I will never forget when my sister, my bestie, told me she wanted to end her life. We were on the phone late one night, tears flowing. Depression was always a companion, but I had never heard her in such a state of despair. We made a plan that she would call the suicide hotline, then call her therapist and her doctor in the morning for urgent care. She made it through the night. Later, I went to her therapist with her so I could better understand and support my sister. She did her due diligence, adjusting medication and staying open and honest in therapy. Suicidal ideations would sometimes flare when there were triggers, but she was able to work through them, and now they are in the past.

Contrast that story with another. Ryan was a sweet woman who developed pudendal neuralgia after a routine hysterectomy. Right away, she told me she had a counselor who she loved who helped her navigate life with DID (Dissociative Identity Disorder) and that I’d probably be interacting with various personalities during our sessions. She helped me understand how to best support her during her care. We worked well together, and although she struggled with both the pain and the unfairness of what happened to her, she was well supported. Then her sweet dog passed away. It was so hard for her. She kept going through pain and heartache and found another pooch to adopt. And then the next visit, she didn’t show. And the next, and the next. And then I found out she was gone. Suicide. This hit me hard. Were there signs that I missed? Was there anything I could have done?

As pelvic rehab providers, we sometimes see people who have intense physical pain often combined with significant emotional wounds. In a study of 713 women seeking support for pelvic pain, 46.8 reported having sexual or physical abuse history, and 31.3 were positive for PTSD (1).

Chronic pelvic pain impacts all aspects of people’s lives: physical, financial, relational, emotional, and mental. People can also become dependent on narcotics or recreational drugs which may lead to intentional or accidental overdose, per Philip Hall, a gynecologist in Australia (2).

In a study of 13,500 women with endometriosis, half reported experiencing suicidal thoughts (3).

So what’s our role as health care providers?

It’s important to note that not everyone who is considering suicide will admit it, and not everyone who thinks about suicide will follow through with it. However, all threats of suicide should be taken seriously. Let people know you care, they are not alone, and help is available.

Ask questions: It may feel scary, but it won’t push someone into harmful action. The Columbus Protocol, listed below, uses three questions to identify suicide risk. If someone answers yes to any question, they have a significantly higher risk of suicide and need support(4).

• Have you wished you were dead or wished you could go to sleep and not wake up?
• Have you had any thoughts about killing yourself?
• Have you thought about how you might do this?

Be observant of warning signs:

1. people may talk about taking their own life, wishing they could end things, wishing they were never born
2. you may observe extreme mood swings
3. the person may start putting their affairs in order
4. there may have been a recent trauma or crisis
5. you may notice withdrawal or sudden calmness
6. the person may participate in risky or reckless behavior

If someone admits to planning for suicide, as health care providers, we MUST take supportive action. If your facility does not have a protocol, consider these steps:

1. Call 911 and perhaps a friend or family member to meet the person at the hospital
2. Stay with the person until help arrives
3. Remove any objects that may be used for harm
4. Listen with kindness and understanding
5. Stay Connected: studies show that follow up after an event decreases the risk of suicide death(5)

It’s helpful also to note the following protective behaviors, as reported by psychiatry.org(6):

1. Connection with health care providers
2. Strong connections between family, friends, community
3. Skillfulness around problem-solving and conflict resolution

Knowing what to look for, what questions to ask, and how to get someone the help they need empowers health care providers to provide the best support for patients struggling with suicidal ideation and contemplation.

There are local and national resources for us as well.

The National Suicide Prevention Lifeline: 1-800-273-(TALK) (1-800-273-8255). The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals in the United States(7).

References:

1. Meltzer-Brody, S., Leserman, J., Zolnoun, D., Steege, J., Green, E., & Teich, A. (2007). Trauma and posttraumatic stress disorder in women with chronic pelvic pain. Obstetrics & Gynecology, 109 (4), 902-908.
2. https://standrewshospital.com.au/about-us/news/news-listing/2016/09/05/chronic-pelvic-pain-linked-to-suicides-in-young-women
3. https://www.bbc.com/news/health-49897873
4. https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/
5. Motto, J. A., & Bostrom, A. G. (2001). A randomized controlled trial of postcrisis suicide prevention. Psychiatric Services52(6), 828-833.
6. https://www.psychiatry.org/patients-families/suicide-prevention
7. https://suicidepreventionlifeline.org/

Ashley Rawlins is a Dallas-based doctor of physical therapy (DPT) with advanced certification in pelvic health and obstetric health. She practices at Origin, leading provider of virtual and in-person physical therapy for women. Dr. Rawlins's areas of specialization include pelvic pain, sexual dysfunction, pregnancy-related pain, postpartum recovery, and bowel and bladder dysfunction. She is a passionate author and educator and enjoys creating educational materials and teaching classes for patients, students, and fellow physical therapists.

I may be biased, but pelvic health is arguably one of the most important specialties in physical therapy. It's well known that pelvic floor muscle dysfunction affects individuals across every age group, life stage, sex, and gender, and can contribute to pain and dysfunction in many other areas of the body. According to research, 23.7% of women have at least one pelvic floor disorder and this percentage only increases with age. (1) So, why aren’t more physical therapists specializing in pelvic health?

A cross-sectional survey completed in 2018 found that the biggest barriers to entering this specialty are “lack of awareness, mentorship, and continued education.” (2) An alarming 59% of physical therapists have received little to no information on pelvic health physical therapy when graduating from their entry-level program. (2)

If you’re a physical therapist reading this, you’ve probably received a peppering of instruction on topics including lymphedema, osteoporosis, pregnancy, and maybe urogenital dysfunction. When I was a student, I only had two lectures covering topics related to pelvic health, plus one afternoon dedicated to observation of the prosected female sex anatomy. Luckily, those lectures and that one afternoon were so fabulous, they got me hooked on this specialty, but it was hardly enough education, given the prevalence of pelvic floor dysfunction.

More awareness of and education on pelvic health is needed so that physical therapists can better care for their patients. At Origin, we’re helping to fill this need by supporting physical therapy students who are interested in pursuing a career in pelvic health, but who may not be able to get the required experience.

Pathways to Pelvic Physical Therapy

There isn’t one specific path to becoming a pelvic physical therapist. Some students will complete a post-professional residency in pelvic health. Some will independently take continuing education courses and pursue certifications or board certifications in pelvic health. Whichever path you take in getting the knowledge and hands-on skills that are critical for safely diagnosing and treating this patient population, one thing is true: It can be both expensive and nerve-wracking!

If you are lucky enough to get a pelvic health clinical rotation, you’ll likely need to complete an advanced training course on pelvic health first. This is so you’re familiar with examination and treatment frameworks. These courses are costly for students in physical therapy school and can make these opportunities an impossibility for those with fewer economic resources.

In addition to being expensive to prepare for, clinical rotations for pelvic health in physical therapy school are intimidating. Yes, it’s exciting to finally be out in the “real world” after being stuck in a classroom for months. But even if you’re didactically prepared, walking through the doors of a new clinic with little more than the name of your clinical instructor (CI) can be terrifying. My clinical rotations felt more like boot camp, at times — I was dropped into the waters of patient care and made to sink or swim, based on my CI’s rules. Looking back, I know this was really more of how it felt versus the reality, but I longed for a rotation that was collaborative and curated to improve my clinical competence.

Educating & Mentoring Students in the Clinical Setting

At Origin, we don’t want finances to be a barrier for those pursuing a career in pelvic health, nor do we want students to feel underprepared or unsupported. We value creating opportunities, providing education, and mentoring those wanting to enter this area of specialty. Much like the patient care standards at Origin, we have worked to create an elevated student clinical experience. Below are some of the ways that we are providing this education and experience in our pelvic health clinics.

Onboarding: We start each clinical rotation with thorough onboarding so every student feels prepared. Prior to the first day in the clinic, students get a Student Handbook which details everything they need to feel prepared in their clinical rotation, from what to wear, to information on our company’s values, mission, and policies. We also take the time to train students on our EMR system, billing practices, telehealth services, and our model of care.

Learning Modules Depending on the length of the clinical rotation, we have developed various training modules for each of the students to complete with their CI. Important topics related to orthopedic and pelvic health physical therapy include infection control, informed consent, internal and external pelvic floor muscle examination, as well as a thorough training on some of the more common conditions that we treat in our clinics—weekly student “check-ins” help to inform the curriculum organization and tailor each student’s experience.

Simulation Experiences: Taking a course in pelvic health in advance of the clinical will set students up for a more in-depth rotation in pelvic health, but if getting this training is a barrier to starting in pelvic health, we’ve developed simulation experiences for the student. Once the students have completed the appropriate learning modules, we pair students to practice on each other, or help in getting volunteer pelvic models. Additionally, skills labs, team Learning and Development meetings, and student in-service assignments help to reinforce concepts learned throughout the clinical rotation.

At Origin, part of our mission to expand access to healthcare includes expanding the community of knowledgeable and expert pelvic health physical therapists. We feel that by improving the student experience and initiating the path to specialization in pelvic health, we can proactively change the status quo of pelvic floor care.

References:

1. Nygaard I, Barber MD, Burgio KL, et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1311–1316. doi:10.1001/jama.300.11.1311.

2. Dockter M, Benson S, Zhang Y, Anderson C, Le D. Factors influencing physical therapists to enter into women's health specialty practice. Journal of Women's Health Physical Therapy. 2018; 42(3): 154-164. doi: 10.1097/JWH.0000000000000107.

Allyson Shrikhande, a board-certified Physical Medicine and Rehabilitation specialist, is the Chair of the Medical Education Committee for the International Pelvic Pain Society. She is a leading expert on pelvic health and a respected researcher, author, and lecturer. Dr. Shrikhande is a recognized authority on pelvic pain diagnosis and treatment and is the author and instructor of the remote course Working with Physiatry for Pelvic Pain. Her course discusses the synergistic nature of pelvic physiatry with pelvic floor therapy.

Chronic Pelvic Pain Syndrome (CPPS) is a condition that causes pain or discomfort in the lower abdominal and pelvic region including the buttocks, lower back, hips, groin, perineum, and deep pelvic structures which last longer than six months. The symptoms of CPPS often affect the function of organs such as the bladder and bowel. It can cause difficulty sleeping and pain with sitting or sexual intercourse. It may also result in mobility issues which can impede your ability to manage basic daily tasks. The symptoms of CPPS should be taken seriously and deserve the attention of a healthcare professional.

What causes CPPS?

CPPS often has no singular root cause but is rather rooted in a combination of multiple different issues. Some of the many common risk factors are:

• Hormonal changes, which may occur naturally, throughout a woman’s lifetime (such as during menopause or pregnancy), or because of a glandular imbalance
• Gynecological disorders like fibroids, endometriosis, adenomyosis, polycystic ovarian syndrome, pelvic inflammatory disease, pelvic congestion syndrome, vulvodynia, and lichen sclerosus
• Infections, including yeast infections, urinary tract infections, and bacterial vaginosis
• Urological causes such as bladder pain syndrome or interstitial cystitis
• Musculoskeletal causes including hip, sacroiliac joint, or spine pathology, Myofascial Pain syndromes, and pelvic floor muscle tightness or spasticity
• Gastrointestinal causes like hemorrhoids, irritable bowel syndrome (IBS), Crohn’s disease, and ulcerative colitis
• Neurologic disorders such as herpes simplex or migraines
• Rheumatological disorders such as Ehlers Danlos Connective Tissue hypermobility disorders, rheumatoid arthritis

We also need to acknowledge how important mental factors like stress, anxiety, and emotional trauma often are in contributing to pelvic floor muscle tension. There also may be hereditary factors that cause an upregulated nervous system, which often contributes to increased pain sensitivity.

What makes CPPS so difficult to diagnose?

The causes of CPPS are complex. It’s a condition that often involves multiple organs as well as the nervous, myofascial, and skeletal systems. Some of the most common risk factors for CPPS, including endometriosis and neuromuscular dysfunction, are hard to accurately diagnose. These conditions may not appear on x-rays, ultrasounds, or other imaging tests. Proper identification of CPPS requires a pelvic pain specialist to make an informed analysis of the patient’s medical history and symptoms.

How would you describe a physiatrist's role in working with other specialists to treat CPPS?

Physiatrists are the “quarterback” of CPPS patient care. This is because physiatrists are not trained in just one organ system, we’re trained to examine the interplay of the different organ systems with each other, as well as with the muscles and nerves. This makes physiatrists uniquely qualified to “quarterback” a CPPS patient’s healthcare team. We take a holistic look at each patient, including mind-body connections. This helps us understand each individual person’s primary pain generators and predisposing factors to having pelvic pain.

To learn more about working with physiatry, join Allyson Shrikhande at her course, Working with Physiatry for Pelvic Pain, scheduled for January 11, 2022. Her course will review the core elements, including diagnosis and non-operative treatment options, for a successful pelvic floor therapy and pelvic physiatry relationship for non-operative management of Chronic Pelvic Pain (CPPS) patients.

Herman & Wallace is excited to announce a collaboration with Dr. Michael Hibner, an international expert on pudendal neuralgia and chronic pelvic pain. Dr. Hibner is presenting a new remote course on January 9, 2022, titled Pudendal Dysfunction: The Physician's Perspective. Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve. This condition is not widely known and often goes unrecognized by many practitioners. Dr. Hibner runs the Arizona Center for Chronic Pelvic Pain (AZCCPP), a comprehensive center for treating chronic pelvic pain, and places a heavy emphasis on working as part of a care team with physical therapists and other pelvic rehab providers.

In a recent publication by Dr. Hibner, he shares that “the International Pudendal Neuropathy Association estimates the incidence of this condition to be 1/100,000; however, most practitioners treating patients with this condition feel the actual rate of incidence may be significantly higher.” Many patients go an average of 10-15 years attempting to get a diagnosis for their pain. Diagnosis of this condition is heavily based on the utilization of Nantes Criteria in conjunction with clinical history and physical findings.

Dr. Hibner began his career as a urogynecologist. In the early 2000s, some of his patients presented with a vulvar burning pain that didn’t fit any known criteria. When he reviewed the histories of these patients, he found that the only thing in common between these patients was kickboxing. Further research then led him to pudendal neuralgia.

What are some of the typical patient characteristics/presentations and the time of diagnosis and referral?

If you think of chronic pelvic pain, it really spans multiple specialties. It spans urology, colorectal, gastrointestinal, and physiatry. A lot of it is musculoskeletal pain, so a lot of it is physical therapy, orthopedics, and neurosurgical. However, for pudendal neuralgia patients, there are three distinct groups of patients. The younger group, 20-year-olds, are mostly injured in some type of athletic activity (skiers, gymnasts, cyclists, workout, etc.). The second group is slightly older, approximately mid-30s. Their most common cause of PN is traumatic vaginal childbirth. The older group often has had a mesh procedure (such as for prolapse) with the older kind of meshes.

What is your standard approach to PN patient complaints?

My protocol is that every patient that comes in gets a pelvic MRI before being seen (while doing Kegels and Valsalva). Even if seeing a physical therapist, I would have them see one associated with my practice so that the PT could take part in the patient meeting. I have my fellow take the patient history. Then we meet in my office, myself, the physical therapist, and my fellow, with MRI results, before seeing the patient. Then I meet the patient and can offer options.

How do I diagnose and treat PN?

I used to believe that the Nantes Criteria is what you had to use when diagnosing pudendal neuralgia. I recently retranslated the criteria for a textbook that is coming out soon. Patients should meet some of these criteria but don’t need to meet all of them. It just means that your pain is in the area of the pudendal nerve, but it doesn’t tell you that the nerve is entrapped. More pain with sitting is an important criterion. Having no pain at night is not true all the time, as it depends on the origin. However, this is not true with mesh origination PN.

The second part of it is the MRI. I have had very high hopes for the MRI in relation to diagnosing PN. This is not the answer for all of it. It is important, but the resolution of the PN is smaller than the MRI so that you can see the vascularization. A lot of times, you find other things than the compression of the nerve. It is a very good test to make sure that there is nothing else you are missing.

When talking about the MRI, what other diagnostic tests are helpful?

The warm threshold test, PN modern terminal latency test (you need to know the length of the nerve so it is not effective as that cannot be determined). The Pinprick test - not useful or accurate. What works best by far is the patient history, just talking to the patient. The [patient's] history is the key. What happened? The nerve can’t become entrapped on its own. If you see enough patients over the years, you can learn through experience. The MRI is valuable to make sure there is nothing else.

A pelvic exam by a qualified pelvic rehab therapist is important because it helps to rule out pelvic muscle spasms. The pain from the PN and the Obturator Levator muscle may be very similar and difficult to differentiate. Does the amount of spasms correlate with the number of symptoms/pain that they have? 

You can’t treat the PN without addressing the pelvic floor. What I tell patients is this. The number one thing for repetitive injury is to stop what you’re doing. The number two thing is to choose physical therapy over anything else. By far the majority of patients are helped by appropriate pelvic floor physical therapy.

Pudendal Dysfunction: The Physician's Perspective is scheduled for January 9, 2022. Course topics include pathoanatomy and clinical presentations, basics of surgical techniques, and terminology. The latter half of the course focuses on the physician and the rehab therapist working together and features case studies and clinical pearls from Dr. Hibner, a pioneer, and leader in the field.

The interview excerpts are taken from Dr. Hibner's interview with Holly Tanner and Jessica Reale for the H&W Pelvic Floor Level 2A course pre-recorded lectures.

Lila Abbate PT, DPT, OCS, WCS, PRPC is the creator and instructor of Bowel Pathology, Function, & Dysfunction and Coccydynia and Painful Sitting. She also co-wrote the course Pudendal Neuralgia and Nerve Entrapment with fellow H&W faculty member Pamela Downey. 

Often pelvic health physical therapists are nervous about treating patients with bowel dysfunction and constipation. Lila Abbate's mentor, Elise Stettner, is proud to be a PT who treats bowel conditions. “Any PT can treat urinary symptoms. The patients who are really suffering are those with bowel dysfunctions.” She passed this passion on to Lila, who is the creator and instructor of the Bowel Pathology, Function, & Dysfunction scheduled next on November 13-14, 2021.

Bowel dysfunctions and constipation are often embarrassing for those who suffer from them and thus are often under-reported, which may lead to statistical underrepresentation. The statistics that we do have show that the average prevalence of constipation worldwide in adults is 16%, and for adults over the age of 60 is over 33.5%. (1) Everyone has a different normal for bowel habits which makes it hard to define a normal frequency. Constipation can generally be defined as less than three bowel movements per week and can present as infrequent bowel movements or difficult passage of stools that lasts for several weeks.

There are many potential facets to pelvic floor muscle problems concerning constipation. Lila shares that she recommends that therapists provide a muscle activity assessment in a sitting position, and can even utilize computerized-biofeedback, with the patient's hip and knees at different heights can help determine the best position for muscle relaxation during defecation. At times, it can also be useful to incorporate abdominal massage in resolving a patient's constipation. Abdominal massage for bowel function is useful in motivating peristalsis in the gut, plus there are no known side effects. This is a safe and non-invasive way to manage constipation and can be taught to the patient for them to perform on their own as needed.

In the Bowel Pathology, Function, & Dysfunction Remote Course Lila focuses on teaching registrants about the details of normal gut motility, bowel function, medical tests, and medications relating to diagnosing and treating the medical side of bowel dysfunction. Some of the highlighted lectures are about fecal incontinence, chronic constipation, and abdominal pain and how they relate to pelvic floor muscle dysfunction and physical therapy interventions. 

Also commonly encountered in pelvic rehabilitation practices are patients with coccyx pain. You may not think of constipation when treating coccydynia. However, defecation is one of the functional complaints that can be present. The coccyx can interfere with defecation as documented in a case study by Salar et al. They reported that the patient presented with an anteverted coccyx, and complained of "worsening rectal pain developing an hour before defecation and lasting for several hours afterward.” (2)

Lila Abbate also instructs the Coccydynia and Painful Sitting Remote Course. This course is a 1-day deep dive into treating patients who complain of coccyx pain with sitting and defecation. Lila shares that "The coccyx course is orthopedically-based and. I take my love of manual, osteopathic treatment, and combine it with the women’s health internal treatment aspects so that we can move more quickly to get patients back on the path to improved function and recovery." 

When asked about the approach she took in creating the course, Lila explains, "this course looks at patients from a holistic approach from the top of their heads down to their feet. In taking on the topic of coccydynia, I focused on honing basic observation skills and using some of my favorite tools in my toolbox. These include the Hesch Method, integrated systems model, traditional osteopathic, and mobilization approaches mixed with internal vaginal and rectal muscle treatment skill sets."

Join faculty member Lila Abbate this November at her upcoming course  Bowel Pathology, Function, & Dysfunction scheduled for November 13-14, 2021, or plan ahead and register for the Coccydynia and Painful Sitting Remote Course scheduled for February 4, 2022.

1.  Forootan, M; Bagheri, N; Darvishi, M. Chronic Constipation: A review of the literature. Medicine (Baltimore) 2018: May. PMID: 29768326 PMCID: PMC5976340 doi:10.1097/MD.0000000000010631
2. Salar et al.: Defecation pain and coccydynia due to an anteverted coccyx: a case report. Journal of Medical Case Reports 2012 6:175. doi:10.1186/1752-1947-6-175

This article is contributed by faculty members Tiffany Lee and Jane Kaufman. Their course, Biofeedback for Pelvic Floor Muscle Dysfunction, is scheduled for December 4-5, 2021 provides a safe space for clinicians to learn and practice this valuable tool.

Rarely do practitioners see a topic so argued in pelvic rehabilitation as the use of surface EMG biofeedback. There are practitioners who 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. This month they published a Special Issue article in the Biofeedback Journal for the Association for Applied Psychophysiology and Biofeedback. These two instructors have over 50 years of combined experience using biofeedback.(*)

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, enabling the patient to learn how to alter the physiological process through verbal and visual cues.  Jane Kaufman explains that "many patients gain knowledge and awareness of the pelvic floor muscle through tactile feedback, but the visual representation is what helps patients to 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, 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 utilization of sEMG technology. This research also noted technical challenges including the limited transfer of ever-evolving sEMG research into the off-the-shelf EMG systems, nonuser-friendly intuitive interfaces, and the need for a multidisciplinary approach for accurate handling and interpretation of data. (1)

To break this down into layman terms, one contraindication 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 that you have a 2 channel EMG system with software. If you are using a hand-held one channel unit, the patient will have a difficult time seeing the muscle activity and the coordination between the abdominals and pelvic floor. This prevents meaningful treatment with this treatment tool 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 and within a few treatments, you can cover the cost of the unit with the appropriate software to offer the proper visualization of muscle function.

Training is another issue, to start utilizing biofeedback in your clinical setting you need to have proper training in the modality. Most therapists have never been properly trained and if they take a course where the instructor doesn’t believe in the benefits of biofeedback, they feel negatively toward a tool 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 a 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 home exercise program alone." She continues, "Biofeedback is a powerful tool that can benefit your patient population and add to your skill-set."(2)

Essentially, 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 sEMG is a non-invasive technique. It has already shown great promise in the field of neuro-rehabilitation and has been a widely-utilized tool to assess neuromuscular outcomes in research. Jane Kaufman concludes that "In short, biofeedback treatment/training using the proper instrumentation provides the precise information necessary to change behaviors."  This gives the patient the opportunity to recognize that ‘yes, they are in charge of this muscle and that they can achieve success in overpowering the symptoms.’  Biofeedback routinely allows the patient 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.

There is a long history of scientific evidence to support the use of sEMG biofeedback in the management of incontinence symptoms or pain symptoms. As a non-invasive, cost-effective, and powerful treatment modality, healthcare providers should consider this treatment tool when managing patients with pelvic floor dysfunction. 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.BCIA.org.

Tiffany asked several PTs and OTs that 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/or 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 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.”
• “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 plan of care, and my reassessment at discharge is a tangible reflection of their progress. Not to mention its strength as a marketing tool.”

The Satellite Lab Course, Biofeedback for Pelvic Floor Muscle Dysfunction, scheduled for December 4-5, 2021 provides a safe space for clinicians to learn and practice this valuable tool. Registrants will gain knowledge about the benefits of using this modality in their clinical practice. Participants will learn how to administer biofeedback assessments, analyze and interpret sEMG signals, conduct treatment sessions, and role-playing patient instruction/education for each diagnosis presented during the many hands-on lab experiences. 

Special Issue article in the Biofeedback Journal for the Association for Applied Psychophysiology and Biofeedback

• *  Pelvic Floor Biofeedback for the Treatment of Urinary Incontinence and Fecal Incontinence. Jane Kaufman, PT, MEd BDB-PMD; Kathryn Stanton, PT, DPT; Tiffany Ellsworth Lee, MA, OTR BCB-PMD, PRPC. Biofeedback (2021) 49 (3): 71–76. https://doi.org/10.5298/1081-5937-49.3.01.

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. The basics of surface electromyography. R. Cram, G. S. Kasman. In E. Criswell (Ed.). Cram’s introduction to surface electromyography (2nd ed., pp. 3–7.) Jones and Bartlett. 2011

An interview with Frank Ciuba.

Frank Ciuba, co-instructor of Osteoporosis Management< alongside Deb Gulbrandson, explains that practitioners need the information provided in their course. "This course is the latest up-to-date research compiled by my partner Deb Gulbrandson and myself in the management of osteoporosis for clinicians." He shares that similar to learning about the pelvic floor, "when physical therapists go to school they get only a small amount of what osteoporosis is and very little on how to treat a patient."

Frank explains that he became interested in teaching osteoporosis management when he learned "that one in four men statistically will get osteoporosis or an osteoporosis-related fracture in their lifetime and they're really not being identified." Osteoporosis Management provides an exercise-oriented approach to treating these patients and it covers specific tests for evaluation, appropriate safe exercises and dosing, basic nutrition, and ideas for marketing your osteoporosis program.

In pelvic health rehabilitation, it's seen that osteoporosis-related kyphosis (curvature of the spine) can affect pelvic organ prolapse, breathing, and digestion. Patients who go through the osteoporosis management program with Frank and Deb, are shown that they reduce the likelihood of compression fracture by 80%.

This course, Osteoporosis Management, is not just for practitioners working with osteoporosis or osteopenia patients. Frank lists the types of patients he's been able to help. "I've used this on high school backpack syndrome, whiplash injuries, adhesive capsulitis, spinal stenosis, low back pain, lumbar strain, even some hip pathologies." He concludes with "We just need to get the word out to more individuals that this a program that can help them. Not only in the short term, but in the long term. This is a program for life."

A different approach to treating prostatectomy patients.

The Pelvic Rehab Report sat down with Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC to discuss her upcoming courses Rehabilitative Ultrasound Imaging - Orthopedic Topics and Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics scheduled for November 12-14, 2021. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain.

As a pelvic floor clinician, you may have worked with patients who are suffering from urinary incontinence following prostatectomy. During a prostatectomy the prostate, seminal vesicles, prostatic urethra, and some connective tissues are removed. The extent of the removal will depend on the size of the tumor and if the tumor has spread into the surrounding tissues.  Because of the surgery, and the loss of smooth muscle surrounding the urethra, there is an inherent risk that these patients will suffer from urinary incontinence. Recently, there have been studies that examined the difference between patients who return to continence and those who do not return to continence following prostatectomy. They found that continent prostatectomy men demonstrated increased displacement of the striated urethral sphincter, bulbocavernosus, and puborectalis compared to incontinent men. They also found that continent prostatectomy patients demonstrated better puborectalis and bulbocavernosus function than controls! (1) This has made researchers conclude that continent men following prostatectomy compensate for the loss of smooth muscle by having better than normal function in their pelvic floor.

In another recent article, researchers put together recommendations for a rehabilitation program. They argue that traditional methods that have been used in pelvic floor therapy are based on applied principles for stress incontinence in women, not men. Men suffer from incontinence for a different reason than women. Thus, their treatment should be approached differently as well.  Additionally, the authors state that examining the pelvic floor muscles via a digital rectal exam does not allow the examiner to assess the underlying issue that leads to incontinence in men, the striated urethral sphincter. Instead, a digital rectal exam identifies issues in the external anal sphincter and puborectalis. They highly recommend the use of transperineal ultrasound imaging in order to view the contraction of the pelvic floor and confirm where the contraction is originating from. They also highly recommend the use of ultrasound in treatment for the use of motor re-learning(2).

We will discuss this more in-depth as well as learn how to use ultrasound imaging to help both male and female patients suffering from incontinence. We also will be learning how to use ultrasound imaging to address orthopedic conditions such as back pain, sacroiliac joint pain, and diastasis rectus. The course “Rehabilitative Ultrasound Imaging for the Pelvic Girdle” is now being offered with satellite locations as well as a limited number of self-hosted online groups and is scheduled for November 12-14, 2021. There are two courses being offered. The 2-day version, Rehabilitative Ultrasound Imaging - Orthopedic Topics, addresses the use of ultrasound imaging to help back and lumbopelvic conditions. While the 3-day course, Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics, includes more pelvic floor related conditions such as prolapse and post-prostatectomy issues. The course includes ample lab time so participants leave with the clinical skills to be able to use ultrasound imaging in their practice.

1. Stafford R.E., Couglin G., Hodges P. Comparison of dynamic features of pelvic floor muscle contraction between men with and without incontinence after prostatectomy and men with no history of prostate cancer. Neurourology and Urodynamics. 2020; 39:170-180.
2. Hodges, PW., Stafford RE, Hall L., et al. (2020). Consideration of pelvic floor muscle training to prevent and treat incontinence after radical prostatectomy.  Urologic Oncology: Seminars and Original Investigations.  38: 354-371

This week The Pelvic Rehab Report sat down with some of our favorite Occupational Therapists to discuss the role of OTs in the field of pelvic rehabilitation. The following blog is provided by Tiffany Ellsworth Lee MA, OTR, BCB-PMD, PRPC, Lindsey Vestal, MS, OT, and Laura Rowan OT/L.

Most people associate pelvic health with PTs- so many are surprised to see OTs in this specialty. Herman and Wallace faculty and instructor Tiffany Ellsworth Lee MA, OTR, BCB-PMD, PRPC, LPF-CT has been an OT for 28 years and has spent the last 20 years specializing in pelvic health. She recalls, “My first Herman and Wallace course was PF1 11 years ago. I was the only OT in a class of 50. I was so appreciative of H&W’s foresight to include OTs in the course offerings. A PT sat down next to me and said, “Why are you here? I didn’t know OTs could treat pelvic health!” Yes, we can! It is within our scope of practice and the majority of therapist specialized learning comes post-graduation.

Lindsey Vestal, OTR/L has been an OT for 11 years and her private practice focuses on pre and postnatal people. She is a moderator of the Facebook group “OTs for Pelvic Health” with over 3,100 members. She is bringing awareness to the PH specialty by educating OTs on the best way to treat and collaborate with PTs and other providers in the field. She says, “ Just as OTs and PTs work side-by-side in other fields of rehab, there's a huge need for us to work collaborating in pelvic health. In grad school, OTs study motivational interviewing, nonverbal communication, we have mental health classes and a strong background in sensory approaches, energy conservation, self-regulation strategies, the involvement of the nervous system, time management, working with trauma, habits, routines, ADLs, the musculoskeletal system, functional movement, and activity grading. Pelvic floor function is a crucial part of a much broader functional task of toileting and intimacy, both of which have broader connections within a person’s emotional, cognitive, and social abilities. It's also important to consider the social implications for people with pelvic floor issues such as withdrawal from social and recreational activities, social isolation, disempowerment, lack of self-esteem, anxiety, depression, and the impact on close relationships such as with our spouse, our friends, and our children. This OT-specific background has given me a great foundation to serve my PF population.”

Another seasoned PHOT is Laura Rowan, OT/L who has been an OT for 21 years and the last 14 years has dedicated her practice to pelvic health. She works with all gender diversities across the lifespan with a focus on complex pain patients and athletes. Laura provides manual therapy courses and mentorship for OTs starting in this specialty. She says, “OTs are great at analyzing how the client is executing functional tasks and offering new strategies, adaptations, and compensation techniques for a less provoking and safer way to accomplish the task at hand. OT’s will often see progress using a whole person approach where a client may have plateaued with a less holistic treatment plan”

Laura shares about her start in the PH journey - “My success did not come without challenges. The vast majority of PTs did not share the same acceptance of OTs as Herman and Wallace. Due to a lack of understanding that continues to exist today, OTs struggle to begin their career in pelvic health. It took me 8 years after PF1 to officially break into the field. I felt like a lone OT in a PT world due to the lack of OT presence and support. I didn’t understand the roadblocks I was facing as pelvic health seemed a natural fit for OTs. OT practitioners have long been lending our expertise in the areas of functional restoration, psychosocial considerations, behavioral modifications, time management, stress management, coping strategies, and task analysis. These are major components of a comprehensive plan of care for individuals with pelvic health dysfunction in relation to their Activities of Daily Living (ADL’s) and Instrumental Activities of Daily Living (IADL’s). I am thankful for the many PTs that mentored me along the way. I was hired by a PT clinic with mentorship and continuing education opportunities. This provided strong foundations for me to later branch out and start a successful private practice. I have further developed into an educator and mentor role to provide the emerging OT practitioners the support I received starting out but through the unique lens of an OT.”

Tiffany adds, “OTs and PTs working collaboratively is a winning combination. We can share patients and focus on treating the whole person. For example, a patient with constipation, dyspareunia, SI dysfunction, and urinary incontinence can work with both OT and PT. I may address their constipation and UI using behavioral therapy, biofeedback, and lifestyle modifications while my PT co-worker addresses the spine, hip, and back dysfunction. If you work in an outpatient setting, you are able to bill separately and treat the same patient. We are taking the same courses side-by-side and learning the same skills. Our backgrounds are diverse and we can serve our patients with a multidisciplinary approach. Instead of being divisive and noninclusive, we should be supporting each other and collaborating. There is plenty of business to go around and PH therapists are some of the most compassionate and empathetic people I have ever met!”

Laura agrees and says, “Pelvic Health is too large of a specialty to be a generalist and have all the answers. It’s always beneficial to have a second set of eyes and even better to have a diverse background for a comprehensive whole-person approach to client-centered care. It’s not about the therapist and their discipline, rather taking a multisystem approach to meet the needs of our clients and how we can better serve them with an interdisciplinary team. We often run out of time to address all of the underlying impairments contributing to the client’s symptoms. OTs and PTs working together allow for all of the contributing factors to be addressed with the appropriate amount of attention required for successful outcomes.”

Lindsey chimes in, “It can take a village to care for pelvic health clients, so why not lean on our colleagues for their areas of strength? I mean isn’t that why we are rehab professionals? To ultimately serve our clients the best way possible? Pelvic health is a very underserved population and in my opinion, there's space for us all.”

Tiffany, Lindsey, and Laura have thriving private practices serving the PH population and each has PH continuing education companies that offer courses and mentoring. They are passionate about spreading awareness of the OT's role in pelvic health and the many benefits of working alongside PTs to meet the needs of this underserved population. By bridging the gap in understanding the valuable role of the PHOT, we can start to decrease extensive waitlists, and open up jobs to qualified passionate OT’s eager to begin their pelvic health careers. You can reach them through email -

This email address is being protected from spambots. You need JavaScript enabled to view it. or www.pelvicfloorbiofeedback.com

This email address is being protected from spambots. You need JavaScript enabled to view it. or www.essentialpelvichealth.com

This email address is being protected from spambots. You need JavaScript enabled to view it. or www.functionalpelvis.com

Proper breathing is discussed and taught in many ways and forms. All of this is a step in the right direction, but what if the person physically can not lengthen tissues to expand certain key structures that are essential to the breathing mechanism? In the remote course, Breathing and the Diaphragm, Aparna Rajagopal and Leeann Taptich teach different methods to identify breathing patterns, dysfunctional breathers, and how to determine motor control issues from mobility or strength issues.

Breath is utilized widely in the exercise world. Pilates uses breath for core stability. Yoga utilizes breath to help connect the body. Strength and conditioning coaches and personal trainers emphasize breath to provide power to lift. Breathing mechanics, aka proper breathing, is also core to any type of abdominal exercise.

Respiratory muscles are directly involved in these core abdominal strengthening, stability, and stretching exercises (1). Research led by DePalo, way back in 1985, concluded that the diaphragm is actively recruited during resistance exercises such as sit-ups (2). Inefficient breathing can lead to muscular imbalances, and motor control changes that can affect motor quality. Therapists are taught at length about tissue and joint mobility versus motor control or strength issues. These same principles can be applied to assess and treat the diaphragm, breathing, and abdominals.

In regards to working with patients, Aparna shares, "Different cues work with different patients. While verbal and tactile cues to correct patterns can work with some of our patients, they do not necessarily work in all of our patients. We need different ways to correct patterns in patients that have a tissue or joint mobility issue. Such issues can cause restriction and force the patient to breathe in a specific way."

Aparna and Leeann deep dive into mobility and learn to assess and treat joint restrictions of the ribs and the thoracic spine during their remote course Breathing and the Diaphragm scheduled for October 23-24, 2021. These mobility techniques combined with specific motor control and strengthening exercises can improve myofascial restrictions that restrict breathing.

Breathing and the Diaphragm will help build a foundation to improve your patients' functional activities. No matter if it is coughing, having a bowel movement, performing wall ball in CrossFit, or hitting a tennis ball!

1. Luca Cavaggioni, Lucio Ongaro, Emanuela Zannin, F. Marcello Iaia, Giampietro Alberti.Effects of different core exercises on respiratory parameters and abdominal strength. J Phys Ther Sci. 2015 Oct; 27(10): 3249–3253. Published online 2015 Oct 30. doi: 10.1589/jpts.27.3249.
2. DePalo VA, Parker AL, Al-Bilbeisi F, et al.: Respiratory muscle strength training with nonrespiratory maneuvers.J Appl Physiol 1985 2004, 96: 731–734.