A recent Cochrane summary about feedback and biofeedback for urinary incontinence has been published that supports patient perception of benefit for symptoms. The summary was first published on-line in July of 2011. 24 trials were included in this review, and the authors compared research of pelvic floor muscle training with studies that included feedback or biofeedback to augment the pelvic floor muscle training. Women who received biofeedback in their rehabilitation for urinary incontinence were less likely to report that they did not improve. Interestingly, compared to those who did not receive biofeedback, there was no significant difference in cure rates or in leakage episodes.

So why would a woman perceive that she has increased recovery of her symptoms simply through the addition of biofeedback to her rehabilitation program? The authors report that in the studies in which biofeedback was included, the subjects spent more time with the therapists. Is it this fact that leads to the increased rate of reported benefit? Speaking from professional experience, I utilized biofeedback consistently when I began working with patients who have urinary incontinence, and as I gained more skills, I used the biofeedback less. (Keep in mind that biofeedback is a global term accompanying any type of information, such as visual or auditory, and that in this article biofeedback refers to electromyographic (EMG) measurement of muscle activity.) As I resumed use of biofeedback, I was reminded of the value of having the patient really "see" the effects of their attempts at muscle activation. Perhaps the internal validation on the patient's part that he or she has a true impact on the machine via the body is quite powerful in itself.

We do know for a fact from the wide body of literature on the topic that urinary incontinence and the perceived interruption in function impacts quality of life ratings. Perhaps the patients who have an increased awareness of their own empowerment through muscular effort, home program practice, and therapist validation of patient effort with biofeedback training also affects the perceived impact of urinary incontinence. If a patient perceives increased benefit from therapy, does that perception then influence quailty of life?

An important take-home point from this research summary is this: the literature supports biofeedback as a tool that augmentspelvic floor muscle training. Biofeedback is not a tool that stands alone in rehabilitation; EMG training is utilized as a part of the process, following synthesis of information gained from the examination and evaluation of the patient. Some providers who refer for pelvic rehabiltation seem to think that biofeedback alone should be utilized, while other providers do not believe we should be using biofeedback with their patients. The needs of the specific patient should drive that decision making, and we as pelvic rehab providers must continually educate our providers about the various tools we have to treat urinary incontinence and other pelvic floor disorders.

If you have been following research in pelvic pain, you may be aware of the diagnostic terms interstitial cystitis (IC) as well as painful bladder syndrome (PBS). And there's always bladder pain syndrome (BPS), or hypersensitive bladder syndrome. While you may have heard at some point that health care providers should use PBS preferentially over IC, that recommendation does not seem to have stuck, and the Interstitial Cystitis Association (ICA) has decided to utilize "IC" until a more definitive diagnostic criteria and test are developed. Much of the literature you will continue to see published will choose to include both IC and PBS together in the title, and recent research has attempted to further define the diagnosis as having a relationship to ulcers versus no ulcers.

Recognized subtypes of IC include ulcerative (5-10% of those with IC) and non-ulcerative (90% of those with IC). According to the ICA, patients who have non-ulcerative IC have tiny glomerulations or hemorrhages on the bladder wall, indicative of inflammation, but not specific to IC. In patients who have ulcerative IC, Hunner's ulcer's or patches of red, bleeding areas are noted on cystoscopy. Recent research aimed to find out if female patients with ulcerative versus non-ulcerative IC have different symptoms or characteristics. 214 women (36 with ulcerative IC, 178 with non-ulcerative IC) were included in this research. While both groups reported triggers such as certain foods, exercise, and stress, more patients who had non-ulcerative IC reported pain with intercourse.

On the Brief Pain Inventory, one of the outcomes tools used in this study, both groups reported similar numbers of painful areas, with lower abdominal and pelvic pain followed by low back pain. Words used to describe the pain were, however, different among the two subtypes of IC: patients with non-ulcerative IC reported aching, cramping, and tenderness, while patients in the ulcerative group reported sharp, stabbing, and hot burning pain. Aside from these differences, the patients in the two groups did not share significant differences in the outcomes measured. The authors suggest that further research is needed to provide more information about the different presentations of patients who have IC/PBS.

For those of us in pelvic rehabilitation, the most important aspect of our care is to treat what is found, and that can only be accomplished through excellent examination and evaluation techniques. If you are interested in learning more about IC, the ICA website provides a wide array of tools for patients and providers. Until then, we will continue to see IC, PBS, BPS, and other abbreviations that point out that there is much yet to learn about this disabling condition.

Even if you currently are not treating male patients in your pelvic rehabilitation program, continue to read for critical information about testicular pathology. Any male patient (or family member, friend, or loved one) can present with a sudden onset of symptoms that require medical follow-up. Testicular pathology, as pointed out in this article from Medscape, can be benign or life-threatening. (If you are not able to view the article, you can first create a free user account for Medscape and then view the information. Medscape is also a great resource as they will send you weekly article reviews on various medical topics.) The article has images of testicular pathology throughout the presentation which can help in understanding the anatomy and pathology present. Following are a few diagnoses that are highlighted in the article, and that may mimic clinical symptoms of thoracolumbar radiculopathy or pelvic pain.

Testicular torsion: Commonly occurring in adolescent males, torsion happens when the testicle twists, impairing the blood flow to and from the testicle. If the twisting last 4-6 hours or longer, the testicle can become necrotic and no longer be viable. Pain, swelling, and erythema are common in this condition, and any patient who presents with acute onset of scrotal pain must be examined for this condition.

Testicular fracture: Blunt trauma can cause significant injury to the testicles, and conservative management may be all that is required. The testicle itself can fracture, or be degloved, and a significant hematoma can occur. Surgical intervention may be required for preservation of the testicle.

Hydrocele: Fluid can collect either in the scrotum or in the spermatic cord (the "tube" that extends from the lower abdominal wall to the scrotum, carrying neurovascular and other structures). A painless lump may be the first sign of this condition. Aspiration or surgical resection may be required.

Varicocele: An enlargement of the veins within the scrotum can lead to a varicocele. While this may not cause dysfunction for the patient, a varicocele can lead to infertility and possibly discomfort due to the dragging sensation and increased pressure from enlargement.

Epididymitis: Testicular swelling, redness, and tenderness may be caused by an infection to the epididymis, a structure within the scrotum. A patient who presents with these symptoms may also have a fever and should be evaluated medically.

In addition to the above diagnoses, a testicular tumor might be first noted as a firm, painless nodule in either testicle. According to the Medscape article, a testicular tumor is the most common solid tumor found in men ages 20-35. Men need reminders just as women do for completing testicular self-exams and reporting any concerns to the physician. Here is a link to information on testicular self-exams, in case you find it helpful for patient education purposes. Keep the above information in mind when a patient presents with a change in symptoms or sudden, severe pain in the testicles.

With the Thanksgiving holiday behind us, the concept of gratitude may be fresh in our minds. Choosing to live with gratitude is often correlated with positive health benefits, such as increased energy, optimism, and empathy, according to the Psychology Today website. Most of us in the healing professions find reward in our work because of the expressed appreciation of others, and we can all tell meaningful stories about the patients who touched our own hearts with their thanks. Such support can boost our own energy levels and help us get through the paperwork or the more difficult patient encounters.

Gratitude, or thankfulness, invites a person to reflect on the aspects of her life that are providing meaningfulness. It is not necessary to be thankful only for the gifts that life brings; a person may also be grateful for a challenging interpersonal experience or life event as we often learn significant lessons during those times. There are abundant resources to encourage the building of a gratitude-filled life, and most of them are quite simple, require very little in terms of investment, and are described as methods that can change a person's outlook and improve quality of life.

According to an article written by Randy and Lori Sansone (click here for full text of the article), both psychologists, an attitude of gratitude can be cultivated by:

• Keeping a journal with entries listing statements of things you were grateful for during the day or week
• Thinking about a person for whom you are grateful (I would add "or a pet" as so many people have wonderful animal companions)
• Writing or sending a letter to someone who you are grateful towards
• Meditating on gratitude
• Completing a "Count Your Blessings" exercise
• Practicing saying "thank you" with sincerity and meaning
• Writing thank you notes
• Being prayerful about gratitude

While our patients may enjoy and benefit from discussions about the above, especially when working towards healing from chronic pain issues, there are many benefits to be gained in many domains of life. For example, gratitude has been described as being important for maintaining intimate relationships, encouraging prosocial behavior by helping others to feel socially valued, and improving job satisfaction. Click here for an excellent article about gratitude and being appreciated in the workplace (and what to do if you do not feel appreciated.)

There is even an app called HappyTapper that allows you (or a patient) to write down five things each day for which you are grateful. If that's not enough to be thankful for, it only costs 99 cents! There are also several free online journals available if you search the terms "free gratitude journal." With the holiday season and the New Year approaching, talk tends to turn to items desired and wishes for a healthier, better body and changes in income or relationshp. What would it sound like if we chose instead to focus on all that we already have and express our gratitude? In the words of physician Christiane Northrup, "Feeling grateful or appreciative of someone or something in your life actually attracts more of the things that you appreciate and value into your life." As we enter the holiday season, and winter, a time of turning inward, may you attract more wonderful things into your life.

"Movember," a men's health movement that began in Australia, has found its way around the globe. In this campaign, men grow mustaches (starting out November 1st clean-shaven) for one month to raise awareness about men's health issues, with particular emphasis on prostate and testicular cancer. Check out some of these images on the website to see for yourself how awesome these staches are.

This is a serious fundraising effort- in 2011 the organization raised over 126 million in US dollars. This money is spent on increasing awareness of male cancers and also on improving the response of the medical community to these conditions. Funds are also directed to organizations such as The Prostate Cancer Foundation.The organization's strategic goals as outlined on their website are to fund survivorship initiatives, increase awareness and education, fund research including clinical trials and research that informs health policy. The first item on the group's list of values is "fun" and we can easily see why this event attracts repeat crowds.

So what if you can't grow a mustache? You can still attend a Movember event sporting a faux such as a mustache-on-a-stick. Learn how to make your own here. Women engaged in the movement are known as Mo Sistas, and certainly men's health issues are issues for all families, as are women's health issues. In the presence of cancer, as we know, early detection can improve survival and allow for more treatment options. If you would like to find an event near you, check out this interactive map. If you live in Seattle or in Orange County, you can attend a "Running of the Mo's" event!

Regardless of your level of participation, what a terrific organization to celebrate and share with others. Consider hosting or attending a Movember event, and consider engaging someone in a dialog about men's health screening as well as pelvic rehab options. (Mustache optional.)

At the annual conference of the California Biofeedback Society last week, a new device was described for the treatment of jaw pain. The SleepGuard biofeedback headband can be worn by the user and when the band senses that the jaw is clenched, an alarm will sound to deter the patient from the clenching. It makes sense that a patient can re-train the body to avoid muscle tension with such a device.

So what can we do about the butt grippers? Although some clever and potentially not-so-comfortable ideas come to mind in relation to biofeedback sensors and the pelvis during sleep, how do we educate our patients who tend to clench at night to let go and avoid that morning pain? If you are unfamiliar with the concept of "butt gripping," please check out the work of Diane Lee, from whom I first heard the term. In an article on her website, Diane discusses the concept of gripping with the chest, back, or butt. Chances are, you can think of a patient who fits one of the categories. (Not that any of us have movement dysfunction, but you might have "a friend" who could use some guidance in re-training one of the gripping patterns.)

Patients who tend to clench any muscle all night will be creating compression in nearby joints, and the muscles will not be getting proper recovery and rest time during sleep. These patients will often wake with increased pain in the area of tension or muscle guarding. The first step in treating a condition of gripping is awareness: if you have no idea that you are creating tension in a muscle, the re-training of the muscle won't happen. Help your patients understand that a tendency to tighten a muscle group may be a habit brought up by the body guarding a region for various purposes. Consider the patient who has low back pain- tightening or splinting the area with muscle contractions may be a useful strategy early in the injury. Once a patient is aware of the tension that may aggravate a painful area or promote a dysfunctional movement pattern, creating new strategies is critical. Your patients may require soft tissue or joint mobilization, muscle balancing techniques, movement re-training (to include functional patterns or tasks), and general awareness or relaxation techniques.

Let's think of the patient who goes to bed and maintains tension in the gluteals, pelvic floor, or pelvic area. What can she do at bedtime? There may be a few stretches that loosen the muscles, breathing and awareness exercises, general relaxation or meditation activities, or some contract/relax to improve the muscle state. She might also have a self-massage or trigger point technique, complete a self-massage or partner-assisted massage, take a warm bath, or apply some heat or cold to the area of tension. Once in bed, what position does your patient adopt for sleep? Is she in supine with a posterior pelvic tilt, in sidelying with the thighs pressed tightly together? You can help the patient recognize the postures, positions, and patterns of holding that may be worsening the condition. Many patients find that completing some simple pelvic tilts or rocking prior to falling asleep can decrease guarding.

As an observational skill, recognizing patterns of gripping can aid in development of a rehabilitation program that looks for static or dynamic postures that need re-training. Butt gripping is one such pattern that will increase tension and muscle dysfunction in the pelvic floor and often in the hips and low back. There are many courses offered by the Pelvic Rehab Institute that incorporate these concepts into rehabilitation principles. If you are unable to attend a live course, or are interested in getting started in pelvic rehabilitation, check out the on-line MedBridge course created by the Institute co-founder, Kathe Wallace. The course is full of examination and intervention techniques that will benefit patients who have pelvic dysfunction.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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