient's needs. As the patient is often discussing intimate and emotionally-charged symptoms with us, it is very typical that trust develops quickly in the therapeutic relationship. It is this trust that may allow the patient to feel safe enough to share information about life stress, prior injuries (emotional or physical), and to share feelings of how their physical symptoms impact other domains in life.

The founders of the Pelvic Rehabilitation Institute, Holly Herman and Kathe Wallace, have always instructed students to inquire of the patient if she has a counselor, psychologist, or trusted friend who can be a listening ear if the pelvic rehabilitation process should bring up some challenging emotional issues. They have also encouraged therapists to keep a list of counselors so that if a patient is interested in talking to a specialist, the list can be easily shared.

Lastly, I wanted to share an article with you from PubMed Central (free, full text!) that discusses the prior 10 years of research on pain and emotion- what a rich topic! The research concludes that emotions are critical in the understanding of, assessment, and treatment of pain, and we need to know more about when to facilitate the sharing of the emotions versus when to encourage the release of the emotions to be replaced by more positive ones. This is an area of health research that I believe will continue to grow dramatically and that will offer us new insights as well as confirm what we observe clinically.

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Patients Seeking Outpatient Pelvic Rehabilitation

In the current issue of the journal Physical Therapy, Wang and colleagues describe the characteristics of patients (and their pelvic floor diagnoses) presenting for outpatient physical therapy. 109 outpatient clinics participated in this data collection and included information about 2452 patients. The system used for collecting data is FOTO (Focus On Therapeutic Outcomes), and you may have heard the results of this research presented at the most recent Combined Sections Meeting of the American Physical Therapy Association. The results of the study include that most of the people presenting to the clinics for pelvic floor dysfunction were women (92%), and that many reported a combination of urinary, bowel, or pelvic pain symptoms. The authors found a mean patient age of 50 with a standard deviation of 16. Most patients reported symptoms as chronic (74%). You can see from the following chart that is adapted from the article that subgroups of patient populations were noted, and the categories used for reporting include urinary disorders, bowel disorders, and pain (not all subgroups of combinations of pain are included in the chart below.) In general, 67% of the patients reported urinary dysfunction, 27% reported bowel dysfunction, and 39% reported pelvic pain.

Breakdown of Diagnoses and Subtypes
Urinary Bowel Pain
Leakage (32.1%) Constipation (53.7%) Abdominal (15.1%)
Frequency (10.9%) Leakage (27.9%) Rectal (3.7%)
Retention (2.7%) Leakage, constipation (18.4%) Sacroiliac (5.9%)
Leakage, frequency (30.2%) Vaginal (23.9%)
Leakage, retention (5.1%) Abdominal, sacroiliac (4.5%)
Frequency, retention (4.7%) Abdominal, vaginal (17.1%)
Leakage, frequency, retention (14.3%) Abdominal, rectal, vaginal (5.1%)

This study delivers valuable information about who is showing up to outpatient clinics and receiving care for pelvic rehabilitation services. There are certainly reasons for which patient data may not have been captured, such as patients voluntarily choosing the portions of the data collection to complete. Although the authors attempt to extrapolate epidemiological incidence of male versus female pelvic floor dysfunction compared to population samples, we have to keep in mind that there are several confounding factors that can influence such attempts. Firstly, it is difficult to obtain accurate data for prevalence of pelvic floor dysfunction in either men or women when varying criteria and definitions are utilized and when symptoms are known to be underreported. It should also be taken into consideration that patients will attend a clinic for a program of rehabilitation when there is awareness on the part of the patient or the referring provider that a particular program exists. In other words, there is still a lack of awareness that pelvic rehabilitation providers are available, that there is a broad scope of what we can evaluate and treat, and that we treat both men and women for pelvic floor dysfunction. This brings us to the fact that not as many rehab therapists treat men, and therefore such a service is likely not being promoted and utilized to its potential in a community clinic.

Although this research targets outpatient physical therapy clinics, regardless of the setting or of the discipline involved in care of patients with pelvic rehabilitation, the use of outcomes data is critical. Some insurances will not reimburse for rehabilitation unless outcome data is collected. It should be a common practice to include at least one outcome tool in evaluation and in the discharge planning process. As pointed out by the authors of this research, the use of computerized systems for medical records allows increased access to patient demographics, diagnoses, and information about treatment. It is terrific to see pelvic rehabilitation highlighted in the Physical Therapy journal, and hopefully the inclusion of pelvic floor dysfunction in mainstream publications will continue to improve awareness of these diagnoses and to further normalize the dialog about such conditions.

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Women's Pelvic Health & Continence Center Celebrated!

The National Association for Continence (NAFC) has recently created a press release naming the Women's Pelvic Health & Continence Center and the Woman's Hospital of Texas a "Center of Excellence (COE): Continence Care in Women." The release highlights the fact that this is the first time a community hospital as well as a private group of physicians have been given this award. A healthcare institution that meets the pre-qualification requirements can apply and then independently collected patient satisfaction data, a site visit, and employee interviews make up part of the rigorous process that can, upon award of the COE designation, help patients find centers of care that the NAFC can stand behind and promote.

Fatima Hakeem, physical therapist and director at Woman's Hospital of Texas, has created the foundation for program development and excellence at her facility which won this prestigious designation. Many of you may know Fatima as an educator, mentor, author, or by the work that she has created for marketing and developing the business of physical therapy. Her advice towards developing a women's health practice was featured in the physical therapy magazine "Advance" in 2005, click here to read the article. She has authored various publications related to the practice of women's health physical therapy, including chapters in Irion and Irion's Women's Health in Physical Therapy. Fatima's accomplishments are many, and you can learn more about the steps on her journey by visiting her website:

Fatima, along with Holly Herman, founding faculty of the Institute, made an epic journey to Saudi Arabia where they took on an 11 day comprehensive women's health training of more than 30 women. (Click here to see the blog post about that trip!) Both educators and the Institute were honored by the Princess herself. Their next travels will be to Dubai later this year, keep an eye out for a blog update about the upcoming trip and learn where the Institute and esteemed educators such as Fatima and Holly will be sharing their wealth of knowledge. There are many women who have paved the way for the growing numbers of pelvic rehabilitation providers, and through tremendous efforts and acts of generosity they have and will continue to provide opportunities for therapists in this country and abroad. Opportunities to offer support and skilled care for other women and men who so desperately need to hear that their conditions can be alleviated or improved. Hats off to Fatima for her dedication to the profession and to her facility, which is now celebrating a "Center of Excellence" award!

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