Today The Pelvic Rehab Report is featuring two short interviews with instructor teams Alyson Lowrey & Tara Sulivan who teach Pain Science for the Chronic Pelvic Pain Population, and Sandra Gallagher & Caitlin Smigelski who teach Transgender Patients: Pelvic Health and Orthopedic Considerations.

The Pain Science for the Chronic Pelvic Pain Population instructors Alyson N Lowrey, PT, DPT, OCS &Tara Sullivan, PT, DPT, PRPC, WCS, IF answered the following two questions:

What Is Pain?
All pain occurs in the brain. Whether it is from acute tissue injury, nerve injury, or chronic pain, all pain has to be interpreted by the brain. How do you explain to a patient that their pain may not be from tissue damage, but from their brain interpreting something as painful that shouldn’t? While their pain may be in their brain, it is NOT in their head!

Pelvic pain is complicated because of a phenomenon called pelvic organ cross-talk. Your brain has a really hard time determining which pelvic organ or muscle is having pain or sensations, so signals can get crossed. Patients can present with uterine pain that can cause bowel or bladder pain and vice versa. We commonly see this with endometriosis and interstitial cystitis. Another example is the prostate and bladder. Prostatitis may present as an overactive bladder. This makes our jobs more difficult because we have to be able to determine the true source of a patient’s pain and understand that their pain may not be coming from an obvious source.

What is pain neuroscience education (PNE) and how can it be used?
Pain neuroscience education (PNE) is the explanation of the neurophysiological changes in the central nervous system to patients that have chronic pain. It is explaining pain, sensitization, and all the factors that can be contributing to their pain and abnormal sensations.

PNE typically decreases the threat value of pain, diminishes catastrophic thinking about pain, and facilitates a more active coping strategy. In the Pain Science for the Chronic Pelvic Pain Population, you will leave with the tools to combine pain science education with current interventions for a more effective treatment.

The Transgender Patients: Pelvic Health and Orthopedic Consideration instructors Sandra Gallagher, PT, DPT, WCS & Caitlin Smigelski, PT, DPT answered the following two questions:

What made you want to create this course?
We created this course on rehabilitation in gender-affirming care in 2018 because, at that time, nothing like it existed. We had learned so much from working with patients preparing for surgery and knew we need more information. Through attending conferences, we had opportunities to talk with experts in the field including surgeons, endocrinologists, primary care physicians, and social workers. Combined with researching additional topics, we made the course we wish we could have taken: a course that bridges physical rehabilitation considerations with medical and surgical information on transgender care.

Today, many brief courses and videos about gender-affirming care exist. You can now find courses and videos that address trauma-informed care, language aspects of gender-affirming care, and physicians and surgeons speaking on their procedures. We think this is great and encourage people to continue to seek out these learning opportunities! Our goal is to expand on the perspective of the rehab professional by offering a course that has both depth and breadth.

Our course has evolved to a hybrid format with pre-recorded self-paced lectures and live webinar content. We know that some participants are well versed in LGBTQ topics and are trained in providing trauma-informed care. For other participants, our course may be the first time they are exploring topics like sex, gender, sexuality, trauma-informed care, and gender-affirming language. The content in the pre-recorded lectures allows participants to work at their own pace, whether it is review or brand new information and allows everyone to have a similar foundation when we meet for the live portion.

What is your message to practitioners about gender-affirming care?
Our message to participants who are just starting their journey on gender-affirming care is to remember that gender is not genitals and that undergoing gender-affirming procedures is not strictly about sexual activity options. Sometimes people get so focused on the genital surgery or changes, that they forget the person. Every patient's path will be a bit different and there is more to gender-affirming care than peri-operative rehab.

Keep learning! Engage with professional organizations like WPATH, watch videos featuring gender diverse individuals, practice language with coworkers, and attend grand rounds. Many university hospitals now have virtual rounds that are available live or as recordings. There is so much information available if you search for it!

Pain Science for the Chronic Pelvic Pain Population

Course Date: October 8-9, 2022
Price:$400
Experience Level: Beginner
Contact Hours: 12

Description: This course is designed to expand the participant's knowledge, experience, and treatment in understanding and applying pain science to the chronic pelvic pain population including endometriosis, interstitial cystitis, irritable bowel syndrome, vaginismus, vestibulodynia, primary dysmenorrhea, and prostatitis. This course provides a thorough introduction to pain science concepts including classifications of pain mechanisms, peripheral pain generators, peripheral sensitization, and central sensitization in listed chronic pelvic pain conditions; as well as treatment strategies including therapeutic pain neuroscience education, therapeutic alliance, and the current rehab interventions' influence on central sensitization.

Lecture topics include the history of pain, pain physiology, central and peripheral sensitization, sensitization in chronic pelvic pain conditions, therapeutic alliance, pain science and trauma-informed care, therapeutic pain neuroscience education, the influence of rehab interventions on the CNS, and specific case examples for sensitization in CPP.

Transgender Patients: Pelvic Health and Orthopedic Considerations

Course Date: October 8,2022
Price: $500
Experience Level: Beginner
Contact Hours: 17

Description:  This course is appropriate for any physical rehabilitation professional, regardless of their specialty area, who has an interest in better serving people who are gender diverse. There is specific content aimed at teaching pelvic health therapists how to expand their skills for working with people of all gender identities. There will be particular education regarding gender-affirming genital surgeries as well as discussion of other gender-affirming surgeries and medical interventions that people transitioning might choose.

Often times therapists think of genital surgeries and sexual function when contemplating work with transgender people. However, therapists have far more to offer transgender patients. For providing optimal care, knowledge of the intricacies of gender transition is essential. We provide that overview in this course. Topics covered include:

• Societal influence on gender transition including interactions with health care providers
• Recognizing difference between sex, sexuality, and gender
• Understand the complexities of the legal system for the person transitioning gender
• Tips and tools for a trauma-informed intake and examination
• Health effects of hormones for gender transition as related to differential diagnosis in rehabilitation
• Supporting healing after gender-affirming surgery
• Operative procedures for face and chest
• Operative procedures for masculinizing and feminizing genital surgery
• Pre-operative evaluation, treatment, and education issues
• Post-operative evaluation, treatment, education, and follow-up for genital surgeries
• Outcome measures with rehab focus for people undergoing gender-affirming surgeries
• Fertility and pregnancy in gender diverse people.

Rachna Mehta, PT, DPT, CIMT, OCS, PRPC is the author and instructor of the Acupressure for Optimal Pelvic Health course. Rachna brings a wealth of experience to her physical therapy practice and has a personal interest in various eastern holistic healing traditions.

One of the main reasons I got into Acupressure was because of my complex orthopedic patients. People who were struggling with chronic pelvic pain, and a lot of my patients were doing complementary and alternative medicine ( CAM ) modalities like Acupuncture and Yoga. That got me interested, because as they were going along with those programs in addition to therapy, the question they always asked was what could they do themselves.

I started looking into Acupressure and found that there was such a big knowledge base, but the information was very scattered. If I found a study that talked about Acupressure points, I wouldn’t know where they were located, what they were good for, where I could use them, or how I could integrate them into my practice. I started to piece the information together and that was the conception of this course Acupressure for Optimal Pelvic Health.

Acupressure for Optimal Pelvic Health  is a two-day course with about an hour and a half of pre-recorded lectures that go over the history of Acupuncture (because Acupressure draws from that), Traditional Chinese Medicine (TCM) concepts, getting our basics down, and terminology. We talk about the meridian channels, Ying and Yang, and where the meridians and Acupoints are located on the body. Next we delve into the scientific and evidence-based perspectives by taking a look at all of the evidence for Acupuncture and Acupressure.

From there we go into how to read the chart and what are the abbreviations. We have 12 main meridians that we look at and out of those there are 4 that we focus more on for pelvic health. Those are the Bladder, the Kidney, the Stomach, and the Spleen meridians - those have the most points that we focus on. There are also other important points all over the body that help and stimulate the nervous system and tap into the peripheral nervous system, the Qi, and improve the physiological functioning of the organs.

Lectures also talk about the fascial and connective tissue networks, and how Acupoints are located along fascial planes. We discuss the connections of the fascia with the peripheral nervous system and how Acupoints have high electrical conductivity on the surface of the skin (there are instruments that can measure this). Next, we tackle the question of how Acupoints tap into the central nervous system and how there are internal connections to the different organs that can help to heal and promote physiological wellbeing. Acupressure can treat conditions like anxiety, incontinence, constipation, dysmenorrhea and a host of pelvic health conditions. Acupressure is good for so many different things.

On day two of class, we dive into Yin yoga. Yin yoga is a very beautiful form of yoga. It’s a quiet, meditative form of yoga, and it connects the Acupressure points by putting the body in specific poses that stress those tension lines along the meridians. It is a mindful way of putting the body in specific positions and supporting the body with props. It is also a meditative state in which we stay in each pose for about  3 to 5 minutes, and we become still. The main principles of Yin Yoga are that we arrive in a pose, become still and stay for time. We get into a pose and basically, we are meeting our body where it is. It’s also a lot of acceptance and mindfulness. Stillness is something that a lot of people have a hard time doing, be it physical or stillness of the mind.

The beauty of us using Acupressure is that we are musculoskeletal specialists and we are so hands on with all of our patients. If we know exactly where the points are, we can work on those points as we are working on other things such as stretching a muscle, doing range of motion, or just working on fascia. There are a lot of things that we can do for our pelvic health patients in particular, but this is applicable to even our orthopedic patients.

Acupressure is truly a mind-body practice that can be taught to patients in their journey towards self-care, holistic healing and wellness.

Acupressure for Optimal Pelvic Health

Course Dates:
October 15-16, 2022
February 4-5, 2023
June 3-4, 2023
October 14-15, 2023

Price: $450
Experience Level: Beginner
Contact Hours: 12.5

Description: This is a two-day course that offers an evidence-based perspective on the application of Acupressure for evaluating and treating a host of pelvic health conditions including bowel, bladder, and pelvic pain issues. The course explores a brief history of Acupressure, its roots in Acupuncture and Traditional Chinese Medicine (TCM), and presents current evidence that supports the use of complementary and alternative medicine as an adjunct to western medicine. TCM concepts of Meridian theory and energy channels are presented with scientific evidence of Acupoints transmitting energy through interstitial connective tissue with potentially powerful integrative applications through multiple systems.

Lectures will present evidence on the use of potent Acupressure points and combinations of points for treating a variety of pelvic health conditions including chronic pelvic pain, dysmenorrhea, constipation, digestive disturbances, and urinary dysfunctions to name a few. Key acupoints for decreasing anxiety, and stress and bringing the body back to a state of physiological balance are integrated throughout the course. Participants will be instructed through live lectures and demonstrations on the anatomic location and mapping of acupressure points along five major meridians including the spleen, stomach, kidney, urinary bladder, and gall bladder meridians. Key associated points in the pericardium, large intestine, small intestine, lung and liver meridians as well as the governing and conception vessels will also be introduced. The course offers a brief introduction to Yin yoga and explores Yin poses within each meridian to channelize energy through neurodynamic pathways to promote healing across multiple systems. Participants will learn how to create home programs and exercise sequences and will be able to integrate acupressure and Yin yoga into their orthopedic and pelvic health interventions.

Holly Tanner is the Director of Education at Herman & Wallace and has curated and instructs the Male Pelvic Floor course. Male Pelvic Floor was first taught in 2008 and has since been expanded to include 22 contact hours. This current content includes 7 pre-recorded lectures and 2 full days of live lectures and labs, allowing more time for hands-on skills in examination and treatment. The schedule covers bladder, prostate, sexual health, and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease.

Post-orgasmic illness syndrome (POIS) is a condition that encompasses a cluster of clinical symptoms. The literature most often reports this presentation in men as a response that occurs shortly after ejaculation and that lasts a period of days or even a week or longer. Symptoms may include transient, flu-like symptoms including, but not limited to headache, sore throat, general myalgia, exhaustion, and cognition that is impacted during the reaction. Understandably, people who experience post-orgasm illness often limit sexual encounters, demonstrate avoidance of sexual function, experience interference in relationships with partners, and report lost time from work and other activities. The diagnosis may be primary (occurring from first ejaculation experience) or secondary (acquired later in life.)

Despite the recognition that clinical presentation can be highly variable, diagnostic criteria have been described by Waldinger and colleagues in 2011 (Part 1) and are based on their study of 45 Dutch Caucasian men with POIS.

Preliminary diagnostic criteria for post-orgasmic illness syndrome include 1 or more of the following:

• Flu-like symptoms, fatigue, muscle weakness, feeling feverish, sweating, mood disturbances or irritation, memory and concentration difficulties, nasal congestion, watery nose, and/or itchy eyes.
• Symptoms occur immediately after or within hours after ejaculation
• Symptoms occur almost always, or in more than 90% of ejaculation events
• Symptoms last for 2-7 days
• Symptoms disappear spontaneously

There are various theories postulating the reason for developing POIS including the autoimmune-allergy hypothesis, cytokine and neuroendocrine disruption, and endogenous m-opioid receptors (orgasm uses large quantities of endogenous opioids). One of the primary reasons that immune reaction to a patient’s own semen has been a strong theory is because sexual activities without ejaculation often do not produce the reaction. Hyposensitization with autologous semen has proven beneficial as a desensitization therapy. (Waldinger et al., 2011, Part 2) Other treatments that may be used include antihistamines, SSRIs, benzodiazepines, and NSAIDs. Comorbidities of POIS reported by Natale and colleagues (2020) include erectile dysfunction, allergies, chronic pelvic pain, autoimmune conditions, and depression and anxiety.

From the standpoint of pelvic rehabilitation, there is much to offer to alleviate symptoms and promote function in patients who have POIS. Genitopelvic pain during or after ejaculation, urinary hesitancy, and difficulty with bowel movements can accompany the syndrome - all complaints that warrant evaluation typical of any patient who has abdominopelvic dysfunction. In the men who have presented to me with this diagnosis, a period of sexual dysfunction including premature ejaculation was described prior to developing POIS. One patient, in particular, described a period of a decade or more of suppressing sexual desires, including masturbation, due to beliefs in his community. When he did masturbate for the first time, he developed post-orgasm illness immediately. I have also observed a tendency to report hypersensitivity to touch, with any palpation to the lower abdomen or groin area causing significant discomfort, and even spontaneous erection or orgasm that was difficult for the patient to manage. In the few cases I have seen, abdominal and pelvic muscle dysfunction was present, and patients responded favorably to manual therapy, education, breathing, and self-management with the use of thermal therapies and self-treatment for soft tissues. It is likely that a combination of medical management, as well as rehabilitation efforts, will provide the best recovery, as anyone who develops fear of an activity usually benefits from learning how to prepare for said activity by addressing concerns prior to, during, and after the activity. Addressing the nervous system response to ejaculation can be part of the rehabilitation process, and a referral to a mental health professional may also prove beneficial in managing the anxiety that often accompanies post-orgasm illness syndrome.

References:

1. Abdessater, M., Elias, S., Mikhael, E., Alhammadi, A., & Beley, S. (2019). Post orgasmic illness syndrome: what do we know till now?. Basic and Clinical Andrology, 29(1), 1-6.
2. Le, T. V., Nguyen, H. M. T., & Hellstrom, W. J. (2018). Postorgasmic Illness Syndrome: What do we know so far?. Journal of Rare Diseases Research & Treatment, 3(2).
3. Nguyen, H. M. T., Bala, A., Gabrielson, A. T., & Hellstrom, W. J. (2018). Post-orgasmic illness syndrome: a review. Sexual Medicine Reviews, 6(1), 11-15.
4. Waldinger, M. D., Meinardi, M. M., Zwinderman, A. H., & Schweitzer, D. H. (2011). Postorgasmic illness syndrome (POIS) in 45 Dutch Caucasian males: clinical characteristics and evidence for an immunogenic pathogenesis (part 1). The journal of sexual medicine, 8(4), 1164-1170.
5. Waldinger MD, Meinardi MM, Schweitzer DH. Hyposensitization therapy with autologous semen in two Dutch caucasian males: beneficial effects in Postorgasmic illness syndrome (POIS; part 2). J Sex Med. 2011a;8(4):1171–6
6. Waldinger, M. D., & Schweitzer, D. H. (2002). Postorgasmic illness syndrome: two cases. Journal of Sex &Marital Therapy, 28(3), 251-255.

Price: $695                                            Experience Level: Beginner-Intermediate                                            Contact Hours: 22

Description:  
The course introduces valuable concepts in pelvic health including urinary and prostate function, chronic pelvic pain, and sexual health. For therapists who have taken Pelvic Floor Function, Dysfunction, and Treatment Level 2A, the Men’s Pelvic Health Course expands on the men’s pelvic health topics introduced in Pelvic Floor Level 2A. This continuing education course is also created at an introductory level, covering topics such as internal rectal pelvic muscle examination, so that a therapist who has not taken prior pelvic floor muscle function coursework can attend. It is expected that participants will only register for satellites in which they are within driving distance, and adhere to all state and local COVID guidelines, including wearing a mask at all times during the course.

Urinary dysfunction such as post-prostatectomy incontinence, benign prostatic hypertrophy, urinary retention, and post-micturition dribble are discussed in this class. Because urinary incontinence is a potential consequence following prostate surgery, risk factors, pre-surgical rehabilitation, and post-surgical intervention strategies following prostatectomy are instructed. The medical aspects of prostate cancer testing are also clearly described, including prostate-specific antigen (PSA) testing, Gleason scores, and any recent updates in recommended medical screening.

Although most men diagnosed with prostatitis do not have a true infection, prostatitis remains a common diagnosis within chronic pelvic pain. The Men’s Pelvic Health course explains typical presentations of prostatitis-like pain, evaluation techniques, and evidence-informed intervention techniques. Other pelvic diagnoses are covered, such as Peyronie's Disease, testicular and scrotal pain, penile pain, and pelvic floor muscle-related conditions. Men who experience pelvic muscle dysfunction including pain or weakness are at risk for sexual dysfunction. Participants will be able to describe the relationships between pelvic muscle function and men’s sexual health, including the evidence that demonstrates pelvic muscle rehabilitation's positive impact on erectile function. This continuing education course includes lectures and labs, including external and internal muscle mapping and neuro-myofascial treatment techniques.

Next Course Date: October 22-23, 2022

Satellites:

• Self-Hosted
• Virginia Beach, VA
• Downer's Grove, IL
• Baltimore, MD
• New York City, NY
• Omaha, NE
• Leesburg, FL
• Smyrna, TN

Bethany Blake, PT, DPT, PRPC sat down with The Pelvic Rehab Report this week to discuss herself and how she came to TA for Herman & Wallace.

Who are you? Describe your clinical practice.
I’m Bethany Blake. I co-own Arkansas Pelvic Health and use social media (@thebladderbaddies previously @thekegelchronicles) to educate about pelvic health.

At Arkansas Pelvic Health we believe everyone should be able to live their life confidently, without pelvic pain or leakage. We believe pelvic therapy should be a standard, not a luxury, and we are on a mission to change this, one pelvis at a time. That's why we started this business, to raise the standard of care in women's health.

As a patient at Arkansas Pelvic Health, you will be paired one-on-one with a Doctor of Physical Therapy, never a tech or computer. You will never be rushed, and your pain and symptoms will be validated. We’re tired of doing things like they've always been done, and we’re tired of women's pain being ignored. We practice evidence-based, patient-centered, compassionate care to get you lasting relief from your pelvic symptoms and get you back to living your life!

What has your educational journey as a pelvic rehab therapist looked like? Where did you start?
I really jumped all in. I took Pelvic Floor Level 1, Pelvic Floor Level 2A, and Pelvic Floor Level 2B all within a month of each other. Very shortly after that, I took a visceral class with Ramona Horton and started teaching courses. I love learning and refuse to settle with not knowing something.

How did you get involved in the pelvic rehabilitation field?
I started my career as an outpatient orthopedic therapist. I picked this site as a clinical rotation because of one therapist in particular, Amanda Brooks-Ritchie. I liked the training that she had and the certifications she was working toward. I had a lot of pregnant and postpartum patients there and worked with a team of pelvic health therapists. Anytime treatment didn’t involve actual vaginal exams, they got “kicked out” to ortho…me. I learned a lot about pelvic health during that time and eventually decided to jump on board the pelvic health ship. I love zooming in and out of the pelvis and bringing the orthopedic background into pelvic health. Soon after I took the courses, I got my PRPC. I realized when studying for that certification, I wanted to merge my orthopedics and pelvic floor, which looked different from how I was practicing at my then-current job. I reached out to a classmate, colleague, and friend, Beth Anne Travis, who had previously approached me about starting a clinic, and told her I was ready to go!

What patient population do you find most rewarding in treating and why?
I love treating pain patients - pelvic pain in general, interstitial cystitis, pudendal neuralgia, and pain with intercourse. It is so rewarding to give people a part of their life back that they hate and to help their bodies work for them instead of against them.

If you could get a message out to physical therapists about pelvic rehab what would it be?
If you suspect pelvic floor issues with your patient, don’t try to manage them yourself.  You are potentially doing more harm than good by blindly issuing Kegels and TA contractions. If you aren’t sure, call your friendly neighborhood pelvic PT, and they would be very happy to help you with your patient. I also love the Cozean pelvic floor screening tool.

What lesson have you learned in a course, from an instructor, or from a colleague or mentor that has stayed with you?
Pelvic floor issues are complex. The evaluation is an ongoing process. You won’t know everything for everyone, but you know how to research, you have colleagues you can talk to, and don’t stop trying. Pain is absolutely not part of being a woman.

What do you find is the most useful resource for your practice?
My colleagues. We have a weekly hour where we chat about cases, practice new techniques, and review. It is the best time of the week.

What is in store for you in the future as a clinician?
Arkansas Pelvic Health is growing and expanding. I see opportunities for growth in space and location. I will continue patient care (it’s my favorite part) and also educating the public on social media and through different PT schools.

What books or articles have impacted you as a clinician?
The Interstitial Cystitis Solution
Come As You Are
Headache in the Pelvis
The Body Keeps the Score
Netter’s Anatomy
and many articles!

What has been your favorite Herman & Wallace Course and why?
Pelvic Floor Level 2B is my all-time favorite because I love treating pain conditions. I also really enjoyed the Nutrition Perspectives for the Pelvic Rehab Therapist course.

What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
Progress is not linear!

What do you love about assisting at courses?
I love teaching people about the pelvis, knowing that they will go out and help so many people. I love the updated evidence at the courses, reconnecting with colleagues, and meeting new ones.

What is your message to course participants who are just starting their journey?
Sometimes the load is heavy, but you get stronger, and colleagues help carry it! This is the most rewarding job you will ever have. It is an honor that people let you help them with a vulnerable issue, don’t take it lightly.

This week The Pelvic Rehab Report sat down with faculty member Ken McGee, PT, DPT. Ken (they/he) is a queer transmasculine pelvic health physical therapist based in Seattle whose mission is to bring greater awareness to the pelvic health needs of the LGBTQIA2S community. Their practice, B3 Physical Therapy, centers on transgender and perinatal rehabilitation. Ken also provides peer bodyfeeding support and doula care, and can be found on Instagram at @b3ptcob3ptco.

You can join Ken in their remote course, Perinatal Mental Health: The Role of the Pelvic Rehab Therapist, scheduled for October 22, 2022.

Who are you? Describe your clinical practice.
Experiencing inadequate care for my own pelvic health conditions as a teenager motivated me to become a pelvic health physical therapist. Being a member of the queer community further drove me to offer trauma-informed care and develop better access to care through home visits. Currently, I split my time between providing gender-affirming physical therapy and serving as a birth doula.

What lesson have you learned (in a course, from an instructor, or from a colleague or mentor) that has stayed with you?
Very few clients will remember detailed biomechanical explanations or every exercise you teach them. However, each client will remember how you treated them and how you made them feel. Asking clients about their preferences for care and following up go a long way in establishing rapport.

What do you find is the most useful resource for your practice?
One of my favorite resources is Decolonizing Fitness. It is an educational platform by Ilya Parker, PTA, (he/they). It provides a catalog of exercises and trainings for people looking to improve their care of gender-diverse people and People of Global Majority.

What books or articles have impacted you as a clinician?
The healthcare field regularly puts people in boxes to determine care. For example, many providers might determine care based on whether someone is a transgender woman or man. However, gender is actually someone’s individual experience rather than a category. Kate Bornstein’s My New Gender Workbook is a good starting point for understanding gender as uniquely one’s own, rather than part of a treatment algorithm.

What made you want to create this course, Perinatal Mental Health?
I wanted to create this course because, as a parent and physical therapist, I see both the challenges that the perinatal period presents, as well as the ways that rehabilitation providers can support mental health. In developing the content, I drew upon my background as a volunteer for a perinatal mental health warm line.

What need does your course fill in the field of pelvic rehabilitation?
Pelvic rehabilitation providers regularly interact with people who have mental health challenges. However, there are very few courses that specifically address the needs of the pelvic health providers serving folks in the perinatal period. This course looks at perinatal mental health from the perspective of pelvic rehabilitation providers, while offering specific actions providers can take to support their clients.

Who, what demographic, would benefit from your course?
Rehabilitation providers of any experience level would benefit from taking this course. Providers who are new parents or considering becoming pregnant may also find the content personally enriching. While the research discussed in this course focused on the perinatal period, much of it can be extrapolated to other populations.

What is your message to course participants who are just starting their journey?
For people just starting in pelvic rehabilitation, I would recommend focusing on patient education. For me, I find that the greatest amount of client improvement comes through reviewing the basics. It’s okay to still be developing skills in manual therapy.

Perinatal Mental Health: The Role of the Pelvic Rehab Therapist

Price: $150

Contact Hours: 5.75

Course Date: October 22, 2022

Description: This one-day remote course covers mental health considerations in pregnancy and postpartum and is targeted to the pelvic rehab clinician treating patients in the peripartum period. Topics include common mental health concerns in the postpartum period including depression, anxiety, OCD, and PTSD, as well as the connectedness between mental health and physical dysfunction. The course will introduce useful screening tools and how to connect patients to resources and diagnosing professionals. Labs will include partnered breakout sessions to practice listening and dialogue skills. The course also includes a review of coping techniques to support mental health and physical symptoms.

This week for the Pelvic Rehab Report, Holly Tanner sat down to interview faculty member Erica Vitek, MOT, OTR, BCB-PMD, PRPC on her specialty course Parkinson Disease and Pelvic Rehabilitation. If you would like to learn more about working with this patient population join Erica on June 24th-25th for the next course date!

This is Holly Tanner with the Herman and Wallace Pelvic Rehab Institute and I'm here with Erica Vitek who's going to tell us about of course that she has created for Herman and Wallace. Erica, will you tell us a little bit about your background?

Yes. Absolutely. Thanks for chatting with me today about my course! So my course is Parkinson Disease and Pelvic Rehabilitation. I'm just so excited to be part of the team and to be sharing all this great information. How I got the idea for the course is that there was a need for more neuro-type topics related to pelvic health, and individuals were reaching out to me because my specialty is in both Parkinson disease, rehabilitation, as well as pelvic health, and I always talked about the connections and wanting to bring that information to more people. So I wanted to plate all that information together in this great course. 

I got started specializing in Parkinson's back in the early 2000s. I was hired at a hospital as an occupational therapist working with people with Parkinson disease. But when I was in college my real interest was pelvic health. So I kind of got thrown into learning a whole lot about Parkinson disease at that time and I got really interested in how it all related to what I really wanted to do, which was pelvic health. I was able to connect that all, really right from the beginning of my career. Even though I started more on the physical rehabilitation side of Parkinson disease, which I continue to this day. I am able to combine those two passions of mine.

I also am an instructor with LSVT Global(1)and so we do LSVT BIG®(2) course training and certification workshops and I work with them a lot. I also have still a physical rehab background, as well as my connection to the public health background, and I bring that all together in my course Parkinson Disease and Pelvic Rehabilitation. We have two packed-full days of information and I think really it does translate well to the virtual environment.

What are the connections between neuro and pelvic health? Can you talk about what some of the big cornerstone pieces are that you get to dive into with your class?

The beginning of the course on the first day is going back to the basics of neuro in general. Really getting our neuro brains on and thinking about terminology, topics related to neurotransmitters and the autonomic nervous system. Individuals with Parkinson’s specifically, their motor system is affected but also their non-motor systems. This includes autonomic function, the limbic system, and all of the different motor functions that also affect the pelvic floor in addition to all of the other muscles in the body.

We have all of this interplay of things going on that affect the bladder, bowel, and sexual health systems in individuals with Parkinson's that is a little bit different than your general population. There are a multitude of bladder issues that are very specific to the PD population, for example, overactive bladder. 

This is just one example of the depths we go into right in the beginning on day one where we get into the neuroanatomy and neurophysiology of why that is actually happening. This then helps us go into day two where we talk about the practicality of what you do in the clinic about the things that are happening neurologically which is causing all of these bladder, bowel, and sexual health issues.

What kind of tools do you give to people to help practitioners understand and implement a treatment program?

People with PD are on very complex medication regimens and many of them are elderly, so the medication complexity is much more challenging in this population. At the end of day one, the last lecture, we go through the pharmacology very specifically for people with Parkinson’s in order to have a base of understanding of how that is interplaying with the pelvic health conditions. 

We set the baseline of getting that information from your patient off the bat, then discuss what you want to be looking for when you start off with that patient and the importance of finding out what kind of bladder and bowel medications they have taken thus far and how that can potentially interplay with their Parkinson’s. Individuals with PD can have potentially worse side effects from some of those medications that are used for bladder issues specifically. We dig into what to look for, we talk a lot about practical behavioral modifications using bladder and bowel diaries and things like that to weed out some things in addition to using our other skills as pelvic health practitioners.

How can people prepare themselves to come to Parkinson Disease and Pelvic Rehabilitation, are there required readings or things that would be helpful for people to catch up a little bit on the pelvic health or neuro side?

I feel like, and I hope, that I did a really good job at the basic review right at the beginning so we can talk through these topics together. I prefer to take a course and not have to spend a lot of extra time on the pre-recordings because sometimes that can be overwhelming with busy lifestyles. When I put together this course I really wanted us to focus together as a group as we start the class to dig into those basics at the beginning and not have a lot of required things to do prior.

So what I did at the beginning of the course is to make a lot of tables, a lot of charts, and a lot of drawings, that we can reference (we don’t have to memorize it) and look at as needed. We can look at a chart and a drawing right next to it in the manual. I spent a lot of time just putting it all down in words, what I’m saying, so you don’t have to take a lot of notes. I think this has really helped practitioners as we get into the course and learn about the details of Parkinson’s and pelvic health.

What is it that makes you so passionate about working with these patients and continuing to learn and share your knowledge?

It is so heartwarming and feels so good to help these individuals. The motor symptoms of PD are really the ones recognized by physicians or even outwardly noticed even by other individuals. These private conditions of pelvic health that we are helping with are things that they might not even mention to their physician. Maybe we find out when we are doing other physical rehab or when colleagues refer them to us because they know what we do, and to help them with something of this magnitude that affects their everyday life - when they have trouble just walking, or moving or transferring. 

Their caregiver burden for these individuals is so high because their loved one - now turned caregiver - is helping them do everything. We can make such an impact on these individuals. I mean, we do on other people too, but when you have a progressive neurologic condition and we can make an effect on shaping techniques they can use to improve their day-to-day. It’s just so great to be able to help them. 

Sometimes these patients with PD can have cognitive impairments, they can have difficulties learning, and that can be helpful for the care partner. It can be a significant reduction in their burdon. I do talk a lot in the course about cognitive impairment and I give a lot of tips about how we can train and some ideas. People with Parkinson’s muscles and minds are a little different so there are some great tips that I can provide and lots of clinical experience. 

I’ve been an occupational therapist for over 20 years, so I have a ton of clinical experience with this population. It’s been the population I’ve worked with my entire career. I hope I can provide the passion that I have for working with these individuals as well as the individuals who take my class.

I’m sure you would agree that we need more folks knowledgeable about Parkinson’s and combine that with pelvic health knowledge as well.

There are over a million people in the United States alone that have Parkinson disease. It’s the second most common neuro-degenerative disorder just behind Alzheimer’s disease. So there are so many individuals dealing with this and I think we can really expand our practices. I don’t think a lot of individuals that work in pelvic health market themselves to neurologists. There is an opening there for additional referrals and more people that we can help.

References:

1. SVT Global is an organization that develops innovative treatments that improve the speech and movement of people with Parkinson’s disease and other neurological conditions. They train speech, physical and occupational therapists around the world in these treatments so that they can positively impact the lives of their patients.
2. LSVT BIG®: Physical Therapy for Parkinson’s Disease and Similar Conditions. LSVT BIG trains people with Parkinson disease to use their body more normally.

The following is an excerpt from the short interview between Holly Tanner and Tara Sullivan discussing her course Sexual Medicine in Pelvic Rehab. Watch the full video on the Herman & Wallace YouTube Channel.

Hi Tara, can you introduce yourself and tell us a little bit about your background?

Sure! So I’m Tara. I’ve been a pelvic health rehab therapist for about 10 years now. I started right out of PT school and I got a job at a local hospital where they were looking to grow and build the pelvic rehab program. So of course, I found Herman & Wallace and started taking all of the classes there that I could and just kept learning over the years. Now the program is expanded across the valley, we have nine different locations, and it’s been very successful and fulfilling. It’s my passion.

Recently, I would say the past four to five years of my career, I’ve started getting more into sexual dysfunctions. I was always into pelvic floor dysfunction in general - bowel, bladder, sexual dysfunction, and chronic pelvic pain, but I  didn’t get specifically into the sexual medicine side of it until recently. I did the fellowship with ISSWSH that really pulled all of that information together with what I’ve learned through the years.

Can you explain what ISSWSH is and how that combined with the knowledge base that you already had?

I feel like ISSWSH for me, where I came full circle. I finally was like “I get it.” ISSWSH is the International Society for the Study of Women’s Sexual Health and it’s all the gurus like Dr. Goldstein, Rachel Rubin, and Susan Kellogg that have been around forever doing the research on sexual medicine. I started attending their conferences, became a faculty member, and presented at their annual fall meeting here in Scottsdale. Then I ended up doing their fellowship. Every year I would attend the conference, but it took a couple of years for all of that knowledge to soak in and for me to be able to really apply it.  For example, that patient with that sticky discharge, maybe that is lichen planus – that’s the kind of medical side that you don’t necessarily learn in physical therapy school.

That for me just really helped my differential diagnosis which means that you can get the patient’s care faster. Get them to that resolution faster because you are working with a team of people and we all have our roles. As PTs and rehab practitioners, we have the time to sit with our patients. We are so blessed to have an hour, and the medical doctors don’t, for us to really take that time to figure out the patient’s history and what they’ve been through, and what could be the cause of it. We have the time to be the detective and help them get the care they need. Whether it’s with us, or in conjunction with something else. My goal is to never tell someone that I can’t help them because it’s not muscular.

How has this knowledge helped you in your collaboration with other practitioners in your practice?

I feel like this knowledge was the missing link for me. It brings it all together for the patient. So the patients come here and the urologist says “that’s not my area,” and then the gynecologist says “that’s not my area.” Then they come to you and you’re like “it’s kind of my area, but I can’t prescribe the medication that you need.”

My practice got so much better, just in the sense of the overall quality of care, when I was able to develop those relationships with the doctors. I could pick up the phone and say “Hey, that patient that you sent me – I think they have vestibulodynia, and I think it’s from their long-term use of oral contraceptive pills. I think that they might benefit from some local estrogen testosterone cream.” They would say, I don’t know about that, and I’d respond “let me send you some articles. Let me tell you what I’ve learned.”

Now I can just pick up the phone or send them a text asking them to prescribe so and so. It really helped bridge that gap. The doctors now will say “Ok. I know something’s going on, but I don’t know if it’s muscular or tissue. I don’t have that training, what do you think?” So it’s just been such a collaboration, it’s been so great. Then I’ll go the reverse of that and watch them do a surgery, watch them do a procedure.

For our patients, we need to take that time and work with the physicians and develop that relationship with them, because it’s easy to pass it off as “that’s not my job.” Especially the vestibule! The gynecologist goes right through it and looks into the vaginal canal and then the urologist is like I’m going to look at the urethra but I’m not looking around it, let me just stick that scope in. This knowledge and ability to use differential diagnosis, for me just brings it all together.

Does your course have an online, pre-recorded portion as well as a live component?

Yes. There are about nine lab videos on manual techniques because everyone wants to know what to do. For me, it’s more about what you know. What can you identify and differentiate with the differential diagnosis. Then we have about two hours of just the basic lectures on general pain and overactivity of the pelvic floor so that we can spend our time in the live lecture getting into the very specific conditions that we as PTs are, not necessarily diagnosing, but recognizing and sending for further care. That’s really where I wanted this class to fill the gap between the urologist, the gynecologist, and the PT.

Is your course primarily vulvo-vaginal conditions or are there some penile, scrotal, or other conditions?

It is both male and female dysfunctions, and I have a few transgender cases. I don’t personally treat the transgender population very often so I only have a couple of examples of that. I have a lot of examples where I’m trying to get practitioners to recognize the problem by what the patient is saying and their history, and how to funnel this into their differential diagnosis. Case studies include different types of vestibulodynia and causes, all the different skin conditions…and it’s not necessarily something that they didn’t learn in one of the Pelvic Floor Series courses, but I wanted one class where they could just talk about all the sexual dysfunctions and get into some of the ones that we don’t see as often but are present.

We also talk about PGAD (persistent genital arousal disorder), and with male dysfunctions, we talk about spontaneous ejaculation and urethral discharge, post vasectomy syndrome. All of these things that you might not see every day, but when you see them you’ll recognize them so that you can help patients talk to the doctor and get the proper care. There are a lot of random, not as obvious, conditions that are not as prevalent. Then there are the common conditions that we see every single day like lichens.

What is the biggest takeaway that practitioners have who come into your class?

It is really being able to access and effectively use differential diagnosis. A lot of practitioners in the course are like “I always wondered what that was.” I have a ton of pictures that I share, and I’m like, I know you guys have seen this before. I think a lot of it is the differential diagnosis. The feedback that I get from every class is “I feel like I can go to the clinic on Monday and apply what I learned.” “I’m going to go buy a q-tip and start doing a q-tip test because now I know what to do with that information.” They feel that confidence of really being able to apply it, talk to the patient, talk to the doctors, and figure out that meaningfulness.

2022 Course Dates:
July 16-17 2022 and October 15-16 2022

Sexual Medicine in Pelvic Rehab is designed for pelvic rehab specialists who want to expand their knowledge, experience, and treatment in sexual health and dysfunction. This course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions for all people and sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, as well as multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Lecture topics include hymen myths, female squirting, G-spot, prostate gland, female and male sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy, as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. Upon completion of the course, participants will be able to confidently treat sexual dysfunction related to the pelvic floor as well as refer to medical providers as needed and instruct patients in the proper application of self-treatment and diet/lifestyle modifications.

Audience:
This continuing education course is appropriate for physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals of all levels and experience. Content is not intended for use outside the scope of the learner's license or regulation. Physical therapy continuing education courses should not be taken by individuals who are not licensed or otherwise regulated, except, as they are involved in a specific plan of care.

Herman & Wallace is committed to providing courses on pelvic rehabilitation for all people across the spectrum. This week the featured courses are those focused on women's health!

Take a look and see if there is one that is a good fit for you.

Breastfeeding Conditions Remote Course - Remote Course
July 16 and November 19

This course provides a thorough introduction to the physiology of the lactating breast, dysfunction and treatment interventions, the therapist's role in breastfeeding and pumping support, as well as when to refer to other health professionals.

Lectures will include the anatomy and physiology of lactation, blocked ducts and mastitis, and breast pain through a biopsychosocial lens. During labs, participants will have the opportunity to systematically assess the breast and practice therapeutic breast massage and manual milk expression. Participants will learn to assess and treat breast inflammation and pain such as mastitis, blocked ducts, milk blebs, and cracked nipples.

Breastfeeding Conditions - July 16-17, 2022

Breastfeeding Conditions - November 19-20, 2022

Menstruation and Pelvic Health - Remote Course
July 16-17, 2022

Menstruation and Pelvic Health is a two-day remote course is designed for clinicians who want to obtain advanced knowledge and skills to educate patients on non-hormonal, non-surgical, and non-prescription interventions for improving the Menstrual Experience. Developed by Nicholas Gaffga, MD, MPH, FAAFP, and presented together with Amy Meehan, PT, DPT, MTC, this course is geared toward the pelvic rehab provider looking to impart Menstrual Interventions that:

• Put control in the hands of people who menstruate to identify and carry out the interventions that are appropriate to them
• Use a holistic approach and advanced knowledge and familiarity with body and mind
• Emphasize healthy practices that can positively impact the Menstrual Experience and beyond, in areas such as mental health and chronic diseases
• Discover root causes of issues, rather than quick fixes, to have benefits that are sustainable across the lifespan.

• Menstruation and Pelvic Health - July 16-17, 2022

Postpartum Rehabilitation - Remote Course
offered monthly through November

The client who is postpartum may be one of the most overlooked clients in health care. Knowing the specific rehabilitation needs to help with common problems and prevent future problems is the goal of this beginner-level course. For the orthopedic-based practitioner, this course will solidify awareness of the common orthopedic needs of the postpartum client. For the non-orthopedic practitioner, this course will provide a foundation for working with clients experiencing common postpartum-related musculoskeletal conditions.

This course will cover examination considerations and modifications specific to postpartum, as well as specific questions to ask during history taking and methods for identifying red flags in postpartum. More comfortable positions during the examination/treatment and common posture/gait/balance changes during postpartum are covered. The participant in this course will understand necessary biomechanics training for daily activities, child care, and breastfeeding. As an expansion from the pregnancy rehabilitation course, participants will be taken through progression in diastasis rectus abdominis (DRA) assessment and rehabilitation, including DRA exercises in lecture and lab. 

Postpartum Rehabilitation - July 23-24, 2022

Postpartum Rehabilitation - August 20-21, 2022

 Doula Services and Pelvic Rehab Therapy - Remote Course
August 6 and December 10

A growing number of pelvic health therapists are recognizing the importance of preparing their clients for the physical and mental challenges of labor and delivery. In some cases, this is extending to a desire to be present during labor for support as a Doula. The purpose of this course is to present the unique challenges of merging a rehab practice with Doula services in order to help the participant better discern whether or not this is a journey worth taking.

Doula Services and Pelvic Rehab Therapy - August 6, 2022

Doula Services and Pelvic Rehab Therapy - December 10, 2022

Fertility Considerations for the Pelvic Therapist - Remote Course
August 13

This course is for practicing pelvic rehabilitation therapists and covers the role of rehabilitation therapists in optimizing female fertility. This course was written and will be instructed by Dr. Yeni Abraham, who is a Dallas-Ft.Worth-based Pelvic Physical Therapists specializing in the treatment of Gynecologic and Fertility related conditions. Lecture topics include medical infertility labs, pertinent information on charting cycles, assisted reproductive technologies and their impact on treatment, hormone regulation, the relationship between inflammation and infertility, amongst other topics. Lab activities/break-out sessions will include manual techniques to influence uterine and ovarian Mal-positions.

*This course will require that each student have a live model that will allow participants to practice the lab techniques on a human body. Due to the nature of labs, please be sure your model partner is not pregnant and does not have an IUD for safety. Additionally, those with hydrosalpinx will not be able to participate in uterine mobility techniques but can still attend the course.

Fertility Considerations for the Pelvic Therapist - August 13, 2022

Menopause Transitions and Pelvic Rehab - Remote Course
August 27-28th and November 12-13th

Menopause Transitions and Pelvic Rehab is a two-day course is designed for the clinician that wants to understand the multitude of changes that are experienced in the menopause transition and how they affect the aging process. Upon completion of this course, participants will have a basic understanding of the hormonal changes during menopause, the impact on various health systems, and interventions that can assist with improving this transition.

This is an excellent opportunity to understand the physiological consequences to the body as hormones decline, in order to assist our patients in lifestyle habits for successful aging. Topics will include cardiovascular changes, metabolic syndrome, bone loss and sarcopenia, neurological changes (headache, brain fog, sleeplessness), Alzheimer’s risk, and urogenital changes. Symptoms and treatment options will also be discussed, including hormone replacement, non-hormonal options, dietary choices, and exercise considerations.

Menopause Transitions and Pelvic Rehab - August 27-28, 2022

Menopause Transitions and Pelvic Rehab - November 12-13, 2022

Medical Perspective in Peripartum Care - Remote Course
September 17-18th

Medical Perspective in Peripartum Care is a two-day course instructed by Dina Gordon, MD, FACOG, a practicing OB/GYN in the Seattle area, and will discuss common conditions encountered in the peripartum period from the medical perspective. Topics include medical screening; medical management of high-risk patients (bed rest, activity limitations, medications, surveillance); and interventions common in the peripartum period

The course is built from the medical perspective, the design of the course aims to share knowledge so that rehabilitation care planning is optimized.

Medical Perspective in Peripartum Care - September 17-18 2022

 Pregnancy and Postpartum Considerations for High Intensity Athletics
September 11

The main focus of this course will be to learn how exercising throughout pregnancy, or returning to exercise postpartum may look different for a high-intensity athlete versus a non-HIIT athlete. Participants will discuss how anatomical and hormonal changes affect training for the pregnant and postpartum athlete, review various modifications for this population, learn how various stresses placed on the body during these activities may affect pelvic floor muscle function, and review various pressure management strategies that can be utilized during high-intensity interval training. This one-day remote continuing education course is designed to educate practitioners on the unique considerations of pregnant and postpartum athletes engaging in high-intensity interval training (HIIT).

During the pregnancy lab, we will review specific exercise modifications for pregnancy, utilization of breathwork to properly support the pelvic floor during pregnancy and review how to assess for and tape for diastasis recti. In the postpartum lab, we will review how to determine proper activity modification based on the ability to manage pressure, review specific activity modifications and breathwork, review accessory work for return to activity, and discuss how to assess pelvic organ prolapse in standing.

Pregnancy and Postpartum Considerations for High Intensity Athletics - September 11, 2022

Perinatal Mental Health: The Role of the Pelvic Rehab Therapist
October 22

This one-day continuing education course covers mental health considerations during pregnancy and postpartum and is targeted to the pelvic rehab clinician treating patients in the peripartum period. Topics include common mental health concerns in the postpartum period including depression, anxiety, OCD, and PTSD, as well as the connectedness between mental health and physical dysfunction.

The course will introduce useful screening tools and how to connect patients to resources and diagnosing professionals. Labs will include partnered breakout sessions to practice listening and dialogue skills. The course also includes a review of coping techniques to support mental health and physical symptoms.

Perinatal Mental Health: The Role of the Pelvic Rehab Therapist - October 22, 2022

Pregnancy Rehabilitation - Remote Course
October 29-30 and November 5-6

Learn how to safely examine and treat the pregnant patient in this beginner-to-intermediate course.

Lectures cover terminology, fertilization, trimesters, medical testing/interventions, imaging, and medications. Participants will learn to differentiate between false labor, progressive labor, and other musculoskeletal pain as well as learn to understand typical hormonal and systemic changes during pregnancy. Examination, evaluation, and treatment of common lumbopelvic conditions will be provided with an introduction to diastasis rectus abdominis, pelvic floor dysfunction, breathing, and deep core assessment/treatment.

Discussions also include general examination considerations and modifications specific to pregnancy, including a discussion of modalities and manual therapy techniques considered safe or precautioned during pregnancy, with further lectures on pelvic girdle examination, diagnosis, and treatment strategies. Finally, to prepare the pregnant client for labor and birth, instruction in perineal stretching, hip and trunk flexibility activities and TENS for labor will be discussed. Lab practice will include labor and birthing positions, with a focus on consideration for positional strategies for women with pre-existing musculoskeletal problems.

Pregnancy Rehabilitation - October 29-30, 2022

Pregnancy Rehabilitation - November 5-6, 2022

This week Ramona Horton sat down with Holly Tanner to discuss manual therapy and her course Mobilization of the Myofascial Layer: Pelvis and Lower Extremity. The following is an excerpt from her interview.

What do we really know about manual therapy? We have decent evidence that shows that asymmetry matters. The tenet of the myofascial course is an osteopathic tenet called ARTS:

• Asymmetry
• Restriction of Mobility
• Tissue Texture Changes
• Sensitivity

The whole myofascial course is designed around looking for ARTS. When you find the asymmetry within the myofascial system then that’s where you direct your efforts and energy.

Often patients have already tried breathing, yoga, medication, etcetera – and it’s the manual therapy piece that they often have not had. It’s not that uncommon for me to be someone’s second or third therapist. Some patients may have tried some type of manual therapy but it was more things like ischemic compression where the problem was that the manual therapy was triggering nociception.

So in the myofascial course, we start with ARTS but we also have an idea where we flip ARTS on its head and we go to STAR. In STAR, you take sensitivity and put it at the top of your list. That becomes the highest portion in your paradigm. Then we use simple techniques that are not non-nociceptive. Indirect technique versus direct technique, such as something as simple as positional inhibition.

The whole idea of the myofascial course is to teach people to think and problem solve. Then have a very broad spectrum way of you find an inner articular issue where this joint is moving and this one is not. Learn to not chase the booboo. Just because it hurts on the right doesn’t mean that you’re going to treat the right. It might hurt on the right because there is a hypo-mobility on the left. Let’s treat where the brain is protecting the tissue, and holding, and guarding the tissue. Trust in the belief that the body is a self-righting mechanism. The body will then normalize itself.

In manual therapy, our job is to get the body moving like it's supposed to. It’s not to fix the ‘booboo.’ The issue is not in the tissue. If the tissue is tight, it’s tight because the brain is keeping it that way. The way I teach manual therapy is the fascial system gives us access to the nervous system. By utilizing the fascial system in a non-nociceptive manner, what we’re really doing is just having a conversation with the brain. We’re not fixing the tissue. That’s the whole premise of the course - to get people to understand and change their thinking and their paradigm to ask what the brain is protecting and utilizing the fascial system.

• Brooklyn, NY
• Columbia, MO
• LaPorte, IN
• Medford, OR
• Newtown, PA
• Omaha, NE

• Self-Hosted - for groups of at least 2 qualified practitioners. 

Congratulations to Dr. Mia Fine (they/she) for achieving their Ph.D. in Clinical Sexology and on their book titled 'From Unwanted Pain to Sexual Pleasure: Clinical Strategies for Inclusive Care for Patients with Pelvic Floor Pain' for their dissertation doctoral project.

Dr. Fine was gracious enough to share a draft of their dissertation with Herman & Wallace and to answer a couple of questions about how this impacts their practice and what they hope other practitioners will take away from their book and course Sexual Interviewing for Pelvic Health Therapists.

Mia's course is for the pelvic rehab therapist and others in the medical profession who work with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns and would like to learn applicable skills from the sex therapist's clinical toolkit. The next course date for Sexual Interviewing for Pelvic Health Therapists is August 13-14,

How does Trauma-Informed Care apply to the skills that you teach in your Sexual Interviewing course?

When I utilize the term ‘trauma-informed’ I am referring to therapeutic work that communicates expectations clearly (including prioritizing people’s access needs with this communication), invites clients awareness of their own agency, and is upfront about my scope of practice and my therapeutic approach, offers mutuality in inviting of questions and ongoing conversation about our work together, awareness that an individual can end therapy at any time, and share information at any time in our therapeutic space. 

The modalities I utilize when working with clients who have experienced trauma include Eye Movement Desensitization and Reprocessing (EMDR), Polyvagal Theory, Somatics, and Developmental Theory. While I integrate various theories and modalities into my work with clients, the methods above are empirical in their data to support healing from trauma wounds.  

Trauma-informed means humility regarding cultural, racial, gender, sexual, and other minority experiences. I will not know all of the things but I will do my best to self-educate and not leave that responsibility to my clients. When I make a mistake I will appropriately, directly, and compassionately apologize for the harm I caused and invite opportunity for repair should the client be interested. Trauma-informed means collaboration in exploring therapy together, co-creating a space that feels safer to the client and checking in with them when I notice non-verbal cues that indicate activation, honoring a client’s pacing, and bringing awareness to the reality that as a therapist I hold power and while I don’t know a person’s full story there is always the potential for me to unintentionally activate a client so to share this possibility with clients and continuously check in about how our therapy is working for them. I keep my client’s well-being at the forefront of our work and I center their needs at all times while maintaining boundaries that keep everyone as safe and secure as possible. 

It is up to us as trauma-informed and inclusive providers to explore a person’s experience of pain by asking questions about onset, process, location, and impact, in addition to offering psychoeducation about anatomy, physiology (arousal, interest, desire), and self-regulation. This must be done alongside commitment to our patient’s co-regulation, normalization, and informed consent concerning the therapeutic process—all of which are needed for comprehensive trauma-informed care. 

Can you explain how expanding what 'normal' is to practitioners can impact the patients and clients that they work with?

Sex is not supposed to be painful. How many people have come to me having had painful sexual intercourse for years and reported “pushing through”? The first time having intercourse does not necessarily have to be painful, but when our cultural narratives tell us “the first time having sex is painful for everyone” we end up ignoring the signals our bodies are offering because we have convinced ourselves that the pain is both okay and normal. The “pushing through” is a reflection of misogyny: people assume the first experiences people have with penetration are supposed to be painful. How is this misogynistic? Well, who benefits from a person “pushing through” pain? The partner with the penis. Important to note here as well is that enthusiastic consent is ableist and ignores the mind-body connection because it does not take into account masking or fawning which are common experiences for many.

A quarter of people who experience sexual health concerns share this with their providers. Why such a small fraction? Fear. Fear of embarrassment and shame. Fear that there is something “abnormal” about them that mutates into the shame humans tend to experience in response. Fear that the concern won’t be held or taken seriously by their provider. Fear that, if it is addressed, will be at such a high financial cost that the treatment will be unaffordable. Fear that there’s not enough time or that they won’t be taken seriously. Fear of exclusivity, feeling othered, or misunderstood by their provider. Fear of the unknown because the reality is that people are afraid of what we don’t understand. 

One of the major cultural issues we have in the US is the perpetuation of sexual stigma which is largely associated with a lack of comprehensive sex education. People don’t have access to basic information about their own bodies which influences our beliefs about sex, pleasure, agency, communication, and self-awareness. Sex education should be a birthright, and yet we are so far behind the curve that it sometimes feels impossible to break down the barriers.

When I first started in this career it would often take clients months of working with me to feel comfortable enough to talk about where they felt pain during sex, but in developing the tools to co-create safety in our therapeutic relationship and the skills to ask the important questions with compassion and patience, I learned how to better hold space for healing.

Patients don’t often know what information is important for them to share with us (which is why offering visuals of where the pain is located is important). How could they know what information is important to offer when mental and sexual health are so deeply stigmatized? The stress of shame and embarrassment that people feel about their bodies is emotional pain that further exacerbates the physical pain that they came to therapy to address in the first place. It’s a terrible and self-perpetuating cycle. 

I teach people the difference between a vulva and a vagina one thousand times a year. If a client does not know the terminology for labia, vulva, vagina, and clitoris, how are they supposed to know when their sexual health is of concern? If a person enters sex therapy with “sexual pain” but is unable to distinguish the difference between their labia and vagina (that they are different body parts, where they are located, and what their functions are) we cannot expect them to accurately articulate the location of pain or comprehend potential solutions. “What is your hygiene process when cleaning your vulva?” may activate the fight or flight response in clients if they do not know what their vulva is or that there could be a good hygiene process, in addition to the shame of not knowing. How are they supposed to know where or to whom they may ask for help?

An online search for “anatomical vulva”, “pelvic floor pain”, “vaginismus treatment” and 99% of the images and figures you will see are those of hairless, slender bodies with white/light skin and small labia. Racism and white supremacy are present everywhere. The anatomical depictions of vulvas are of white bodies, the people modeling in vaginismus treatment advertisements are white, and the language is geared toward and written for white people. I was intentional about not featuring white vulvas in this book because white bodies should not be the default of what is mainstream. This lack of diversity in skin tone and variation of body type is another reflection of racism called “colorism”. White and light skin bodies are viewed as more ‘normal’ and when we continue to center white bodies in visuals “because that is what is available” we perpetuate white supremacy. One goal is to disrupt the idea and practice of whiteness as the default. This is what it means to practice anti-racism and attempt to divorce ourselves from white supremacy. 

The impact of shame shows up in the pervasive erotophobia rampant in our society. Erotophobia can be broadly defined as a “fear of sex” or more specifically a “fear of intercourse”. When erotophobia is judgment as a result of societal shame and stigma, we can navigate it by deconstructing the etiology and impact of messages received; when it is a result of a mental health condition such as Obsessive Compulsive Disorder (OCD) or Post Traumatic Stress Disorder (PTSD), we do deep trauma and/or anxiety/exposure work. Because of the vast impact of shame, people fear sharing sensitive information about themselves with others,  including therapists who are trained to help them. Often, therapists are untrained in sexual health which also can contribute to erotophobia and shame. When therapists have not done their own work on sexuality, and remain untrained in these areas, they may be afraid to discuss sex with their clients which reinforces the belief that topics regarding sex are shameful. 

When people do not have the language to articulate what is happening in their body, as significant as the pain or discomfort might be, talking about sex with a provider is often the last item on a long list of concerns they bring to a medical appointment. Symptoms of sexual pain may be hidden by other “more pressing” concerns such as anxiety, depression, PTSD, or sleep issues. While these are of course vital for a medical provider to know, having 20 minute appointments with a physician who will prioritize the “presenting concern” that they came in to seek treatment for leaves very little time to discuss unwanted sexual pain. After 15-20 minutes of a medical appointment (if it goes well), a patient might feel comfortable enough to bring up their sexual concern, but this might leave 1 minute for it to be acknowledged and no time to conduct a comprehensive assessment or develop an intentional plan. We call these last-minute oh-by-the-way’s “door-knobbing” for a reason. This is a call for medical clinics to have training in sexual health so they can create intake documentation that explores clients’ sexual health and ask the questions that are vital to gather necessary information ahead of time. 

In the same way that people lack language and anatomic understanding, people also lack awareness of the mind-body relationship. Due to the ableist sex-negative culture in which we live, people are often not taught to have knowledge of or listen to our own body. We’re not taught that pain is a signal from the body telling us that something’s wrong.