In this article titled "Too Posh to Push?"the value of elective cesarean (or "c-section") deliveries for childbirth is revisited. Statistics in Britain are referenced, as rates for the procedure have increased from 4.5% in 1970 to nearly 25% today. This trend is stated to have occurred without a corresponding obstetric need for the the procedure. The US has experienced a similar debate, with stories of women demanding an elective surgery, sometimes for the preservation of the pelvic floor, other times because she is interested in avoiding the pain of pushing. Some providers also promote elective cesareans for birth, perhaps due to their own beliefs about potential benefits, or for the value of having more control over a schedule. Regardless of the motivations and beliefs of the patients or providers, pelvic rehabilitation providers can land in the middle of such an important discussion.

The choice about desired birth practices is between a mother, her family, and her providers. At no time is it appropriate for a pelvic rehab therapist to impose an opinion upon a woman who is pregnant. It is, however, most appropriate to answer questions that may arise in relation to musculoskeletal health and about discussions the patient may be hearing or reading about elective cesareans. The literature in the past decade has been decidedly in favor of avoiding vaginal births in order to avoid pelvic floor injuries. The other half of the story is that birth is not the only factor in pelvic floor health and injury, and that cesarean deliveries also carry risks- some of those risks are lessened in a vaginal birth.

Basic information about a cesarean delivery are available on many sites, including the National Institute of Health's MedLinePlus. While c-sections are always described as a "safe" surgery, all surgeries carry risks. Personally, I have been amazed at the nonchalance of surgeons who give an air of "no-big-deal" for common surgeries that is contrasted with the informed consent waiver a person is asked to sign before entering the operating room. All surgeries have risks. While it is acknowledged that vaginal deliveries are associated with increased incontinence, the actual cause of the pelvic floor injuries cannot be directly correlated with the delivery itself.

A recent study from Brazilevaluated the use of 3D perineal ultrasound to measure pelvic floor injuries at the second postpartum day. 35 patients were allocated to groups according to delivery type: elective cesarean (10), vaginal delivery (16), and forceps delivery (9), with episiotomy performed in 3 of the deliveries. The urogenital hiatus was found to be significantly increased from the cesarean group, at 12.4 cm, to 17 cm in the vaginal delivery group and 20.1 cm in the forceps delivery group. 3 of the 25 women in the non-cesarean groups had a tear of the levator ani. The authors recommend routine assessment of pelvic floor integrity following childbirth. While vaginal birth may be correlated with increased rates of incontinence and prolapse, a recentstudy that evaluated 84 women (grouped by mode of delivery) did not find any correlation between mode of delivery and return to sexual function.

The controversy is far from over, as we continue to see research that aims to answer questions about long-term benefits for pelvic floor health in relation to cesarean versus vaginal deliveries. As is often the case, the swinging pendulum that headed towards recommending elective cesareans will likely swing back towards the middle ground when more research comes in, and when more providers and women understand the total implications of various birth practices on not only the mother and child, but on families and communities as well. In the meanwhile, pelvic rehabilitation providers will continue to support a woman regardless of birth history, focusing instead on patient presentation, goals, and examination findings when applying best practices.

We are excited to announce Herman & Wallace instructor Ginger Garner, PT, MPT, ATC, PYT will speak at the National Athletic Trainers’ Association’s (NATA) 64th Annual Meeting and Clinical Symposia this June. Her advanced presentation, titled Yoga Pulls Double Duty: Establishing Controlled Flexibility in Athletes, has already sold out!

Her presentation will be on June 27th in Las Vegas, NV and will focus on medical therapeutic yoga as treatment for athletes, a topic she pioneered in the healthcare industry here in the United States. With more than 35,000 members, the NATA Annual Meeting and Clinical Symposia is the foremost annual continuing education event for athletic trains in the US. The event offers professionals an opportunity to learn new skills and advance their education in the medical athletic services. More than 350 companies from around the US will attend this year.

H&W is thrilled to be offering two of Ginger's courses this year: Yoga as Medicine for Pregnancy and Yoga as Medicine for Postpartum. Both these courses are designed to instruct on a biopsychosocial yogic model as applied to the pregnant and postpartum patient. These courses cover the physical, psychological, and social factors that can complicate pregnancy, as well as demonstrate the benefits of yoga to aid in their treatment. The Yoga as Medicine for Pregnancy course examines the systemic and natural changes experienced during pregnancy, and their complications. The course on Yoga as Medicine for Postpartum is aimed towards helping clinicians prepare expectant mothers and partners for the labor, delivery, and recovery that are a natural part of giving birth. It also establishes yogic methods for aiding patients who are struggling with body confidence, postpartum depression, and stress. These courses are unique in that they use current, evidence-based flexibility theories and information to improve health.

According to Ginger, yoga has been used as a theoretical healing system for more than five-thousand years. In 2001, she founded Professional Yoga Therapy Studies, an organization that blends yoga, sports medicine, and physical therapy curricula to educate clinicians and patients alike. Her medical yoga undergraduate, graduate, post-graduate, and medical continuing education programs are the first of their kind in the US. While her clinical focus ranges from orthopaedics to public health education, Ginger considers maternal health her most important work.

Ginger says: pregnancy and childbirth have a powerful impact on every aspect of a woman's life. Ideally, pregnancy should occur without unnecessary medical interventions and the delivery of a healthy baby; however, this is often not the case. Complications from motherhood often stem from the mother's physical, mental, emotional, and even socioeconomic health. Furthermore, many women do not get the care they need during pregnancy. The National Hosptial Discharge survey recently noted that more than 30% of women are hospitilazed for illness or other complications during pregnancy.

We are so lucky to have Ginger as part of our team and thrilled about the work she is doing to improve the lives of women!

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 first two sessions and shared their story and experience with Pelvic Rehab Report:

For the past few weeks, we’ve had a unique experience: leading a four-session workshop for 22 men recovering from prostate surgery. This experience was unique in that it's rare to get a group of men together to discuss health issues- it happens...about as often as congress reaches a bipartisan agreement!

So far it's been an amazing journey. At the first session we did a quick go round, well, actually not so quickly, as each participant had a story to tell. Things picked up when one participant mentioned he was using a penile clamp. Sex, sports, politics couldn't compete in that moment for the groups attention. (Perhaps the details will be shared in another blog.) For now, the key point we'd like to make is that groups work well for this type of practice. Obviously, individual treatment is imperative, but groups help foster the "new habits" learned in therapy and, perhaps more importantly, from other group members. The mutual support and sharing of information can't be beat.

Given there are only four one-hour-and-fifteen minute sessions, choosing the "lessons," took a little thought. Ultimately we selected four from the Integrative Techniques for the Pelvic Floor & Core Function: Weaving Yoga, Qigong, Feldenkrais & Conventional Therapies live course and online course series that aims to reintegrate of the pelvic floor with the core and full body movement. Below is an overview of each lesson:

Lesson 1 - The Pelvic Breath: The pelvic breath serves as the foundation for the program. In this lesson, participants begin to develop an awareness of the pelvic floor; sense how it moves in relation to the respiratory diaphragm; gently contract and release the pelvic floor as a whole and in sections: right, left, front and back. This focus helps participants develop a keener awareness of the pelvic region and notice differences such as the right side is tighter than the left, how one side can be sensed more clearly, or noticing that while doing Kegel exercises how the back, anal portion, was contracting, not the front.

The pelvic floor is also referred to as the pelvic diaphragm. Given we breathe in and out over 20, 000 times per day, reeducating the pelvic floor to dance with the respiratory diaphragm, is key to maintaining the pelvic floor’s suppleness. By focusing on the breath, this lesson also promotes the relaxation response.

Lesson 2 – Standing Stake: Standing Stake, which goes by a variety of names, is practiced within Tai Chi Quan and Qigong and is an important part of internal martial arts training. In Standing Stake, the participant stands with their feet shoulder width apart, toes straightforward. The hips and knees are slightly bent. The tailbone is released down as if it a weight was attached to the coccyx. The chin is slightly tucked while imaging the head floats upward. The arms are protracted, as if hugging a wide tree, while keeping the shoulders relaxed down and out. There are a few more adjustments, but this gives you an idea, which might have you asking…and how does this relate to the pelvic floor? First, after developing an awareness of the pelvic breath in the first lesson, is it possible for the participant to allow the pelvic diaphragm to move in concert with the respiratory diaphragm, while the upper and lower extremities are engaged? Can the rest of the body maintain a relatively relaxed state in this form? If not, can the holding or tension be identified and released? Standing Stake ups the ante, helping the nervous system relearn that the pelvic breath can be available even when other parts of the body are actively engaged.

Participants are also guided through a short experiential comparing how locked versus slightly bent knees impacts their breath, lower back/pelvic comfort and stability. Participants typically report that when the knees are slightly bent, the breath is deeper, the pelvis and back feel more comfortable and easy to move, the feet are more grounded and…they “feel” their quadriceps. Many people experiencing pelvic discomfort tend to lock their knees and this is an effective strategy to foster the “new Habit”…of keeping the knees slightly bent when doing everyday activities such as microwaving food or waiting on a line at the store. Not bad for one activity.

Lesson 3 - Coordination of the Pelvic Floor with the Obturator Internus and Adductor Muscles: This lesson builds on the integration of the pelvic floor with the core, obturator internus and adductor muscles. The participant first learns to coordinate the pelvic breath while contracting the obturator internus and adductor muscles and then adds pursed lip breathing or Ujjayi breath to activate the abdominals. On the first go round; it can feel like juggling three or more balls, but by having participants work gently and easily, the coordination begins to emerge.

Lesson 4 - Integrating the Pelvic Floor into Everyday Movements: How many people adhere to their home exercise program? Not enough. In this final lesson, the participants learn to engage the pelvic floor into everyday movements such as sit-stand, lifting objects, bridging and going up stairs. After all that’s the goal…to help the nervous system relearn how to use the pelvic floor muscles in everyday activities, which will help maintain their strength and suppleness.

Broadly speaking this work can also be seen within the context of energy conservation and joint protection, as the powerful muscles of the pelvic floor “reassume” their role in everyday movements, thereby contributing to the health, function and well-being of our clients.

So far, two weeks into the program, we’ve covered the first 2 lessons and all is going well. Our next blog will highlight the participants’ reaction and comments, along with any other interesting anecdotes that arise.

If you would like to contact Bill or Richard, you can do so through their website, EastWestRehab.com

Our Pelvic Rehab Report blogger sat down with Dr. Heather Howard, the instructor of our Sexual Health Clinical Toolkit course, to talk about her course, her practice, and the experience and knowledge she brings to the field of pelvic rehab. Here's what Heather had to say:

What inspired you to create this course?

This course was inspired by my gratitude to the physical therapists who helped me through my own debilitating pelvic pain crisis. The support I received, coupled with the lack of sexuality research and resources for the sexual effects of my condition, led me to become a sexologist and mind-body health facilitator. My mission as a sexologist is to improve sexual health care for all people. In my clinical practice, I help people meet their sexual goals by providing relevant education and skills training. I can help even more people by sharing my tools, resources, and clinical perspective with women's health care providers.

What resources and research were used when writing this course?

In over a decade of collaborating with women's health PTs as a client, researcher, clinician and educator, I have learned the extent to which patients are looking to their PTs for sexual advice, and how PTs are providing sexuality education and counseling on a daily basis. I have also learned about the challenges new and experienced PTs face in providing sexual solutions and what training they would most appreciate in this area. Many of those challenges were revealed in the natural course of my collaboration, and I decided to gain a thorough understanding by conducting a mini-study which consisted of asking co-investigating PTs in my dissertation research about what tools and training they would find helpful in supporting their clients with the sexual challenges they face. There were 12 PTs in the 9 co-investigating PT and medical practices for my dissertation, and I created a list of requested tools and training from those interviews. I have covered most of those requests in this course. I also conducted extensive literature reviews for both my dissertation on integrating sexual response in interventions for pelvic pain, and for a published article on sexual adjustment counseling for women with chronic pelvic pain. The literature establishes what is needed, such as what most of us see in clinical practice: that patients with CPP report more sexual problems than patients with any other type of chronic pain; that a multimodal, multidisciplinary approach is to optimal for treating pelvic pain; that pain management and psychotherapy do not necessarily lead to improved sexual function for people with pelvic pain; and what elements of are needed in sexuality education to implement change. I will address the elements contained in this course later in this interview, which were determined based on the literature and my own interviews with women's health PTs. While research describes what this large population is missing in terms of sexuality adjustment support, it offers few practical solutions for the problem. Clinical protocols and educational resources for sexual rehabilitation for people with chronic health conditions are not well defined or researched yet, so I have built my own educational and clinical approach based on well-established sexuality counseling and embodiment techniques. The sexuality information I teach is based on the research and methodologies of experienced sexuality researchers and counselors that date back to Alfred Kinsey, William Masters and Virginia Johnson, Helen Sanger Kaplan, Jack Annon, and William Hartman and Marilyn Fithian. The experiential mind-body health approaches that I utilize borrow from the traditions of Voice Dialogue, Body Dialogue, Mindfulness, and Somatic Experiencing, all of which are taught in Somatic Psychology programs. I hope to conduct more clinical research soon to add to the literature.

What can you tell us about this continuing education course that is not mentioned in the "course description" and "objectives" that are posted online?

This course provides attendees with a personalized clinical toolkit, which consists of a framework for sexual health management, as well as practical sexual solutions for patients. Attendees improve their ability to conduct sexual health assessments and suggest innovative and relevant sexual solutions and resources. We also discuss approaches to facilitate patient embodiment, which is an important component for pain management and sexual satisfaction. Even the most experienced providers gain new approaches and a deeper understanding of the problems they see every day.

Can you describe the clinical/treatment approach/techniques covered in this continuing education course?

Sexual health is a vast topic and the majority of the courses out there focus on teaching sexuality information. The problem is that information alone is rarely sufficient for health care providers to integrate what they have learned in a course into their clinical practices. Research has shown that the elements of sexuality education that are needed for effective implementation are as follows:

1. Sexuality information (aimed at improving knowledge and resources)

2. Sexuality attitudes self-assessment (aimed at helping providers become more comfortable with a broad spectrum of sexual attitudes and behaviors, and more aware of their personal biases and "blind spots," so that they can provide a safer space for sexual discussions)

3. Sexuality counseling practice and supervision (aimed at improving professional confidence and appropriate practical solutions)

I am most concerned about optimizing clinical implementation, so I offer some of all 3 elements in this course, with an emphasis on #3. This course complements other available courses in sexuality information (such as the upcoming H&W ISSWSH course on sexual medicine), sexuality attitudes assessment (such as the H&W Sexual Spectrum Education course coming soon), and sexuality counseling (AASECT conferences).

Why should a therapist take this course? How can these skill sets benefit his/ her practice?

Patients look to their women's health care providers for sexual advice, and most providers offer excellent support and advice with little formal training in the area of human sexuality. Patients benefit from a methodical approach to care, and a sound methodology is never more important than with a topic as sensitive as sexuality. My more than 1500 class hours of training in human sexuality have helped me see sexuality problems from a broad perspective and re-framing client problems is often as important as the specific rehabilitation solutions we offer. As a result, many providers who take this course see sexuality through a new lens, which can have benefits on a professional and personal level. They also become familiar with the variety of tools and solutions available to help their patients, many of which they integrate into their own practices.

Don't miss the chance to learn more from Heather! The next offering of this course is in San Diego, CA on June 22-23 - Register today!

Pelvic rehabilitation providers tend to have personalities that inspire patients to share intimate concerns and issues. One issue that we can play a part in bringing to light is that of medication usage for male sexual performance. Viagra, or the generic version, sildenafil, is a drug that improves blood flow to the penis. It is also one of the the most counterfeited drugs in the world, according to this report. The issue has been in the media for several reasons in recent weeks, with counterfeit manufacturing as one of the concerns.

The United States Food and Drug Administration recently issued a warning about a recall for an over-the-counter male sexual enhancement supplement, "Lighthening Rod," because the supplement contained an undeclared amount of the medication sildenafil. What's the harm? Drugs.com lists 34 major drug reactions for sildenafil, including blood pressure changes (hypotension) or other cardiac effects when taken with nitroglycerines. A national study completed in Australia reports that erectile dysfunction may be a clinically relevant predictive tool for cardiovascular risk, and it may be that men are not sharing information about their sexual function with providers due to embarrassment. In fact, in a news report about a presentation at the American Urologic Association, research presented found that only 25% of men with erectile dysfunction seek treatment.In what has been described as an unprecedented move, Viagra has now made the drug available for purchase on its website, issuing a warning about acquiring the drug without a prescription or ordering a counterfeit drug. While this approach may help to avoid black market purchases of the medication, it also may allow men who don't feel comfortable filling prescriptions for the drug to purchase it in the privacy of their own home.

In terms of our role in helping men avoid the pitfalls of the diagnosis of erectile dysfunction as well as the potential harm from medication available without a prescription, we can start by asking more questions. A good question to start with is "Are there any other supplements or medications that are not on your medication list?" or "Are there any medications or supplements that you purchase from the internet or from a local store?" We can also be sure to include questions about sexual function and health on patient intake forms, and include such verbal questions in our history taking. Because the patient may not feel comfortable on a first visit discussing intimate issues such as erectile dysfunction, in our education of the patient we can provide anatomy and physiology lessons related to sexual function. For any patient who admits to purchasing sexual enhancement drugs that have questionable contents, the patient should be referred to his medical provider to discuss the issue immediately, and the patient can be instructed in the potential adverse effects and in the need to discontinue such medications.

Many pelvic rehabilitation providers are more comfortable discussing sexual health with female patients than with male patients. This topic may be an excellent place to start when it comes to ensuring that our male patients have a place where they can feel safe discussing such sensitive issues, and where they can receive the most current information about their issues. To learn more about erectile dysfunction in general, you can visit sites such as Medline where interactive educational modules can be found.

While the co-existence of fecal incontinence (FI) and constipation is well-recognized in the pediatric and geriatric population, the authors of this article suggest that the relationship is under-appreciated in the adult population. Samuel Nurko, MD, and Mark Scott, PhD, describe the association between pediatric functional fecal incontinence and constipation, stool retention, and incomplete evacuation. In adults, they point out, constipation may also be related to pelvic floor dysfunction and denervation. The negative impact on quality of life creates the need for these issues to be addressed more readily, both in adults and in children.

The study mentioned above cites a prevalence of fecal incontinence in school-aged children of 1-4%. The majority of the research cited in the article report that this incontinence is related to underlying constipation. Factors that may contribute to childhood holding of stool or to rectal dysfunction include constipation early in childhood, painful bowel function, "coercive toilet training practices and social stressors", fecal impaction, and treatments involving anal manipulation. It has been surprising to me how many adult patients describe psychologically stressful childhood associations with bowel function.Fortunately, the psychological stress, low self-esteem, and decreased quality of life that is associated with childhood bowel dysfunction improves with successful treatment of the condition. Childhood behavioral issues including bullying, disruptive behavior, and social withdrawal also are noted to improve following improvement in fecal issues, suggesting that the terrible social impact of fecal incontinence may be to blame for some of the behavioral issues.

In relation to the adult population, the authors state that while the coexistence of constipation and FI may not be known, constipation has been shown to be an independent risk factor for FI and incomplete emptying is associated with fecal incontinence.In the patient who has poor emptying of the bowels, overflow can occur, and this type of leakage is then associated with constipation. It follows, then, that treatment of the constipation should improve the fecal leakage. Three mechanisms are described regarding the pathophysiology of incontinence caused by constipation: overflow due to fecal impaction; post-defecation leakage caused by rectal stool retention from a rectal evacuatory disorder; and general pelvic floor weakness or denervation. Certainly, neurological or other disease conditions can cause bowel dysfunction, yet this article focuses on "functional" constipation not caused by such diseases.

Clinically, patients who present with fecal leakage can have a difficult time understanding the relationship between constipation and fecal incontinence. Educating the patient about bowel health and function are critical in "selling" the self-management strategies that will form the foundation of the patient's recovery. If you are interested in learning more about bowel health and function, come to the 2A course that instructs the participant in common colorectal conditions, constipation, and fecal incontinence. If you have already taken the course, check out the Institute's new course on bowel dysfunction that includes a lab for anorectal balloon re-training.

Last weekend, Pelvic Rehab Report guest-blogger, Erica Vitek MOT, OTR, BCB-PMD, attended H&W's Pediatric Incontience and Pelvic Floor Dysfunction course in Madison, WI. This course was developed and is instructed by Dawn Sandalcidi. Erica had this to say about her experience in the course:

The most recent Herman & Wallace course I attended was Pediatric Incontinence course taught by Dawn Sandalcidi. I had been patiently waiting for this course to come to the Midwest/Wisconsin area and when it did I signed up immediately.

I have been treating women's and men's health patients for just over 8 years. Since I took the level 1 pelvic floor course with Herman and Wallace, I have been so impressed with the layout and organization of the material. The take-away information from each course allowed me to return to the clinic on Monday and begin treating patients in new and different ways. I've found that the ideas presented can be immediately implemented and improve the quality of life of all the individuals in need of such specialized treatment. As an occupational therapist coming into the field of pelvic floor disorders, I needed the additional depth and focus on pelvic structure and anatomy since this was not a main focus of my underlying educational degree and I can not say enough about how much their coursework prepared me.

Prior to last weekend's course, I had always treated pelvic floor dysfunction in adults but would get the occasional phone call from a parent looking for help with a child who had bowel or bladder issues. The parents sounded so desperate to find help and I struggled to locate someone in my immediate area that could help them. Since generalized pediatric evaluation and treatment is not something with which I have experience, I was not sure if this course would be able to provide me with all the things I would need to get going. If anything, I thought, this course might help me to better understand my adult patients and even get some additional ideas to help them. The pediatric course exceeded all of my expectations! Dawn packed the two days with all the diagnoses for which pediatric patients would be referred, reseached based data with up-to-date terminology, endless practical ideas for behavioral modification specific to children, medical testing interpretation, the psychological considerations, start-to-finish clinic video evaluations of pediatric pateints, and an affordable start-up list of things to purchase to get going right away. Dawn put a passion in me to widen my base of referrals to include pediatrics and give children and parents with these problems somewhere to turn. Changing a child's life in this way could mean all the difference.

In the April Physical Therapy Journal, authors ask the question: does the relationship between the patient and the physical therapist impact patient outcome? This relationship, or therapeutic alliance, was measured through use of the Working Alliance Inventory at the second treatment session. The 182 patients included in the reporting were all diagnosed with chronic low back pain, and they completed outcomes before and after 8 weeks of treatment including the Patient-Specific Functional Scale, the Global Perceived Effect Scale, the visual analog scale, and the Roland-Morris Disability Questionnaire. The patients were divided among 7 experienced physical therapists.

The authors conclude that "Higher levels of therapeutic alliance...were associated with greater improvements in perceived effect of treatment, function, and reductions in pain and disability." Considering that this alliance was measured at the second visit, it clearly does not take a patient long to decide if there is a positive alliance formed. So how do we create that alliance? One of the reported limitations of the study is the lack of knowledge about the therapists' behaviors or interpersonal skills, therefore a correlation between such skills and patient's perceived alliance cannot be made. Another research article appearing in the same journal may offer some clues towards this issue.

An article titled "Measuring Verbal Communication in Initial Physical Therapy Encounters" suggests that clinical communication is critical in providing the patient with a positive experience. How can that be measured? 27 patient initial evaluations completed among 9 physical therapists were observed, audio recorded, and categorized using the Medical Communications Behavior System, a tool created to measure information-providing interactions. The results of the categorizations included that the therapists spoke for nearly 50% of the time compared to the patient's 33%. Emotional content was rarely included. Experienced clinicians were found to give more advice or suggestions, to utilize less restatement, and were also noted to be more likely to talk concurrently or interrupt the patient.

Documented negative therapist behaviors included being interrupted in the clinic, giving disapproval, or using jargon. These types of interactions or behaviors may be easily limited with setting standards for limiting interruptions (only in emergencies), or by being certain that each treatment room is stocked with similar equipment, that sort of thing. Avoiding disapproving statements or use of jargon requires that the therapist "listen" to him or herself, avoid falling into verbal habits, and make an effort to consciously choose language that is patient-centered and positive. The authors point out that basic clinical communication requires listening without interruption and making effort to hear what the patient is truly saying or is trying to say.

In our efforts to provide information in our clinic setting, where it seems there is never quite enough time to complete patient and clinician paperwork/documentation, share home program information and complete clinical interventions, it is easy to understand why the above tasks may be challenging. Both research articles are groundbreaking in that when evaluating some of the factors that are related to the patient/therapist relationship and communication, our profession is beginning to make connections among variables that appear to be less tangible. It is this information that can help explain why some patients are more adherent, why some respond better to particular interventions, or to a particular person. For our part, when outside of the research community, we can make efforts to attend to patient rapport, relationships, and communication, and look for more guidance on how to measure these variables and provide the optimal experience for our patients.

In January, H&W faculty member Elizabeth Hampton PT, WCS, BCB-PMD presented at the APTA’s Combined Sections Meeting in San Diego, CA in a presentation sponsored by the Orthopedic Section. The presentation was called “Core Rehab without ‘Going There’: Evidence Supporting Direct and Indirect Evaluation and Treatment of PFM Dysfunction.”

In her talk, Elizabeth discussed contributing factors to pelvic health and continence, including muscular, fascial, neural, biomechanical and motor control factors. She also noted a pilot study done by HW’s own Stacy Futterman, PT, MPT, WCS, BCB-PMD, which prompted a wonderful discussion about the role hip labral tears and femoral acetabular impingement has on the pelvic floor.

Elizabeth was gracious enough to share details about her presentation with Pelvic Rehab Report. Below is what she had to say about this topic.

EH: In this talk, I focused on pelvic health and continence being a distinct specialty within orthopedic manual therapy. Considering the interrelationship between musculoskeletal, urinary, colorectal and sexual function, I believe an integrative understanding of all systems is required for autonomous, direct-access physical therapists as we look towards Vision 2020. Indeed, IFOMT’s definition of orthopedic manual therapy correlates directly to the women’s health physical therapist.

In my talk, I proposed that a comprehensive pelvic health and orthopedic manual therapy evaluation is required for the evaluation and treatment of pelvic pain and pelvic health conditions. I noted (and the audience agreed) that the reality is that not all PTs will have a comprehensive pelvic health knowledge base. Key items for a pelvic pain exam have not been standardized for physical therapists that do not have training in direct pelvic health and continence evaluation and treatment methods. Barriers to clinician evaluation of pelvic floor function and dysfunction can include education, apprehension, aversion, risk management concerns and knowing how and when to include pelvic health questions during client history- taking.

One example of a lack of comprehensive pelvic health knowledge base is the therapist who instructs on pelvic floor contractions - without prior assessment by the therapist - during a clinician- designed core rehabilitation program. Without evaluation, the competence of pelvic floor muscle contraction is in question. Cueing a muscle contraction without assessment, therefore, is not a skilled intervention in and of itself.

This prompted a discussion of whether a direct pelvic floor evaluation is indicated with all clients needing core rehabilitation. We also discussed external (i.e. indirect) assessment via the Ischiorectal fossa or client’s hand on their sacrum/ischii as options for a general screening. Further research is needed to determine when direct (internal) or indirect (external) evaluation methods of PFM contraction/relaxation are appropriate.

I encouraged all clinicians to attend the minimum of a Level One Pelvic Floor course through Herman & Wallace or the APTA. Regardless of the long term clinical interest of each PT in pursuing pelvic rehab as a focus, a Level One PF course would enable each clinician to perform a fundamental history, effective bowel and bladder screening and an understanding of the anatomy of the pelvic ring, even if they chose not to perform direct PFM assessment and treatment in the clinic.

I observe that the attitude of ‘us’ vs. ‘them’ still persists between clinicians who do have women’s health PT skillset and those who do not. This attitude has the potential to impair clinical collaboration and the inclusion of PTs of other specialties into the study of pelvic health, continence and women’s health physical therapy. Our profession would be well-served to focus on meeting the needs of the clients through a comprehensive orthopedic/ biomechanical/ urogyn/ colorectal knowledge base, rather than by separating client treatment according to clinician toolbox (i.e. women’s health vs. orthopedic.)

The Description of Specialty Practice for the Women’s Clinical Specialty includes a highly-detailed orthopedic skillset. Likewise, women’s health physical therapy is a highly-specialized field within orthopedic manual therapy. Both toolboxes are required for comprehensive evaluation and treatment of clients with women’s health, pelvic health and continence dysfunction.

Among the patients who we serve, the diagnosis of orthotopic neobladder, or "neobladder" can leave the pelvic rehab therapist wondering about the procedure itself as well as the best course of therapy. Understanding the anatomy and physiology of the surgical diversion, the risks and benefits, and the common urinary dysfunctions can assist in development of the plan of care.The neobladder surgery is one option for patients who must have the bladder removed, often in the event of bladder cancer. As the 4th most common cancer in the United States, theNational Cancer Instituteestimates that there will be over 72,000 new cases of bladder cancer in the US in 2013. Other reasons a patient may be a candidate for a neobladder surgery include a neurogenic bladder that risks renal function, radiation injury to the bladder, severe urinary incontinence, and pelvic pain syndromes.

The surgery involves creating a pouch for storage of urine from a portion of the small intestine. For a brief and helpful video of how this surgery is completed, click here. Early complications of the surgery include rupture of the new bladder reservoir and bacterial peritoneal infection. This is a medical emergency and would be treated with antibiotics and surgical revision. Late complications can include urinary obstruction. More commonly, patients who are referred for pelvic rehabilitation may experiencedysfunctions including urinary incontinence and retention. While the latter tends to be an issue in the immediate post-surgical period, incontinence is more prevalent in later recovery. A Medscape article about urinary diversions and neobladder can be accessed here.

An article reviewing 1000 cases of neobladder surgery over 25 years reports complications including hydronephrosis, incisional hernia, ileus or small bowel obstruction, urinary tract infection, B12 deficiency, and occasional obstruction and even death. The authors conclude that patient age and comorbidities contribute to the challenge of avoiding such complications, and that patients are best managed in a surgical center where many of the operations are completed. In another article describing the urinary function outcomes in 49 women who were treated with a neobladder diversion, daytime incontinence was reported in 43%, nightime incontinence in 55%, and hypercontinence in 31%. Hypercontinence refers to difficulty emptying the neobladder. Aweb postingon a site for survivors of bladder cancer describes a technique that women can use to aid in emptying the pouch.

A review of websites and journal articles describing postoperative interventions typically lists "Kegel exercises" as one part of training. Further research will assist in providing recommendations for treatment, yet at this time, patients will be able to benefit from standard therapy approaches for urinary dysfunction. Behavioral training can help the new pouch stretch to some extent, the patient may need to learn to relax the pelvic floor while using low level abdominal pressure to empty the bladder, and information about proper hydration will also be beneficial. Because the lining of the neobladder is mucosal, it sloughs off bits of tissue that appear in the urine as a normal part of postoperative voiding. This fact increases the importance of maintaining a hydrated level of fluid in the body to help pass these bits of tissue and avoid blockage. Keep in mind that many patients who present with a neobladder may have experienced other medical treatments for cancer or other disease processes or illnesses, and the effects of these other medical interventions can affect speed of recovery.

A patient who was recently referred to me for continence training following a neobladder surgery progressed to 75% improvement of stress incontinence over a period of 6- 8 weeks, with a further recovery with home program to near 90% recovery. His examination included pelvic muscle strength, coordination, and endurance assessment via the rectal canal, and his treatment plan included a progressive exercise program based on the findings of the exam. Each patient who presents to our facilities will have a varied history, and a thorough subjective exam will guide the pelvic rehab provider in determining the appropriate examination approach. There are patient resources available on the internet that also inform the rehab therapist. For example, the Bladder Cancer Advocacy Network provides this handout "for patients from patients" that highlights suggestions and common questions. If you are working in or near a large hospital system, finding out who performs these surgeries may offer an opportunity for marketing if you are not yet seeing these patients. If you are in a more rural location, you may find that a patient living in your community can complete follow-up in your clinic while attending medical appointments with the surgeon as needed.