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.

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 (www.noigroup.com) 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.

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.

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!

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.

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.

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.

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: fatimahakeem.com.

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!

The prevalence of urinary incontinence in women who have multiple sclerosis (MS) is dramatic, according to research recently published in the International Neurourology Journal. The authors conducted the study within a treatment center that is dedicated to the care of patients with MS. Out of the 143 women surveyed, stress UI occurs in 55.9%, urge symptoms in 70.6%, and 44.8% had both stress and urge symptoms, also known as mixed incontinence. The authors report that the condition of UI significantly impacts quality of life (QOL.) The Urogenital Distress Inventory (UDI-6) and the Incontinence Impact Questionnaire (IIQ-7) were utilized to collect data about both stress and urge urinary symptoms and QOL impact. Women in the study ranged in age from 20-72 years of age, and the subjects who reported stress urinary incontinence were older and tended towards a higher body mass index (BMI). The women with complaints of stress UI also scored higher on the Incontinence Impact outcomes survey as it related to physical activity. This article is available for free in full-text format by clicking here.

One of the challenges for the patients who have MS and for the providers who work with them is the potential fluctuation in symptoms. This chronic neurologic disease is characterized by "flare-ups" that usually require a period of medical intervention followed by a time of recovery in which the patient often has to gradually return to prior levels of function. Neurologic lesions of MS can occur in varied levels of the nervous system, thereby influencing the neurologic control of the urinary system to a varying extent. If a patient is going through a flare-up it may be best to limit the amount of intervention such as strengthening of pelvic muscles until the exacerbation has eased. Some patients are fortunate to experience periods of relative stability in symptoms, even so, fatigue and the risk of increasing fatigue through overactivity is significant. During your subjective history taking, you can inquire of the patient how the disease has tended to manifest for him or her, and then inquire about stability of symptoms and the patient's warning signs for fatigue. It is also important to screen for signs of a urinary tract infection (UTI), as UTI's frequently occur in this patient population. Regarding objective examination, it is imperative to assess the patient's current level of pelvic muscle awareness, strength, sensation, coordination, and endurance. The patient may return for another bout of care at a different time and present with very significant differences in level of function, therefore it is not safe to assume that the patient has a similar baseline to the last bout of therapy.

In my clinical experience, patients who have MS often experience both urge and stress symptoms. For clarification of this terminology, please click here. Utilization of electrical stimulation for either strengthening or neuromodulation of urge symptoms can be a useful adjunct to education and home program management. You can use the knowledge that you have regarding application of electrical stimulation for any patient population, with the consideration that significant fatigue should be avoided. This requires that your exercise prescription skills are applied carefully to the patient's current level of strength and endurance, with close follow-up prior to any increase in home program strengthening. An earlier study by McClurg et al. (2008) suggested that electrical stimulation in addition to pelvic muscle training and biofeedback should be offered as a first-line treatment for lower urinary tract dysfunction in MS. Sacral nerve stimulation is also an option that your patient may have utilized or is interested in discussing. Information about sacral nerve stimulation can be found here. The National MS Society in the US has a clinical bulletin published regarding many medical topics for both health care professionals and patients. The bulletin regarding urinary incontinence can be accessed here, and although it does not discuss the use of rehabilitation, there is a useful algorithm that medical providers are utilizing for the treatment of UI, and the bulletin also emphasizes that early referral to an urologist is important. The study referenced in the first paragraph of this posting points out that the majority of patients in their study were consulting with a neurologist, but not a urologist. It is also significant to remember that urinary symptoms may be one of the first signs of a neurologic disease or condition, and that medical evaluation must be completed prior to rehabilitation commencing so that conditions may be identified and treated early in the process.

As many of you know, the Herman & Wallace Pelvic Rehabilitation Institute is currently developing a Pelvic Therapy Practitioner Certification process (PTPC). As part of the multi-step process involved in the development of a robust certification, the job task analysis survey was completed by more than four hundred providers (403 to be exact.) The Institute was thrilled that so many current, past, or future course participants believe in this process so strongly that even a seemingly endless survey could not deter you from completing the tedious, yet crucial questions that were posed. In another step of the process that occurred after the results of the survey were tallied, I was able to view the tables of responses and I found the information very interesting- I thought that you might also be interested to know a bit more about the answers that we received in the survey.

Keeping in mind that the pelvic rehabilitation specialty is one that is not as well-represented in the clinic as orthopedics, for example, and yet is a specialty that is gaining in popularity, it was interesting to note that nearly 1 in 5 therapists completing the survey had less than one year of experience working in pelvic rehabilitation. Approximately 82% of the more than 400 people completing the questions has been working within pelvic rehabilitation for 10 years or less. In terms of the education of the people represented, the highest degree earned at the time of the survey was a doctorate for 41.4% of people, with 8.4% of those represented by transitional doctorate degrees, and less than 1% by an academic doctorate.

Several people indicated that they had board certifications in either cardiovascular and pulmonary (2), geriatrics (2), neurology (1), pediatrics (1), sports (3), and orthopedics (23), or women's health (17). Other qualifications listed by those completing the survey included LANA certification for lymphedema therapy, manual therapy certifications, yoga, Pilates, and biofeedback certifications, to name a few that appeared frequently.

Geographically, most were from the United States, with the addition of 7 Canadians and 4 "Other." The states in the US most represented included California, with 54 people holding a license in that state, followed by Washington (38), New York (30), Illinois (27), and Florida (22).Employment status for the most part was reported as full-time salaried (55%), and part-time salaried (29%). Just over 13% of those responding reported that they were either full-time or part-time self-employed. Only 5% reported spending 50-100% of working hours in an acute care hospital setting, with approximately 3.5% working in acute care setting 90-100% of the time. 1 out of 3 respondents work exclusively in a health system or hospital-based outpatient setting, and an additional 1 of 3 people work in a private practice setting. Other work environments such as home care or rehabilitation hospital made up a very small percentage of work settings reported. Direct patient care constituted 71-100% of the workload for 92.1% of the group, and nearly 3/4 of the respondents reported spending 0% of his or her time completing administration. Nearly 90% answered "0" for percentage of time spent on research, and the most amount of time indicated for research (by one person) was 20%.

When addressing pelvic rehabilitation specifically, here is an approximate breakdown of time spent in treatment:

% time in pelvic rehab % of respondents

Hopefully you are enjoying the heat of August, and staying cool while we enjoy record breaking heat in many states. This time of the summer is often when we feel the panic of the season slipping away, preparing to enter into the fall season of back-to-school and changing our wardrobes. It may seem slightly out of season, then, to discuss handwarming at a time when most of our hands are staying pretty toasty, but it is such a simple, tangible, and effective clinical tool that it is worthy of a blog post. Hand warming, also described as temperature biofeedback, is a form of self-regulation that allows a small probe to be heated, or warmed, by the skin temperature. Recall that biofeedback is a broad term that describes an approach in which a subject is given some type of information, perhaps in the form of an audio or visual signal, which is related to the subject's physiologic response to an intervention or experience.

According to the very thorough textbook "Biofeedback: A Practitioner's Guide" by Mark Schwartz and Frank Andrasik (3rd edition), the measurement of changing skin temperature is meaningful because sympathetic arousal is correlated to vasoconstriction. When the nervous system is calmed, and the blood vessels dilate, more heat is allowed into the local vessels thereby increasing local temperature. I was first introduced to the clinical tool of "handwarming" using a thermistor by Janet Hulme who taught a wonderful course on the topic of fibromyalgia. On her website she offers a device called the PhysioQ for $25. That seems like the going rate for many of the devices on the market, including this "stress thermometer" sold by bio-medical.com. The bio-medical site also has a terrific page explaining the concept of handwarming as well as specific strategies to apply for teaching its use. Click here to access that page.

The instruction in the clinic of handwarming can be billed as part of your home program training. In this time of decreasing reimbursement and emphasis on self-care, a device such as a thermistor could be a perfect training tool for your patient who wants to continue to manage stress, tension, and to use handwarming as a part of his or her rehabilitation program. The great thing about devices that give feedback is the instant gratification and measure of success that a patient can achieve when the ability to monitor and influence physiologic measures is seen. A thermistor typically has a wire that terminates in a sensor that can be attached (with tape or a little piece of velcro) to the underside of a fingerpad. The readout is observed in degrees, and some devices will have the ability to set goals or use tones for audio feedback. The use of a thermistor has been documented in the literature for the treatment of Reynaud's syndrome, migraines, and other conditions that have a stress-related component.

Schwartz & Andrasik recommend considering the following to avoid "artifact" which can alter the accuracy of readings when using temperature biofeedback.

• A very cool room can also cool the sensor.
• A very hot room will affect the ability of the subject to reduce heat in the hands.
• When coming in from the cold, allow the hands to warm to room temperature first.
• Avoid placing a blanket or other item that will restrict air flow and affect the sensor.

I have seen several articles talking about the “Grey Effect.” The idea is that the incredibly popular book series beginning with “Fifty Shades of Grey” has created a frenzy of female sexual interest. (When I say “incredibly popular” the series has allegedly outsold the paperback Harry Potter series…) I won't go into detail about the book, or about the various critiques and controversies, let's save that for the people who are well-poised to do so. In a nutshell, the book series contains “explicitly erotic scenes.” Reports suggest that the book series craze is sending women in droves to the sex toy shops and is giving women permission to explore their sexuality. What does that have to do with pelvic rehabilitation?

The book may be a topic of discussion with our patients and this in itself may encourage us to explore our own comfort zones related to sexual health. How do you respond when a woman says that she has pelvic pain, is using a sex toy to stretch the vaginal opening, but her husband's penis is much bigger than the toy and she still has pain? How do you give advice about masturbation- or do you? What is the correct response to "my partner thinks I should be able to have an orgasm with penetration?" The replies to any of these questions depend on several factors, such as your level of knowledge about sexual health including anatomy and physiology, your own belief systems, the standards and culture at your place of work, as well as your understanding of sexual practices that are different from your own. What are the ethical issues that surface when faced with the above questions? If you are outside of your comfort zone and do not want to talk about sexual function, is it ok to say so, or are you denying your patient access to available information? How much do you share, knowing that these conversations are intimate and potentially confusing if your patient has poor boundaries? What if a patient asks you some questions and you are feeling unclear about the patient's motivations? These are really good topics for discussion, and outside of giving comprehensive answers, I would like to point out some ideas and resources that may be helpful to you. The Herman & Wallace Pelvic Rehabilitation Institute offers several courses that provide education about sexual health and function or dysfunction. All courses in the series discuss sexual function to some extent, and the Level 3 course has quite a bit of detail about sexual health. The Male course discusses rehabilitation of male sexual function, and there is a newer class instructed by Heather Howard, PhD, all about sexual interviewing and counseling.

It can be a challenge to navigate this territory as this type of “real-world” education rarely happens in school. First, we have to respect ourselves enough to take care of ourselves. This means that when you are not feeling very comfortable with the content of the conversation, say so. A statement such as “I'm not really comfortable with our conversation, let me think about your questions and come back to that next visit if that works for you.” This allows you to take the time to consult with a mentor, a supervisor, or a textbook if needed, or to process how you feel about the question so that you can give a more objective answer. If the patient is being inappropriate, such as asking for your phone number or saying anything suggestive, bring it up. “That is an inappropriate comment, and in order for you to continue to attend rehabilitation here, you must respect that.” If the inappropriate behavior continues, fire the patient, document it, contact the referring provider, and move on. If you are not really sure what sexual technique or act the patient is referring to, a phrase that can be helpful is “tell me more about that.” It is possible to discuss body mechanics in a respectful, professional manner even when discussing sexual health. It's not typically the way we are acculturated, so it takes practice and thoughtfulness.

When patients are interested in accessing websites for the purchase of devices to stretch, stimulate, or vibrate the pelvic muscles, the vendors listed on the hermanwallace.com website have ordering information for some commonly chosen devices. Other sites that are helpful for the patient are www.babeland.com or www.goodvibes.com. The American Association of Sexuality Educators Counselors and Therapists or AASECT website is also one that might be helpful for you as a provider or for your patient as a consumer. If you are looking for a certified sex therapist, that site also lists them by region. Most experienced therapists will tell you that as long as we stay open and listen well, it is our patients who will teach us as much as we can learn in any course or textbook. Optimizing our own comfort levels with sexuality can bring us closer to having meaningful dialog with our patients who trust us enough to inquire about such sensitive topics.