The following is the first in a series of posts by Erica Vitek, MOT, OTR, BCB-PMD, PRPC. Erica joined the Herman & Wallace faculty in 2018 and is the author of Neurologic Conditions and Pelvic Floor Rehab.

A well-respected colleague of mine brought something to my attention. My desire to learn everything possible about Parkinson disease and pelvic health was a unique passion, a combination of expertise not seen in many rehabilitation clinics.

Looking back, being passionate about how to physically exercise a person with Parkinson disease to produce the best functional outcome actually became a passion of mine when I was offered my first job. I was thrown into treating people with Parkinson disease in an acute care setting. I had very limited knowledge about Parkinson disease at the time, but I learned quickly from the vast opportunity that was offered to me through my place of work, which was the regions sought after Parkinson disease center of excellence. At the same time, I was eager to further advance my skills as a pelvic floor therapist, which I developed a substantial interest in when I was in college.

As I learned more about what people with Parkinson disease had to manage in their daily lives, it became very clear to me that autonomic dysfunction was a very challenging, and sometimes disabling, aspect of the disease. Being knowledgeable about the neurological and musculoskeletal system along with the urinary, gastrointestinal, and sexual systems seemed to fit well together but there was no specific place to go to combine this knowledge. The research I began collecting on this topic was abundant and very intriguing. Bringing this information together could be practice changing for me to help people living with Parkinson disease.

As clinicians, we already know how to be understanding about the very personal details of the people we work with. People with Parkinson disease deal with an extra layer of challenge, such as, bradykinesia, freezing of gait, and tremor affecting their day to day self-care and relationships. Adding urinary incontinence, constipation or sexual dysfunction to the list makes for even more difficult management.

How does one clinician share their passion with other clinicians that also have the same desires to give the best care to their patients with Parkinson disease? Having a great deal of respect for Herman and Wallace and what they have to offer clinicians practicing pelvic rehabilitation, it seemed like it could be the perfect fit for a course like this. The work that would lie ahead if this idea took off was overwhelming but did not hinder me from my proposal. In fact, it has led to an even larger scope addressing the of treatment of the pelvic floor for a multitude of neurologic conditions many of us see daily in our clinics. Pulling it all together to share is a process that will reward not only people with Parkinson disease in my practice but hopefully yours as well.

Male Pelvic Pain: What Therapists Can Do to Help End the Desperation

Recently, a note was left at my doorstep by the wife of an older gentleman who had chronic male pelvic pain. His pain was so severe, he could not sit, and he lay in the back seat of their idling car as his wife, having exhausted all other medical channels available to her, walked this note up to the home of a rumored pelvic floor physical therapist who also treated men. The note opened with how she had heard of me. She then asked me to contact her about her husband’s medical problem. It ended with three words that have vexed me ever since…we are desperate.

Unlike so many men with chronic pelvic pain, he had at least been given a diagnostic cause of his pain, pelvic floor muscle dysfunction, rather than vaguely being told it was just a prostate issue. However, the therapists that had been recommended by his doctor only treated female pelvic dysfunction.

“We are desperate”: A Call to Action for All Therapists to become Pelvic Floor Inclusive

My first thought after reading the note was, “I bet shoulder or knee therapists don’t get notes like this on their doorstep.” My next thought, complete with facepalm, “THIS HAS TO STOP! Pelvic floor rehab has got to become more accessible”.

Pelvic floor therapists see men and women and even transgenders. They treat in the pediatric, adult, and geriatric population. They treat pelvic floor disorders in the outpatient, home health and SNF settings. They treat elite athletes and those with multiple co-morbidities using walkers. They can develop preventative pelvic wellness programs and teach caregivers how to better manage their loved one’s incontinence. This is due to one simple fact: No matter the age, gender, level of health or practice setting, every patient has a pelvic floor.

The pelvic floor should not be regarded as some rare zebra in clinical practice when it is the workhorse upon which so many health conditions ride. It interacts with the spine, the hip, the diaphragm, and vital organs. It is composed of skin, nerves, muscles, tendons, bones, ligaments, lymph glands, and vessels. It is as complex and as vital to function and health as the shoulder or knee is, and yet students are lucky if they get a “pelvic floor day” in their PT or OT school coursework.

I call for every therapist, specialist, and educator to learn more about the pelvic floor. Here are some steps you can take today toward eliminating the need for such a note to be written.

If you are a pelvic floor therapist who treats men, shout it from the rooftops!

Contact every PT clinic, every SNF, every doctor, every nurse, every chiropractor, every acupuncturist, every massage therapist, every personal trainer, every community group and let them know! If you have already told them, tell them again. Send a one page case study with your business card. Host a free community health lecture at the library or VFW hall. Keep the conversation going. Reach out to your local rehab or nursing school programs and volunteer to speak to the students. Feature pelvic health topics in your clinic’s social media stream. Get on every single therapist locator that you can so people can find you. Click here to go to the Herman and Wallace Find a Practitioner site.

If you only treat pelvic dysfunction in women, please consider expanding your specialty to include men.

The guys really need your help. You literally may be the only practitioner around that has the skills to treat these types of problems. Yes, the concerns you have about privacy and feeling comfortable are valid. But, you are not alone in this. Smart people like Holly Tanner have figured all that stuff out for you and can guide you on how to expertly treat in the men’s health arena. Sign up for Male Pelvic Floor or take an introductory course online at Medbridge. If you have only taken PF1, it’s time to sign up for Pelvic Floor Level 2A: Function, Dysfunction and Treatment: Colorectal and Coccyx Conditions, Male Pelvic Floor, Pudendal Nerve Dysfunction. Reach out to other pelvic floor therapists that treat men and ask for mentorship.

If you are general population therapist, consider taking a pelvic floor course.

Good news! Not every pelvic floor course requires you to glove up and donate your pelvis to science, so to speak. Yes, there are several external only courses you can take that do not have an internal examination lab. Click here and look under “course format” to see a list of external only courses. If you treat in the outpatient, ortho, or sports medicine arena, consider taking Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System or the Athlete and the Pelvic Floor .

If you treat in the Medicare age population, work in skilled nursing, or home health, join me in New York on May 21-22 for Geriatric Pelvic Floor. It is an external course and we cover documentation and self-care strategies extensively for incontinence and pelvic pain in older adults across multiple settings. Older adults with pelvic pain, like the man in the back seat, are at risk for being diagnostically ignored. We will address biases, such as “prostato-centric” thinking, ageism, and the ever-present “no fracture no problem” prognosis given to seniors who sustain a fall, but are left with disabling soft tissue dysfunction.

If you are a PT or OT school educator, eliminate “Pelvic Floor Day”.

Sorry, but it sounds silly. It’s like saying you offer a “Knee Day” in your program. Replace it by including the pelvic floor into Every. Single. Class…anatomy, ther ex, neuro, peds, geriatrics, and even cardiopulmonary!

As the baby boomer population grows, pelvic floor disorders are expected to rise significantly (download a free white paper on pelvic floor trends here).  Are you preparing your doctorate students to be competent screeners of pelvic floor dysfunction? Pelvic floor rehab is becoming the gold standard of first line treatments for pelvic dysfunction. Are you giving your students the skills to be competitive in a job market that recognizes pelvic floor rehabilitation as standard of care? Bias is learned. Excluding the pelvic floor in your student’s coursework or presenting it as a niche specialty subtly reinforces this bias.

Reach out and ask your local pelvic floor therapists to guest lecturer throughout the program. Send your instructors to pelvic floor courses. Encourage your students to take Pelvic Floor Level 1 in their last 6 months of coursework. Offer a clinical rotation in pelvic floor rehabilitation. Include case studies and patient perspectives on pelvic dysfunction, such as A Patient’s Pelvic Rehab Journey.

The Silver Lining

Thanks to the champions of pelvic floor rehab education, we’ve come a long way. The good news in this story is that this man’s doctor recognized early that he had pelvic floor muscle dysfunction and recommended that he see a pelvic floor physical therapist. The bad news-it took 2 years before he could find one. The ball is in our court, therapists. Let’s do better. Until there are no more men in the back seat, we still need to #LearnMoreAboutThePelvicFloor.

Herman & Wallace are pleased to announce a new course! Pudendal Neuralgia and Nerve Entrapment will be presented by Michelle Lyons in Freehold, NJ on June 17/18, 2017. We chatted with Michelle about this new course to hear her thoughts and get an overview of the contents

There are a number of courses which I teach for Herman & Wallace including Pelvic Floor Level 2A, my Male Oncology and Female Oncology and the The Athlete and the Pelvic Floor courses. They all have sections on pudendal dysfunction and it’s an area that participants always want more information on. There’s no other nerve that elicits the same interest, discussion and confusion! Nobody really talks about iliohypogastric or ulnar neuralgia with the same intensity as pudendal neuralgia, and no other nerve dysfunction provokes the same amount of controversy and mystery.

When I was approached about developing this course for the Institute, I jumped at the opportunity. For those who don’t know me, I really like to bring an integrative approach to my work, both clinically and educationally. I have experience and training in nutrition, coaching, yoga, Pilates and mindfulness as a therapeutic intervention and I think these fit really well alongside traditional pelvic rehab approaches. Manual therapy and bespoke exercise prescription will always be the bedrock of my approach, but sometimes our patients, especially those with chronic pain, need some extra support. I’m also a bit of an anatomy nerd, so the chance to delve deep into pelvic neuroanatomy and neurodynamics was too much to resist!

I think this is a Golden Age in pelvic health – there are so many great learning opportunities and resources available to us to help serve our patients better. Another area that I find fascinating to explore is the huge leap we have made in understanding neuroscience and the role of pain education when it comes to chronic pelvic pain. I’m a big fan of the work done by Moseley and Butler in Australia, and I love how authors like Hilton, Vandyken and Louw have transferred that to the world of pelvic pain in their book "Why Pelvic Pain Hurts". The language that we use is very important when discussing how the brain responds to chronic pain and the changes that occur with central sensitization. We never want our patients to feel as if we think their pain is ‘all in their heads’ but at the same time, we need to be able to incorporate strategies such as motor imagery and graded exposure and to demonstrate to our patients that"…it is important to acknowledge that chronic pain need not involve any structural pathology" (Aronoff 2016).

Those are some of the discussions we’ll be having in Freehold, NJ next June – I hope you’ll come and join the conversation!

"What Do We Know About the Pathophysiology of Chronic Pain? Implications for Treatment Considerations" Aronoff, GM Med Clin North Am. 2016 Jan;100(1):31-42
"Why Pelvic Pain Hurts: Neuroscience Education for Patients with Pelvic Pain" Hilton, Vandyken, Louw, International Spine and Pain Institute (May 28, 2014)

More than a year ago, after working on updating the pelvic floor series courses PF1, 2A and 2B, the Institute turned our attention to the final course in our popular series, PF3. To determine what content our participants wanted to learn about in the last continuing education course of the series, we asked that exact question. From a large survey of therapists who had taken all or most of the courses in the pelvic core series, we collected detailed data from therapists about what was needed to round out their comprehensive training. The results of that survey guided hundreds (and hundreds!) of hours of work completed by a team of instructors. This month, in the beautiful city of Denver, the three instructors who created the Capstone course will share their wisdom, clinical experiences, as well as their thoughtfully-designed lectures and labs. You will have an opportunity to learn in depth about topics covered in the prior courses in the series. 

Such topics include lifespan issues and health issues common to different ages, conditions of polycystic ovarian syndrome, endometriosis, infertility, pelvic organ prolapse and surgeries, pelvic fascial anatomy, pharmacology and nutrition. Lab components are detailed and comprehensive for working with specific common implications from conditions in pelvic dysfunction or surgery. This course focuses on the female pelvis, including diving into the complexities of female pelvic health issues. The instructors have all worked in the field for many years, are experienced in working with complex patient presentations, and all excel at manual therapies. I asked each of them to briefly share thoughts about the Capstone course that they each dedicated the last year in developing; following you can read their thoughts.

Nari Clemons

"I'm excited for every therapist who will take this course, as it is made to help you approach your practice at a whole new level.  We are eager to help your hands work dynamically with more intelligence and how to tackle complex restrictions in the pelvis and abdomen that go far beyond releasing muscles.  Additionally, the practitioners will raise their capacity of recognizing and helping the patient manage complex conditions, such as endometriosis, PCOS, fibroids, and IBS." 

Allison Ariail

"One of the best things about the Capstone course is that it provides the participants tools to treat more complicated patients. Topics such as endocrinology, oncology, vulvar dermatology, and surgical procedures are addressed, which will complete the picture for some of those patients that are hard to treat due to the complexity of their case. This knowledge, along with more advanced manual treatment techniques, will add to the skill set of the participants to improve their treatment outcomes. I am excited for the participants to combine their current clinical skills along with some new knowledge and techniques to be able to treat the whole person when working with complex and challenging patients." 

Jennifer van de Vegte

"Designing and creating Capstone with Nari and Allison was an incredible experience. My own knowledge and clinical expertise grew profoundly while researching and writing this material. Capstone is designed to really take the experienced pelvic health therapist to the next level of understanding and treating more complex patients. I can't wait to see the impact this material has on participants and their patients."

There is still time to register for the few remaining seats in Denver this weekend!