If you’ve spent any time on social media as a healthcare practitioner, you’ve probably encountered a flood of ads promoting shockwave therapy as a miracle solution for everything from orthopedic pain to urological and gynecological conditions. The marketing push for these devices has skyrocketed over the past five years, driven by claims of its ability to treat a wide range of diagnoses. Recent research, including a comprehensive review published in The Journal of Clinical Medicine, confirms that shockwave therapy is making significant waves in modern medicine. But with all the buzz surrounding this technology, the real question remains: is it truly a game changer for patients and clinics alike?

As a medical professional, my approach to any new treatment, procedure, or modality begins with skepticism. I believe it is my responsibility to ensure that the interventions I offer in my clinic are grounded in solid research, and proven efficacy. When I first encountered shockwave therapy in early 2020, I was highly skeptical. The companies I spoke with made sweeping claims, portraying shockwave therapy as a universal solution for virtually every condition. Despite their promises, I remained cautious. However, after hearing positive feedback from a few trusted colleagues and witnessing a session that yielded seemingly impressive results, I decided to delve deeper into the research.

I found that while there is a substantial amount of literature available, much of it is confusing and, it lacks clarity — especially in the area of pelvic health. The majority of the research outside of orthopedics focuses on conditions such as erectile dysfunction, with little attention given to men’s pelvic health concerns and even less given to women’s pelvic health issues.

Recent advances in shockwave therapy have highlighted its growing potential in the field of men's and women’s sexual and pelvic health. The latest research trends are clear. As a non-invasive treatment, shockwave is no longer considered solely beneficial for orthopedics and sports medicine. Its applications are expanding rapidly in gynecology, urology, and pelvic floor disorders. This shift is driven by the therapy’s ability to enhance blood flow immediately and provide significant pain relief faster than traditional methods, making it an innovative option for conditions such as chronic pelvic pain, dyspareunia, and vaginal atrophy.

However beneficial, the fact remains that confusion abounds when, as a clinician, you are deciding which device would be best for your patients. At the forefront of the confusion when you delve into the research are:

1. protocols vary substantially between devices
2. energy levels and units of measure aren’t consistent among devices,
3. There are popular devices in the research labeled shockwave, when in fact, they do not produce shockwaves and create different outcomes.

If you would like to learn more about incorporating shockwave therapy into your daily practice, register for my one-day remote course Shockwave Treatment: Therapeutic Interventions in Pelvic Health & Demystifying the Research scheduled for October 22, 2024. This course provides an introduction to using this cutting-edge technology in the clinic for improved patient outcomes and an understanding of how shockwave can enhance manual therapy treatment skills. Course lectures cover what is shockwave, how it decreases pain and potentially accelerates healing, the research behind it, the different types of shockwave devices, and the best indications of use for each of them as well as case studies discussing patient protocols and outcomes.

AUTHOR BIO
Stacey Roberts, PT, RN, MSN

Stacey Roberts, PT, RN, MSN (she/her), has been a physical therapist specializing in outpatient orthopedics and sports medicine, since 1990. After completing a sports medicine fellowship and working at several hospitals and outpatient clinics, in 2000 Stacey had an opportunity to move overseas, where she became adept with complementary medicine approaches, becoming a master in herbalism in 2003. From 2004 to 2017, Ms. Roberts owned and operated a cash-based health and wellness clinic on the Gold Coast of Australia specializing in women’s health and hormones and couples' fertility, where she began seeing patients via Telehealth in 2006.

Combining her knowledge of functional medicine, conventional medicine, and complementary medicine, Stacey emphasizes lifestyle changes, and her treatment programs are based on cutting-edge evidence-based research. Currently, she is a co-principle investigator for an IRB-approved study related to shockwave and Dyspareunia.

She has written 3 hard-copy books and 7 ebooks on women’s health and couples' fertility. Her new book, The Pain-Free Formula: A Holistic Approach to Finally Getting Rid of Pain Without Surgery, Drugs, Or Injections, is coming out in 2025. Ms. Roberts has mentored over 100 medical professionals in her women’s health and couples fertility training program. After returning to the United States, Stacey was hired by a national physical therapy company, Aegis Therapies, from 2018 to 2020 to assist in the growth and development of their orthopedic outpatient practice in Wisconsin. She set records for the company related to bringing clinics to profitability faster than any of their other outpatient clinics in the country at that time.

From 2016- to 2020 Stacey was an associate clinical professor at the University of Wisconsin Milwaukee’s Physical Therapy doctoral program until opening New You Health and Wellness, a cash-based clinic, where she brings her knowledge of wellness, hormone health, fat loss, and musculoskeletal health to treating patients with issues related to musculoskeletal injuries, sexual health, and pelvic health. Since 2020 she has been analyzing Shockwave research extensively to develop clear and concise therapeutic applications and protocols for pelvic health, sexual health, and muscular-skeletal patients. She is finding extraordinary results with her patients using this modality in her cash-based practice.

Stacey completed her MBA in 2021, her RN license, and her master’s in nursing (MSN) in 2020. She will eventually complete a nurse practitioner certificate. Stacey has also appeared on World News Now in New York, was featured on Oprah, locally on TMJ4’s Morning Blend, and on several news shows and radio stations in the United States and Australia.

Surface EMG is the only modality that can isolate the active component of tone and is, therefore, a very valuable tool in the assessment of patients with altered tone conditions. However, it is the most misunderstood modality in pelvic health therapy. Rarely do practitioners see a topic so argued in pelvic rehabilitation as surface EMG biofeedback. Some practitioners boldly state they are for or against it on their social media accounts and clinic pages. Therapists are not questioning the use of biofeedback with neurologic or orthopedic applications, so why is it such a polarizing topic in pelvic health? The Pelvic Rehab Report sits down with faculty members Tiffany Lee and Jane Kaufman to discuss the tool they love. These two instructors have over 50 years of combined experience using biofeedback and have been teaching biofeedback board certification courses together for the past 16 years.

Biofeedback provides visual and auditory feedback of muscle activity and is a non-invasive technique that allows patients to adjust muscle function, strength, and behaviors to improve pelvic floor function. The small electrical signal (EMG) provides information about an unconscious process and is presented visually on a computer screen, giving the patient immediate knowledge of muscle function and enabling the patient to learn how to alter the physiological process through verbal and visual cues. Jane Kaufman explains “Many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation helps patients hone in on body awareness and connect all the dots." Muscle evaluation through digital exam offers strength but does not appropriately address electrical activity such as resting tone and the ability to recruit or release tone in the muscle. The use of biofeedback addresses the specificity of muscle contraction and release, offering an additional view of muscle function.

In a 2020 research study by Pilkar et al., clinicians reported sEMG barriers of use, which included limited time and resources, clinically inapplicable sEMG system features, and the majority of clinicians' lack of training and/or confidence in the utilization of sEMG technology. This research also noted technical challenges, including the limited transfer of ever-evolving sEMG research into off-the-shelf EMG systems, nonuser-friendly intuitive interfaces, and the need for a multidisciplinary approach to accurately handling and interpreting data.

One barrier may be the price of a biofeedback unit. Tiffany Lee recommends using a 2-channel sEMG biofeedback hand-held unit with the software on a laptop or computer. In fact, to become board-certified in pelvic floor biofeedback, the Biofeedback Certification International Alliance (BCIA) requires a 2-channel EMG system with software. If you use a hand-held one-channel unit, the patient will have difficulty seeing the muscle activity and the coordination between the abdominals and pelvic floor. This prevents meaningful treatment as the patient cannot understand or interpret the LED bars on the machine (and often, the therapist cannot understand either). In truth, the benefits outweigh the cost of the equipment. You can cover the unit's cost and software to visualize muscle function and tone within a few treatments. Training is another issue; you need proper training in the modality to start utilizing biofeedback in your clinical setting. Most therapists have never been adequately trained. If they take a course where the instructor doesn’t believe in the benefits of biofeedback, they feel negatively toward a modality they have never personally explored. Biofeedback relies on a skilled clinician to interact with the patient, give verbal cues, ensure that the proper muscles are contracting and relaxing, and must be used in conjunction with their other skills and knowledge.

Think of sEMG biofeedback as one tool in your toolbox. Tiffany shares, "In a study by Aysun Ozlu MD et al., the authors conclude that biofeedback-assisted pelvic floor muscle training, in addition to a home exercise program, improves stress urinary incontinence rates more than a home exercise program alone." She continues, "Biofeedback is a powerful tool that can benefit your patient population and add to your skill set.

The acceptance of sEMG biofeedback in rehabilitation requires a unit (with software and sensors), training, and a multidisciplinary approach. Used correctly, it can positively impact patient performance and care in the clinic. Keep in mind that sEMG is a non-invasive technique. It has already shown great promise in neurorehabilitation and has been a widely utilized tool to assess neuromuscular outcomes in research. Jane Kaufman concludes, "Biofeedback treatment/training using the proper instrumentation provides the precise information necessary to change behaviors." This allows the patient to recognize that ‘yes, they are in charge of this muscle and that they can achieve success in overpowering the symptoms.’ Biofeedback routinely allows patients to understand that they are empowered to heal themselves with the tools you offer. They are in charge of their bodies and the outcome of treatment. It is also an important tool to use with patients who have experienced trauma and who are not ready to participate in manual therapy, and it is valuable for the pediatric population as well. Tiffany adds, “This modality can bring new business to your clinic. My local GI and colorectal providers often refer up to 5 new patients a week to my practice.

There is a long history of scientific evidence supporting the use of sEMG biofeedback in managing incontinence or pain symptoms. As a noninvasive, cost-effective, and powerful treatment modality, healthcare providers should consider this tool when managing pelvic floor dysfunction patients. Providers should be educated in the proper use of this valuable modality to gain the most out of the skills and knowledge that can be achieved through this intervention. For more information regarding courses and certification, please visit www.pelvicfloorbiofeedback.com.

Tiffany asked several PTs and OTs who have been to the board certification courses what they love about biofeedback. Here are a few answers

• “Biofeedback empowers my patients and gives them the confidence that they are actually doing their exercises and relaxing correctly! I’ve had nothing but positive feedback from patients, and it’s such a great tool to have as a pelvic floor therapist.”
• “My patients really love it, and they ask for it. I especially see the value for dyssynergia work on bearing down and learning eccentric abdominals and relaxed pelvic floor muscles. For men, I work on relaxing in standing and toileting postures if they can’t empty their bladder.”
• “Ultimately, the treatment needs to be meaningful to the patient. Biofeedback can complement other treatments. Their needs come before ours. We should offer all of our patients the ability to control their own muscles and SEE how to do it.”
• “After ONE session with a 5-year-old with constipation, mom called me in sheer excitement, screaming over the phone that he pooped on the potty!!! Something he has NEVER done before. Biofeedback helped him find and coordinate the potty muscles and tummy muscles, and this made a huge difference for him!”
• “Becoming certified in biofeedback has only been positive for me. My patients feel that the initial sEMG evaluation sets the stage for my care plan, and my discharge reassessment is a tangible reflection of their progress. Not to mention its strength as a marketing tool.”

Jane Kaufman adds “Biofeedback in treatment has been a game changer. Using this tool as a foundation for treatment in my clinic allowed my practice to grow, thrive, and achieve great acclaim in our region and beyond. It is not unusual for patients to travel several hours to seek treatment because of the empowering effect the biofeedback visual had on their understanding of their dysfunction.”

Biofeedback for Pelvic Floor Muscle Dysfunction is scheduled for July 28^th and December 7^th, 2024, and provides a safe space for clinicians to learn and practice this valuable tool. Registrants will need equipment to participate in this online course and will learn about the benefits of using this modality in their clinical practice.

In this course, Tiffany and Jane guide participants through learning to administer biofeedback assessments, analyze and interpret sEMG signals, conduct treatment sessions, and role-play patient instruction/education for each diagnosis presented during the many hands-on lab experiences.

References:

1. Use of Surface EMG in Clinical Rehabilitation of Individuals With SCI: Barriers and Future Considerations Rakesh Pilkar, Kamyar Momeni, Arvind Ramanujam, Manikandan Ravi, Erica Garbarini, Gail F. Forrest. Front Neurol. 2020; 11: 578559. Published online 2020 Dec 18. doi: 10.3389/fneur.2020.578559 PMCID: PMC7780850
2. Comparison of the efficacy of perineal and intravaginal biofeedback-assisted pelvic floor muscle exercises in women with urodynamic stress urinary incontinence. Aysun Ozlu MD, Neemettin Yildiz MD, Ozer Oztekin MD. Neurourol Urodyn. 2017 Nov;36(8):2132-2141. Epub 2017 Mar 27. doi: 10.1002/nau.23257 PMID: 28345778.
3. Cram, J. R., & Kasman, G. S. (2011). The basics of surface electromyography. In E. Criswell (Ed.). Cram’s introduction to surface electromyography (2nd ed., pp. 3–7.) Jones and Bartlett.
4. Kaufman, J., Stanton, K., & Lee, T. E. (2021). Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Biofeedback, 49(3), 71-76.
5. Shelly, Beth & Kaufman, Jane (2023). Foundations of Pelvic Floor Muscle Assessment Using Surface Electromyography. APTA Academy of Pelvic Health Physical Therapy.

AUTHOR BIOS

Tiffany Lee, OTR, OTD, MA, BCB-PMD, PRPC

Tiffany Lee holds a BS in OT from UTMB Galveston (1996), an MA in Health Services Management, and a post-professional OTD from Texas Tech University Health Sciences Center. In 2004, she received her board certification in Pelvic Muscle Dysfunction from the Biofeedback Certification International Alliance. She is a Herman & Wallace Pelvic Rehab Institute faculty member and teaches biofeedback courses. She has been treating pelvic health patients for 25 out of her 30-year career. Her private practice in San Marcos, Texas, is exclusively dedicated to treating urinary and fecal incontinence and pelvic floor disorders. Her continuing education company, Biofeedback Training & Incontinence Solutions, offers clinical consultation and training workshops. She also enjoys mentoring healthcare professionals working toward their BCIA certification.

Jane Kaufman, PT, M.Ed, BCB-PMD

Jane has been practicing PT for more than fifty years. She is a graduate of the Ithaca College Physical Therapy program and earned her master’s degree at the University of Vermont. In her early career, she practiced in outpatient settings, skilled nursing, and acute rehabilitation. Jane’s career began at Columbia Presbyterian Medical Center and progressed to the University of Vermont Health Network where she supervised the Department of Physical Therapy’s outpatient services. In the late 1990s, Jane became intrigued with pelvic floor muscle dysfunction, evolving to a quarter-century career in this highly specialized field.

In 2001 she began her career as a sole practitioner in pelvic floor muscle dysfunction and in 2003 established Phoenix Physical Therapy, PLC with a staff of clinicians specializing in the treatment of pelvic floor dysfunction, incontinence, and pelvic pain for all genders and all ages. In 2005, Jane became certified in the use of surface EMG biofeedback for pelvic floor muscle dysfunction (BCB-PMD ) from the Biofeedback Certification International Alliance. She sold her practice in 2022, having established a renowned reputation in Vermont, upstate New York, regionally, nationally, and internationally. Post Phoenix, Jane continues to offer workshops for other healthcare providers in the use of biofeedback for pelvic muscle dysfunction, and mentors healthcare professionals around the world toward certification in this field through the Biofeedback Certification International Alliance. Jane teams with Tiffany Lee, OTR, OTD through Biofeedback Training and Incontinence Solutions (www.pelvicfloorbiofeedback.com).

Jane has recently begun a consulting practice helping adults with pelvic floor muscle dysfunction issues and has continued helping children/teens through her new practice, PottyTime Physical Therapy (www.pottytimephysicaltherapy.com). In addition to her practice and teaching, Jane has participated in research through the University of Vermont Health Network on pelvic organ prolapse, incontinence, and sexual dysfunction. She has authored an article published in the online international journal Biofeedback and was a co-author in the APTA self-study manual for Foundations in Pelvic Floor Muscle Assessment using Surface Electromyography with Dr. Beth Shelley, PT, DPT, WCS, BCB-PMD. She is a Herman & Wallace Pelvic Rehabilitation Institute faculty member and teaches biofeedback courses through this company. Jane may be reached by email at: This email address is being protected from spambots. You need JavaScript enabled to view it.

Congratulations on completing Pelvic Function Level 1 (PF1) and entering the world of pelvic rehabilitation. Are you ready for your next course but not quite sure which one to take? Well, you’re not alone. Everyone’s pelvic health educational journey is different based on their interests and patient demographics and there are a lot of course options available.

I’m going to zero in on the intermediate-level courses in the Pelvic Function Series for you as HW does recommend that practitioners take at least one or two of these. If you’ve looked at the course page you’ve noticed that there are three courses with a Level 2 designation – as well as a lab course. What does this mean? These courses are designed to be a progression of knowledge and skills learned in the foundational course Pelvic Function Level 1.

Here are the intermediate courses:

• Pelvic Function Level 2A (PF2A) - Colorectal Pelvic Health, Pudendal Neuralgia, and Coccyx Pain
  • Labs provide an introduction to internal anorectal examination for all genders.
• Pelvic Function Level 2B (PF2B) Urogynecologic Examination and Treatment Interventions
  • Labs provide external abdominal and pelvic and internal vaginal approaches.
• Pelvic Function Level 2C (PF2C) Men’s Pelvic Health and Rehabilitation
  • Labs provide external abdominal, gluteal, perineal, and internal anorectal approaches.
• Modalities and Pelvic Function (PFMOD) The Pelvic Health Toolkit
  • Labs provide supervised instruction to practice modalities.

Ready for a more in-depth look at the courses? Here is a more detailed breakdown:

Pelvic Function Level 2A (PF2A) Colorectal Pelvic Health, Pudendal Neuralgia, and Coccyx Pain
This course is intended for the pelvic health clinician who treats patients with common functional gastrointestinal (GI) dysfunctions and is interested in learning internal anorectal examination and the use of balloon re-training.

In this course, you will learn about common functional gastrointestinal (GI) dysfunctions including irritable bowel syndrome, fecal incontinence, and constipation. Course topics provide an introduction to nutrition for bowel health, colorectal conditions, and oncology. Participants will be educated on how diagnoses such as hemorrhoids, fistulas, fissures, and anorectal pain including pudendal neuralgia and coccygodynia may be improved with pelvic rehabilitation.

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic function evaluation with external observation, palpation, and internal anorectal examination of pelvic skeletal and soft tissues. These labs include an external perineal and internal anorectal approach as well as education in the use of balloon re-training.

Pelvic Function Level 2B (PF2B) Urogynecologic Examination and Treatment Interventions
This course is intended for the pelvic health clinician who treats patients with conditions including urinary incontinence, chronic pelvic pain (CPP), and pelvic organ prolapse.

In this course, you will learn, with increased specificity, evaluation for urogynecologic conditions as well as an overview of medical management, and multi-disciplinary pelvic healthcare. Course topics provide a more in-depth understanding of urinary incontinence, chronic pelvic pain (CPP), and pelvic organ prolapse.  Participants will be educated on how diagnoses such as interstitial cystitis/painful bladder syndrome (IC/PBS), urinary tract infections, vaginismus, vulvar pain, dyspareunia, polycystic ovarian syndrome (PCOS), and endometriosis may be improved with pelvic rehabilitation.

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic structures in relationship to the vaginal canal and surrounding structures such as the lumbopelvic nerves, the uterus, urethra, bladder, and rectum. Interventions instructed will include patient management of trunk and pelvic pressure, relaxation training, breathing, and manual therapies for a variety of pelvic dysfunctions. These labs include an external abdominal and pelvic and internal vaginal approach.

Pelvic Function Level 2C (PF2C) Men’s Pelvic Health and Rehabilitation
This course is intended for pelvic health clinicians who are interested in treating male pelvic health conditions.

In this course, you will learn critical detailed information about men’s pelvic health conditions including post-prostatectomy urinary incontinence, erectile dysfunction, and chronic pelvic pain (CPP). Participants will be educated on how diagnoses such as hard/flaccid, urgency/frequency, scrotal, testicular, and penile pain may be improved with pelvic rehabilitation.  

Practical, trauma-aware, hands-on labs provide supervised instruction of pelvic health evaluation with external observation, palpation, and internal anorectal examination of pelvic structures and soft tissues. These labs include an external abdominal, gluteal, perineal, and internal anorectal approach. 

Modalities and Pelvic Function (PFMOD) The Pelvic Health Toolkit
This course is for the pelvic health clinician who has the opportunity to use modalities as an adjunct to their patient's care and goes beyond the "Big 3" (E-Stim, Biofeedback, and Ultrasound).

In this course, you will learn about and practice a variety of modalities. Modalities in PFMOD include biofeedback, cold laser/light therapy, electrotherapy, real-time ultrasound imaging, belts, braces, supports, lubricants, myofascial tools/techniques, and “special topics” that can be used to assist in relaxation, bowel and bladder health, and sexual function. Specialized knowledge from experts in different subjects will be shared throughout the course. 

Certain modalities that are impractical to practice live will be shared and demonstrated via video. These Interventions include shockwave, rehabilitative ultrasound imaging, dry needling, and light therapy. 

Practical, trauma-aware, hands-on labs provide supervised instruction to practice utilizing biofeedback and other modalities to allow kinesthetic learning before prescribing and recommending them to patients. 

Previous course sponsors who have provided samples and products have included:

• Nix
• Flyte
• OhNut
• Replens
• RockTape
• Bellies Inc.
• Ice Soothers
• BabyBellyBand
• Intimate Rose
• The Pro Group
• Good Clean Love
• Cushion Your Assets

If you are interested in taking an intermediate-level Pelvic Function Course but still have questions, then please contact us.

Have you ever heard the phrase “In one ear and out the other?” I sure have, I have vivid memories of my grandmother scolding me for just that. She could never understand how when she said things to me, particularly a list of tasks to do, I could never seem to remember. Funnily enough, my grandfather’s nickname for me was “rabbit ears” because he swore I could pick up on a conversation from anywhere in close proximity so it wasn’t my hearing. Pretty conflicting and confusing, right? I had trouble processing things I heard or remembering them long enough to do them. Years of Catholic school helped to give me structure and tools to keep myself and my fun little brain organized and on task, and I ended up being able to keep up with the rest of my class. 

The older and more self-aware I got, the more I realized my brain doesn’t work the way everyone else’s does. The more I worked with kiddos with autism and ADHD, the more I realized my brain worked similarly to theirs. When I first heard the term “neurodivergent” I felt immediately like I had found the answer to a question I didn’t even know existed for myself. This was why I wasn’t the same as other people in processing all things! This is why I had to touch everything to learn about it. This is why I had to rewrite all my notes from professors instead of just being able to absorb what they said. This is why I needed mnemonics, stories, acronyms, and other little “hacks” to learn things. 

There are many different ways people can learn. The most common forms of learning consider if a person learns best through visual, aural/ auditory, reading/writing, or kinesthetic movement. Individuals can be any combination of these, which can vary as they grow through life. Someone may start out learning better kinesthetically and learn to process information better visually as they age. In our COVID era, a new format of teaching became more prevalent, bringing “at distance” learning in to save the day in many instances.

The prevalence of distance learning via forums such as Google Meet or Zoom brought up some questions about how well students could learn. Did students learn as well virtually? Did different types of learners have different results? Did how students felt they learned correlate with the outcome measures of learning? Distance education provides the ability for some populations to get education they would not be able to attain otherwise. In a study by Wakahiu & Kangethe, 2014, “participants described learning experiences with profound statements that endorsed online learning as an excellent strategy for fulfilling their dreams to acquire an education.”

Distance learning has many benefits including the ability to learn new materials and achieve new intellectual goals in most locations on a flexible time schedule. Another benefit is the access to visual resources and the potential to be able to rewatch. The decreased cost of transport and the safety (and hopefully less stress) of staying home were also huge benefits. Some disadvantages include not being able to guarantee effective learning, the ability to stay attentive, or be successful with materials. There can be connection and technological problems as well as some students not having the best learning environment in their home (Masalimova et al, 2022). When I think of learning and pelvic health, I think not having face-to-face interaction, accountability, and reinforcement of practicing the skills can hinder some student’s learning ability.

A report by the U.S. Department of Education compared the exam grades for online and face-to-face versions of the same course from 1996 to 2008 and concluded that “online learning could produce learning outcomes equivalent to or better than face-to-face learning (Zheng, 2021).” Cacault et al., 2021 also assessed the effects of online lectures finding that having access to a live-streamed lecture in addition to an in-person option “improves the achievement of high-ability students, but lowers the achievement of low-ability students.”

 How does this apply to Herman and Wallace? The pelvic institute has a variety of ways to learn including online courses, self-hosted options, satellite in-person classes with TAs, and in-person classes with instructors. They have made sure to account for different scenarios in order to make pelvic health learning accessible for all they can. The newest addition to the categories of “in person” and “with instructors” is Modalities and Pelvic Function. I had the pleasure of being on the curriculum team for this class and also being one of the instructors for the first run.

I thought people would like the stuff. I thought they would be excited to try biofeedback and electrical stimulation. I thought they would be pleasantly surprised by prizes and goodie bags full of awesome takeaways. I knew it would be a novel learning experience.

What I did not expect was the overwhelming feedback from participants stating things like“this course was one of the best I have met for my learning style.” The curious part is that when they were asked what their preferred learning style was, they were all different! Some liked to see, some needed to hear it, and some just were there to touch and feel and touch again. Varied practitioners, varied experience levels, varied treatment settings and population and one very consistent point of feedback…”This class just gets me.” 

If you’re on the hunt for a class that “puts it all together” when it comes to the tools and toys that can be used for the pelvic floor, check out Modalities and Pelvic Function. Not only are there SO MANY samples (think three shipping crates full - sorry UPS) BUT this class shows you how much is out there to treat pelvic health patients, the pros/cons, the indications, contraindications, and relative precautions as well as the language on how to educate your patient on the use of these items in the clinic or as part of their home self-care routine. Join me this summer either in Raleigh NC on July 13-14  or in Manchester NH on August 24-25!

Don’t believe me…here are two testimonials from our inaugural class!

“Of all of the pelvic floor courses I have taken up to date, this is by far the most enjoyable one! not only did it include how to efficiently treat patients, but it was well organized, exciting content, and everyone was lovely! the instructors were so personable and taught in a way to benefit any learning style. I will be recommending this to all of my fellow PF PTs!” - Rachel Biek, PT, DPT

“I loved the in-person portion of this class! The instructors (Mora and Jenna) were perfect in their roles, we were relaxed and had so much fun exploring the variety of tools to use. The feel of the class was supportive and intimate, and we had adequate time to explore everything. Mora and Jenna did an excellent job, hard to believe this was their first time teaching this class!” - Allison M. Gannon, PT, DPT

REFERENCES:

• Cacault, Christian Hildebrand, Jérémy Laurent-Lucchetti, Michele Pellizzari, Distance Learning in Higher Education: Evidence from a Randomized Experiment, Journal of the European Economic Association, Volume 19, Issue 4, August 2021, Pages 2322–2372, https://doi.org/10.1093/jeea/jvaa060
• Masalimova, A. R., Khvatova, M. A., Chikileva, L. S., Zvyagintseva, E. P., Stepanova, V. V., & Melnik, M. V. (2022, March). Distance learning in higher education during COVID-19. In Frontiers in Education (Vol. 7, p. 822958). Frontiers Media SA.
• Wakahiu, J., & Kangethe, S. (2014). Efficacy of online distance learning: Lessons from the Higher Education for Sisters in Africa Program. European Journal of Research and Reflection in Educational Sciences, 2(1), 1-25.
• Zheng, M., Bender, D. & Lyon, C. Online learning during COVID-19 produced equivalent or better student course performance as compared with pre-pandemic: empirical evidence from a school-wide comparative study. BMC Med Educ 21, 495 (2021). https://doi.org/10.1186/s12909-021-02909-z

AUTHOR BIO:

Mora Pluchino, PT, DPT, PRPC

I am a graduate from Stockton University with my BS in Biology (2007) and Doctorate of Physical Therapy (2009). I have experience in a variety of areas and settings, working with children and adults, including orthopedics, bracing, neuromuscular issues, vestibular issues, and robotics training. I began treating Pelvic Health patients in 2016 and now have experience treating women, men, and children with a variety of Pelvic Health dysfunction. There is not much I have not treated since beginning this journey and I am always happy to further my education to better help my patients meet their goals.

I strive to help all of my patients return to a quality of life and activity that they are happy with for the best bladder, bowel, and sexual functioning they are capable of at the present time. In 2020, I opened my own practice called Practically Perfect Physical Therapy Consulting to help meet the needs of more clients. I have been a guest lecturer for Rutgers University Blackwood Campus and Stockton University for their Pediatric and Pelvic Floor modules since 2016. I have also been a TA with Herman and Wallace since 2020 and have over 150 hours of lab instruction experience.

There are currently two scheduled course offerings available for Modalities and Pelvic Function: Philadelphia PA in April 6-7 and Manchester NH in August 24-25. If neither of these work for your location or schedule then consider hosting! The hosting requirements and interest form can be found on the Host a Course page. 

The new Modalities and Pelvic Function - Pelvic Health Clinical Toolkit is an in-person two-day continuing education course targeted to pelvic health clinicians covering frequently used modalities in pelvic health, including biofeedback and EStim. This course was designed to answer the clinician’s need to understand how to choose and access the right tools, both for in-clinic care and for patient self-care application.

One of the course co-creators, Mora Pluchino shared “This class will be unlike one you've taken before. The H&W curriculum team sat down and thought about how we could make this the most interactive, hands-on, and practical course while still staying evidence-based and professional. This will be an in-person learning opportunity with 2 days of lab, demonstration, and interactive learning opportunities. If there is a modality that exists in pelvic health, it will likely have a debut here. This class is made for anyone who wants to learn to apply modalities in the variety of uses possible for pelvic health!"

Biofeedback and electrical stimulation are covered in this course, as are introductions to understanding tools such as shockwave, dry needling, real-time ultrasound, laser, and electrotherapies. With hands-on lab time and learning modules grouped into tools specific to pelvic health conditions such as bowel dysfunction and sexual health challenges, practitioners will have the opportunity to trial various tools and applications that previously may have only been available as an image in a presentation.

When our popular Pelvic Function Level 1 course, which introduces participants to the world of pelvic health, was transitioned to a satellite lab course one of the content pieces that was left out was the modalities focus - simply because the equipment was too difficult to ship to multiple satellite locations around the country. Herman & Wallace is thrilled to announce that not only have we solved this issue, but designed a way for clinicians to learn about dozens of modalities in an environment that allows the clinician to move beyond theoretical and soundly into the practical delivery of a variety of technologies and tools.

Current Medical Technologies will be in-person with us as we design this learning experience and will be available to answer your questions about products and clinical set-up. The interactive environment has been designed to be stimulating and allow the clinician to apply a variety of learning strategies including tactile opportunities to try things on themselves or a lab partner. This is a unique course that provides a foundational understanding of technology and tools, clinical practice research, and recommendations in an in-person environment. Many equipment providers have been generous in providing sample products for trial and even some giveaways to take home!

We believe this Modalities course is so foundational to our skillset in pelvic health that we have added it to our core Pelvic Function Series. This course is intended to be taken after Pelvic Function Level 1 and can be taken at any point following the introductory course as you work your way through the PF Series. If you’re wondering “When should I take this course?” the answer is “as soon as you can!”  

Rehabilitative ultrasound imaging has been used in clinical practice for well over a decade now. It has been used for core stabilization, as well as with female incontinence patients. In recent years, transperineal ultrasound imaging has emerged as a useful tool for assessing prolapses and identifying other women’s health issues in the anterior compartment.

Like other things in men’s pelvic health, the use of ultrasound imaging for rehabilitation has lagged behind that in women’s pelvic health. Ryan Stafford is a researcher that is working to change that. In 2012, Stafford began looking at the normal responses to pelvic floor contractions and what is seen on ultrasound in men. He has since taken his research further to examine differences in men that present with post-prostatectomy incontinence. Stafford, van den Hoorn, Coughlin, and Hodges performed a study looking at the dynamic features of activation of specific pelvic floor muscles, and anatomical parameters of the urethra. The study included forty-two men who had undergone prostatectomy. Some of these men were incontinent and others remained continent. Transperineal ultrasound imaging was used to obtain images of the pelvic structures during a cough, and a sustained maximal contraction. The research team calculated displacements of pelvic floor landmarks with contraction, as well as anatomical features including urethral length, and resting position of the ano-rectal and urethra-vesical junctions.

The data was analyzed and combinations of variables that best distinguished men with and without incontinence were reported. Several important components were identified in the study. Striated urethral sphincter activation, as well as bulbocavernosus and puborectalis muscle activation were significantly different between men with and without incontinence. When these two parameters were examined together, they were able to correctly identify 88.1% of incontinent men. They further reported that poor function of the puborectalis and bulbocavernosus could be compensated for if the man had good striated urethral sphincter function. However, the puborectalis and bulbocavernosus had less potential to compensate for poor striated urethral sphincter function. This is important for a therapist that works with post prostatectomy patients to know. This can explain part of why some men improve and do so well after a prostatectomy and others don’t, even with therapy to help. If the striated urethra sphincter is damaged and its normal responses are changed during surgery, then incontinence after prostatectomy may be more likely.

Using ultrasound imaging, the therapist can examine and see exactly where a man is deficient in response; whether it is the puborectalis, or the striated urethra sphincter. It is exciting to see this new research and see how rehabilitative ultrasound imaging can influence men’s pelvic health! Come and learn how to use ultrasound imaging for your men’s pelvic health patients as well as your women’s health and back pain patients! You will see how ultrasound imaging can change your practice and how much your patients will enjoy seeing real-time images of their contractions! Thanks to our partnership with The Prometheus Group, this course includes hands-on training on the latest in pelvic ultrasound imaging.

1. Stafford R, Ashton-Miller J, Constantinou C, et al. Novel insights into the dynamics of male pelvic floor contractions through transperineal ultrasound imaging. J. Urol. 2012; 188: 1224-30.
2. Stafford RE, van den Hoorn W, Couglin G, Hodges P. Postprostatectomy incontinence is related to pelvic floor displacements observed with trans-perineal ultrasound imaging. Neurol and Urodyn. 2018; 37:658-665.
Image credit Gupta et al. 2016 https://doi.org/10.1016/j.ajur.2016.11.002 https://www.sciencedirect.com/science/article/pii/S2214388216300881#fig2

Authors: Tamara Rial, PhD, CSPS, Kathleen Doyle-Elmer, PT, DPT and Rebecca Keller, PT, MSPT, PRPC

Tamara Rial, PhD, CSPS, co-founder and developer of Low Pressure Fitness will be presenting the first edition of Low Pressure Fitness and Abdominal Massage for Pelvic Floor Care Level 2 and 3 in Princeton, New Jersey in September, 2019. Rebecca Keller and Kathleen Doyle-Elmer are certified Low-Pressure Fitness specialists with training in rehabilitative ultrasound imaging. In this article, the authors discuss and explore the use of transabdominal ultrasound during Low Pressure Fitness on the abdominal and pelvic floor structures.

Real-time ultrasound imaging is a reliable and valid method to evaluate muscle structure, activity and mobility. Over the past few years, there has been increasing interest in the use of transabdominal ultrasound in the field of rehabilitation. The additional value of ultrasound imaging is that it allows for real-time analysis and visual feedback during the performance of pelvic floor and abdominal exercises (Hides et al., 1998). In the field of pelvic health, this is of notable importance when assessing proper movement of the deep abdominal and pelvic muscles during voluntary muscle actions. Transabdominal ultrasound has been found to be a safe, noninvasive, and accurate method to assess and observe muscular and fascial activity (Khorasani et al., 2012). When therapists learn how to properly use and apply ultrasound imaging, this technique can be a comprehensive tool for the clinician and a comfortable procedure for the patient. Moreover, it may be the method of choice for some patients who don’t want to have an internal pelvic examination (Van Delft, Thakar & Sultan, 2015). In this regard, a cross-sectional study found a moderate-to-strong correlation between ultrasound measurements and both digital examination and perineometry for the assessment of pelvic floor muscle actions (Volløyhaug et al., 2016).

Recently, Low Pressure Fitness has gained popularity as a pelvic floor training program aimed at reducing pressure on the pelvic structures while engaging the stabilizing muscles through postural and breathing exercises. In order to evaluate proper execution of Low-Pressure Fitness exercises as well as abdomino-pelvic muscle function during this type of training, real-time transabdominal ultrasound can be a clinically relevant tool.

Sagittal and Transverse Pelvic Floor/Urinary Bladder Assessment

The amount of movement of the bladder base on transabdominal ultrasound is considered an indicator of pelvic floor muscle mobility during pelvic floor muscle exercises (Khorasani et al., 2012). When properly executed, the Low-Pressure Fitness technique will allow the bladder to lift and the pelvic floor muscles to contract. These observed actions can be cued and progressed due to the real-time imaging biofeedback of the ultrasound. Because of the postural activation and diaphragm lift occurring during Low Pressure Fitness, the bladder fascial support system is tensioned resulting in a desirable bladder lift.

For example, we used a Pathway® Musculoskeletal Rehabilitative Ultrasound Imaging unit with a curvilinear transducer and Prometheus Pathway® rehabilitative ultrasound software utilizing the pre-set parameters (Abdominal Wall 7.5MHz and Bladder 5.0MHz) during a Low-Pressure Fitness basic supine posture. A standardized bladder filling protocol was used before imaging to ensure sufficient bladder filling to allow clear imaging of the base of the bladder and pelvic floor muscles.

For the transverse view, radiologic standards were used, and the ultrasound transducer was placed in the transverse plane suprapubically and angled in a caudal/ posterior direction to obtain a clear image of the inferior-posterior aspect of the bladder. The participant was asked to perform the Low-Pressure Fitness Demeter exercise in the supine position with a neutral pelvis and knees flexed (Figure 1).

^{Figure 1. Demeter exercise with postural technique and with postural and abdominal vacuum technique combined.}

The following video illustrates the pelvic floor/urinary bladder during: a) resting position; b) active pelvic floor contraction; c) Low Pressure Fitness Demeter exercise and; d) Low Pressure Fitness Demeter exercise combined with a voluntary pelvic floor muscle contraction. It is noticeable a greater bladder lift and pelvic floor activation with the postural and breathing cueing added to an active pelvic floor contraction than with the pelvic floor contraction alone.

Lateral Abdominal Wall Assessment

The lateral abdominal muscle ultrasound assessment allows us to observe the structural changes produced in the transversal section of the abdominal muscles in the midpoint between the anterior iliac crest and the costal angle. At low levels of contraction, the extent of transverse abdominis thickening measured using ultrasound is reported to be a valid method of assessment compared with either fine wire electromyographic measures of transverse activity (McMeeken et al., 2004). It is well established in the scientific literature that the lateral abdominal muscles provide stability to the trunk in different functional activities. Therefore, the assessment of the size, thickness and sliding of the abdominal wall is important for patients who present with lumbo-pelvic and/or pelvic floor dysfunctions. In this regard, patients with low back pain show different abdominal wall muscle activation patterns (i.e. less slide of the abdominal fascia and muscle thickness) than those without low back pain (Gildea et al., 2014; Unsgaard-Tondel et al., 2012).

Figure 2 shows the three muscle layers of the lateral wall in the resting position. The superficial layer corresponds to the external oblique, the middle layer to the internal oblique and the deep layer to the transverse abdominal muscle.

^{Figure 2. View of the right lateral abdominal wall at rest.}

A key breathing component of the Low-Pressure Fitness program is the abdominal vacuum which manipulates intra-abdominal, intra-thoracic and intra-pelvic pressures during the breath-holding phase. Another key aspect of Low-Pressure Fitness is the shoulder girdle activation, spine elongation and ankle-dorsiflexion (Rial & Pinsach, 2017). Of note, previous studies have demonstrated greater transverse abdominis activation when performing ankle dorsi-flexion (Chon et al., 2010). We used transabdominal ultrasound to assess the lateral abdominal wall response during ankle dorsiflexion, shoulder girdle activation and the abdominal vacuum during Low Pressure Fitness.

In the following video, a voluntary (active) abdominal contraction is performed in order to distinguish this action from the involuntary abdominal contractions during Low Pressure Fitness. Afterwards, the postural technique of ankle dorsiflexion and shoulder girdle activation are performed in the Demeter exercise with arms in middle position (Figure 1). Lastly, an abdominal vacuum maneuver is added to the postural technique. If the exercises are properly executed, the progressive sliding and thickness of the abdominal muscles throughout exercise sequence should be observable (Figure 3).

^{Figure 3. Ultrasound imaging at rest and during the complete LPF technique.}

Muscle thickness of the transverse and internal oblique as well as a noticeable slide of the anterior abdominal fascia are observable during the Demeter exercise of Low-Pressure Fitness. This exercise pattern reflects an abdominal draw-in maneuver and a “corseting effect”. In this regard, notice the lateral pull or displacement of the edge of the anterior fascial insertion of the transverse the internal oblique muscle.

Navarro et al., (2017) used transabdominal ultrasound to assess the muscular responses of the pelvic floor and abdominal muscles in a group of women who underwent pelvic physiotherapy over two months. They found a significant increase in the transversal section of the transverse abdominis, external oblique, and internal oblique muscles when compared to resting in the supine position. Similar to the position assessed by Navarro et al. (2017), we also assessed the pelvic floor and abdominal muscle responses during a Low-Pressure Fitness supine exercise.

Transabdominal ultrasound can provide a noninvasive and informative visual biofeedback when training patients with Low Pressure Fitness. This ultrasound imaging can be a valuable tool to both the client and the clinician to objectify progress, assist with validating correct Low-Pressure Fitness form with positioning and vacuum/hypopressive maneuver as well as a motivational technique for the client. As demonstrated during our rehabilitative ultrasound imaging, observable bladder lift, pelvic floor activation and desirable lateral abdominal muscular corseting (slide and thicking) occurs during Low Pressure Fitness postural exercises and breathing. Since Low Pressure Fitness is a progressive exercise program, qualified instruction, technique driven progression and understanding pelvic floor health are needed to optimize patient outcomes.

Chon SC, Chang KY, You JS. Effect of the abdominal draw-in manoeuvre in combination with ankle dorsiflexion in strengthening the transverse abdominal muscle in healthy young adults: a preliminary, randomised, controlled study. Physiotherapy 96: 130-6, 2017.
Gildea JE, Hides JA, Hodges PW. Morphology of the abdominal muscles in ballet dancers with and without low back pain: a magnetic resonance imaging study. J Sci Med Sport. 17(5): 452-6, 2014.
Khorasani B, Arab AM, Sedighi Gilani MA, Samadi V, Assadi H. Transabdominal ultrasound measurement of pelvic floor muscle mobility in men with and without chronic prostatitis/chronic pelvic pain syndrome. Urology, 80: 673-7, 2012.
McMeeken JM, Beith ID, Newham DJ, Milligan P, Critchley DJ. The relationship between EMG and change in thickness of transversus abdominis. Clin Biomech 19: 337–342, 2004.
Hides JA, Richardson CA, Jull GA. Use of real-time ultrasound imaging for feedback in rehabilitation. Man Ther. 3:125-131,1998.
Navarro B, Torres M, Arranz B, Sanchez O. Muscle response during a hypopressive exercise after pelvic floor physiotherapy: Assessment with transabdominal ultrasound. Fisioterapia 39: 187-94, 2017.
Rial T, Pinsach P. Practical Manual Low Pressure Fitness Level 1. International Hypopressive & Physical Therapy Institute, Vigo, 2017.
Unsgaard-Tøndel M, Lund Nilsen TI, Magnussen J, Vasseljen O. Is activation of transversus abdominis and obliquus internus abdominis associated with long-term changes in chronic low back pain? A prospective study with 1-year follow-up. Br J Sports Med, 46(10): 729-34, 2012.
Van Delft K, Thakar R, Sultan AH. Pelvic floor muscle contractility: digital assessment vs transperineal ultrasound. Ultrasound Obstet Gynecol, 45: 217-22, 2015. Volløyhaug I, Mørkved S, Salvesen Ø, Salvesen KÅ. Assessment of pelvic floor muscle contraction with palpation, perineometry and transperineal ultrasound: a cross-sectional study. Ultrasound Obstet Gynecol 47: 768-73, 2016.

As so many of our patients are shallow breathers, I found this research on the effects of mindful attention to the breath (MATB) on prefrontal cortical and amygdala activity especially informative and relevant to patient care. Twenty-six healthy volunteers with no prior meditation experience were introduced to MATB by an experienced meditation teacher and instructed to practice a 20-minute audio guided MATB meditation daily for 2 weeks.¹ At the end of the 2-week training period, subjects underwent fMRI scanning while viewing distressing emotional images with MATB and with passive viewing (PV). Participants were shown aversive pictures or no pictures and were instructed to “Please focus your attention on your breath as you were instructed in the training” or “Please watch the picture without changing anything about your feelings.” Subjects indicated their current affect on a 7 point scale ranging from -3 (very negative) to +3 (very positive).

Breathing frequency significantly decreased during MATB compared to PV. Researchers controlled for this by including breathing frequency as a covariate in further behavioral and brain data analysis.

Analysis of affective ratings showed that participants felt significantly less negative affect when viewing distressing visual stimuli during MATB than PV. During negative visual stimuli, MATB significantly decreased bilateral amygdala activation compared to PV. Also, right amygdala activation decrease specifically correlated with successful emotional regulation. That is, those participants with greater reductions in right amygdala activation reported greater reductions in aversive emotions during the MATB. In addition, emotion-related functional connectivity increased between the prefrontal cortex and amygdala during the viewing of negative images and MATB.

It’s exciting to have some initial science behind the benefits of MATB. I teach all of my patients MATB and have found it rewarding to get feedback from participants in my courses about their integration of MATB into their own patient care. Patients with complex pain conditions can be challenging to treat, however sometimes a simple practice of taking 2 to 3 minutes prior to and/or at the end of a treatment to have a patient calmly focus on their breath with the mindful attitudes of acceptance, kindness and curiosity can help a person shift from tension and distress to calm and confidence. I look forward to presenting this and additional research on the impact of mindful meditation on brain structure and function in my upcoming course, Mindfulness-Based Pain Treatment, in Seattle, November 4 and 5. Hope to see you there!

1. Doll A, Holzel BK, Bratec SM, et al. Mindful attention to breath regulates emotions via increased amygdala-prefrontal cortex connectivity. Neuroimage. 2016;134:305-313.

The following case study comes from faculty member Deb Gulbrandson, PT, DPT, a certified Osteoporosis Exercise Specialist and instructor of the Meeks Method. Join Dr. Gulbrandson in The Meeks Method for Osteoporosis on September 22-23, 2018 in Detroit, MI!

The first sight I had of my new patient was watching her being wheeled across the parking lot by her husband. A petite 72-year-old, I could see her slouched posture in the wheelchair. With the double diagnosis of osteoporosis and Multiple Sclerosis (MS) it didn’t look good. However, “Maryanne“ greeted me with a wide grin and a friendly, “I’m so excited to be here. I’ve heard good things about this program and can’t wait to get started.“

That’s what I find with my osteoporosis patients. They are highly motivated and willing to do the work to decrease their risk of a fracture. Maryanne was unusual in that she was diagnosed with MS at a very young age. She was 18 and had lived with the disease in a positive manner. She exercised 3X a week and had a caring, involved husband. They worked out at a local health club, taking advantage of the Silver Sneakers program. Maryanne was able to stand holding onto the kitchen counter but had stopped walking five years ago due to numerous falls. She performed standing transfers with her husband providing moderate to max assist. Her osteoporosis certainly put her at a high risk for fracture.

Even though she had been exercising on a regular basis, she was unfortunately doing many of the wrong exercises. Her workout consisted of sit-ups and crunches. She used the Pec Deck bringing her into scapular protraction and facilitating forward flexion. She was also stretching her hamstrings by long sitting reaching to touch her toes.

Spinal flexion is contraindicated in patients with osteoporosis. A landmark study done in 1984¹ divided a group of women with osteoporosis into 4 groups. One group performed extension based exercises, a second group did flexion. A third group used a combination of flexion and extension and the fourth was the control and did no exercises. Below are the results 1-6 years later.

• Extension Group: 16% incidence of fracture or wedging of vertebral bodies
• Flexion Group: 89% rate.
• Combination Extension/Flexion: 53% rate
• No Exercise Group: 67%

The results were astounding. Granted, it was a small study- 59 participants and it was done a long time ago. But this is a one study that no one wants to repeat, or volunteer for!

Several take home messages followed this study.

1. Flexion is contra-indicated for individuals with osteoporosis.
2. It’s better to do no exercise than the wrong exercise. The No Exercise group faired better than the Flexion group although at 67% it’s clear that many of our everyday activities- making beds, placing items on low shelves, and now computing and texting put us at risk.

Sadly, many individuals with osteoporosis are told by their physicians to start exercising.......but without any guidance they do what Maryanne did. Just start exercising. And putting themselves at greater risk.

Maryanne was also doing nothing to strengthen her back extensors and scapular area. After giving an overview of the vertebral bodies, pelvis, and hip joint with my trusty spine, I showed both my patient and her husband how forward flexion puts increased compression on the anterior aspect of the spine, particularly in the thoracic curve at T 7, 8, 9, the most common site of compression fractures. We started with Decompression, which is the beginning position for the Meeks method. Many therapists know this as hooklying. This position allows the spinous processes to press against the hard surface of the floor, opening up the anterior portion of the spine and providing tensile forces throughout the length of the spine. With the help of her husband, Maryanne could get down on the floor but I often advise patients who are unable to safely transfer to the floor to lay across the end of their bed. This is less cushy than lying longways where they sleep. Adding a yoga mat or a quilt on top to give more firmness improves the effect.

Supine is the least compressive of all positions; sitting is the most compressive. While Decompression may not seem like much of an exercise it is vital to reduce the effects of gravity and compression on the spine.

We addressed sitting posture by firming up the base of her wheelchair as well as recommending transferring into other chairs and positions frequently throughout the day. Spending time sitting towards the edge of a firm chair in what we call Perch Posture and practicing Foot Presses into the floor created improved alignment in her spine as well as isometrically activating glutes, abs, quads. Using the Foot Press is an example of Newtons 3^rd Law, “For every action there’s an equal and opposite reaction” so by pressing her feet down she actually lengthened her torso and head. We also discussed discontinuing the contraindicated exercises in her workout routine and I assured her that the Meeks method would progressively challenge her core (the reason everyone thinks they should do sit-ups) and target the right muscles to help strengthen her bones. We use site specific exercises to target certain muscles that pull on the bone and increase bone strength.²

With instructions to Decompress several times daily to reduce compression on the spine along with the other adjustments made, I felt Maryanne was on her way to reducing her risk of fracture and increasing the quality of her life. She thanked me profusely for the education and the exercise of that session. We both look forward to the next one.

1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984 Oct;65(10):593-6.
2. Frost HM1. Wolff's Law and bone's structural adaptations to mechanical usage: an overview for clinicians. Angle Orthod. 1994;64(3):175-88.

My name is Tina Allen.  I teach a course called Manual Therapy Techniques for the Pelvic Rehab Therapist. I developed this course in 2016 out of desire to help clinicians feel comfortable in their palpation and hands on skills.

My journey as a pelvic rehab therapist started with a patient whispering to me in the middle of a busy sports/ortho clinic gym;  “is it normal to leak when you laugh”.  I was treating her after her total hip replacement and my first question was “where are you leaking”? I was concerned that her incision was leaking, that she had an infection and it was beyond me to understand why it would happen when she laughed! I was 24 years old and 2 years out of PT school. Little did I know, that one whispered question would lead me to where I am today. I am in my 25^th year as a PT and 20^th year specializing in pelvic rehabilitation.

When I started out there just were not many classes. I spent time learning from physicians, reading anything I could find and applying ‘general ‘orthopedic principles to the pelvis.  I traveled to clinics and learned from other clinicians. I soaked up anything I could and brought it back to my clinical practice. When Holly Herman and Kathe Wallace asked me to teach with them I was humbled, honored and terribly nervous. Holly and Kathe where two of my greatest resources and to be able to teach along side them to help others along was humbling.  As I prepared to teach I realized the breadth of what we do as pelvic rehab clinicians has grown exponentially since I started out.

Over the past 10 years of teaching the pelvic series with H&W; I noticed that for some of the participants there was a gap in confidence in palpation skills and in treatment techniques applied to the pelvic floor region. For most, it’s confidence in what they are feeling and where they are.  This course came out of wanting to fill that gap. I wanted to allow a space that clinicians could come and spend two days learning, affirming and building confidence in their hands. They could then take those skills and confidence back to their clinics and help more patients.

The thought of writing this course was daunting. First off, written words are not my thing. Don’t get me wrong I love to read but me coming up with what to put on paper, much less a power point slide, frightened me. With much encouragement and support from colleagues and H&W, I got to work. The first thing was to think about what techniques to include. At some point after 20 years in the field, your hands just do the work and you don’t think about how you do something. My colleague and dear friend Katy Rice allowed me to sit down with her, practice a technique and then write down each specific step to do the skill. She would read them over and then attempt to do the technique by following only the written instructions. I also had patients who were instrumental in helping me choose what techniques to include. They would say to me “that is what made all the difference for me; it has to be included in what you teach others. “

I would think about who taught me each technique, whether it was a course, another clinician or a patient.  I know that I did not make any of these up myself; while I may have modified a technique to work with my hands I did not originate them. Holly Tanner was so kind to brain storm with me and lead me to references for some of the techniques that we as clinicians use every day and that I was planning to include.

What happened next was months of me sitting at the kitchen table combing through books, articles, course manuals and online videos looking for origins of the techniques I use every day in my clinical practice. I wanted to be sure to give credit to sources. It was tedious but also inspiring to realize that some of these techniques have been around and documented since 1956 (Dicke, E., & Bischof-Seeberger, I.) and also that the same techniques are sited by multiple different sources. After about 6 months of our kitchen table not being suitable for dinner it was time to see what I had gathered and how it would all fit together. The result was this 2 day course: Manual Therapy Techniques for the Pelvic Rehab Therapist which has seven labs including internal, external and combination techniques, home program/self care ideas and time for brainstorming treatment progressions. Join me in Philadelphia, PA this October 20 - 21 to learn these essential skills.