The female sexual response cycle is more than physical stimulation. As pelvic therapists, we frequently find ourselves treating pelvic pain that has interrupted a woman’s ability to enjoy her sexuality and sensuality. As physical therapists, we focus on the physical limitations and pain generators as a way of helping patients overcome their functional limitations. However, many of us find that once many of the physical symptoms have cleared with pelvic floor and fascial stretching, our patients are still apprehensive to engage physically, or they are not able to derive pleasure. There is clearly a gap that needs to be bridged that goes beyond pain.

Last year I taught my class, Lumbar Nerve Manual Assessment and Treatment. I was honored and astounded to have Dee Hartmann, PT in my class. For those of you who do not know Dee, she has been a champion of our field for a long time, and she has been instrumental in elevating physical therapy as a first line of treatment in pelvic pain through her work, international leadership, and representation in multiple organizations, including APTA SOWH, ISSVD, IPPS, NVA, ISSWSH, and as an editor for the Journal of Sexual Medicine.

In this manual nerve class, I was teaching how to treat the path of the genitofemoral nerve, which affects the peri-clitoral tissues and sensation. We also covered manual therapy approaches to decrease restriction in the clitoral complex and improve the blood flow response in this region. Dee was fascinated and looped me into what she had been working on for the past several years. She has been working as part of a company called Vulvalove with her partner, sex therapist, Elizabeth Wood on studying and teaching women how to recapture their sensuality. Immediately, we wanted to combine forces in some way to present a way to approach these issues. So, when Dee invited me to present with Elizabeth and her at the Combined Sections Meeting of the American Physical Therapy Association (CSM) this year, I was humbled and excited to jump on board.

With improved tissue mobility in the clitoral and vaginal area, blood flow is able to improve through any previously restricted tissues. With any manual therapy or soft tissue work, it is expected that cutaneous circulation of blood and lymph will alter. In studies, a measure of this blood flow, VPA (Vaginal Pulse Amplitude) is higher in the arousal than the non-arousal state in women.⁴ “The first measurable sign of sexual arousal is an increase in the blood flow. This creates the engorged condition, elevates the luminal oxygen tension and stimulates the production of surface vaginal fluid by increased plasma”.⁵ Manual therapy can likely affect this.^1,2. During our CSM talk, I will discuss the neurovascular anatomy and will have a brief video of manual techniques to enhance these pathways in my portion of the presentation.

In the 19th century, female orgasm and sensuality was believed to be more vaginal, but as the 20th century unfolded, understanding of the clitoral tissues improved. More recent research reveals the origin of female pleasure is more complex, involving the clitoris, vulva, vagina, and uterus.³ However, female response is more complicated than just anatomy below the waist.

Heart Rate Variability (HRV) is a measure of autonomic nervous system health and the ability to flux between sympathetic and parasympathetic states. Autogenic training and meditation or mindfulness have been shown in multiple studies to improve HRV. A study by Stanton in 2017 demonstrated that even one session of autogenic training can increase HRV and VPA (Vaginal Pulse Amplitude, a measure of arousal). In our talk at CSM, Dee will cover the role of autogenics and how to specifically and practically use our autonomic state to influence our perception and feeling of pleasure. Dee will also cover extensive clitoral anatomy to have a better understanding of how this intricate complex functions and is structured in women.

Elizabeth Wood, a former sex therapist who is now a sex educator, will then present on the arousal cycle and what can be done physiologically to prepare the arousal network for climax. Elizabeth will help us to better define and understand the roles of arousal, calibration, and exploring sensuality, including exercises to help a patient have a more fulfilling experience once the physical pain is resolved. As Elizabeth says, “Knowledge is an antidote to shame and an invitation to pleasure”.

If you will be at CSM, please come join us at the opening session, Thursday February 13 from 8am-10am (PH2540), “Now That The Pain Is Gone, Where’s the Pleasure”.

If you can’t make it to CSM, I hope to see you at one of my nerve classes, “Lumbar Nerve Manual Therapy and Assessment” this year in Madison, WI April 24-26 or Seattle, WA October 16-18 to further explore manual therapies to improve sensation and neural feedback loops and to continue this conversation!

1. Portillo-Soto, A., Eberman, L. E., Demchak, T. J., & Peebles, C. (2014). Comparison of blood flow changes with soft tissue mobilization and massage therapy. The Journal of Alternative and Complementary Medicine, 20(12), 932-936.
2. Ramos-González, E., Moreno-Lorenzo, C., Matarán-Peñarrocha, G. A., Guisado-Barrilao, R., Aguilar-Ferrándiz, M. E., & Castro-Sánchez, A. M. (2012). Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women. Complementary therapies in medicine, 20(5), 291-298.
3. Colson, M. H. (2010). Female orgasm: Myths, facts and controversies. Sexologies, 19(1), 8-14.
4. Rogers, G. S., Van de Castle, R. L., Evans, W. S., & Critelli, J. W. (1985). Vaginal pulse amplitude response patterns during erotic conditions and sleep. Archives of sexual behavior, 14(4), 327-342.
5. Stanton, A., & Meston, C. (2017). A single session of autogenic training increases acute subjective and physiological sexual arousal in sexually functional women. Journal of sex & marital therapy, 43(7), 601-617.

Going to the Combined Sections Meeting of the American Physical Therapy Association (CSM2019)? Look for Herman & Wallace instructor Carolyn McManus, MPT, MA at the educational session titled “Pain Talks: Conversations with Pain Science Leaders on the Future of the Field”. Carolyn will be a panelist along with Kathleen Sluka, PT, PhD, Steve George, PT, PhD, Carol Courtney, PT, PhD and Adriaan Louw, PT, PhD. The panel will be moderated by Derrick Sueki, DPT, PhD and Mark Shepherd, DPT, OCS.

These influential leaders will share how they personally became interested in the field of pain and discuss innovative pain treatment, as well as leading edge pain research and its translation into clinical practice. Initiatives to standardize entry-level curriculum, develop pathways to pain specialization and create post-professional opportunities such as pain-specific residencies and fellowships will be explored. The session will conclude with the leaders discussing their views on the future of pain and the role of physical therapy in its management. The audience will be able to submit questions via text or email to the moderator for individual or panel discussion.

We are thrilled to have Carolyn on our faculty and excited that she has been offered this honor to contribute insights from her over 30-year career experience in the field of pain with her colleagues at CSM2019. Carolyn will offer her popular courses, Mindfulness for Rehabilitation Professionals at University Hospitals in Cleveland, OH on April 6 and 7, and Mindfulness-Based Pain Treatment in Portland, OR May 18 and 19, and Houston TX, October 26 and 27. We recommend these unique opportunities to train with a nationally recognized leader who pioneered the successful applications of mindfulness to the field of physical therapy. Hope to see you there!

As brain research in pain processing suggests, pain engages overlapping cortical networks responsible for nociception, cognition, emotion, stress and memory, a treatment model targeting nociceptive mechanisms alone can be inadequate to address the complexities of a patient’s pain experience.¹ To help physical therapists understand and more effectively address multiple factors influencing a patient’s pain, the APTA, Orthopaedic Section and Pain Management Special Interest Group have brought together 10 physical therapists and a physician from around the country to present an informative and dynamic 2-day pre-conference course, Keep Calm and Treat Pain, Feb 21 and 22 at CSM 2018 in New Orleans. Presentation topics include the Science of Pain, Pain Education, Pain Psychology, Motivational Interviewing and Sleep and Pain. In addition, I will present An Introduction to Mindful Awareness Training and Its Role in Pain Treatment, and my colleague at Herman and Wallace, Megan Pribyl, PT, MSPT, will present Pain and Nutrition: Building Resilience Through Nourishment.

As we are in the midst of the opioid crisis, this programming could not come at a better time. In this regard, I am especially excited to share information on how mindfulness training has been shown to help patients who are reducing opioid medications to increase positive affect, decrease pain interference and reduce opioid craving.^{2, 3} I will also describe how mindful awareness training helps address a patient’s fears and fear avoidant behavior and will guide mindfulness exercises.^{4, 5}

I am honored to be a part of this pioneering program that combines didactic presentations with experiential exercises and lab practice to offer participants the latest science of pain and practical skills to more successfully treat pain. In addition, I am presenting an Educational Session sponsored by the Federal Section on the topic Mindful Awareness Training for Veterans with Comorbid Pain and PTSD based on my research experience at the Puget Sound VA in Seattle. I hope to see you at CSM!

While these presentations offer a taste of mindfulness training to improve patient outcomes, they provide just a glimpse into its potential. My joy and passion is my course, Mindfulness-Based Pain Treatment, where I can offer an in-depth exploration of the role mindful awareness training in pain treatment through a thorough review of mindfulness and pain research, the detailed exploration of the application of mindful awareness training to the biopsychosocial pain model and multiple experiential exercises and lab practices that provide participants with practical strategies to bring into the clinic Monday morning. I hope you can attend a Mindfulness-Based Pain Treatment course offered by Herman and Wallace in 2018 at Samuel Merritt University in Oakland, CA, June 9 and 10, Virginia Hospital Center in Arlington VA Aug 4 and 5, or Pacific Medical Center in Seattle, WA Nov 3 and 4. I look forward to helping you expand your toolbox of treatment techniques for patients with pain conditions.

1. Simons LE, Elman, I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev. 2014;39:61-78.
2. Garland EL, Thomas E, Howard MO. Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. J Pain Symptom Manage. 2014;48(6):1091-9.
 3. Garland EL, Froelinger B, Howard MO. Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RTC. J Behav Med. 2015;38(2):327-36.
4. Schutze R, Rees C, Preece M, Schutze M. Low mindfulness predicts pain catastrophizing in fear avoidance model of chronic pain. Pain. 2010; 148(1):120-7.
5. Jay J, Brandt M, Jakobsen MD, et al. Ten weeks of physical-cognitive-mindfulness training reduces fear-avoidance beliefs about work-related activity. Medicine (Baltimore). 2016;95(34):e3945.

“Keep Calm and Treat Pain” is perhaps an affirmation for therapists when encountering patients suffering from pain, whether acute or chronic. The reality is this: treating pain is complicated. Treating pain has brought many a health care provider to his or her proverbial knees. It has also led us as a nation into the depths of the opioid epidemic which claimed over 165,000 lives between the years of 1999 and 2014 (Dowell & Haegerich, 2016). That number has swollen to over 200,000 in up-to-date calculations and according to the CDC, 42,000 human beings, not statistics, were killed by opioids in 2016 - a record.

So why has treating pain eluded us as a nation? The answers are as complicated as treating pain itself. Which is why we as health care providers must seek out not simply alternatives, but the truth in the matter. Why are so many suffering? Why has chronic pain become the enormous beast that it has become? What might we do differently, collectively, and how might we examine this issue through a holistic mindset?

In just a few weeks, I have the privilege of teaching amongst 10 physical therapy professionals and one physician from around the nation who with coordinated efforts created a landmark pre-conference course at CSM in New Orleans through the Orthopaedic Section of the APTA. Included in the 11 are myself and another Herman & Wallace instructor Carolyn McManus, PT, MS, MA who teaches “Mindfulness Based Pain Treatment” through the Institute.

The CSM pre-conference course title is “Keep Calm and Treat Pain” representing a necessary effort to provide the clinician with ideas and inspiration for helping the profession as a whole treat pain with an integrative approach.

“Pain and Nutrition: Building Resilience Through Nourishment” is the section I look forward to sharing. It will introduce concepts we can leverage to allow us confidence in seeking alternate ways of taming this beast which is chronic pain - ways which can enhance health and well-being of our clients in pelvic rehabilitation. We must not be passive observers of the opioid epidemic. We must come to terms with the fact that our nations go-to tool for treating pain unfortunately causes side-effects which can and does include loss of life. We can do better. And we will.

While the CSM pre-conference course will give you a taste of the nutrition concepts available to you, it is a mere tip of the nourishment iceberg. I continue my passion and mission with the two-day course titled “Nutrition Perspectives for the Pelvic Rehab Therapist”, an experience that can elevate your conversations with clients. It will pave a path of understanding for the provider, allowing us to share options, understanding, and hope. “Nutrition Perspectives for the Pelvic Rehab Therapist is coming next to Maywood, IL March 3 & 4, 2018. I welcome you to join me.

APTA CSM: https://apta.expoplanner.com/index.cfm?do=expomap.sess&event_id=27&session_id=13763. Accessed January 8, 2018.
CDC: https://www.cdc.gov/drugoverdose/index.html. Accessed January 8, 2018.
Dowell, D., & Haegerich, T. M. (2016). Using the CDC Guideline and Tools for Opioid Prescribing in Patients with Chronic Pain. Am Fam Physician, 93(12), 970-972.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Murthy, V. H. (2016). Ending the Opioid Epidemic - A Call to Action. N Engl J Med, 375(25), 2413-2415. doi:10.1056/NEJMp1612578