The following post was contributed by Herman & Wallace faculty member Ramona Horton. Ramona teaches three courses for the Institute; "Myofascial Release for Pelvic Dysfunction", "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 1: The Urologic System", and "Mobilization of Visceral Fascia for the Treatment of Pelvic Dysfunction - Level 2: The Reproductive System". Join her at Visceral Mobilization of the Urologic System - Madison, WI on June 5-7!

My physical therapy training and initial experience were in the US Army, so I had a strong bias toward utilization of manual therapy techniques based on a structural evaluation. When the birth of my 10 pound baby boy threw me head-long into the desire to become a pelvic dysfunction practitioner, I became plagued by the question: how do you treat the bowel and bladder, without treating the bowel and bladder? That, along with a mild obsession for the study of anatomy was the genesis of my desire to explore the technique of visceral mobilization.

The field of pelvic physical therapy has moved far beyond the rehabilitation of the pelvic floor muscles for the purpose of gaining continence, which was its origin. Now pelvic rehabilitation is a comprehensive specialty within the PT profession, treating a variety of populations and conditions (Haslam & Laycock 2015). Research has provided a greater understanding of the abdomino-pelvic canister as a functional and anatomical construct based on the somatic structures of the abdominal cavity and pelvic basin that work synergistically to support the midline of the body. The canister is bounded by the respiratory diaphragm and crura, along with the psoas muscle whose fascia intimately blends with the pelvic floor and the obturator internus and lastly the transversus abdominis muscle (Lee et al. 2008). The walls of this canister are occupied by and intimately connected to the visceral structures found within. These midline contents carry a significant mass within the body. In order for the canister to move, the viscera must be able to move as well, not only in relationship to one another, but with respect to their surrounding container. There are three primary mechanisms by which disruption of these sliding surfaces could contribute to pain and dysfunction: visceral referred pain, central sensitization and changes in local tissue dynamics.

Since the inception of physical therapy, manual manipulation of tissues has been a foundational practice within the profession. Manual therapy is a generic therapeutic category for hands-on treatment of a structural anomaly; it encompasses a variety of techniques which can be subdivided into either soft tissue based or joint based. Although the majority of manual therapy research has been on the musculoskeletal system, its effects are not exclusive to any particular region of the anatomy. The Orthopaedic Section of the American Physical Therapy Association (APTA) defines the technique of mobilization as "the act of imparting movement, actively or passively, to a joint or soft tissue" (Farrell & Jensen 1992). Visceral mobilization is a treatment approach focusing on mobilizing the fascial layer of the visceral system with respect to the somatic frame; it therefore falls under the classification of soft tissue based manual therapies. Soft tissue and or fascial based manual therapies have higher-levels of evidence to support their use for treating musculoskeletal pain and dysfunction (Ajimsha & Al-Mudahka 2014; Gay et al. 2013). Although many models have been proposed, the specific mechanisms behind the response of the musculoskeletal system to manual interventions are still not fully understood (Bialosky et al. 2009; Clark & Thomas 2012).

The previous model of manual therapy directly relieving local tissue provocation has given way to a recognition that the observed clinical improvement is not simply a result of the practitioner directly altering the structure beneath their hands through mechanical means. Rather this improvement is a combination of afferent input influencing the neurophysiologic output, changes in the endogenous cannabinoid system, and even a placebo responses simply because of touch (Bialosky et al. 2009; McParland 2008; Gay et al. 2014).

There is significant clinical evidence that issues of somatic pelvic pain, bowel, bladder and reproductive system dysfunction may be the result of visceral referred pain, central sensitization and restrictions in visceral tissue mobility which may further contribute to dysfunction within the canister of core muscles. The musculoskeletal framework is a mysterious, perplexing and complicated system. It is unique in that it offers us a variety of tissues and techniques from which to choose in order to help our patients from a manual therapy perspective. Science has acknowledged that the visceral structures and their connective tissue attachments indeed have an influence on the function of the somatic frame, the question is can we manually manipulate these structures and bring about an effect with a reasonable degree of specificity while producing a therapeutic outcome.
Part 2 of this report will discuss the evidence to support visceral mobilization.
Ajimsha M.S., Al-Mudahka N.R. & Al-Madzhar J.A. (2015) Effectiveness of myofascial release: Systematic review of randomized controlled trials. Journal of Bodywork and Movement Therapies 19, 102-112.
Clark B.C., Thomas, J.S., Walkowski S., Howell J.N. (2012) The biology of manual therapies. The Journal of the American Osteopathic Association 112 (9), 617-29.
Bialosky J., Bishop M. & Price D. (2009) The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual Therapy 14 (5), 531-538.
Gay C.W., Robinson M.E., George S.Z., Perlstein W.M. & Bishop M.D. (2014) Immediate changes after manual therapy in resting-state functional connectivity as measured by functional magnetic resonance imaging in participants with induced low back pain. Journal of Manipulative and Physiologic Therapeutics 37 (6), 614-627.
Haslam J. & Laycock J. (2015) How did we get here? The development of women’s health physiotherapy special interest groups in the UK. Journal of Pelvic Obstetric and Gynecological Physiotherapy 116 (Spring), 15-24.
Farrell J.P. & Jensen G.M. (1992) Manual therapy: a critical assessment of role in the profession of physical therapy. Physical Therapy 72, 843-852.
Lee D.G., Lee L.J. & McLaughlin L. (2008) Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies 12 (4), 333-348.
McPartland J M (2008) Expression of the endocannabinoid system in fibroblasts and myofascial tissues. Journal of Bodywork and Movement Therapies 12(2), 169-182.

A few weeks ago, a pelvic course participant shared some sensitive and intimate thoughts about being at a course and being "the biggest girl in class." This week, we will address specific strategies for communicating with your patients and for adapting your exam techniques when appropriate. The following quote is from an educational book for Nurse Practitioners, and echoes a very healthy and realistic sentiment about our role when working with patients in pelvic rehabilitation.

"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit."

Unfortunately, according to the authors, women who are obese are less likely to receive routine gynecologic care due to bias and fear of judgement, or even practical issues like exam tables, gowns, and equipment not being adequate. Another issue is that of mobility: is the exam table too narrow for safety and comfortable positioning? In my own clinical practice, I have had patients ask me: "Is that massage table going to hold me?" In order to answer that question, you need to know what the safe weight limits are for your chairs, walkers, exam tables, and any other equipment your patients may use. You might imagine that if a patient is concerned about falling off of a table, completing an appropriate exam could be difficult due to muscle guarding. Other techniques recommended include the following:

- ask an assistant to gently hold back skin folds if vagina or vulva is obscured
- ask the patient to flex her hips upward if able
- ask patient to help hold back excess skin in lower abdomen if helpful
- ultrasound may be used rather than palpation as needed (this is in reference to a medical gynecologic exam, but how might rehab US contribute to our toolkit?)
- document any difficulty with the examination - placing a small towel or pillow under the patient's hips may also help in viewing the cervix

This "Bias Tool Kit" offers further suggestions to avoid causing harm when evaluating a woman who is obese:

- if you would like to weigh the patient, ask for consent first, using sensitive language, i.e. "would you like to be weighed today?" and maintain privacy
- in addition to considering equipment like tables, think about having a stepstool with a handle, properly sized blood pressure cuffs, sturdy, armless chairs, and a long exam speculum
- use words that patients find more acceptable, such as excess weight or BMI

Advice to the nurse practitioners include the following to counter the fact that obese women are often discriminated against:

"If the exam is limited by obesity, the patient should be told in a clear, non-judgmental manner. Patients have a right and responsibility to understand the findings of the health care visit." For example, for a medical exam: "Due to the shape and size of your body, I wasn't able to feel your uterus and ovaries." Any similarly needed communications can be shared in a professional and warm tone.

While sensitive topics can require patience, practice, and an abundance of professionalism, everyone wins when difficult subjects are approached with honesty. Thanks again to Erin B. for shining her light on this sensitive and valuable topic.

Earlier this week a blog post asked the question "Do male therapists belong in pelvic rehab?" With increased frequency, male therapists are participating in pelvic rehab coursework and practices. Some of the male therapists are even attending coursework as students. I asked Justin Stambaugh, a student from Duke University (who very much impressed me with his command of the material, and his calm, curious, and competent demeanor), a few questions about his path into pelvic rehab. Below are his responses.

Holly: How did your path lead towards pelvic rehab in general?

Justin: Pelvic rehab really necessitates an openness and sense of comfort regarding issues that can be seen as very personal, private, and even taboo. I was drawn to pelvic rehab because I am the type of person who doesn’t believe that individuals should have to suffer in silence because of fear or embarrassment of addressing their issues. I want people to know that they can and should seek treatment for their pelvic health issues, and that physical therapy can be a valuable resource in this regard.

I also value the complexity of pelvic rehab. In addition to the clinical aspect of care there is also the psychosocial element that adds to the scope and depth of treatment. I appreciate that pelvic rehab requires the clinician to continuously evaluate and adapt their approach in order to be proficient.

Additionally I find that often times many physicians, patients, and other physical therapists don’t realize the extent of what we are capable of treating, and how great of an impact we can have on someone’s life. I get excited about educating and promoting this side of the profession.

Holly: What is your viewpoint on how you will be perceived as a male therapist in treating pelvic rehab with a female patient?

Justin: As a male therapist in the pelvic rehab setting I understand that there are some female patients who will be hesitant to work with me solely because of my gender. I think this is an unfortunate fact, however it simply requires me to be a bit more industrious as a practitioner. Patients who may initially be uncomfortable with me due to my gender are really just asking me to prove to them that I know what I’m doing and that I am trustworthy. It is completely understandable that I need to win their trust before moving forward with any type of treatment. I respect my patients and ultimately just want what’s best for them. We can work together on achieving this goal, and find the correct path that suits each patient’s needs based on their comfort level. Often times I think of the phrase “to a man with a hammer, everything looks like a nail”. Although I am capable of performing an internal pelvic floor exam and subsequent treatment, there are also external approaches that may work just as well for an apprehensive patient depending on their presentation. This may also help gain their trust in order to implement more effective care in future sessions.

Holly: How do you think your generation differs from those before you in addressing the entire issue of gender?

Justin: I would like to think that my generation is more open regarding issues of sex and gender. However I think there are still many hurdles left to climb in this regard. I feel that socially my generation is part of an evolution in tolerance and empathy towards diversity with respect to issues such as gender, gender identity, sexual orientation etc. All of these qualities define some part of all of us and are constantly being communicated and evaluated. If we look back through history we see the dynamics of social inequality based on gender. Today we continue to see broad discussions regarding sex and gender. I feel that each generation continues to grow from these conversations and socially we persist in advancing our understanding and comfort regarding this topic.

Holly: Where do you see us (on the continuum) as a profession in normalizing the experience of having treatment directed to the pelvis by any gendered therapist to any gendered patient?

Justin: It would be my hope that in the future more institutions will instruct pelvic health with patient models that allow students to interact and conduct treatment based therapies in a clinical manner. I feel that in order to alleviate some of the gender based fears and apprehension regarding pelvic rehab from a professional perspective, all students should get to experience this aspect of physical therapy before deciding if its for them. I do feel it’s unfortunate that there are not more males who are interested in pelvic rehab. Oftentimes people are afraid of what they don’t know. It seems that perhaps pelvic rehab has remained somewhat enigmatic in that many individuals don’t get to experience this type of patient care, and therefore never approach it. It is such a great benefit to be able to work with this population of patients. I feel that the more exposure and normalization pelvic rehab gets to the patient population as well as to the professionals in the field of physical therapy the more we will see an increase in gender representation within the profession.

If the work of pelvic rehab is in the hands of students like Justin, we have so much to look forward to in our field. Thank you to Justin for being willing to articulate his thoughts and experience so that we can continue to explore issues of gender in pelvic rehabilitation.

Today's post on the Pelvic Rehab Report comes from faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. Allison instructs the ultrasound imaging courses, the next of which will be Rehabilitative Ultra Sound Imaging: Women's Health and Orthopedic Topics in Baltimore, MD on Jun 12, 2015 - Jun 14, 2015.

In the past several decades there has been quite a bit of research regarding stabilization of the low back and pelvic ring. We as therapists have changed our focus from working more of the global stabilization muscles to the local stabilizing muscles; the transverse abdominis, the lumbar multifidus, and the pelvic floor. Both research studies and clinical experience has shown us what a positive difference working on these muscles can makes for back pain and pelvic ring pain, as well as for the risk of injury in the back and pelvic ring. However, what does it do for risk of injury for the lower limb? In 2014, Hides and Stanton published a study looking at the effects of motor control training on lower extremity injury in Australian professional football players. A pre- and post-intervention trial was used during the playing season of the Australian football league as a panel design. Assessment included magnetic resonance imaging and measurements of the cross-sectional area of the multifidus, psoas, and quadratus lumborum, as well as the change in trunk cross-sectional area due to voluntary contraction of the transverse abdominis muscle. A motor control program included training of the multifidus, transversus abdominis, and the pelvic floor muscles using ultrasound imaging for feedback that then progressed into a functional rehabilitation program was used with some of the players. Injury data was collected throughout the study. Results showed that a smaller multifidus or quadratus lumborum was predictive of lower limb injury during the playing season. Additionally, the risk of sustaining a severe injury was lower for players who received the motor control intervention.

This is interesting and intriguing information. Yes, there are many factors that are involved in sustaining an injury during a sport. However, it would be a good idea to do a quick screen of the local stabilizing muscles before a playing season, whether it is a professional player or an adolescent player. Do adolescents really have issues with weakness in their local stabilizing muscles? Yes! Clinically I have seen adolescent players who display back pain and other issues related to weakness in their core muscles. Usually this occurs after they have gone through a growth spurt, but some of these adolescent athletes did not recover, even several years after the large growth spurt.

What a nice community service it would be to screen a local sports team for strength of the local stabilizing muscles in order to decrease injuries! It would also be nice to see additional research regarding this topic! To learn more about recent research and how to use ultrasound imaging to accurately assess and treat the local stabilizing muscles, join me at Johns Hopkins in Baltimore this June for the Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor course.

Hides JA, Stanton WR. Can motor control training lower the risk of injury for professional football players? Med Sci Sports Exec. 2014; 46(4): 762-8.

If you area clinic owner, are in a management or leadership position, one of your jobs is making sure your therapists are using best practices. This can be a challenge when best practices are continually being researched and discussed, and when systematic reviews continue to tell us that pelvic rehabilitation research lacks homogeneity and enough high-level evidence to make convincing arguments about interventions. In the absence of this, we can still integrate recommendations from clinical practice guidelines and from best practice statements. The American Physical Therapy Association's (APTA) Section on Women's Health (SOWH) is participating in the APTA's initiative to develop clinical practice guidelines. For current guidelines, check out their page here. To see which guidelines are in development at the APTA, click here.

The American Urological Association (AUA) has also developed practice guidelines, including the Guideline on the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome (IC/PBS). Within this guideline, the first line treatments are listed as general relaxation/stress management, pain management, patient education, and self-care/behavioral modification. Second-line treatments include "appropriate manual physical therapy techniques", oral medications, bladder medications (administered inside the bladder), and pain management. What is very interesting about this guideline is that the authors define what types of manual therapy approaches are appropriate, and these include techniques that resolve muscle tenderness, lengthen shortened muscles, release painful scars or other connective tissue restrictions. The guidelines also define who should be working with patients who have IC/PBS and pelvic muscle tenderness: "appropriately trained clinicians". Very importantly, the authors state that pelvic floor strengthening exercises should be avoided.

How can these guidelines be used to assess best practices? Find out if your therapists who work with patients who have IC/PBS are indeed instructing in relaxation strategies, using pain education and pain management techniques (for pain-brain education specific to pelvic pain, check out the book "Why Pelvic Pain Hurts". Find out if your therapist is instructing in pelvic muscle strengthening as a first-line of treatment, since this would not be in line with the AUA guidelines. (Having said this, teaching pelvic muscle strengthening can be very appropriate when done with consideration of pelvic muscle pain.) Lastly, ask your therapist if she feels that her skill set and training is sufficient to treat the condition. Even in our comprehensive pelvic floor series, there is so much to learn at the initial course that IC/PBS is not discussed in great detail until PF2B. Maybe a little more knowledge and training would help your therapist feel that she is providing the "appropriate manual physical therapy techniques" recommended in the guidelines.

To find out when the next intermediate or advanced course in the series is happening, or to find other specialty courses, check our course listings to see if there is a course happening near you!

Many diagnoses that live under the umbrella of "chronic pelvic pain" have similar symptoms, confounding the differential diagnosis and development of a treatment pathway. Dr. Charles Butrick, in an article published in 2007, suggested that gynecologists "…be alert to…interstitial cystitis in patients who present with chronic pelvic pain typical of endometriosis." The concurrent conditions of bladder pain syndrome (BPS) and endometriosis have been described as "evil twins syndrome" in the realm of chronic pelvic pain. Bladder pain syndrome. also known as Interstitial Cystitis (IC), is a condition commonly associated with pelvic pain, bladder pressure, and urinary dysfunction such as urgency and frequency. Endometriosis can also cause or contribute to pelvic pain, and a variety of pelvic dysfunctions including bowel, bladder, or sexual dysfunction.

A study published in the International Journal of Surgery reported on the prevalence of these two conditions. Utilizing a systematic review approach, the authors located articles reporting on the prevalence of bladder pain syndrome and endometriosis in women with chronic pelvic pain. Nine observational studies were included, and the range of endometriosis diagnosis ranged from 11%-97%, with a mean prevalence of 61%. The prevalence of endometriosis ranged from 28%-93% with a mean prevalence of 70%. The large variation in these rates were explained as potentially being due to the variations in study quality and sample selection. (The authors point out that the highest rates of prevalence for BPS and endometriosis were noted in the patient groups recruited from specialist clinics and from lists of patients from operating lists.) The study concludes that in women who present with chronic pelvic pain (CPP), screening for bladder pain syndrome is important so that appropriate treatment can be directed to all issues.

If another chronic pelvic pain condition, pudendal neuralgia, is added to the diagnoses of endometriosis and painful bladder syndrome, "evil triplet syndrome" can be experienced by a patient. The various symptoms of each of these conditions can add to the total level of pain and dysfunction experienced by a woman with chronic pelvic pain. Having the tools to evaluate and treat symptomatology and address the chronic aspect of tissue, joint, neural, myofascial, and the processing of pain is a skill that most pelvic rehabilitation therapists continue to work on throughout their careers. Michelle Lyons, faculty member from Ireland, brings her "Special Topics in Women's Health" course to Chicago in a couple of weeks. Within the course, Michelle will be discussing each of these conditions from the standpoint of a multidisciplinary approach, and with the role of the pelvic rehabilitation provider in mind. She will also be sharing up-to-date and practical information about infertility and hysterectomy. If you are interested in joining Michelle and colleagues in Chicago, you still have time to sign up! And if you would like to host Michelle's course in your facility, give us a call or send us a note!

Even after teaching for a couple of decades, both in graduate level courses and in continuing education settings (live and online), I am humbled by all there is to learn and relearn about how to teach well. We all teach every day, regardless of what setting or roles we work in, and are required to share our thoughts and knowledge with respect, equanimity, and non-judgement. After teaching a course last month, I received feedback about an important topic that was not clearly addressed from an instructional or clinical standpoint, and the participant who brought it to my attention agreed to share her experience so that we as pelvic rehab providers can do a better job of addressing the issue when needed. The following post was written by Erin B. after I encouraged her to share her own thoughts about the issue.

"Having recently participated in the PF1 class after several years out of the classroom-style of continuing education, I made a few observations I felt compelled to share. (I do want to preface this with the fact that I am fully aware that my own insecurities play a role in my experiences and I recognize that they may alter my judgment of the situation.)

I am 5' 4" and currently 240 pounds. Although that is 50 pounds lighter than I was 6 months prior to attending this class, it is still significantly larger than 90% of the class participants, lab assistants and instructors. I am not someone who feels that fat is healthy. I do not feel that you need to act like I am in as good of shape as anyone else in the room. However, I do feel that there are certain assumptions made about me that are based on my physical appearance alone. Take a minute and think about your first reaction to seeing a person who is obviously overweight. (I do realize that I have made my own assumptions about some of you as well!) Just because you are much thinner and more fit looking I assume you exercise regularly, you always eat healthy and you judge me negatively for my appearance. I do know that my assumptions about you may be just as wrong as what I believe you assumed about me. However, when I see that the larger people in class have placed themselves more to the back of the room, when I have a hard time finding a lab partner and when the lab instructor struggles with how to say to the partner that got stuck with me "things may be different on her", I begin to feel like I am taking something away from the class experience for everyone else. I do not want to hinder another clinician's learning process so I don't push anyone to be my partner, but then I am actually denying myself the learning opportunities I came for. Not to mention that I may be denying the other participants the opportunity to learn how to handle a client that may look and feel like me.

The reality of our world is that there is a very large obese population. I firmly agree this leads to a multitude of chronic illnesses and astronomical medical costs for the individual and our society as a whole. It does need to be addressed on a large scale. However, we as clinicians don’t know where these individuals are on their weight journey. For someone like me who has made drastic lifestyle changes to move me in a positive direction but have not yet gotten my appearance in line with the "norm" that the health care professionals, the media and society are pushing, your response to me can be devastating to my progress, my hope and my desire to continue toward a healthier lifestyle. Again I want to acknowledge that this is as much my problem as it is for those around me and I am addressing this as well. But please have the awareness that an obese person above all is a PERSON FIRST! Then their physical size becomes just another item on the list of "facts" about them, instead of a source of anxiety and separation. Approaching an obese person with respect, acceptance, honesty and openness not only puts them at ease, it also strengthens the rapport that is so crucial in pelvic rehabilitation.

Although I was born and raised in the north east, I now live in Alabama, home of corn bread, fried chicken and sweet tea. The population I deal with is more likely to be at least overweight if not truly obese. So, quite honestly, the practical instruction of how pelvic floor evaluation and treatment may be different with the obese patient would be directly beneficial to my practice. This might include openly addressing in labs how to assess/reposition an obese patient will give each therapist an awareness and confidence when approaching this population and may minimize the patient's embarrassment and keep the doors of trust and communication open. Or taking a moment to recognize the larger participants in the classroom setting and professionally suggesting during a lab session how they can reposition themselves and still affectively achieve appropriate assessment/treatment for the patient would make the transition from class to the reality of the clinic more smooth. Also, taking a moment to offer suggestions for what the obese patient who can’t physically reach their perineum or even palpate the pubic symphysis and or coccyx and doesn’t have a willing partner to assist can do to effectively complete the rehab activities suggested. You have to admit, this is not an easy specialty of practice to broach in the first place, and anything to take the pressure off of the clinician and or patient is helpful!

I so greatly appreciate the respect and professionalism the many delicate topics related to pelvic health are addressed in this program. I would also appreciate that same respect and professionalism when it comes to the reality of the many different body types that are the represented in our practices!"

Thank you to Erin for sharing her thoughtful suggestions, and reminding instructors and fellow course participants that an open, curious and helpful approach is needed for all situations. We at the Institute will address this issue among our instructors so that we can provide more clear guidance regarding patient and provider positioning. Stay tuned for a blog post about helpful positioning and communication tips for working with patients who are obese.

Today's post is written by faculty member Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC. You can join Allison in her Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics course, which takes place in Baltimore this year, June 12-14.

Since the mid 1990’s the POP-Q has been used to quantify, describe and stage pelvic organ prolapse. A series of 6 points are measured in the vagina in relation to the hymen. In a recent years, translabial ultrasound imaging has been used to look at the pelvic organs and the pelvic floor. A skilled practitioner can view pelvic floor muscle contractions, as well as Valsalva maneuvers and the effects each of these have on the pelvic organs. For example funneling of the urethral meatus, rotation of the urethra, opening of the retrovesical angle, and dropping of the bladder neck and uterus can be viewed using ultrasound imaging of the anterior compartment during Valsalva maneuvers. Pelvic organ descent seen on ultrasound imaging has been associated with symptoms of prolapse.

Until now the relationship between ultrasound and clinical findings has not been examined. A recent study by Dietz set out to see if there is an association between clinical prolapse findings and pelvic descent seen on ultrasound. Data was obtained on 825 women seeking treatment at a urogynecological center for symptoms of lower urinary tract or pelvic floor muscle dysfunction. Five coordinates of the POP-Q scale were measured and compared to ultrasound measures of descent. All data was blinded against other data obtained. Clinically, 78% of the women were found to have a POP-Q stage of 2 or greater. It was found that all coordinates were strongly associated with ultrasound measures of descent. The association was almost linear, particularly for the anterior compartment. This means that ultrasound measures can be used to quantify prolapse and be comparable to the POP-Q. Proposed cutoffs have been made for the bladder, uterus, and rectum in relation to the pubic symphysis.

It is exciting to see ultrasound use in the quantification and identification of more gynecological disorders. The use of translabial ultrasound imaging is growing and continuing to be researched. It is an exciting field to be a part of and I look forward to seeing where this research goes. I believe it will be used to help improve surgical procedures as well candidate selection for surgery. Join more for more discussion regarding translabial ultrasound imaging and learn how to view these images in Rehabilitative Ultrasound Imaging for the Pelvic Girdle and Pelvic Floor in Baltimore this June!

Dietz HP, Kamisan Atan I, Salita A. The association between ICS POPQ coordinates and translabial ultrasound findings: implications for the definition of ‘normal pelvic organ support’. Ultrasound Obstet Gynecol. 2015; April.

Today the Pelvic Rehab Report presents a conversation with Dr. Kimberlee Sullivan, DPT. Kimberlee was kind enough to share her thoughts on the importance of pelvic rehab and her experiences in the field.

Tell us about your clinical practice.

Sullivan Physical Therapy is an outpatient private practice physical therapy clinic in Austin, Texas that specializes in women's and men's health. We have seven physical therapists who evaluate and treat pelvic floor dysfunction, pre and postpartum, pediatric bladder and bowel dysfunction, and lymphedema. Our practice takes a full body approach that looks at a person from different aspects to analyze how various factors in their life may be contributing to their symptoms. We also strive to be an integrated health care practice that communicates well with both the patient and their referring physician or multiple practitioners. The physical therapists work closely with the patient's entire medical team in order to provide the best care.

How did you get started doing pelvic rehab?

I attended physical therapy school with the idea that I would work in sports medicine. As the daughter of a college football coach, my whole life had been surrounded by athletes and this made sense with my Bachelor's in Sports Medicine. Fortunately, I had the wonderful opportunity to be able to have one of my clinical affiliations at a women's health clinic. This was very rare for the early 2000's. I thought that I would be able to work with female athletes or those women who were having back pain with pregnancy. I had no idea what I was in for nor that I would instantly fall in love with it. There is no better feeling in the world than helping someone with such private matters as incontinence, constipation and pain with intercourse. I feel lucky every day that a flip of the coin allowed me the opportunity that became my professional passion.

How do you feel the addition of pelvic rehab provides a unique service to your community?

There are so many people that suffer in silence with pelvic floor dysfunction. It is unfortunate that patients often feel embarrassed by their symptoms and that they are all alone. It is so rewarding to be able to help patients achieve their goals that relate to some of the basic aspects of life such as bladder function, bowel function, and sexual function. Patients who once felt that they would have to live with their pelvic symptoms now have a place to go that can help them reach their goals.

What skills have their therapists been trained in that they have found most helpful?

I asked the six women I work with and they felt what was most helpful was connective tissue manipulation, visceral mobilization, orthopedic approaches for treatment of the spine, pelvis and hip, understanding of how hormones can influence pelvic pain, lymphedema, pre-and post-natal care and specialized care for the male patient.

In addition, our therapists are constantly pushing themselves and each other to learn more and bring themselves to the next level. They communicate not just with local physicians to learn more about the pelvic floor, but they communicate with the top physician's in the country that treat pelvic floor disorders. An example of this is my coworkers' blogs of "Blog about Pelvic Pain" and "What is Up Down There?" We try to keep our finger on the pulse of physical therapy treatment but at the same time educate the public as we learn.

Do you find that medical providers and referral sources are still surprised at all the of conditions pelvic rehab providers can treat?

Absolutely! This will probably never end as our profession evolves. But I have to say it is much better and is getting better. I see this in the number of patients we see. Ten years ago we were fighting to have providers understand what we could offer their patients and we were seeing about 7 patients a week. Now we see around 220 patients a week and have providers calling us asking our opinion on their patients. It has been a long road, but I think as we get better as a profession communicating what we do we will see our practices continue to grow. It is exciting not only to inform providers of what we do, but also to see their faces and the faces of other physical therapists when we tell them what we do. "You do what? And it works?" Yes I do AND yes it does!

What are challenges you face managing a clinic? What are some things that have helped you get over these challenges?

I think the main challenge is the ever changing challenge of reimbursement. We chose to have a clinic that was contracted with insurances in order to provide less stress to patients who were already under so much stress dealing with their current conditions. However, insurance companies have difficulty recognizing that care can sometimes take a while for someone who has been suffering with pain for years or that a specific type of treatment could be beneficial to a patient having trouble understanding how to contract or relax their pelvic floor muscle. With all the new Medicare and other insurance paperwork requirements, I have to remind my staff why we do all of this extra work. At the end of the day the patients' care should and does always come first. As a team we participate in a lot of webinars and research to make sure that even if insurance changes, we will be here for the patients and provide them with the best care.

What aspect of your program do you look forward to further developing?

As we continue to grow and develop new programs we have discovered that there are a lot of physical therapists who are not as lucky as we are to have seven physical therapists to work with. We have a physical therapist office that is always full of discussion, sharing ideas and challenging current thought. We have had several physical therapists and physical therapist assistants come to visit us in Austin and asking to stay connected to that type of environment. For this reason, we have established a mentorship program for licensed physical therapists who are not in Austin but would like to have access to an enriching environment to efficiently grow in Women's and Men's Health Physical Therapy. In addition, we are looking at different possibilities for conducting research at the clinic in order for us to contribute back to our profession.

How has H&W helped you reach your goals?

Herman & Wallace has provided me with extraordinary information and skills in order to better serve my patients and also challenge my staff. Herman and Wallace provides classes that are up to date and constantly evolving. The instructors provided by Herman and Wallace are highly skilled therapists who are able to answer questions and challenge you to be a better physical therapist. We especially find value in the excellent lab experiences provided by Herman & Wallace.

If you could get a message out to other providers about pelvic rehab, what would it be?

Pelvic floor physical therapy is very different from orthopedic physical therapy in that both internal and external work is performed and that treatment goes so much further than instructing patients to perform kegels. It is usually of sensitive nature and patients need to feel comfortable knowing there are providers qualified to address their concerns. Every patient is different and so is treatment. I would also encourage providers to ask all of their patients if they have any bladder, bowel, or pelvic pain issues and if the answer is yes to assist them in finding the help they need.

If you are in a solo practice, find a way to stay connected with other practitioners. There is so much information coming out that it is impossible to stay up to date without accessing resources or other practitioners. I feel very fortunate to work in a practice that is set up for the physical therapists to constantly ask questions and bounce ideas off the each other.

If you could get a message out to patients/ the community at large about pelvic rehab, what would it be?

Recognize that the pelvis is just another part of your human body, just like your low back. Do not be fearful about discussing this region of your body. You would be surprised at how many other people are dealing with the same issue. Pelvic floor physical therapy can be a very effective conservative treatment for those suffering from bladder and bowel dysfunction as well as pelvic pain. Many people suffer from these diagnoses and do not know there is treatment available. Even though pelvic floor physical therapy may sound scary for those that are not familiar, an experienced physical therapist should put you at ease by walking you through step by step of what to expect and always making sure you are comfortable before proceeding. Pelvic floor rehabilitation can be powerful in changing and eliminating pelvic floor symptoms. For many patients, this is life-changing so please continue to advocate for yourself.

Today's post is written by faculty member Martina Hauptmann, who instructs the Pilates for Pelvic Dysfunction, Osteoporosis, and Peripartum course. Come learn how to apply Pilates in your practice this September 19-20 in Chicago, IL!

Treating the incompetent pelvic floor (urinary incontinence and pelvic organ prolapse) is a staple of therapists who have specialized in this complex area.

Ever since Dr. Arnold Kegel published his research “A Non-surgical Method of Increasing the Tone of the Sphincters and Their Supporting Structures” back in 1942 women have been strengthening their pelvic floor by conscious contraction of their perineum by either squeezing or lifting.

Another method to strengthen the pelvic floor is through the muscles that are extrinsic synergists to the pelvic floor musculature. The hip abductors, adductors, extensors and lateral rotators are extrinsically linked to the pelvic floor musculature. Except for one of the hip lateral rotators, the obturator internus, which by its anatomical attachments is actually an intrinsic synergist of the pelvic floor.

Pilates is an exercise method that seeks to increase a client’s strength, posture, control, and body awareness through precise exercises. The Heel Squeeze exercise is an excellent exercise to indirectly strengthen the pelvic floor via isometric contraction of the hip lateral rotators and hip extensors.

To perform the Heel Squeeze exercise, have the client lie prone with their legs hip distance apart, knees bent. The heels are touching and the toes pointing away from center. Draw the client’s awareness to their abdominals and have them slightly lift their stomach away from the mat. Instruct the client that she should continue with this contraction of her abdominals. Then as she exhales, the client squeezes her heels together and presses her pubic bone down into the mat. The client should hold this contraction for 5 seconds and do 8-12 repetitions.