The hip flexor muscles include the Iliopsoas group (Psoas Major, Psoas Minor, and Iliacus), Rectus Femoris, Pectineus, Gracillis, Tensor Fascia Latae, and Sartorius. When the hip flexors are tight it can cause tension on the pelvic floor. This can pull on the lower back and pelvis as well as change the orientation of the hip socket, lead to knee pain, foot pain, bladder leakage, prolapse, and so much more. The ramifications of iliacus and iliopsoas dysfunctions are discussed in a contemporary and evidence-based model with Steve Dischiavi in the Athletes & Pelvic Rehabilitation remote course.

A common issue with the iliacus and hip flexors is that they can shorten over time due to a lack of stretching or a sedentary lifestyle. When this happens, the muscle adapts by becoming short, dense, and inflexible and can have trouble returning to its previous resting length. A muscle that resides in this chronic contraction can become ischemic, develop trigger points, and distort movement in the body.

If you are treating patients with pain in their lower abdomen, sacroiliac joint, or that wraps around the lower back and buttocks, it could be because the hip flexors are tight. Traditional testing performed by medical practitioners tends to come back negative as many tests do not evaluate soft tissue issues. The best way to diagnose these concerns is through assessment with skilled palpation and structural evaluation.

One assessment test, the Thomas Test used for measuring the flexibility of the hip flexors, is discussed in the Athletes & Pelvic Rehabilitation course. In this test, the patient is supine while flexing the unaffected, contralateral leg at the hip until lumbar lordosis disappears. The length of the iliopsoas is determined by the angle of hip flexion displayed by the patient. The test is positive when the patient is unable to keep their lower back and sacrum against the table, the hip has a posterior tilt (or hip extension) greater than 15°, or the knee is unable to meet more than 80° flexion. A positive test indicates a decrease in flexibility iliopsoas muscles.

Treatment plans for the iliacus and hip flexors include stretching. An example includes the hip extension stretch or other active isolated stretches. Manual therapy, including trigger point release, can be used in conjunction with stretching to help muscle adhesion and release muscle tension. As with all treatment, the practitioner should discuss the risks, benefits, and treatment options, and obtain consent with patients. Prior to proceeding with manual therapy treatment make sure to establish a pain scale, assess the patient's range of motion and strength, and (if needed) perform the appropriate neurologic testing.

To learn more about treatment philosophies for the pelvis and pelvic floor and global considerations of how these structures contribute to human movement you can join Steve Dischiavi in the Athletes & Pelvic RehabilitationRemote Course.

You may be interested in attending this course if you have taken:
Yoga for Pelvic Pain
Sacroiliac Joint Current Concepts
Mobilization of the Myofascial Layer: Pelvis and Lower Extremity
Weightlifting and Functional Fitness Athletes

Bre Stuhlmuller is an LA-based doctor of physical therapy (DPT) who practices at Origin, a leading provider of virtual and in-person physical therapy for women and individuals with vaginal anatomy. Dr. Stuhlmuller is especially interested in helping women through their pregnancy/postpartum journey and strives to help her patients understand the purpose behind the therapy they are receiving so they can begin to relate to their bodies differently and take an active role in their rehabilitation process.

When Covid ramped up in 2020 and Origin began to focus more fully on virtual care, many PTs were excited about this new way to reach patients. Although the prospect of working from home piqued my interest, I was still skeptical. I dabbled in virtual care at the beginning of my time at Origin, with the occasional appointment here and there. Even still, the concept of it was hard for me to fully grasp and I couldn’t say that I loved it. It felt unknown and even intimidating. I love to connect with my patients — establishing a good rapport is one of my strong suits — and I was worried that what I did in person wouldn’t translate the same way through a screen.

Looking back, I realize my attitude was very much informed by what I’d learned in training. I had a mentor during one of my rotations who emphasized the importance of human touch, how it was integral to the healing process. What would assessment and healing look like if I couldn’t use my hands?

To be fully transparent, manual therapy had also become a fallback for me while caring for my patients. If a patient was struggling to understand a concept, I could use my hands to show them. If I found myself at a loss of what to do next, I could provide manual therapy — it was always welcomed, felt productive, and gave me time to plan. With virtual, I knew I would have to rethink how I approached my assessment and treatment strategy, and I had no idea what that might be. 

New Fuel for Creativity & Connection

When it was clear I didn’t really have a choice, I gave virtual PT a try for more than just those occasional appointments. At first, as I was building up my caseload, it lived up to my not-so-positive expectations. It just wasn’t the same and I felt completely out of my element. It wasn’t until I began filling my caseload entirely with virtual visits that it began to surprise me. 

As I engaged more consistently with patients on Zoom, my creativity kicked in. Without my hands to fill in the gaps, I really had to think about the cues that I was giving and how I was explaining things. Suddenly, my mind was lighting up with new ideas and ways of getting my point across. Where should the patient be focusing their attention? What should they be noticing or feeling?

I began helping patients tune into their bodies, instead of solely looking to me to give them information. Often, when I first ask “What do you feel when you do X?” a patient’s first response is vague and unsure. Then I’ll try again, talking through the concepts and movement in more detail. I’ll describe the outcome I am after and provide analogies and examples. If that doesn’t work, I’ll have them try a different position, or experiment with a new analogy that relates to their life and specific situation.

What happens next has been so encouraging — I see them have a pretty powerful ah-ha moment. (And because they’re not wearing a mask, it’s great to be able to see the understanding on their face!) They’re connecting with and learning from their body directly, which gives them so much empowerment. They tap into their own abilities instead of only relying on mine, which is exactly what we hope to give to our patients. On my side, I continue to gain clarity and hone my communication skills. I’m excited to share that despite doing all of this through a screen, my connection with patients feels as strong as ever.

That’s not to say that patients aren’t missing manual therapy! If you’re a PT who sees patients in person, you know how much they like (and often expect) it. I think they can tend to rely on it too much — and a decent number of people really want to come in and just get something like a massage. That can be a struggle. We are not massage therapists. And unfortunately, some patients think they need it in order to get better. I think that will be an ongoing struggle when it comes to getting patients to try virtual physical therapy. But, in my experience, once they do try virtual, they are quickly won over.

The Habit Building Power of Home

Another unexpected benefit of virtual physical therapy is the level of follow-through. For starters, patients cancel much less, which makes sense — it’s a lot easier to hop on a Zoom call at the last minute than it is to get in the car (and find parking). And if childcare isn’t available, they can keep an eye on their kids while we do our visit. We may not always get quite as much done, but at least we are able to do something, which I’m constantly reminding my patients is always better than nothing. 

Along the same lines, in the few months since I’ve switched to solely treating virtually, I’ve been surprised to discover that patients seem more consistent with their exercises, not less. We’ll be collecting more data on this at Origin, but my guess is that being introduced to an exercise in the same environment where they’ll be doing it on their own makes a difference. When they do their exercises with me during a virtual visit, they’re creating a foundation of a habit. Later on, when it’s time to continue on their own, they can pick up right where they left off.

As much as I absolutely love our clinics at Origin  — having all the equipment on hand, the music playing, and the other patients and PTs around — it is a very different experience for patients compared to being at home. At home, patients have to self-motivate and are limited to the equipment they happen to have or are willing to buy. Starting from scratch in their own space can often be a major barrier.

When we’re in a virtual visit, I can help a patient set up the space where they’ll do their exercises, and we can improvise. They may need to use a thick pillow instead of a pilates ball, or a rolled-up towel instead of a yoga block. This eliminates all those excuses along the lines of, 'I couldn't do my exercises because I didn’t have X.’ It not only helps me stretch and refine my skills as a PT, it helps patients gain more agency— it encourages patients to get into the mindset of “let’s see how I can make this work with the resources I have.”

Just as invaluable is being able to coach a patient through functional movements. I can watch a new mom lift their baby out of their crib or get up from their couch, then give tips and recommendations that are specific to their setup. Then I watch them immediately apply those tips and feel the difference. And boom, I know they’ve got it.

Tips for PTs Interested in Going Virtual

As a PT, having a separate, designated space to work is critical. At first, I was doing it in the corner of my bedroom, next to my bed, with limited lighting. Although I made it work, it was awkward to not have room to move and didn’t serve my patients the way I wanted. I have now made a space in our garage with bright lighting and a white backdrop behind me. You don’t necessarily need a whole setup, but you want to ensure that your patient can see your entire body when demonstrating movements or exercises. And of course, you need strong, reliable wifi!

One challenge that comes up is that virtual patients can be distracted at the start of or even throughout a visit. Because they’re at home and may have just stepped away from kids or work, they may need time to refocus. This is very different from being at the clinic, where the few minutes it takes to check-in and get settled helps them be more present. So I’ve learned to expect this, give them some grace, and will spend a few minutes bringing their attention back to their goals.

I also want to say that I do miss being in the same space with other Origin PTs. I miss the time in between patients when you can have those quick, but incredibly helpful conversations like “oh have you had a patient who presents like this,” or “let’s go into a room and I’ll show you how I do this.” It’s hard to recreate that kind of spontaneous interaction online. We have a shared Slack channel where PTs can chat throughout the day about our cases and although it helps to fill in that missing gap, it can also be nothing but crickets and still lacks that same feeling you get physically being in the office with your colleagues. 

One major perk, however, is being able to spend more time between patients with my 2-year-old daughter. It makes being a working mama feel a little less of a sacrifice. But don’t get me wrong, it also comes with its challenges. I don’t have that same downtime driving to/from work to decompress and switch between mom mode and work mode. And it can be easy to get distracted between appointments and do chores or play with my daughter instead of cranking out my notes. At some point, I imagine I will want to split my time between the clinic and working from home. But for now, I am honestly more than content working virtually.

Origin is already working on new ways to integrate virtual and in-person therapy — thinking beyond either/or, toward a model where we can choose what works best from patient to patient and visit to visit. In the meantime, I’m excited to continue with virtual care and our patients are loving this option. My schedule has been more full in the past 4 months than it was before I went virtual, and I’m seeing more people get better under my care. It’s truly amazing to see them making so much progress, right at home. 

As 2022 has gotten underway, it has already brought many of us to a place where we simply need to hear something lighthearted. The start of a new year also gives us a chance to examine priorities and make room for what matters most. “What matters most” can look different for each of us; for me, it’s my family – including two dogs – Stella and Sadie. Of course, the dogs fall in line behind my human nuclear and extended families, however, they are such a part of my daily life and contribute to my quality of life, it seems only natural to share this story with a wider audience -especially because this story revolves around one of my favorite topics – intentional nourishment!

Let me begin by telling you about our 5-year-old Golden Retriever named Stella. She came to us as one of only three puppies in a litter; a pleasantly plump pup, she was well developed, well-fed, and well-loved. According to everyone who has had the opportunity to meet her, she is the happiest dog they’ve ever met. When we brought her home at eight weeks, she topped the scale at 21 lbs. 

Stella's fur was shiny, her disposition sunny; she emanated maturity and wisdom. She slept through the night with such efficiency, we hardly remember having to let her out at night as a puppy. She was content; the perfect combination of calm and energetic. She was a breeze to housetrain, has an impeccable record of only two accidents in the house, and nary an indoor fecal incontinence episode. Stella brought us so much joy that we decided on a whim to add a second puppy to the milieu.

The second puppy is our ~16-week-old Golden Retriever puppy named Sadie. This past October – by coincidence – my family learned about some surprise Goldens needing homes – 17 to be exact – and we wondered if we might be interested in one. Two weeks later, sweet Sadie came home with us. 

Weighing in at only 13 lbs 6 oz at eight weeks, she was miniature compared to Stella at the same age. It didn’t take us long to figure out that not only was she smaller, but her digestive tract and elimination systems were not like Stella’s either. Sadie pooped often - what seemed like every hour – including sometimes in the house. Her bottom was sore and irritated, and she seemed frustrated and uncomfortable. My husband and I looked at each other more than once thinking the same thought: WHAT did we get ourselves into?!?

Sadie tested negative for parasites, and the vet said she was just working on adjusting to her new home and to give it time. He also suggested we might be feeding her too much. So, we fed her less - but that didn’t help. We tried adding pumpkin, that didn’t help either. Then we upped her food amount again, tried timing her foods differently, tried feeding her more often, then less often. None of these approaches helped. The messes continued. 

We began to feel exasperated. I was reluctant to try adding new foods for fear of upsetting her GI tract further. 

This puppy was pooping nonstop – much of it type 6 & 7 applying the Bristol Scale to dogs (1). She barely came in at 16 lbs. week 10 and alarmingly, she still weighed 16 lbs. at week 12. The vet confirmed our concerns – she was too thin and needed to put on weight.  

Now I started to worry. With all the bowel troubles she had, how could she thrive? We weren’t getting any continuous hours of sleep at night which meant she wasn’t either. It was an exhausting few weeks. 

Given what we had tried – with no success – we had no choice but to begin what we called “Operation Nourishment” for this little puppy. We put worries aside about adding new foods and applied what we understand about functional nutrition to help our sweet Sadie.

“Operation Nourishment” consisted of following several basic digestive principles:

1. Make her food more digestible
2. Feed her nutrient-dense options (dog appropriate, of course)
3. Practice puppy-version mindfulness at mealtime
4. Help support her puppy microbiome

#1: Make her food more digestible: Without changing the kibble she was eating, we soaked it with a bit of water before ingestion to soften it. This helped make her food easier to break down in her digestive tract and also helped S L O W D O W N her tendency to inhale food. Prior, she was definitely not chewing her food thoroughly which can result in undigested food reaching the colon and causing irritation. The softened food facilitated just the slightest bit of chewing and tripled the time it took her to finish a meal, giving her GI tract less of a shock.

#2: Feed her nutrient-dense options: We began adding an organic egg (3,4) softly cooked in a tiny bit of coconut oil (2) to her breakfast. The egg adds a whole food-based protein-containing cholesterol, vitamins, and minerals -all important for building her gut lining and nervous system. Coming from such a large litter in a somewhat stressful/chaotic environment, her gut and nervous system may not have been at their healthiest and needed extra support (4).

#3: Practice mindfulness at mealtime: The egg at breakfast has quickly become the highlight of her day.

The anticipation while watching us cook it calms her. She intently follows as the pan comes out of the cupboard and onto the stove. She watches more intently as we slowly cook the egg. Then she must wait even longer while it sits in her bowl to cool up on the countertop. 

I presume this has taught her mindfulness and presence before eating – essential for thorough digestion!

#4: Help support her puppy microbiome: We gradually began to add a dollop of kefir (5) to her breakfast and dinner – knowing that even dogs have a microbiome and that cultured foods can help normalize gut flora which can help normalize stool consistency. A healthy gut helps us extract nutrients from the food we eat. It can also, fascinatingly, modulate our stress responses.

“Operation Nourishment” began to take effect almost immediately. She jumped from 16 to 24 lbs. in 3 weeks! We were so proud! She finally began to have a soft, healthy belly - and the vet was thrilled, “whatever you’re doing, keep it up!”. She began to sleep through the night – and WE were thrilled. She also began to sprout her golden retriever fur patterns and take on more shine. Brilliantly, her stools became formed – a perfect 4 on the Bristol Stool Scale (1) and had significantly less urgency which led to the elimination of accidents. We were shocked at how quickly her body adapted to a diet higher in nutrient density and digestibility– one that was safe and appropriate for puppies.

Upping her nutrient density and digestibility helped unlock her potential so she could become the best sweet version of herself. Once more deeply nourished, she happily settled into her calm, gentle nature. She and Stella have become quite the pair. And we – her humans - are finally, gratefully sleeping again (most nights), which makes us adore her even more.

How might A Tale of Two Goldens provide us with insight relevant to pelvic rehabilitation?

We acknowledge that no two people come into this world in exactly the same circumstance and that we each arrive with a certain level of built-in resiliency. Some of us come into this world with our tails wagging, ready to greet everything that comes our way. Many of us and those we serve– let’s face it –are figuratively more like Sadie. We have the potential waiting inside of us to become the best version of ourselves.  

Sometimes reaching that potential takes just a little tweaking, a little coaxing, a little know-how. Maybe that tweaking, coaxing, and know-how could include principles of “Operation Nourishment” for ourselves and those we serve in the form of nourishment-focused guidance. With a little patience, time, and intentional action, we may be surprised to see how a few small changes have an enormous impact on what matters most to each of us and those we serve. 

Nourishment knowledge – now more than ever – is vital. 

Join us in 2022 for Nutrition Perspectives for the Pelvic Rehab Therapist to learn more about these principles and beyond. Upcoming 2022 remote offerings include Feb 26-27, April 29-30, July 23-24, August 27-28, Sept 23-24, Oct 22-23, and Nov 11-12. We welcome you to join us.

References:

1. https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC002_Bristol-Stool-Chart-Jan-2016.pdf  Accessed January 11, 2022.

2. Alves DVS, Sousa MSB, Tavares MGB, Batista-de-Oliveira Hornsby M, Amancio-Dos-Santos A . Coconut oil supplementation during development reduces brain excitability in adult rats nourished and overnourished in lactation. Food Funct. 2021 Apr 7;12(7):3096-3103. doi: 10.1039/d1fo00086a. Epub 2021 Mar 15. PMID: 33720258.

3. Avirineni BS, Singh A, Zapata RC, Phillips CD, Chelikani PK. Dietary whey and egg proteins interact with inulin fiber to modulate energy balance and gut microbiota in obese rats. J Nutr Biochem. 2022 Jan;99:108860. doi: 10.1016/j.jnutbio.2021.108860. Epub 2021 Sep 11. PMID: 34520853.

4. Choi, M., Lee, J. H., Lee, Y. J., Paik, H. D., & Park, E. (2022). Egg Yolk Protein Water Extracts Modulate the Immune Response in BALB/c Mice with Immune Dysfunction Caused by Forced Swimming. Foods, 11(1). doi:10.3390/foods11010121

5. Vieira CP, Rosario AILS, Lelis CA, Rekowsky BSS, Carvalho APA, Rosário DKA, Elias TA, Costa MP, Foguel D, Conte-Junior CA. Bioactive Compounds from Kefir and Their Potential Benefits on Health: A Systematic Review and Meta-Analysis. Oxid Med Cell Longev. 2021 Oct 27;2021:9081738. doi: 10.1155/2021/9081738. PMID: 34745425; PMCID: PMC8566050.

This is a common question that faculty member, Mercedes Eustergerling, is asked. To paraphrase this question – why does H&W (a pelvic rehabilitation institute) offer a breastfeeding course – Breastfeeding Conditions? Well, if you consider that new parents who are breastfeeding have just experienced a birthing event then the answer is – it has plenty to do with pelvic rehabilitation.

Most pelvic therapists have exposure to patients who have given birth and are experiencing a range of postpartum pelvic issues including painful intercourse, prolapse, and incontinence. Have you considered how breastfeeding affects these issues? After giving birth the body’s levels of estrogen drop and the levels of prolactin rise. Prolactin is the hormone responsible for stimulating milk production and will remain elevated during breastfeeding. Thus, estrogen levels remain low during this time and can result in vaginal dryness, delayed menses, low libido, and painful sex.

Women or any person who has experienced childbirth, with pelvic organ prolapse (POP) are often told that the condition will improve after breastfeeding. While many do see improvement after weaning their child there is no correlation between breastfeeding slowing the healing of pelvic floor muscles or worsening POP long-term (1). POP has been linked with sleep quality (2). Which anyone with a newborn can tell you is in short supply. Not surprisingly, sleep is important for your body to recover from birthing, managing postpartum mood disorders, and of course, staying awake to take care of your baby. For breastfeeding parents, sleep deprivation is a way of life as they are waking up every 2-3 hours to feed their baby and establish a strong milk supply. It may be beneficial at this point for the new parent to work with a lactation consultant. These professionals can guide new parents through latching, feeding, milk supply issues, breast pump use, and can help reduce stress and promote optimal rest and recovery postpartum.

Mercedes pointed out in a past interview that “Anytime we talk about breastfeeding we are talking about two people working together, the mother and the baby, it's a team effort. As physiotherapists, we can help with issues or conditions that arise on the maternal (breast) side of things, and on the infant side of things. When it comes down to it, the physiotherapist's role is not about what or how much (nutrition) gets into the baby’s belly, but rather how it gets in (mechanics).” Fast milk flow can make the task of suckling more difficult for babies with an uncoordinated suck/swallow/breathe pattern. If the mechanics or timing is off, the infant will prioritize airway protection and may appear to go on and off the breast throughout the feed.

Another common concern for postpartum parents is urinary incontinence, aka bladder leaking. Breastfeeding does not make incontinence worse, but there is research showing that breastfeeding triggers intense thirst in relation to plasma vasopressin, oxytocin, and osmoregulation (3). The connection is that drinking more water due to this thirst will increase your urge frequency and possible urine leakage.

Mercedes Eustergerling’s remote course Breastfeeding Conditions provides a thorough introduction to the physiology of the lactating breast, dysfunction, treatment interventions, and further discusses the pelvic rehab therapist’s role in breastfeeding and pumping support. As a rehab therapist, it is within the scope of practice to assess and treat breast inflammation and pain such as mastitis, blocked ducts, milk blebs, and cracked nipples. However, Mercedes also discusses when it is important to refer to other health care professionals.

Mercedes sat down with The Pelvic Rehab Report this week to talk about herself and her course.

Tell me a little bit about yourself and your practice.
I studied physical therapy to work with athletes and quickly developed an interest in chronic pain and complex health conditions. As I worked with these populations, I found that I wasn’t able to fully evaluate or treat them without a better understanding of pelvic health, so I took continuing education in pelvic health, and my skills as a physical therapist expanded tremendously.

Then I had a baby and encountered every infant feeding hurdle you can imagine. At our lactation appointments, I was fascinated by it all and realized that I could not provide whole-person physical therapy without understanding the physiology and conditions that are unique to lactating individuals.

In my practice today, I work as a part of a team that provides physical therapy and mental health occupational therapy for chronic pain, trauma, pelvic health, breast health, and infant feeding. We teach courses and workshops, and we do research in chronic pain and breast health.

How do you incorporate physical therapy principles when helping parents meet feeding goals?
At its core, physical therapy is about optimizing a person’s function. What makes physical therapy for infant feeding interesting is that we consider the functional goals and limitations for two individuals: the parent and the infant. In this course, the focus is on the parent’s function. Physical therapists already have the knowledge and skills necessary to manage inflammation, pain, and skin integrity. We apply a biopsychosocial, trauma-informed approach to concerns such as musculoskeletal overuse injuries, ergonomics, breast inflammation, and nipple wounds. Physical therapists are especially helpful for individuals with existing musculoskeletal, neurological, or cardiorespiratory conditions because of our extensive knowledge in these areas

What made you want to create this course?
I was asked to create a course for physical therapy in lactation and infant feeding after attending a women’s health course and discussing it with a colleague. At the time, I was in a solo practice and seeing patients with breast inflammation. They would go onto their parenting groups on Facebook and advise other parents to seek physical therapy for blocked ducts, mastitis, etc. The problem was that I was the only physical therapist in the country providing this service! As physical therapists received requests from their patients to help with these conditions, they started looking for continuing education opportunities. 

A lot of our information on lactation comes from oral history that is passed down from one generation to the next. This is a beautiful thing from a cultural perspective. However, one of my goals in creating this course was to provide evidence-based information for health professionals so we could deliver the best care possible. For lactating individuals, there is no shortage of advice or opinions on every topic. I dove into the literature to compile information for a research-informed course and I continue to review the literature and update the course often.

If you could get a message out to practitioners about bodyfeeding and lactation what would it be?
This is a population that is underserved and needs care. In all studies done on the subject, pain is consistently one of the top three reasons for stopping chest/breastfeeding. Physical therapists have unique training and backgrounds that make us a valuable resource for these individuals. It is not difficult to apply our existing knowledge and skills once we gain some understanding of the anatomy, physiology, and sociocultural context of lactation.

What lesson have you learned that has stayed with you and impacted your practice?
When I met one of my first patients with mastitis, she was curled up on the exam table and the lights in the room were off. Her partner answered all my questions because she felt too ill to talk. Two days later, she came to her appointment with makeup on and smiling. She said she was feeling like herself again. I have a great deal of sympathy for anyone experiencing the acute symptoms of breast inflammation and I take care to consider their psychosocial impacts instead of treating it as a purely physical condition.

What do you find is the most useful resource for your practice?
There is a phenomenal community of lactation professionals in my city of Calgary, Canada. We are fortunate to have physicians who specialize in lactation and infant feeding, and they value collaborative care. I shadowed with them in their clinics for 500+ hours and gained a great deal of skills and knowledge from a medical perspective. Now, we continue to collaborate and I am able to refer patients for an evaluation or to check any possible red flags. I encourage all physical therapists entering this practice area to connect with lactation professionals and physicians in their area.

What books or articles have impacted you as a clinician?
The works of Donna Geddes and Maya Bolman have changed my understanding of breast anatomy, physiology, and inflammation. Similarly, the World Health Organization’s publication on mastitis was a great introduction to the pathophysiology and available literature.

A book that I have read several times and recommend to those who are interested in the pediatric side of things is Supporting Sucking Skills in Breastfeeding Infants by Catherine Watson Genna. And in 2021, a book on breastfeeding and public health was published with a chapter on the role of physical therapists, which I wrote. That book is called Lactation: A Foundational Strategy for Health Promotion by Suzanne Hetzel Campbell. The chapter on physical therapy for lactation and infant feeding can be helpful to understand our role and communicate how this practice area fits into our scope of practice.

Breastfeeding Conditions is a two-day remote course and is scheduled for:

• · February 19-20
• · July 16-17
• · November 19-20
  

This course may be of interest to you if you have taken any other the other H&W peripartum courses including:

• · Pregnancy Rehabilitation
• · Postpartum Rehabilitation
• · Pregnant and Postpartum Rehabilitation Special Topics
• · Doula Services and Pelvic Rehab Therapy
• · Medical Perspective in Peripartum Care
• · Perinatal Mental Health: The Role of Pelvic Rehab Therapist
• · Pregnancy and Postpartum Considerations for High-Intensity Athletics

References:

1. Iris S, Yael B, Zehava Y, et al. The impact of breastfeeding on pelvic floor recovery from pregnancy and labor [published online ahead of print, 2020 May 19]. Eur J Obstet Gynecol Reprod Biol. 2020;251:98-105. doi:10.1016/j.ejogrb.2020.04.017
2. Ghetti C, Lee M, Oliphant S, Okun M, Lowder JL. Sleep quality in women seeking care for pelvic organ prolapse. Maturitas. 2015;80(2):155-161. doi:10.1016/j.maturitas.2014.10.015
3. James RJ, Irons DW, Holmes C, Charlton AL, Drewett RF, Baylis PH. Thirst induced by a suckling episode during breastfeeding and relation with plasma vasopressin, oxytocin, and osmoregulation. Clin Endocrinol (Oxf). 1995;43(3):277-282. doi:10.1111/j.1365-2265.1995.tb02032.x

Mia Fine, MS, LMFT, CST, CIIP is the creator of the remote course, Sexual Interviewing for Pelvic Health Therapists. This course is for pelvic rehab therapists who want to learn tools and strategies from a sex therapist’s toolkit who works with patients experiencing pelvic pain, pelvic floor hypertonicity, and other pelvic floor concerns. Mia (they/she) is a student of Queer Theory, Intersectionality, and Social Justice and offers holistic, anti-oppressive, and trauma-informed therapy in the Seattle area.

As a Licensed Marriage and Family Therapist, Certified Medical Family Therapist and trained AASECT Certified Sex Therapist, Mia has clocked hundreds of hours in direct client contact, supervision, and consultation. She has also attended numerous sex therapy trainings, continuing education opportunities, and trains incoming sex therapists on current modalities and working with vulnerable client populations.

Sexuality is core to most human beings’ identity and daily experiences. Human beings are hard-wired for connection, intimacy, and pleasure. When there are concerns relating to our sexual identity, sexual health, and capacity to access our full potential, it affects our quality of life and holistic well-being. Practitioners who work with folks on issues of sexual health and decreasing sexual dysfunction are in the position to encourage awareness and healing. Mia shares, “Imagining a world where human beings don’t walk around holding shame or traumatic pain is imagining a world of health and happiness.”

Unwanted sexual pain often goes unaddressed because culture does not teach the interactions between feelings, relationships, and the body. Our society often tells us that there is something wrong with us, that we are defective, for wanting a healthy sex life and for addressing our human needs/sexual desires. People are not taught that sex should not be painful and that pain is our body giving us information that something is going on. It’s not uncommon that most people who experience sexual pain often feel as if they are broken. Mia’s favorite thing to say is that “No person is broken. Each and every one of us are uniquely special beings worthy of being loved and nurtured.”

Providers must be aware of their own biases and be introduced to the various sexual health resources available to providers and patients. Mia further stresses, "Always listen to your patient to understand what they are saying and feeling. Do not respond defensively. Remember that this can feel like a threatening situation for patients. It is vital that providers working with pelvic floor concerns have the necessary education and training to work with patients on issues of sexual dysfunction."

From a business standpoint, happy patients are more likely to return to your practice in the future, recommend your practice to their friends, and pay their bills on time and in full. Patients want to have quality interactions with a healthcare provider who cares about them. As a practitioner, your satisfied patient is more likely to make follow-up appointments and maintain their prescribed treatment plan, which can lead to more positive outcomes.

Sexual Interviewing for Pelvic Health Therapists offers current and empirically-founded sex therapy and sex education resources for both the provider as well as the patient. Mia will broaden your scope of competence in working with patients who experience forms of sexual dysfunction and who hope to live their full sexual lives. This course will add the extensive skills of interviewing for sexual health. It also offers the provider a new awareness and self-knowledge on their own blind spots and biases.

Check out Mia's interview with Holly Tanner on the Herman & Wallace YouTube Channel for more information on the course.

Sexual Interviewing for Pelvic Health Therapists - Remote Course

• February 26 - 27, 2022
• August 13 – 14, 2022

How do you explain pain to a patient? How do you reeducate the nervous system to be less sensitive? These are the questions that Tara Sullivan, PT, DPT, PRPC, WCS, IF, and Alyson N Lowrey, PT, DPT, OCS address in their new course Pain Science for the Chronic Pelvic Pain Population. The chronic pain population is often dismissed or misled that they have something drastically wrong with them, or worse, nothing wrong with them at all. Alyson and Tara share that “this population often has the most functional deficits and the worst clinical outcomes. We want to change that.”

Tara has specialized exclusively in pelvic floor dysfunction treating bowel, bladder, sexual dysfunctions, and pelvic pain since 2012. Alyson became involved with pelvic rehabilitation through working in a clinic with Tara Sullivan. She is a board-certified orthopedic specialist and primarily works with the ortho patient population. When Tara came into the clinic she brought along the pelvic floor population and they joined forces. Alyson, with her ortho perspective, is better able to recognize that in some of her orthopedic patients, a lot of their pain was coming from the pelvic floor. The pelvic pain patient population crosses over from physical therapy to the orthopedic and occupational therapy worlds. By treating their patients wholistically Tara and Alyson have been able to make a huge difference to both of their practices.

By focusing specifically on the topic of pain science in their new course, Tara and Alyson delve into the true physiology of pain including the topics of central and peripheral sensitization. Pelvic specialists that can benefit from this course are those whose patients have chronic pelvic pain including endometriosis, interstitial cystitis, irritable bowel syndrome, vaginismus, vestibulodynia, primary dysmenorrhea, and prostatitis. The biggest thing is to learn how to recognize if there is a sensitization component to your patient’s pain.

Alyson shares that being able to recognize chronic pain in the patient is huge, that this is “not your regular patient who has a peripheral injury and we just need to rehab them through that process. It’s a whole different ballgame when we’ve got our nervous system in a hypersensitive state.” She continues, “a huge part of the treatment is educating your patient about pain and trying to decrease the fear around movement…and how we use our words to decrease fear is huge.” This course also discusses how to desensitize the nervous system through dry needling, diaphragmatic breathing, sleep hygiene, and bowel and bladder retraining.

Pain Science for the Chronic Pelvic Pain Population is scheduled for February 19-20, May 21-22, and September 10-11. This course is targeted to physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals. The full interview with Tara Sullivan and Alyson Lowery is available on the Herman & Wallace YouTube channel.

Elena Teare, the Communications Lead from Open Arms Perinatal Services sat down with The Pelvic Rehab Report to discuss their organization and annual fundraiser Labor of Love.

For our practitioners who are not familiar with Open Arms, can you tell me the organization?

Open Arms is the leading independent, community-based program in Washington State providing wraparound perinatal services to low-income families. We serve nearly 300 families every year and our award-winning program is not hospital-directed or based. Our trusted, community-centered approach always prioritizes the unique cultural, linguistic, and emotional needs of each client free of charge.

We provide services across four program areas: birth doulas, community-based outreach doulas (who provide in-home support up to two years of age), family support services, and lactation support peer counseling. We also train emerging birth workers to serve families in their own communities.

Our communities of focus are Black/African American, Somali, Latinx, and American Indian/Alaska Native communities of King, Snohomish, and Pierce counties. 87% of our clients are of color.

Can you share a success story?

In 2019, Asha was experiencing homelessness when pregnant with her second child. She heard about Open Arms through her shelter and soon was matched with Suad Farole, a Community-Based Outreach Doula. Originally from Somaliher through pregnancy, birth, and her daughter for two years. When Asha became pregnant with her son in late 2020, she knew she wanted Suad to be with her. In Asha’s words, “When I first decided to get a doula, I didn’t expect what I received. Suad was a true gift that not only oversaw the safety of my child as she came into this world, but she truly cared for my well-being and helped me to become the mother that I am now.”

What is the importance of the yearly Labor of Love event?

Labor of Love is our most important fundraising event of the year! It is a chance for us to engage our community and highlight the extraordinary outcomes our families achieve. When community members invest in the work that we do, they provide Open Arms with the flexibility to allocate dollars to any part of the organization that needs extra support. Given the uncertainty in today’s world, it’s important that we have the ability to respond quickly to the changing circumstances of our client families.

What makes you, the staff, volunteers, and the community passionate about this organization?

Our approach is evidence-informed, culturally appropriate, and community-centered and is effective in reducing medical interventions and the costs of perinatal care. By prioritizing the emotional needs of birthing people, our staff and volunteers set the stage for new mothers and parents to be strong and confident advocates for their children and families. By removing the cultural barriers to perinatal care by providing culturally competent care, we facilitate better community linkage to the health care system.

Our doulas and lactation consultants, as well as community of midwives, are committed to improving the health outcomes for birthing people and children of systematically underserved communities. Our families’ outcomes exceed those of Washington state and the country. As of 2021, 95% of our families give birth at full term and healthy birth weight, 85% avoid unplanned cesareans, and 82% are still breast/chestfeeding at six months.[i]

How do persons in need find your organization and what partnerships do you have?

Many of our families are referred from other organizations and service providers, and others find us through word of mouth in the community. Through our Perinatal and Lactation Support Collaborative, we have strong partnerships with the organizations like the Center for Indigenous Midwifery, Generations Midwifery Services, Global Midwifery Services, The Pacific Islander Health Board of Washington, and Rainier Valley Midwives. Additionally, the Program for Early Parenting Support (PEPS) and the Tubman Center for Health and Freedom are additional partnerships we have.

What is the awareness level in the community of Open Arms?

Open Arms clients are referred from other community partners and agencies who trust us to provide the best possible, culturally sensitive care. Over 30% of our referrals are from previous clients who seek our services again or refer friends and family.

How can people who are interested in supporting Open Arms donate or support the organization?

Interested supporters can make a gift to Open Arms online at https://www.openarmsps.org/get-involved/donate/make-gift-today/. To make an even bigger difference in the lives of the families we serve, community members can join our Baby Whisperers Monthly Giving Circle with a sustaining monthly gift. We also value gifts of time and welcome volunteers to assist with some of the behind-the-scenes logistics of the organization. People can stay up to date with our work and opportunities to get involved by heading to our site and subscribing to our newsletter or following our social media channels.

[i] Compared to King county’s rates: 91% of people give birth at full term; 93% are at a healthy birth weight, and 39% are breast/chestfeeding at six months.

Elijah Sharrieff is the content writer for My Community Health Network. MYCHN is a full-service healthcare provider in Houston Texas, that provides accessible health care in multiple Houston Communities. Elijah specializes in blogs that educate patients on relevant topics such as: prenatal care, mental health, the importance of diet and exercise, and dental care. Elijah’s holistic approach to health care blogging stems from his background in education. Elijah taught preschool, middle school, and tutored college and high school students. Teaching allowed Elijah to realize the interconnected nature of health as it relates to the mind and body.

Cervical Health Awareness 

Cancer is among the leading causes of death in America. Despite this, cancer is one of those things that you don't think will happen to you. We like to think we are healthy individuals, but cancer is unpredictable and complicated. 

Around 300,000 women are diagnosed with cervical precancers in America. MYCHN has created a list of prevention tips to ensure a healthy cervix! 

What Causes Cervical Cancer? 

Cervical Cancer typically develops when healthy cervix cells grow and multiply continuously. In other words, they don't die like normal cells. Instead, these continually replicating cells form a mass, also known as tumors. 

In many cases, HPV can lead to cervical cancer. However, an HPV diagnosis doesn't mean you will be diagnosed with cervical cancer. 

What are Cervical Cancer Risk Factors? 

Risk factors can increase your cancer risk. There are multiple risk factors for cervical cancer; some of them may surprise you.

• Sexual history: Your sexual history can put you more at risk for cervical cancer.

If you are sexually active at a young age (18 years old and under)

• Diet: If you do not consume a balanced diet, you could be at higher risk for cervical cancer

• Cervical Cancer in the family: If you have family members who have cervical cancer, your chances of developing cervical cancer are higher than if no one in your family has it. In some cases, this is because of rare inherited conditions that make it harder for some women to fight HPV. 

• Smoking: It's a difficult habit to quit. However, smoking has been shown to harm the body. Women who smoke are twice as likely to develop cervical cancer. 

Tobacco by-products have been found in the cervical mucus of women who smoke. Some studies have shown that the chemicals in cigarettes can damage the DNA of cervix cells. This occurrence can lead to the development of cervical cancer. 

How can you Have a Healthy Cervix? 

Prevention is going to be vital to lowering your risk of cervical cancer. What are some cervical cancer prevention methods? 

1. Pap Smear: 

A pap smear is a screening that looks for abnormal changes that could lead to cancer. Luckily, cervical cancer doesn't develop overnight, so regular pap smears are useful in cervical cancer prevention. 

2. Following up with your health care provider:

Following up with your health care provider is crucial to cervical health. Health care providers provide access to pap smears and other preventative measures. 

3. Get the HPV Vaccine:

The HPV vaccine protects against sub strains of HPV that lead to cervical cancer. 

4. Limit your sexual partners: 

Unfortunately, HPV is easily spread. It is relatively easy to become exposed to HPV. The virus spreads through skin-to-skin contact, so it can be spread without having sex. The American cancer society has stated that HPV can be spread through hand to genital contact. 

With the aforementioned in mind, limiting the number of sexual partners could put you at a lower risk of HPV. 

5. Stop smoking:

Smoking is a tough habit to shake. However, the consequences of smoking are severe for the body's health in the long term. Many cigarettes and tobacco products have harmful cancer-causing chemicals. In addition, smoking weakens your immune system. 

A weakened immune system makes it harder for your body to fight viruses like HPV. Just a gentle reminder, HPV can lead to cervical cancer. 

Pap Smear Near Me

According to The World Health Organization, cervical cancer is the fourth most common cause of cancer in women. Pap Smears are an excellent cervical cancer prevention method. MYCHN offers pap smears and other women's health services. We have 11 locations in the metropolitan Houston area. 

CHN Cares for patients with private insurance, Medicaid, Medicare, and uninsured! Visit https://mychn.org/services/womens-health/ for more.

Bottom Line

Cervical cancer is common cancer for women and, in many cases, can be deadly. Thankfully, there are prevention methods to prevent the disease. For example, regular Pap smears can be used to prevent Cervical cancer. 

Eating a balanced diet and not smoking can also be excellent prevention methods. 

My Community Health Network. MYCHN is a full-service healthcare provider in Houston Texas, that provides accessible health care in multiple Houston Communities.

References: 

• https://www.healthline.com/health/cervical-cancer#prognosis
• https://www.nfid.org/2019/01/17/cancer-prevention-in-practice/
• https://www.cancer.org/cancer/cervical-cancer/causes-risks-prevention/risk-factors.html
• https://www.verywellhealth.com/how-to-have-a-healthy-cervix-582022

Sarah Haran PT, DPT, OCS, CF - L2 earned a BS in exercise science from Gonzaga University and a DPT from the University of Washington. She has been practicing in Seattle for almost 15 years and opened her private practice, Arrow Physical Therapy in 2016. Her specialties include dance medicine, the CrossFit and weightlifting athlete, and conditions of the hip and pelvis such as femoroacetabular impingement and labral tears. In 2017, she began coaching other PTs who wanted to start their own practices and from there, she co-founded Full Draw Consulting with her partner Dr. Kate Blankshain. Together, they offer coaching, consulting, and several 8-week online business courses for Physical Therapy entrepreneurs. Sarah Haran instructs Weightlifting and Functional Fitness Athletes, next scheduled for February 26th, 2022.

As a physical therapist who works with CrossFit® athletes, I want to address a persistent problem we have in our professional community. Many PTs don’t know what to do with CrossFit® athletes.

When CrossFit® first came on the scene, a lot of PTs would encounter athletes who had injuries or dysfunctions related to their sport. Perhaps shoulder pain from kipping pull-ups or low back pain from deadlifts or kettlebell swings, maybe stress incontinence from box jumps.

Whatever it was, it seemed like we were seeing Crossfitter after Crossfitter in our practices. Was it that they were injuring themselves more than other athletes? Was it that their sport was bad and full of terrible ideas and awful coaching? I think what we were seeing was the quick growth of a popular sport (lots of people participating) and a community of people who not only were pushing themselves in the gym but who were interested in getting better and back into the gym quickly (ie. seeking rehab quickly). And then we were seeing rehab professionals who didn’t know how to help and were overwhelmed by the complexity of the sport.

And while there are some folks in healthcare who would like to see CrossFit® lose popularity, the reality is that it is here to stay and you will likely be faced with treating these athletes in some capacity. But what do we do with them? How do we keep our patients healthy when they want to continue to participate in CrossFit®??

The 3 primary duties of the physical therapist:

• Work to understand the sport
• Educate ourselves about where in the body these injuries commonly occur and how they happen
• Design rehab programs:
  • ○ which address training volume just as we would in any other sport
  • ○ that are functional to these athletes
  • ○ that supplement CrossFit® workouts with accessory work to:
  • • ■ drill positions
    • ■ strengthen weaknesses
    • ■ mobilize tightness
    • ■ improve endurance for these positions/movements

The messaging we need to communicate to our CrossFit® patients:

• Form and technique need to come first… then volume, weight, difficulty, and intensity.
• Mobility is not just flexibility; we also need to emphasize stability through a range of motion.
• Scaling and modifying is critical to all athletes at some point in their career. Work with your PT and coach to make appropriate decisions.
• CrossFit® is here to stay. Let’s keep our athletes in this sport for the long haul.

Treating CrossFit® athletes has been a primary passion of mine for many years and it is very exciting to be able to offer a course with Herman & Wallace that introduces the sport to other PTs. You do not have to be a CrossFit® athlete or specialist to want to help these patients and we want all the fabulous PTs out there to be able to impact the CrossFit® community effectively.

Weightlifting and Functional Fitness Athletes will review the history and style of Crossfit exercise and Weightlifting, as well as examine the role that therapists must play for these athletes. Common orthopedic issues presented to the clinic will be examined.

Check out the Herman & Wallace YouTube Channel for the full interview with Dr. Yeni

Dr. Oluwayeni Abraham stumbled into the niche field of fertility. She shares, "I had all of these women who would come in with painful periods that would have significant post-surgical problems and would end up having fertility concerns. As I was picking up my visceral mobilization techniques, I started to see that I was able to help women conceive and help women who maybe have experienced reoccurring miscarriages actually carry to term. That's when I said, "I think I'm doing something here that could be something else." That's when I tried to hone in on the specific skills that were influencing and maximizing the results and outcomes. 

In Dr. Yeni's course, Fertility Considerations for the Pelvic Therapist, she shares manual therapy techniques and a lot of data on hormones, the endocrine system, and other pieces of the puzzle. The language in the fertility world is based on these building blocks. Specific fertility-related diagnoses are discussed that help you formulate a pathway in treatment. Another important thing Dr. Yeni teaches is how to collaborate and work with these other providers that are going to be on this journey with your patients.

When working with fertility it's important to ask ourselves how do we bring value to this puzzle? How do we bring value after someone has had multiple failed IVF cycles? We can't just say we're going to do a bunch of manual work. We also have to speak the language and understand the body in its entirety and how it's playing a role in being able to maximize fertility outcomes. 

When asked what sparks her passion and keeps her so excited about working with this population Dr. Yeni stated, "the outcomes! We're still therapists, and we love to see results."

Fertility Considerations for the Pelvic Therapist - Remote Course

• Feb 5, 2022
• Jun 4, 2022
• Aug 13, 2022
• Nov 5, 2022

This course requires each registrant to have a live model. Due to the nature of labs, please be sure your model or 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.