Herman & Wallace instructors Bill Gallagher PT, CMT, CYT and Richard Sabel MA, MPH, OTR, GCFP are currently leading a four-session workshop for men who recently underwent prostate surgery. They recently completed the second two sessions and shared their story and experience with Pelvic Rehab Report:

You can read their dispatch from Sessions 1-2 here.

The group was a rousing success. In fact, the opening narration to Star Trek, with some modification, can be used here: The pelvic floor program was, for many, the final frontier. It’s 4-week mission: to explore strange and unusual sensations, to boldly go where man has never gone before, works well. Everyone had fun. There were lots of laughs, but some cognitive dissonance too - especially the first week when we were learning the pelvic breath. However, by the end, most were smiling as they felt the dance between their respiratory and pelvic diaphragms.

In fact, the pelvic breath led to some interesting discoveries. Everyone found it relaxing, and a majority, for the first time, could sense the movement and dimensionality of pelvic floor, thereby making it easier to differentiate the front, back, left and right quadrants. Some additional discoveries were 1) only noticing movement on one side, 2) feeling the whole pelvic floor move, but discerning differences among the quadrants, 3) those with pelvic pain found it easier to pinpoint and release, 4) one participant discovered he was breathing paradoxically and 5) several of the participants were surprised to hear that the front quadrant is where the “action is” for improving urinary incontinence and sexual function. Everyone agreed that the pelvic breath lesson helped fine-tune their practice.

Prior to our workshop, Kegels was the exercise of choice, or rather lack of choice. Most were given a piece of paper with the instructions. A couple were actually taught the exercise, but not always given good information. One member was told by the urologist to squeeze his anus during the exercises. Learning that there were other exercises - or lessons, as we like to call them - surprised some participants who thought Kegels was their only option.

The Tai Chi lesson also created some cognitive dissonance as participants tried to maintain the pelvic breath in Standing Stake. There were also some unprintable comments on what some felt in their quadriceps after being in the form for a minute, but by the end, 2-3 minutes was, as one participant said, “no problem.” All of the participants could sense how softening the knees and dropping the tailbone - key elements of Standing Stake - reduced the stress in their lower back, freed the pelvic region and made it easier to breathe and sense the pelvic hammock.

The final session, which focused on learning to use the pelvic floor in everyday activities such as lifting, standing, bridging in bed, was met with pleasant surprise. Sensing how engaging the pelvic floor made each of these movements easier, clarified the contribution these muscles make in day-to-day activities. As one participant said, “although it felt funny at first, using my pelvic muscles added a little propulsion to helping me stand.” After four weeks, although the stress incontinence had not resolved, most noticed an improvement, meaning less leakage and pads. Everyone felt more hopeful now that they had more tools at their disposal.

We plan to meet with the group for 2 follow-up sessions late in the fall. At that time we’ll have a “check –in” to see how everyone is doing, review the lessons and based upon the needs of the group, teach 1-2 new lessons.

Eight weeks after the program we bumped into “Jack” - he was the paradoxal breather and, at 82, he was the oldest participant. “Jack” shared:

“I’ve been practicing your program and didn’t force my breathing to change. I kept working gently like you recommended, and after 4 weeks it changed (his breathing) and hasn’t come back. By the way I’m no longer incontinent. That went away too.”

When we asked Jack how often he practiced, he said everyday, which obviously was the key to his success. Unfortunately, too many give up too soon.

All of the lessons came from our “Integrative Techniques for the Pelvic Floor & Core Function: Weaving Yoga, Qigong, Feldenkrais & Conventional Therapies” online courses and live program. As mentioned in our previous blog, the lessons can be used one-to-one or in groups. From our experience, the group format is extremely effective for pelvic floor work. Participants learn from each other as much as they learn from us. Most of all, groups lend themselves to everyone having fun, which keeps the work light and playful. Not a bad thing when focusing on the “down under.”

Herman & Wallace is excited to announce that we will be offering a Pelvic Floor Level One course this year in Birmingham, UK!

This course will be hosted at Coventry University and taught by Michelle Lyons, PT, MISCP.? Unlike our usual PF1 courses, the Birmingham course will be a two-day event, starting on November 30^th.

Michelle, who is based in Ireland, had this to say about the course ?[Pelvic Floor Level One is] is of the highest quality and the clinical usefulness is immediately applicable?I worked with Siv on teaching PF1 in Belfast in February of this year - it was a big success and there is nothing of comparable quality being taught in England so we thought the time was right. ?Gerard Greene, who will be organising the course, is a fantastic clinician himself, and recognises the importance of assessment and treatment of pelvic floor dysfunction in promoting women's health.?

H&W has made an effort to offer courses outside the U.S.? As we discussed in a previous Pelvic Rehab Report, this September, Founder Holly Herman will be teaching a course in Chile.

Michelle frequently teaches around the world.? About the prospect of teaching this course, she had this to say:

?I love teaching! ?I am very passionate about women's health, especially pelvic health, and to share this information with other clinicians and see them get excited about this work is such a reward for me. ?I have taught all over the world - Europe, the US, Canada and the Middle East, but I am especially happy to bring this work to England. ?I have been a PT for twenty years, working in a variety of clinical settings and I really believe the PT'?s in the UK will appreciate the magnitude with which we can help women with pelvic floor dysfunction - we really do change people's lives with our work.?

Personally, we want to thank Michelle for all her hard work in organizing and teaching this course.? Thanks so much for all your hard work Michelle!

France has it right when it comes to treating the pelvic floor of postpartum women.

On Monday, The New York Times published an article, ?The Re-Education of My Perineum.?? In it, author Ruth Foxe Blader tells the story of her experience in France after giving birth.? As she tells it, her experience in France is close to ideal.? Her physical therapist, Aude, handles the reality of pelvic rehab with the professionalism that is needed:

?Aude politely suggested that I insert the sonde, a tampon-like metal-and-plastic contraption with a long wire she would hook up to the computer. When I flinched, she reiterated the importance of perineal re-education. She delivered this practiced discourse with an air of utter professionalism, flicking through computer exercises with a mouse, her back pin straight. Thankfully. Because had she so much as cracked a smile, I wouldn?t have survived the ensuing psychic trauma.?

Physical therapists play a key role in pelvic rehabilitation.? More often than not, ignoring the role of a therapist in treatment can cause more problems for a patient in the long run.

Blader puts the significance of the therapist brilliantly: ?Four years later, I can say with confidence that the exercises, far more extensive than the standard Kegels that American gynecologists mention offhandedly, worked. Unlike in the United States, where a hypermedicalized pregnancy is followed by a perfunctory six-week follow-up, in France women aren?t left treading water in a sea of untold postnatal soreness.?

Considering Beyond Kegels was published more than fifteen years ago, it is amazing that there is a persistent attitude that pelvic rehab professionals are just Kegel doctors.

Herman & Wallace offers a series on treating pregnant and postpartum patients, a time at which injury to the pelvic floor is common.? Care of the Pregnant Patient, Care of the Postpartum Patient, and Peripartum Special Topics each focus on the special considerations a therapist must have for patients during these distinct times surrounding motherhood.

For those interested in learning more about treating this population, each of these courses has at least one course-event between the now and the end of the year.? Sign up today!

It is a reality in the world of pelvic rehab that too few patients are comfortable discussing their genitalia, anus, or the functions of any pelvic organ when things are going smoothly, much less when something goes amiss.? Often, questions about them are more likely to give blushes than honest answers.

Role/Reboot, a blog that focuses on gender roles and relations, published a blog this July titled ?The Sex Education I Wish I Had.?? In it, author Marianne Cassidy catalogues some of the main problems with sexual education.? While much of the piece is a litany of ?I wishes? for sexual education, Cassidy?s piece reminds me of the wonderful ?Camp Gyno? video Pelvic Rehab Report discussed two weeks ago. ?It?s refreshing to read a blog that is both honest and to the point about perfectly normal things like menstruation and masturbation.

At the end of her litany of ?I wishes,? Cassidy drives home the ultimate point of this blog, ?Most of all, I wish I?d grown up in an environment where my peers and I felt comfortable discussing sex and asking questions, because then maybe none of the above would ever have been scary or mysterious. ?I wish we had classroom discussions about sex and exams on sex and reflective essays on sex and it was all as normal and interesting and important as algebra or poetry.?

Truly, a medical professional?s duty is to treat patients.? Therefore it?s vital for pelvic therapists to be able to speak frankly to their patients.? However, it is equally important to do so without passing judgment about the gender, sex life, or sexuality of a patient.

Herman & Wallace offers a course that focuses on treating sexual concerns for pelvic wellness patients, titled Sexual Health Clinical Toolkit.? This course was last offered in June 2013 in San Diego, California and is currently being planned for 2014.? Keep your eyes peeled for our 2014 calendar (coming this September)!

The Las Vegas Guardian published an article yesterday titled, ?Pregnancy Yoga Magic,? that articulates the benefits of yoga for pregnant patients.? Yoga, the article explains, ?can be the perfect choice for helping to increase endurance little by little, as well as improving muscle strength and honing one pointed focus ? important for birth preparation.?

This article does an excellent job illustrating that, while exercise is important for everyone, pregnant women must find exercise that is effective without being harmful: ?Pre-natal yoga practices are often geared to tune women into their pelvis and the flexibility therein as well as breath control and leg strength ? all critical tools to have during labor and delivery.? Unlike walking, weight-lifting or other ?regular? exercise, pre-natal yoga is fine-tuned to specifically prepare women for the birthing experience and to empower them into the knowledge that they can do this.?

However, few moms-to-be get as much exercise as they should: ?as many as 75% of pregnant women don?t do any type of exercise.?? This means that it is critical for anyone working with pregnant patients to emphasize the how crucial of a role exercise takes for both their health and the health of the child.

This September Herman & Wallace will be offering a course on Yoga for Pregnancy.? This course is geared toward therapists who wish to utilize yoga to treat patients with both complicated and healthy pregnancies.? Yoga for Pregnancy is less than two months away so register today, before the Early Bird Discount expires!

The Border Mail, an Australian newspaper, published an article today following Brian Costello, a man who underwent a prostatectomy.? Surgery for prostate cancer often leaves patients suffering with erectile dysfunction and incontinence.? However, Brian?s physicians did not send him into outpatient rehab, leaving him and his wife Jill, ?on their own.?

The piece titled ?Sex and Secret Men?s Business,? outlines how important pelvic floor and penile rehabilitation is, as well as how few hospitals are prepared to treat outpatients who survive prostate cancer.

Brian?s wife and daughter Leah started ManUp!, an advocacy organization meant to promote better prostate care in Australia.? All too often they hear stories like Brian?s; physicians who show ?no interest in what happens to their patients after prostate cancer treatment.? One man left impotent and incontinent after his robotic surgery[, and] was told the doctor?s job was simply to deal with the cancer.?

One of the many reasons that erectile dysfunction and incontinence are under-serviced conditions though is that patients frequently do not bring it up: ?it?s hard for busy practitioners to keep up to date with the recently developed erection treatments.? It?s also a two-way street, with some men finding it difficult to talk about these issues,? says Prem Rashid, a urologist and associate professor at the University of NSW.? ?Issues surrounding erectile dysfunction following prostate cancer treatment are complex and multi-factorial and often require the help of a multidisciplinary team,? - a team in which pelvic PTs play an important role.

Herman & Wallace will be offering a course on The Male Pelvic Floor in Minneapolis this September.? Participants in this two-day course will learn how to treat conditions such as sexual dysfunction, pelvic pain, and incontinence.

A recent article examines the relationship between sexual dysfunction and body image. The authors note that little is known about the relationship between dyspareunia (painful intercourse) and body image and genital self-image. Could it be that body image issues link to the fact that women who report dyspareunia also complain of overall sexual impairment, anxiety, and feelings of sexual inadequacy?

The research included an on-line survey of 330 premenopausal women, and 58% reported dyspareunia, 42% were pain-free controls. The women with dyspareunia reported more distress about their body image and more negative genital self-image. This study presents an excellent literature review related to the myriad of challenges a woman faces when dealing with pain limiting intercourse. Such examples include decreased sexual desire, feelings of guilt, shame, failure, and a sense of being incomplete. Women will frequently describe their genital area as a "dead" part of the body. These intense thoughts and feelings are rarely addressed in studies of dyspareunia, and in the treatment of the condition, according to the authors. In studies using the Female Genital Self-Image Scale (FGSIS) in a sample of young college women, women reporting impaired sexual function also reported negative genital self image.

How do we help? In addition to providing caring pelvic rehabilitation, how can the medical community offer a more comprehensive approach that encompasses body image? As discussed in the article, if health care providers view dyspareunia as a chronic pain syndrome rather than only as a sexual dysfunction, patients may benefit from addressing how their "sense of self" becomes negative in relation to the pain. Interestingly, body image and sexuality are intertwined, as a positive body image may "...facilitate the subjective experience of sexuality..." while a negative body image can inhibit sexual health.

In our role as pelvic rehabilitation providers, we can discuss the potentially negative relationship between a woman's sexual dysfunction and her body image. As a minimal level of intervention, instructing in awareness of the problem, in use of positive self-talk, and in ways to evaluate self-worth as a "whole" person despite sexual health issues. Ideally, rehabilitation and medical management can alleviate sexual dysfunction, yet the patient may continue to struggle with anxiety, fears, and self-doubt. Through education, encouragement, rehabilitation, and further research, patients may continue to address issues of sexual health as well as body image. We may not know if decreased genital self-image causes decreased sexual dysfunction, or if having sexual dysfunction causes the poor body image, but this research creates an excellent, well-cited platform from which we can launch meaningful discussions with our patients. Referring providers can also be consulted when the patient may benefit from a consult with an expert in psychological health or counseling.

Pelvic Rehabilitation is often incorrectly considered a women?s health issue. ?This is because, as this wonderful video from Aligned and WellTM demonstrates, ?childbirth often gets blamed for pelvic floor disorder.?? Male or female, hip and pelvic biomechanics play an important role in the functioning of the pelvic floor.

Tucking one?s pelvis while sitting or favoring one leg when you stand can have a tremendous effect on the strength of one?s hip and pelvic muscles.? Weakened pelvic floor muscles often correlate with or cause such common conditions as urinary/fecal incontinence and sexual dysfunction, as well as chronic lower back and pelvic pain.

However, as Jessica Powley, PT, DPT, WCS, says in a recent blog post on Pelvic Guru, "rehabilitation for the pelvis is much more involved than simply strengthening a muscle group. It involves restoring function?improving muscular support around the pelvis, improving behavioral/dietary habits, and re-training body movements to allow for optimal organ and structural function"(emphasis added). ?In short, by focusing on the biomechanics, practitioners can better educate patients on treatment.

This August, Herman & Wallace will be presenting a course on the Biomechanics of the Hip & Pelvis. In the course, instructor Steve Dischiavi will demonstrate how one?s biomechanics affect the pelvis and hip, enabling clinicians to better instruct patients on treatment.

This course is less than one month away - register today!

The Great Falls Tribunepublished a piece Tuesday about McKenna Fromm, an eighteen-year-old girl who suffers from interstitial cystitis, pudendal neuralgia, and levator ani syndrome. Alone, each of these conditions can be debilitating, leaving patients in pain. Often each of these conditions is coupled with urinary or fecal incontinence. This piece, titled ?Great Falls Teen Fighting Three Painful Pelvic Conditions,? elucidates the struggle of patients who suffer from these conditions.

Each of these conditions is known to be difficult to diagnose, particularly interstitial cystitis which has ?[n]o specific diagnostic tests.?? Sometimes these conditions require surgery.? Other times, treatment includes ?a ?cocktail? of medications that include topical anesthesia or anti-inflammatory.?

However, one aspect of this article fails to truly emphasize is the role of physical therapy in treatment.? Stephanie Prendergast, president of the International Pelvic Pain Society, demonstrated this point well in a Facebook post about the Tuesday article.

?More often than not, pelvic pain syndromes are driven by the musculoskeleture of the pelvic floor. That said, when something goes amiss with the pelvic floor all of the many systems that make up this unique part of the body will most likely become involved--the muscles, nerves, organs, and derma of the area become locked in a vicious pain cycle that needs to be broken. Physical therapy has an important role to play in the unwinding of this pain cycle. That's because a PT is in the best position to uncover and treat any musculoskeletal impairments that are contributing to a patient's pain/symptoms?

??What often happens in these cases is that the patient's pelvic floor muscles guard in response to the pain of the infection; however, once the infection clears, the muscles remain in this tight, guarded state causing a lack of blood flow to the area and the formation of trigger points, both of which can cause the symptoms that McKenna presents with. What a PT can do in such a case is to manually relax any tight muscles, and treat any trigger points or other musculoskeletal impairments contributing to the patient's pain. That said, to date, there is no standard of care when it comes to pelvic floor PT. It is my opinion that manual, hands-on treatment under a multidisciplinary setting is the best approach to treating pelvic pain for a patient like McKenna. I am hoping that this is the kind PT that McKenna is currently receiving.?

Well said, Stephanie.? We completely agree.? The more people know about these conditions and realize the role PTs have in treatment, the better off patients will be.

Scientists at the National University of Ireland in Maynooth reported the detection of a protein, Pellino3 that may stop Crohn's disease from developing. The Irish Times article, University breakthrough in fight against Crohn's disease, described the benefit as diagnostic: [Researchers] will now use the protein as a basis for new diagnostic for Crohn's and as a target in designing drugs to treat the illness.

Researchers noticed that levels of Pellino3 are dramatically reduced in Crohn's disease patients. Prof. Paul Moynagh, who led the researchers, believes that identifying Pellino3s role in Crohn's disease may lead to better treatments for other inflammatory bowel diseases.

In the United States, more than a half-million people suffer from Crohn's disease and more than a million suffer from some type of inflammatory bowel disease. Symptoms often include abdominal pain and diarrhea. These symptoms are often debilitating and even life-threatening. There is neither a known cause nor cure for Crohn's disease.

Therapy has been known as one of the few treatments that can reduce symptoms and even lead to remission.

Hopefully, this discovery will lead to further advancements in treating Crohn's disease: The findings by Prof Moynagh and his team have the potential to impact positively on many lives.