When it comes to discussing nutrition with our clients in pelvic rehab, it is normal to initially feel both uncertain and perhaps a bit overwhelmed at the prospect of delving into this topic. Yet we know that there must be links, some association between nutrition and the many chronic conditions we encounter. Gradually, over the last several years, a cornerstone of my practice with patients in pelvic rehabilitation has become providing nutritional guidance.

I was both humbled and immensely grateful when many of my colleagues and peers attended Nutrition Perspectives for the Pelvic Rehab Therapist (NPPR) in Kansas City last March. In the following months, our clinics underwent a significant change in the types of discussions occurring with our patients. By embracing concepts presented in NPPR, a continuous stream of patient stories developed about lives having been touched by this shift. For many, “one small change” made a very big difference or served as the catalyst to many more positive lifestyle changes. Simply placing a high priority on re-thinking health situations through the lens of nourishment has been a very important shift, one that can occur across the spectrum of pelvic rehab practitioners if we choose to answer the call to “do what’s necessary”.

Learning the essence of a topic outside our comfort zone is not easy, yet in present time is necessary for providers trying to grapple with how to wrap our professional minds around what we know in our hearts to be true: the effect of nourishment on health is profound. This brings to mind the resonating wisdom of Francis of Assisi:

“Start by doing what’s necessary, then do what’s possible;
and suddenly you are doing the impossible.”

At this crossroads in our health care system we know that nutrition matters. We must start by doing what’s necessary: acknowledging our role in helping patients along their path to a better life through less pain, ease of movement, normalization of function, and healing. With commitment to our patient’s well-being, we too must commit to investigating the realm of nutrition and rehabilitation. Next, we can strive to do what’s possible. NPPR can serve as a springboard for professionals ready to develop programs incorporating sound nourishment principles in relation to both specific conditions in pelvic rehab and general health and well-being. Finally, we may - in a few short years - realize that suddenly we are doing the impossible; integrating these vital principles as standard care in rehabilitation.

Please join us in White Plains, NY March 31-April 1, 2017 for Nutrition Perspectives for the Pelvic Rehab Therapist. Whether you are just beginning to integrate nutrition and its correlates to pelvic rehab or are already well on your way along this path, you will come away with both a strong understanding of how food affects function along with tools you can immediately begin sharing with the clients you serve.

In 1998, faculty member Debora Chassé was asked to evaluate a patient with bilateral lower extremity lymphedema following repeated surgeries for cervical cancer. Her formal education did not cover this in school, so Dr. Chassé began to study peer-review research and consult with other clinicians about the diagnosis. Her journey down the rabbit hole began.

Dr. Chassé became a certified lymphedema therapist in 2000 and a certified Lymphology Association of North America therapist in 2001. She continued training by moving into osteopathy taking her into the direction of lymphatic vessel manipulation. In 2006 she began taking courses in pelvic pain and obstetrics with a focus on pelvic floor dysfunction. It was at this point that Dr. Chasse realized nobody was applying lymphatic treatment to women’s health and pelvic floor dysfunction. In 2009 she became a Board Certified Women’s Health Clinical Specialist in Physical Therapy and began traveling around the United States offering workshops in the area of lymphatic treatment.

Dr. Chassé’s approach is to incorporate all her varied skills in the clinic to produce the best patient outcomes. Debora explains that she is “…showing the similarities between pelvic pain and the lymphatic system. The treatment principles are the same, when you are treating both lymphedema or pelvic pain, you are working to reduce inflammation, pain and scarring.”

Another advantage of the lymphatic treatment approach is that it is more comfortable for the patient. “Most intravaginal techniques causes increased pain and inflammation. However, using lymphatic drainage intravaginally is well tolerated and decreases the intravaginal pain. The results are phenomenal!”

Dr. Chassé recollects her experience with a 21 year old female who suffered from chronic pelvic pain. By applying intravaginal lymphatic drainage techniques for 5 consecutive days, the patient experience a 4.83 reduction in pelvic girdle circumference and her intravaginal pain went from 8/10 to 2/10. The patient was amazed at how much better she felt. “My pants fit better, my energy level increased 25% and pain decreased more than 50%. I went from having 2-3 bad days per week to having 2-3 bad days per month, even when my work level increased. My feet no longer swell and I haven’t missed any classes since receiving this treatment.

In her course, “Lymphatics and Pelvic Pain: New Strategies”, Dr. Chassé seeks to train practitioners to utilize lymphatic drainage techniques when treating specifically pelvic pain. Participants will learn lymphatic drainage principles and techniques. They will learn how to clear pathways to transport lymph fluid and internal techniques which will have incredible impacts for patients.

Honestly, I have never noticed Curcumin on any of my patients’ lists of pharmaceuticals or supplements, but I will be certain to look for it now. Curcumin is the fat-soluble molecule that gives turmeric its yellow pigment, and it is best absorbed with the addition of black pepper extract. Patients often complain non-steroidal anti-inflammatory medicines (NSAIDs) tear apart their stomachs, so newer studies showing positive results with the use of an herb sound promising, even for pelvic health.

A 2015 study by Kim et al. researched the inhibitory effect of curcumin on benign prostatic hyperplasia induced by testosterone in a rat model. Benign prostatic hyperplasia (BPH) is common among men and has a negative impact on the urinary tract of older males. Steroid 5-alpha reductase converts testosterone into dihydrotestosterone (DHT), and this increases as men age and may have negative effects on the prostate gland. Because of the side effects of conventional drugs (like finasteride) to inhibit steroid 5-alpha reductase, the authors wanted to determine if curcumin could play a protective role in BPH. They divided 8 rats into 4 groups after removal of testicles: 1) normal, 2) BPH testosterone induced subcutaneously, 3) daily curcumin (50mg/kg orally), and 4) daily finasteride (1mg/kg orally). The group receiving curcumin had significantly lower prostate weight and volume than the testosterone induced BPH group, and curcumin decreased the expression of growth factors in prostate tissue. The authors conclude curcumin may be a useful herb in inhibiting the development of BPH with fewer side effects than conventional drugs.

In the urology realm, Cosentino et al.²⁰¹⁶ explored the anti-inflammatory effects of a product called Killox®, a supplement with curcumin, resveratrol, N-acetylcysteine (NAC) and zinc. When benign prostatic hyperplasia (BPH) is not treated with drugs, a surgical intervention can be executed called a transurethral resection of the prostate (TURP); or, for bladder cancers, a transurethral resection of the bladder (TURB) can be performed. Either surgery generally requires administration of NSAIDs post-operatively for inflammation, urinary burning, or bladder spasms or to prevent later complications such as urethral stricture or sclerosis of the bladder neck. This open controlled trial involved Killox® tablet administration to 40 TURP patients twice a day for 20 days, to 10 TURB patients twice a day for 10 days and to 30 BPH patients who were not suited for surgical intervention once a day for 60 days. The control group received nothing for 1 week post-surgery, and 52.5% of TURP and 40% of TURB patients required NSAIDs to treat burning and inflammation the following 7 days. None of the Killox® treatment groups had post-operative or late complications except one, and none suffered epigastric pain like those using NSAIDs. The authors concluded Killox® had significant positive anti-inflammatory and analgesic effects on the patients and could be used as a safe alternative to NSAIDs by physicians.

Although “just” an herb, the use of curcumin should be supervised by a healthcare professional who understands proper dosage and any possible contraindications for a particular individual. The curcumin needs to be in a form that can be easily digested and used effectively by the body. Ultimately, it is exciting to learn about an alternative to gut-wrenching NSAIDs, making curcumin a noteworthy anti-inflammatory option for patients.

Nutrition plays an important part in patient wellness and rehabilitation. There are many reasons to consider diet when designing treatment regimens and you can learn all about them in Megan Pribyl's Nutrition Perspectives for the Pelvic Rehab Therapist course. Your next chance to take this course is March 31 - April 1, 2017 in White Plains, NY. Don't miss out!

Kim, S. K., Seok, H., Park, H. J., Jeon, H. S., Kang, S. W., Lee, B.-C., … Chung, J.-H. (2015). Inhibitory effect of curcumin on testosterone induced benign prostatic hyperplasia rat model. BMC Complementary and Alternative Medicine,15, 380. http://doi.org/10.1186/s12906-015-0825-y
Cosentino, V., Fratter, A., Cosentino M. (2016). Anti-inflammatory effects exerted by Killox®, an innovative formulation of food supplement with curcumin, in urology. Eur Rev Med Pharmacol Sci. 20: 7, 1390-1398. http://www.ncbi.nlm.nih.gov/pubmed/27097964#

In my mid 20’s I had a sudden onset of severe, persistent pain at the bottom of my spine. I had fallen while running on trails and thought maybe I had fractured my coccyx. It hurt terribly to sit, especially on hard surfaces. When I finally succumbed to seeing a doctor, he diagnosed me with a pilonidal cyst and performed a simple excision of the infection right there in the office. I recall passing out on the table and waking up with an open wound stuffed with gauze. What I thought was “just” coccydynia turned out to be something completely different, requiring a specific and immediately effective treatment.

Differential diagnosis is essential in all medical professions. Blocker, Hill, and Woodacre²⁰¹¹ presented a case report on persistent coccydynia and the necessity of differential diagnosis. A 59-year old female reported constant coccyx pain after falling at a wedding. Her initial x-rays were normal, as was an MRI a year later, despite continued pain. Neither an ultrasound nor abdominal CT scan was performed until 16 months after the onset of pain, which was 2 months after she started having bladder symptoms. A CT scan then showed a tumor stemming from her sacrum and coccyx, and an MRI confirmed the sacrum as the tumor location. Chordomas are primary bone tumors generally found at the sacrum and coccyx or the base of the skull. They are relatively rare; however, they do exist in males and females and can present as low back pain, a soft tissue mass, or bladder/bowel obstruction. Clinicians need to listen for red flags of night pain and severe, unrelenting pain and ensure proper examination is performed for accurate diagnosis and expedient treatment.

In a more recent case study by Gavriilidid & Kyriakou ²⁰¹³, a 73 year old male presented with 6 months of tailbone pain, worse with sitting and rising from sitting. The physician initially referred him to a surgeon for a pilonidal cyst he diagnosed upon palpation. The surgeon found an unusual mass and performed a biopsy, which turned out to be a sacrococcygeal chordoma. The tumor was excised surgically along with the gluteal musculature, coccyx, and the fifth sacral vertebra, as well as a 2cm border of healthy tissue to minimize risk of recurrence of the chordoma. These authors reported coccygodynia is most often caused by pilonidal disease, clinically confirmed by abscess/sinus, fluid drainage, and midline skin pits. They concluded from this case study if one or more of those characteristic findings are absent, differential diagnoses of chordoma, perineural cyst, giant cell tumour, intra-osseous lipoma, or intradural Schwannoma should be investigated.

Honestly, if I were not a physical therapy tech when my coccyx started killing me 20 years ago, I am not sure I would have gone to the doctor right away. My boss called me out when I winced every time I sat down, and he sent me off to get an exam. The majority of patients are not blurting out specific details about buttock pain when they come for evaluation. Modesty prevails but does not always benefit a patient with persistent coccydynia. Thankfully I did not have a chordoma, but the pain was intense enough to bring me to tears, and it could have required surgery if I had not been diagnosed early enough. Providing a comfortable environment for our patients during their initial encounter can help them feel less vulnerable and discuss the root of their pain. If we can decipher between chordoma and other causes of coccydynia, we may strike a chord that saves a patient from a poor outcome.

The Herman & Wallace course "Coccyx Pain Evaluation & Treatment" is an excellent opportunity to learn new differential diagnosis techniques for coccyx pain patients. The next opportunity to attend this course is March 25-26 in Tampa, Florida.

Blocker, O., Hill, S., & Woodacre, T. (2011). Persistent coccydynia – the importance of a differential diagnosis. BMJ Case Reports, 2011, bcr0620114408. http://doi.org/10.1136/bcr.06.2011.4408
Gavriilidis, P., & Kyriakou, D. (2013). Sacrococcygeal chordoma, a rare cause of coccygodynia. The American Journal of Case Reports, 14, 548–550. http://doi.org/10.12659/AJCR.889688

In the world of pelvic health, we are constantly meeting patients who are surprised to learn about the scope of what we do. Oftentimes, it is because we mention the pelvic muscles’ roles in sexual health that a patient will offer up symptoms with their sexual health, or ask a few more questions. Outside of pelvic health professionals asking about sexual function, do men bring up these issues with anyone? Not usually. In Fisher and colleagues 2-part “Strike up a conversation” study (2005), the authors reported that men who have erectile dysfunction (ED) are worried about their partner’s reaction, don’t want to admit to having a chronic problem, and frankly, just don’t even know where to start. Unfortunately, the partners of men who have ED have the same concerns. In addition, partners are worried about bringing it up and “making their partners feel worse about it.” When men did bring up sexual concerns with their physician, although they reported feeling nervous and embarrassed, they also reported feeling hopeful and relieved.

This issue was highlighted in a recent interview and article published on National Public Radio. The article shares that for war veterans, sexual intimacy is often affected, and yet, is often ignored. A Marine who suffered PTSD after a head injury and shrapnel to the head and neck describes how he had to go to the doctor several times just to work up the nerve to ask for help for his sexual dysfunction. He also shared how it was difficult to talk about “…because it contradicts a self-image so many Marines have.” Apparently you don’t have to be a Marine to feel the same intense pressure related to talking about sexual issues. I have spent more time in the past year trying to better understand why men don’t discuss these issues, with a best friend or partner, and each time, my question of “what would that be like if you brought it up?” is met with near bewilderment, as if revealing this issue were akin to revealing your deepest, darkest secret. Apparently, it is. Telling a buddy you have erectile dysfunction, for men, seems to be like showing your enemy where the chink in your armor is, or like setting yourself up to be the center of every “getting it up” joke for the remainder of your life.

The bottom line is that we can be part of the solution to this problem, because men must be certain that their medical provider knows about any emerging or worsening erectile dysfunction. Loss of libido, or changes in erectile function can be associated with heart issues, with diabetes, or with other major medical concerns. Research such as the referenced “strike up a conversation study” has demonstrated that health care providers or partners may positively influence a patient’s access to care. Once medical evaluation has been completed, the role of the pelvic health provider is critical in improving sexual health for men with dysfunction. If you are interested in learning more about the role of the pelvic health provider for erectile dysfunction or pain related to sexual function, the Male Pelvic Health continuing education course will be offered 3 times this year through the Herman & Wallace Pelvic Rehabilitation Institute. Your next opportunity to learn about urinary and prostate conditions, male pelvic pain, sexual health and dysfunction is next month in Portland, Oregon.

Chang, A. (2016). For veterans, trauma of war can persist in struggles with sexual intimacy. Retrieved from http://www.npr.org/sections/health-shots/2017/01/01/507749611/for-veterans-trauma-of-war-can-persist-in-struggles-with-sexual-intimacy
Fisher, W. A., Meryn, S., Sand, M., Brandenburg, U., Buvat, J., Mendive, J., ... & Strike Up a Conversation Study Team. (2005). Communication about erectile dysfunction among men with ED, partners of men with ED, and physicians: The Strike Up a Conversation Study (Part I). The journal of men's health & gender, 2(1), 64-78.
Fisher, W. A., Meryn, S., Sand, M., & Strike up a Conversation Study Team. (2005). Communication about erectile dysfunction among men with ED, partners of men with ED, and physicians: the Strike Up a Conversation study (Part II). The journal of men's health & gender, 2(3), 309-e1.

Jason Hardage is a physical therapist who practices in Alameda, CA. He recently attended the Mindfulness-Based Pain Treatment course which is written and instructed by faculty member Carolyn McManus, PT, MS, MA. Dr. Hardage was kind enough to send in the following review in order to help spread the good word about this powerful course. Your next opportunity to learn how to apply mindfulness practices in your clinic will be in Boston, MA on March 4-5, 2017.

Carolyn McManus' 2-day course, Mindfulness-Based Pain Treatment, was truly outstanding. In my opinion, the integration of mindfulness into healthcare is a paradigm shift and in that sense Carolyn is a visionary who is ahead of her time, as she has been practicing in this arena for many years. Her expertise is clear (as is her joy in teaching).

In this course, she introduces the basic terminology, concepts, and mindfulness practices in a way that is experiential, practical, and accessible, with many tools and techniques to integrate into clinical practice. She thoroughly reviews the evidence in a way that is skillful and compelling and provides the theory as to how mindfulness works, then provides case studies from her own clinical practice. She also provides a brief survey of other tools and approaches that are complementary, such as yoga, loving kindness meditation, and motivational interviewing, then shows how to put it all together, including suggestions for documentation and billing. She is generous in sharing resources, including patient education materials and four open-access guided relaxation and meditation sessions from her Web site, as well as resources for continued study. Furthermore, she presents ways for the healthcare practitioner to use mindfulness for self care, to help combat the burnout that can come with serving those with complex needs in a demanding healthcare environment.

This is certainly one of the best courses that I've taken in over 17 years as a physical therapist. While it's easy to see how the content of the course is applicable to people with chronic pain, in my opinion, this approach is broadly applicable across patient populations. It's exciting to know that we have a physical therapist who is an expert, long-time practitioner and teacher of mindfulness from whom to learn. I highly recommend this course! At the same time, it left me wanting more and I'd love to see Carolyn develop other ways to deliver content--such as a blog and online video content--that would allow her to connect with a wider audience and also to stay connected to those who have taken her course.**

Sincerely,
Jason Hardage, PT, DPT, DScPT, GCS, NCS
Alameda, CA

Editor's note: Since publication of this review, Carolyn has began to publish a blog on mindfulness! See more at The Mindfulness in Healthcare Blog

On November 15th, 2016 a new class of Pelvic Rehabilitation Practitioner Certification was crowned! Today we get to celebrate with Andrea Wood, PT, DPT, PRPC from New York. Andrea was kind enough to share some of her thoughts on pelvic rehabilitation and what certification means to her. Thank you Andrea, and congratulations on earning your PRPC credential!

Describe your clinical practice:
I work in an orthopedic clinical practice that has one on one care which I think is valuable. I joined my practice to help offer another view that included pelvic floor knowledge to various patient cases. My coworkers and I collaborate a lot because we both may see things differently, and exchanging ideas is always invaluable for optimal patient outcomes. I really believe the best health care practitioners can admit when they don’t know everything and seek out other viewpoints to learn.
 
How did you get involved in the pelvic rehabilitation field?
I actually had no idea I originally wanted to do pelvic floor rehab. I was lucky to fall into it right out of graduate school up in Boston at a wonderful place called Marathon Physical Therapy. I found it fascinating how important it was to consider in a lot of patients, especially those presenting with hip, back, or pelvic pain. Two years into working, I found out I had mild congenital hip dysplasia in my left hip and underwent a periacetabular osteotomy to correct it. Going through the rehab on the other side as a patient and having to experience what it means to practice a lot of the principles I teach patients made me excited to continue to help people overcome obstacles. I’m a better physical therapist now because of my personal history. It taught me to always give patients the means to keep moving within their means and not provide only passive treatments. My two physical therapists that helped me through that became my biggest role models on how to approach complicated patient problems.
 
What patient population do you find most rewarding in treating and why?
I find it most rewarding to work with pelvic pain patients. I like to think of them as a puzzle. With those patients, I’m an orthopedic physical therapist first, because of how much influence other parts of the body can have on the pelvis. I also am a big advocate of collaborative health care with those patients, and when you bring a team of different views together (i.e. medical doctor, physical therapy, nutritionist, and psychologist to name a few) I find I learn something new each time.
 
If you could get a message out to physical therapists about pelvic rehabilitation what would it be?
It is not just about 3 layers of muscles in your pelvic floor and Kegels. Your pelvis is a center of your body with various biomechanical, vascular, and neurological influences. For example, erectile dysfunction in males can be influenced by pelvic floor muscle dysfunction, cardiovascular health, and psychological or neurological conditions. A woman with painful intercourse could have various contributing factors ranging from a back or hip problem to a dermatological skin issue. I think physical therapists not properly educated on pelvic floor rehab oversimplify it unknowingly.
 
 
What has been your favorite Herman & Wallace Course and why?
My favorite Herman & Wallace course was the Pudendal Neuralgia and Nerve Entrapment. That course opened my eyes up to pain science and how much we really don’t know about pain as a medical community.
 
What lesson have you learned from a Herman & Wallace instructor that has stayed with you?
That the amount of pain a patient may have does not always signify the amount of damage that is present. When patients realize this, they feel a lot more hopeful and in control.
 
What do you find is the most useful resource for your practice?
I love learning from other physical therapy blogs. Blog About Pelvic Pain by Sara Saunder and Julie Weibe’s blogs are two of my favorites to follow. I lend the book Pelvic Pain Explained to a lot of my patients.
 
What motivated you to earn PRPC?
I like to challenge myself, and I felt it was a good test to access areas I need improvement in and should study more or seek out further continuing education.
 
What makes you the proudest to have earned PRPC?
I’m proud to have earned the PRPC because I earned something that I am passionate about. Some people don’t get that blessing.
 
What advice would you give to physical therapists interested in earning PRPC?
Just being passionate and asking a lot of questions about what I don’t know in clinical practice provided me with best tools to prepare for the exam.
 
What is in store for you in the future?
Continuing to learn as much as I can. I plan on seeking out some continuing education in areas of physical therapy like neurology or cardiovascular issues that can all still influence the pelvic floor. I think its important to be a well rounded physical therapist.

Lymphedema with regards to women’s health is most commonly associated with breast cancer. Upper extremity lymphedema can be limiting and painful without a doubt, and I have seen women suffering from irritating edema and limited shoulder range of motion and function after radical mastectomy. However, we may not always consider lower extremity lymphedema which can occur as a result of urogenital cancers and their treatments. Our knowledge and skilled hands can impact the quality of life of these patients who may seek treatment for their post-cancer complications.

Mitra et al., published a 2016 retrospective study on lymphedema risk post radiation therapy in endometrial cancer. They considered 212 endometrial cancer survivors, and 7.1% who received adjuvant pelvic radiation therapy developed lower extremity lymphedema after treatment, whether they had chemotherapy or not. Finding at least 1 positive pathological lymph node was directly correlated with an increased risk of lymphedema, regardless of attempts to control pelvic lymph-node dissection. These statistics encourage finding prophylactic measures to take for stage III endometrial cancer patients to minimize the risk for long-term lymphedema. Regarding treatment for lower extremity lymphedema, this paper discussed compression stocking use, pneumatic compression stockings, and complex decongestive therapy, an intensive regimen of physical therapy and massage that is unfortunately not easily accessible for a majority of patients. The authors encouraged future research on the efficacy of exercise and compression for lymph node positive patients.

Shaitelman et al. presented a review of the progress made in the treatment and prevention of cancer-related lymphedema (2015). They stated gynecologic cancer treatment is associated with 25% incidence of lymphedema. Endometrial cancer had 1%, cervical cancer had 27%, and vulvar cancer had 30% incidence specifically. Sentinel lymph node biopsy (SLNB) can be an important part of cancer treatment, as lymphedema incidence was shown to average 9%. With treatment of genitourinary cancers, lymphedema occurred in 4% patients with prostate cancer, 16% patients with bladder cancer, and 21% patients with penile cancer. Shown to decrease limb volume and improve quality of life, the current standard of care is complete decongestive therapy (CDT). These authors state CDT involves the use of manual lymphatic drainage (MLD), bandaging on a daily basis, skin care, exercise, and a 3-phase protocol of compression. The use of SLNB helps identify the risk of lymphedema post cancer treatment; however, clinicians need to be aware of the signs and symptoms of lymphedema so the affected patient can be recognized early and referred to the appropriate specialist for treatment.

We may be referred patients with the confirmed diagnosis of lymphedema, but often we see post-cancer patients for rehab who develop lymphedema months after radiation or chemotherapy. Any healthcare professional involved with regular treatment of a cancer-surviving patient needs to have a keen sense for diagnosing and properly taking care of lymphedema. Courses such as “Lymphatics and Pelvic Pain: New Strategies” can open a whole new avenue for understanding what patients may need from us following urogenital and genitourinary cancers. Why not be prepared to face with knowledge and skill whatever pathology our patients present?

Mitra, D., Catalano, P.J., Cimbak, N., Damato, A.L., Muto, M.G., & Viswanathan, A.N. (2016). The Risk of Lymphedema After Postoperative Radiation Therapy in Endometrial Cancer. Journal of Gynecologic Oncology, 27(1), e4.
Shaitelman, S.F., Cromwell, K.D., Rasmussen, J.C., Stout, N.L., Armer, J.M., Lasinski, B.B., & Cormier, J.N. (2015). Recent Progress in Cancer-Related Lymphedema Treatment and Prevention. CA: A Cancer Journal for Clinicians, 65(1), 55-81.

During labor, I had no problem breathing out. My hang up came when I had to inhale - actually oxygenate my blood and maintain a healthy heart rate for my almost newborn baby. When extra staff filled the delivery room, and an oxygen mask was placed over my face, my husband remained calm but later told me how freaked out he was. He was watching the monitors that showed a drop in my vitals as well as our baby’s. In retrospect, I wonder if practicing yoga, particularly the breathing techniques involved with pranayama practice, could have prevented that moment.

A research article by Critchley et al., (2015) broke down breathing to a very scientific level, determining the consequences of slow breathing (6 breaths/minute) versus induced hypoxic challenges (13% inspired O2) on the cardiac and respiratory systems and their central neural substrates. Functional magnetic resonance imaging measured the 20 healthy subjects’ specific brain activity during the slow and normal rate breathing. The authors mentioned the controlled slow breathing of 6 breaths/minute is the rate encouraged during yoga practice. This rate decreases sympathetic activity, lessening vasoconstriction associated with hypertension, and it prevents physiological stress from affecting the cardiovascular system. Each part of the brain showed responses to the 2 conditions, and the general conclusion was modifying breathing rate impacted autonomic activity and improved both cardiovascular and psychological health.

Vinay, Venkatesh, and Ambarish (2016) presented a study on the effect of 1 month of yoga practice on heart rate variability in 32 males who completed the protocol. The authors reported yoga is supposed to alter the autonomic system and promote improvements in cardiovascular health. Not just the breathing but also the movements and meditation positively affect mental health and general well-being. The subjects participated in 1 hour of yoga daily for 1 month, and at the end of the study, the 1 bpm improvement in heart rate was not statistically significant. However, heart rate variability measures indicated a positive shift of the autonomic system from sympathetic activity to parasympathetic, which reduces cortisol levels, improves blood pressure, and increases circulation to the intestines.

Bershadsky et al., (2014) studied the effect of prenatal Hatha yoga on cortisol levels, affect and depression in the 34 women who completed pre, mid, and post pregnancy saliva tests and questionnaires. While levels of cortisol increase naturally with pregnancy, yoga was found to minimize the mean levels compared to the days the subjects did not participate in yoga. After a single 90-minute yoga session, during which breathing was emphasized throughout the session, women had higher positive affect; but, the cortisol level was not significantly different from the control group. Overall, the authors concluded yoga had potential to minimize depression and cortisol levels in pregnancy.

Considering the positive effect of slow breathing practiced in yoga, the positive shift in the autonomic nervous system function and the decrease in cortisol levels, yoga is gaining credibility as an effective adjunct to treatment during pregnancy. If a woman enters the delivery room with a solid practice of slow breathing under her belt, she may be equipped to handle the intensity of contractions and the pain of pushing a little better. Yoga may help a woman breathe for her life and her baby’s as well.

If you're interested in learning more about yoga for pregnant patients, consider attending Yoga as Medicine for Pregnancy with Ginger Garner, PT, DPT, ATC/LAT, PYT. The next opportunity is in Fort Lauderdale, FL on January 28th and 29th, 2017. Don't miss out!

Critchley, H. D., Nicotra, A., Chiesa, P. A., Nagai, Y., Gray, M. A., Minati, L., & Bernardi, L. (2015). Slow Breathing and Hypoxic Challenge: Cardiorespiratory Consequences and Their Central Neural Substrates. PLoS ONE, 10(5), e0127082.
Vinay, A., Venkatesh, D., & Ambarish, V. (2016). Impact of short-term practice of yoga on heart rate variability. International Journal of Yoga, 9(1), 62–66.
Bershadsky, S., Trumpfheller, L., Kimble, H. B., Pipaloff, D., & Yim, I. S. (2014). The effect of prenatal Hatha yoga on affect, cortisol and depressive symptoms. Complementary Therapies in Clinical Practice, 20(2), 106–113.

Myofascial release (MFR) can be one of your greatest treatment tools as a pelvic rehabilitation practitioner. Just in case you don’t think about fascia often here are a couple helpful things to remember. Fascia is the irregular connective tissue that covers the entire body, and it is the largest sensory system in the body, making it highly innervated. The mobilizing effect of MFR techniques occurs by stimulating various mechanoreceptors within the fascia (not by the actual force applied). MFR techniques can help to reduce tissue tension, relax hypertonic muscles, decrease pain, reduce localized edema, and improve circulation just to name a few physiological effects.

An interesting case report published in 2015 by the Journal of Women’s Health Physical Therapy¹ offers a wonderful example of how a physical therapist used specific MFR techniques for a patient with clitoral phimosis and dyspareunia. The specific MFR techniques used helped to provide relief and restore mobility to the pelvic tissues for this patient.

Clitoral phimosis is adherence between the clitoral prepuce (also known as the clitoral hood) and the glans. This condition can be the result of blunt trauma, chronic infection, inflammatory dermatoses, and poor hygiene. In this case report, the 41-year-old female patient had sustained a blunt trauma injury to the vulva (when her toddler son charged, contacting his head forcibly into her pubic region). She presented to physical therapy with complaints of dyspareunia, low back pain, a bruised sensation of her pubic region, vulvar pain provoked by sexual arousal, decreased clitoral sensitivity, and anorgasmia. The physical therapist completed an orthopedic assessment for the lower quarter (including spine and extremities), as well as a thorough pelvic floor muscle assessment.

Treatment for this patient addressed not only the pelvic complaints, but the lower quarter complaints as well. A detailed treatment summary for each visit is outlined in the case report. The clitoral MFR and stretching was performed by applying a small amount of topical lubricant to the clitoral prepuce. Then, a gloved finger or a cotton swab was used to stabilize the clitoris, a prolonged MFR or sustained stretch was applied in the direction away from the fixated clitoris by the therapist’s other finger. The therapist applied this technique along the entire length of the prepuce. The other physical therapy interventions this patient was treated with were stretching, joint mobilization, muscle energy techniques, transvaginal pelvic floor muscle massage, clitoral prepuce MFR techniques, biofeedback, Integrative Manual Therapy (IMT) techniques, nerve mobilization, and therapeutic and motor control exercises. Additionally, between the physical therapy evaluation and the second visit the patient did use topical Clobetasol 0.05% cream (commonly prescribed for vulvar dermatitis issues such as Lichen Sclerosis) for 30 days with no change to her clitoral phimosis.

After 11 sessions, the patient had resolution of dyspareunia, vulvar pain, pubic pain, and reduced low back pain. Also, the patient had 100% restored mobility of the clitoral prepuce, as well as normalized clitoral sensitivity and clitoral orgasm. The patient felt these improvements were still present at her 6-month follow-up interview over the phone. Current medical management for clitoral phimosis is surgical release or topical/injectable corticosteroids. Having a conservative treatment option, such as MFR, for this condition can be helpful for patients. As with most evolving treatment techniques, more research and studies are appropriate.

Not one health care professional had ever assessed the fascial mobility of the clitoris until this physical therapist did. This case report is an example of how MFR techniques can be effective treatment tools for your patients with pelvic disorders and a good reminder to check the fascial mobility of the pelvic tissues.

Morrison, P., Spadt, S. K., & Goldstein, A. (2015). The Use of Specific Myofascial Release Techniques by a Physical Therapist to Treat Clitoral Phimosis and Dyspareunia. Journal of Women’s Health Physical Therapy, 39(1), 17-28.