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.

Pelvic Floor Muscles: To Strengthen or Not to Strengthen?

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images.

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles.

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted.

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels."

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a few images. 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

Rhonda Kotarinos and Mary Pat Fitzgerald did the world of pelvic rehab an immense good with their promotion of the concept of the "short pelvic floor."  If a patient presents with pelvic muscle tension, shortening of the muscle, and poor ability to generate a contraction, a relaxation phase, or a bearing down of the pelvic muscles, how in the world will trying to tighten those overactive muscles bring progress? This concept is further described in a 2012 article from the Mayo Clinic by Dr. Faubion and colleagues. The article explains the cluster of symptoms commonly seen with non-relaxing pelvic floor muscles including pain and dysfunction in bowel, bladder, and sexual function. Medical providers and rehab clinicians should look for this cluster of symptoms and combine this knowledge with a pelvic muscle assessment to decide if pelvic muscle strengthening is warranted. 

If this has not been a part of your current practice, please consider ruling out a shortened or non-relaxing pelvic floor prior to suggesting any "Kegels" or pelvic muscle strengthening. If you are well aware of this issue, then it is our responsibility and opportunity to educate the public and the medical community to STOP! strengthening when it is not appropriate. The way I often explain this to patients or students is to pretend that a patient has walked in to the clinic with the shoulders elevated maximally, complaining of headaches or shoulder dysfunction. Then I say, "Great! Let's hit the weights- you just need to strengthen your upper traps." This always gets a giggle or a smirk, but the point is this: that is exactly what providers are doing to patients who walk in with bowel, bladder, pain, or sexual dysfunction when the announcement is made that "you just need to do your Kegels." 

While we do not want to villainize Kegels or strengthening of the pelvic muscles, we do want our colleagues, our patients, and the valued referring providers to know that there is way more to pelvic health than strengthening. The abundance of bad advice available to our patients may leave them in worse condition and with less hope about finding relief. While well-intentioned, advice that only describes strengthening as the cure is misleading and potentially harmful.

In April of this year, H&W is thrilled to be offering a brand new course on Bowel Pathology and Function. Our Pelvic Rehab Report blogger interviewed the instructor Lila Abbate, PT, DPT, MS, OCS about her new course.

1. 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 goes into detail about laxative weaning, how and when to use over-the-counter products and some supplements, food that are helpful to aid in bowel function. The course looks at different concomitant past medical histories such IBS, the neurogenic bowel with a SCI patient, MS and fibromyalgia and the progression of their bowel issues and how PTs can assist these patients. The course discusses evidence-based treatment vs. anecdotal and clinical experiences.

2. What inspired you to create this course?

I felt that there was a need for a course like this. So many patients have very complicated bowel issues and there is so much more to think about regarding a complicated bowel patient. As a pelvic PTs, I realized that I needed to understand more of the general knowledge of the gut and how physicians approach the problem, how so many over-the-counter products can be destructive to normal bowel function and the dysfunction bowel patients that most patients get in to and cannot get out of and how we are able to help them.

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

As all H&W courses have an emphasis on the manual orthopedic approach, we screen and treat both vaginal and rectal pelvic floor muscles in this course, evaluate and treat for diastasis recti in both the male and female population and we discuss the use of biofeedback for the complicated patients. We also complete rectal ballooning as part of the lab.

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

If you have bowel patients that have been difficult to take through the course of care, or if you took PF2A a while ago and need a refresher on bowel pathology, or if have a deeper interest in bowel dysfunction, this course will give you the additional knowledge that you are looking for.

5. How has this knowledge and skill set benefited you in your own practice?

My practice specializes in pelvic pain and bowel dysfunction. Bowel dysfunction is such an underserved population within pelvic floor dysfunction population. In the US alone in 2004, a primary complaint of constipation was responsible for 6.3 million patient visits to medical care centers, resulting in total (direct and indirect) costs of $1.7 billion, which we can surmise 8 years later, has almost doubled and these patients need care.

6. What resources and research were used when writing this course?

Evidenced-based research is the primary guide used to present most information. However, clinical expertise and anecdotal information cannot be ignored due to the fact that we have such low peer-reviewed articles presented on this topic. Information gathered from medical conferences will also be presented.

This course will be offered April 13-14 at Stony Brook University in New York. Don't miss this excellent opportunity - Register today!

I would estimate that a large majority of pelvic rehabilitation providers are current or past students of yoga- some of you may even be experienced or new yoga teachers. As a yoga student myself (of various teachers and approaches, and a tendency to wish I was more consistent with my own practice) I have often marveled at how old and well-founded so many yogic practices are in relation to the "new" techniques "discovered" by entrepreneurial practitioners in health-related fields. Look at pelvic muscle activation: by engaging our patients in awareness techniques involving the pelvic floor we are continuing a long tradition of a yogic principle. This principle, known to many as mula bandha, is an ancient phrase often interpreted as referring to "root" and "lock."

Over the past 5 years I have observed a tremendous increase in yoga practitioners who are interested in not only exploring the ability of the locking or stabilizing ability of the pelvic muscles, but also in exploring the necessity to "unlock" the person who is holding too much tension in the base of the spine and pelvis. The discussions related to this issue are at times hotly debated as well as thoughtful and elegant. One article might suggest a flow within which mula bandha can be integrated, and other articles warn against the overuse of the lock and the lack of awareness required to properly use mula bandha during asanas.

Last year I was approached by a local yoga school and studio, Yoga North, to learn more about how they were already incorporating pelvic floor awareness and practices into curriculum and classes dedicated to pelvic health. I had an opportunity to attend a class by a yoga teacher trained in their curriculum and in somatics, and I was very impressed at the language and techniques used to improve pelvic muscle awareness. More than ever, pelvic rehabilitation providers have an opportunity to engage other community practitioners and teachers so that we can learn from each other. It is not necessary that we speak each other's languages fluently, but that we find the common principles and share successes and challenges with which our patients/students present.

Another valuable resource recently announced is the coursework created by Ginger Garner in Medical Therapeutic Yoga. Check out her website for more background information and the course information available at MedBridge Education. If you prefer to see Ginger at a live course, she will offer "Yoga as Medicine" courses for peripartum issues- check these courses out on the Institute's home page for courses. Dustienne Miller is also offering this weekend! her new Yoga for Pelvic Pain course. You may have seen her well-attended presentation at CSm this year in San Diego. If you would like to host one of these courses at your facility, please contact the Institute.

We are thrilled to announce the launch of a brand new series of online courses, Integrative Techniques for Pelvic Floor & Core Function. This three-part series instructs on low-tech, non-invasive techniques to address pelvic floor dysfunction that draw from Yoga, Tai Chi, Qigong, Feldenkrais and conventional rehab therapies, with a goal of guideing clients toward improved health and function. These courses were developed and are instructed by Bill Gallagher, PT, CMT, CYT and Richard Sabel, MA, MPH, OTR, GCFP. Throughout each course in this series, Bill and Richard will walk you through various exercises that you are encouraged to perform at home, in order to better prepare you to guide your own patients through the same exercises in your setting of care.

Part A lays the foundation for the series by covering anatomy, core concepts related to "habits of the mind," and the physiology of breathing as it relates to the pelvic floor. Part B will begin by covering modifications of yoga poses to address soft tissue tightness, functional movement, and pelvic dysfunction. The pelvic clock in supine from Part A will be reviewed, and techniques for the facilitation of a client’s understanding of the pelvic clock will be presented. Part C concludes the series with integrating the pelvic floor muscles into everyday functional movements such as standing, lifting from a squat, bridging, and going up steps, as a means to maintain the suppleness (strength and flexibility) of the pelvic floor. These courses can be taken sequentially or in any order.

Don't miss Bill and Richard teaching their live seminar as well. The two course, Integrative Techniques for Pelvic Floor & Core Function: Weaving Yoga, Tai Chi, Qigong, Feldenkrais and Conventional Therapies will be held this September in New London, CT!