In this “quick fix” society, few people accept that musculoskeletal pain will require a commitment to following an exercise program for an extended period of time. If a hypomobile joint just needs to get moving and lubricated, one may get relief with a few manual therapy treatments and exercise sessions. However, if a joint is hypermobile (unstable) or degenerative and provokes a high level of pain, the rehab requires more time. The sacroiliac (SI) joint is one of those areas often requiring patients to work harder for the resolution of pain and dysfunction, but many seek surgical intervention instead.

Polly et al. (2016) performed a randomized controlled trial of minimally invasive sacroiliac joint fusion (SIJF) with placement of a system of triangular titanium implants using a lateral transiliac approach versus non-surgical management (NSM) for SI dysfunction. Of the 148 subjects, 102 underwent SIJF and 46 had NSM. The NSM group received medication, physical therapy per American Physical Therapy Association guidelines, steroid injections and radiofrequency ablation of sacral nerve root lateral branches. The surgical group showed superior outcomes at a 2 year follow up, as clinical improvement per VAS pain score was 83.1% and ODI was 68.2%. The NSM group showed <10% improvement.

Sachs et al. (2016) studied outcomes of patients ≥3 years after SIJF for chronic (>5 years) SIJ dysfunction secondary to degenerative sacroiliitis or SIJ disruption. One hundred and seven patients participated in the study, and minimally invasive transiliac SIJF was definitively correlated with decreased pain, low disability scores, and improvements in activities of daily living performance. Sadly, these authors stated, “there is no high-quality evidence that physical therapy is effective in chronic SIJ pain.”

Even radiofrequency neurotomy or neural ablation revealed positive results for patients according to Reddy et al. (2016). The authors explored 14 patients’ responses 1 year after Simplicity radiofrequency (RF) of the lateral branches of S1-S3 in a retrospective review. Improvements in global health per SF12 as well as pain reduction were statistically significant.

Jonely et al. (2015) presented a case study of a woman with a 14-year history of SIJ pain whose symptoms persisted after 2 months of physical therapy. A multi-modal approach was then pursued with success, even at the 1 year follow up. The patient received 4 prolotherapy injections, SIJ manipulation into nutation, a pelvic girdle belt, and specific stabilization exercises. Over a 12-month period, the patient had 20 physical therapy sessions. Her Oswestry Disability score improved from 34% to 14% at 6 months and was 0% at 1 year. Numeric pain scale rating improved to 4/10 at 6 months and 0/10 at 1 year. The authors concluded a multimodal approach can be successful to manage SIJ dysfunction.

Clearly, if quality of life is so poor a person cannot function because of SIJ pain and therapy has failed, surgery may be the only choice. I exhaust all conservative measures before I cry “uncle” for a surgical fix. Despite a paucity of literature on manual therapy and sacroiliac treatment, I know there are clinicians successfully treating patients with SI dysfunction. Taking the Sacroiliac Joint Evaluation and Treatment can broaden your scope of understanding the SI joint and how to provide the most effective treatment, possibly preventing more invasive techniques for patients.

Polly, D. W., Swofford, J., Whang, P. G., Frank, C. J., Glaser, J. A., Limoni, R. P., … and the INSITE Study Group. (2016). Two-Year Outcomes from a Randomized Controlled Trial of Minimally Invasive Sacroiliac Joint Fusion vs. Non-Surgical Management for Sacroiliac Joint Dysfunction. International Journal of Spine Surgery, 10, 28. http://doi.org/10.14444/3028
Sachs, D., Kovalsky, D., Redmond, A., Limoni, R., Meyer, S. C., Harvey, C., & Kondrashov, D. (2016). Durable intermediate-to long-term outcomes after minimally invasive transiliac sacroiliac joint fusion using triangular titanium implants. Medical Devices (Auckland, N.Z.), 9, 213–222. http://doi.org/10.2147/MDER.S109276
Anjana Reddy, V. S., Sharma, C., Chang, K.-Y., & Mehta, V. (2016). “Simplicity” radiofrequency neurotomy of sacroiliac joint: a real life 1-year follow-up UK data. British Journal of Pain, 10(2), 90–99. http://doi.org/10.1177/2049463715627287
Jonely, H., Brismée, J.-M., Desai, M. J., & Reoli, R. (2015). Chronic sacroiliac joint and pelvic girdle dysfunction in a 35-year-old nulliparous woman successfully managed with multimodal and multidisciplinary approach. The Journal of Manual & Manipulative Therapy, 23(1), 20–26. http://doi.org/10.1179/2042618614Y.0000000086

After greeting a patient referred for temporomandibular joint dysfunction, the conversation began with an outpouring of emotion over a failed bladder sling surgery that left the woman with significant chronic pain, causing her to clench her jaw all the time. No matter what I was to find objectively with the examination, there was no doubt the treatment had to extend beyond joint mobilization, soft tissue work, and exercise. This woman clearly saw her cup as half empty, so filling her mind with a new approach to thinking about and dealing with her pain was essential for relieving her secondary jaw pain.

Su et al. published a study called, “Pain Perception Can Be Modulated by Mindfulness Training: A Resting-State fMRI Study” (2016). The pain-afflicted group had 18 participants while the control group had 16. Brain behavior response of all subjects was measured per resting-state functional magnetic resonance imaging and 3 forms (Dallas Pain Questionnaire, Short Form McGill Pain Questionnaire-SFMPQ, and Kentucky Inventory of Mindfulness) before and after 6 weeks of mindfulness-based stress reduction treatment. Training consisted of mindfulness meditations such as a body scan, hatha yoga, walking and sitting meditation, and instruction on how to use the methods for pain management. After six 2.5-hour sessions/week and one 8-hour non-verbal session in the 4th week, the fMRI showed an increased connection from the anterior insular cortex (AIC) to the dorsal anterior midcingulate cortex (daMCC), and the SFMPQ scores were significantly improved in the pain-afflicted group. The authors suggested mindfulness training can change the brain connectivity responsible for our perception of pain.

Chadi et al.²⁰¹⁶ performed a pilot study of female adolescents with chronic pain regarding the efficacy of mindfulness-based treatment. The experimental group (n=10) and the wait-list control group (n=9) consisted of girls between the ages of 13 and 18. For 8 weeks they met for a 90 minute session led by a psychiatry resident. Some of the mindfulness practices in this study included body scan, sitting and walking meditations, love and kindness meditations, mindful eating, compassion and deep listening, and breathing exercises. The wait-list control group also completed the 8-week program. Although all participants reported a positive change in the way they coped with pain, no statistically significant changes in quality of life, depression, anxiety, pain perception, and psychological distress were found. Significant salivary cortisol level improvements were observed (p<0.001) post mindful-based treatment session, indicating feasibility in pursuing further research with a larger randomized controlled trial.

Panahi and Faramarzi²⁰¹⁶ studied mindfulness therapy effects on anxiety and depression for premenstrual syndrome (PMS). Sixty students (30 experimental, 30 control with no treatment) with mild to moderate PMS with depression underwent 8 weekly 120 minute sessions of mindfulness-based cognitive therapy (MBCT). Mean score improvements in depression, anxiety, and PMS were statistically significant from pre to post treatment for the subjects receiving MBCT. The authors stated MBCT psychotherapy could be considered beneficial for depression in mild to moderate PMS.

If jaw-clenching chronic pain owns a patient, he or she could benefit from managing the relationship through mindfulness. Our perception of pain is at the core of “whole body” treatment. The Mindfulness Based Pain Treatment course could help fill your patients’ as well as your own cup with healing.

If you're interested in learning more about mindfulness-based treatment techniques, Herman & Wallace offers three courses which you should consider. Mindfulness-Based Pain Treatment focuses on patient treatment, and the Mindfulness for Rehabilitation Professionals.

Su, I.-W., Wu, F.-W., Liang, K.-C., Cheng, K.-Y., Hsieh, S.-T., Sun, W.-Z., & Chou, T.-L. (2016). Pain Perception Can Be Modulated by Mindfulness Training: A Resting-State fMRI Study. Frontiers in Human Neuroscience, 10, 570. http://doi.org/10.3389/fnhum.2016.00570
Chadi, N., McMahon, A., Vadnais, M., Malboeuf-Hurtubise, C., Djemli, A., Dobkin, P. L., … Haley, N. (2016). Mindfulness-based Intervention for Female Adolescents with Chronic Pain: A Pilot Randomized Trial. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 25(3), 159–168.
Panahi, F., & Faramarzi, M. (2016). The Effects of Mindfulness-Based Cognitive Therapy on Depression and Anxiety in Women with Premenstrual Syndrome. Depression Research and Treatment, 2016, 9816481. http://doi.org/10.1155/2016/9816481

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.