A two-hour teleseminar by Talli Rosenbaum & Dr. Tammy Nelson

Available June 11, 2013, as MP3 files (*can listen to it after June 11th too)

*The course is targeted for pelvic physical therapists, but many other healthcare professionals AND patients dealing with painful sex will find this very informative.

Course Overview:

Objective: Participants will be introduced to the multi-factorial nature of sexual pain and to mindfulness based treatment protocol to address anxiety and aversion in women with sexual pain disorders.

Part One: Understanding and treating sexual pain disorders

Part Two: Exploring the dynamics of anxiety and pain – Unconsummated relationships and sexual aversion.

(*picture from teleseminar)

TELESEMINAR REVIEW: 

How many times have patients dealing with painful intercourse told us that their healthcare professional advised them to “just relax” or “drink some wine” or “stop worrying so much and just take your mind off of it”?  How often is this advice successful? Hardly ever, right!? So, what can we do to make a drastic, positive change for patients that is effective and gentle?  Have you wondered why traditional pelvic floor therapy and use of dilators just isn’t enough?  Talli Rosenbaum, a pelvic physiotherapist AND AASECT sex therapist, has fantastic insight to share in the teleseminar.

Often in the discussion of treatment dysfunction, there’s an assumed paradigm in which the doctor will treat the dysfunctions of the skin or visceral organs, the sex therapist will address the couple’s issues and patient’s emotional issues, and the physical therapist will make sure the muscles are functioning correctly. Talli Rosenbaum and Tammy Nelson seek to shatter this way of thinking and replace it with a shift towards empowerment and mindfulness.

The two hour course is presented in a conversational interview style. Tammy asks questions to Talli to provide her the opportunity to lay out her multifactorial  approach to addressing sexual limitations. In addition to discussing the variety of sexual dysfunctions and the differences between them, she dives into that zone that many of us who treat sexual dysfunction are aware of but is poorly defined in the physical therapy world- the psychology associated with the pelvic floor. The role of anxiety, both for the patient and for the couple, is a considerations to treating the patient thoroughly and holistically.

Not only is theory discussed in this class, but Talli even goes as far as to lay out very straightforward guidelines on elements of treatment for counseling and for ways of implementing physical treatments (such as the use of dilators) in a way that is culturally appropriate, developmentally appropriate, and take into account a patient’s or couple’s aversions or struggles.

This class is great for anyone who is working with people affected by painful sex and is very focused on giving a global image of what it takes to bring a woman back into sexual wholeness. If you are a physical therapist treating people with painful intercourse or associated issues, this course is well worth the two hours spent.

Some great quotes from the class (without giving it all away!):

“Challenge notion that sex is about intercourse only”

“Get away from talking about success or failure of sex rather than just enjoying sexual experience”

“Perceive anxiety not as an enemy but as part of the experience”

“Fear is based on myths…let’s talk about myths about the hymen”

“You are not going through treatment, you are not pathological and you do not have a problem. You are here to experience a journey”

** Side commentary: Over the years, I treated patients who “failed” treatment by other pelvic physical therapists for pain with intercourse (regardless of the diagnosis).  The reason these patients experienced good outcomes ultimately is very strongly correlated to the shift in focus of treatment, not the wealth of knowledge of pelvic floor anatomy or use of a new, exciting manual technique. As pelvic physical therapists, we tend to focus on the muscles of the pelvic floor and the physical pain. As Talli states: “The pelvic floor is a window to an emotional state”.  Proficiency in treating patients with an integrative approach is very helpful:  Understanding and assisting with anxiety management using a mindfulness approach and gentle progression; promoting a healthy patient self-awarness and appreciation of her sexuality and body; and dispelling myths and providing hope.  Talli suggests emphasizing the dynamic nature of the intervention instead of just focusing on the one individual as having a “problem”. This is an excellent approach. The only caveat is that sometimes the patient associates anxiety and fear with the partner (even at a subconscious level) so I first make sure the individual has tools and interventions to promote her own healing journey separately as well.

[AASECT (American Association of Sexual Educators, Counselors, and Therapists) is an excellent organization. I'm a proud member and feel that the knowledge from the conferences and member listserv helps my practice tremendously] ~ Tracy Sher, MPT, CSCS

Want to register for this great course? 

Available June 11, 2013, as MP3 files 

(*can listen to it after June 11th too)

$99 (approved for 2 AASECT CEs)

Here’s the link to register. You can do it now!:
Sex and Pain Teleclass Information and Registration

Talli Yehuda Rosenbaum, M.Sc., PT, IF, is both a physical therapist and an AASECT certified sex therapist, who is an internationally recognized expert on the integrated roles of physiotherapy, sex therapy, and couples therapy, in the treatment of sexual pain disorders and unconsummated relationships.

Tammy Nelson, PhD, LPC, is a Certified Sexologist and a Certified Imago Therapist. She is the author of Getting the Sex You Want: Shed Your Inhibitions and Reach New Heights of Passion Together, and The New Monogamy; Redefining Relationships After Infidelity.

* Pelvic Guru does not receive financial gain from this post. Review only.

Breaking News: Updated PDF Version of Pelvic G-Codes is Here!

Changes that have been made include:
- More outcome measures included! Thank you for the feedback on what you would like added!
- revised some of the range endpoints that were rounded incorrectly.
- added EXTRA SHORTCUTS for 4 tests so that they can be scored from the raw score instead of doing the additional calculations for the official scores. Both official and raw scores yield the SAME modifier ranges.
- Medicare guideline ranges more specific.
- Alphabetized for quicker access.

A huge thank you goes to Heather Edwards for pouring lots of energy and time in to making sure the tables are accurate and well organized! She rocks!!  Here’s a message from her:

“Here it is! The tables are back and better than ever! This will be a continual work in progress for the next couple of months while we’re collecting feedback and seeing how we can make it the most effective tool possible to save clinicians as much time as possible with the new Medicare changes. If you have any requests for more tests to be added or feedback on the scoring methods, please let us know!

* Update 5/5/13: 

The purpose of this is to save time by eliminating the additional calculations required for the official scoring. Tests included in this list provide a range of options for documenting a patient’s dysfunction. The ranges are for levels of “impairment, limitation, or restriction” as listed on http://www.cms.gov. If the APTA SoWH produces a list of which tests are acceptable and unacceptable to use, this table will be modified and will be able to be found at http://www.pelvicguru.com. Currently, no such list of acceptable tests exists, and modifiers are based on outcome measures or clinical judgment. The intent of these tables is to save time and create fewer errors. It is the responsibility of the PT to use clinical judgment in choosing the best possible test for her need. 

There are numerous tests and we had requests for a more printer-friendly version.

TO ACCESS THE PELVIC G-CODE TABLES WE CREATED,

PLEASE OPEN THIS PDF FILE:  

Pelvic Modifiers PDF

Here’s a list of the pelvic tests in our update PDF:

http://www.pelvicguru.com

PELVIC

• COLORECTAL-ANAL DISTRESS INVENTORY 8 (CRADI-8)
• FECAL INCONTINENCE QUALITY OF LIFE INSTRUMENT
• FEMALE SEXUAL FUNCTION INDEX (FSFI)
• FEMALE NIH – CHRONIC PROSTATIS SYMPTOM INDEX (CPSI)
• INCONTINENCE IMPACT QUESTIONNAIRE
• INTERNATIONAL PROSTATE SYMPTOM SCORE
• NIH – CHRONIC PROSTATIS SYMPTOM INDEX (NIH-CPSI) FOR MALES
• PAIN DISABILITY INDEX
• PATIENT SPECIFIC FUNCTIONAL SCALE
• PELVIC FLOOR DISTRESS INVENTORY- SHORT FORM 20 (PFDI-20)
• PELVIC ORGAN PROLAPSE DISTRESS INVENTORY 6 (POPDI-6)
• PELVIC ORGAN PROLAPSE/URINARY INCONTINENCE SEXUAL FUNCTION QUESTIONNAIRE (PISQ-12)
• PROSTATITIS SYMPTOMS QUESTIONNAIRE
• UROGENITAL DISTRESS INVENTORY (UDI-6)
• VULVAR PAIN FUNCTIONAL QUESTIONNAIRE (V-Q)

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Here’s a bonus for you! We received lots of requests for these two tests and associated modifiers: Oswestry and Berg. So, here they are for you. In the near future, we will be sharing a link for you to access a PDF for many more tests such as: 

BALANCE, VESTIBULAR, NEURO, & GENERAL MOBILITY 

• 30 SECOND CHAIR STAND TEST
• ACTIVITIES-SPECIFIC BALANCE CONFIDENCE SCALE (ABC)
• BERG BALANCE
• DIZZINESS HANDICAP INVENTORY (DHI)
• DYNAMIC GAIT INDEX (DGI)
• FUGL-MEYER ASSESSMENT
• FOUR SQUARE STEP TEST (FSST)
• FUNCTIONAL REACH TEST
• GAIT SPEED
• PATIENT SPECIFIC FUNCTIONAL SCALE
• PERFORMANCE ORIENTED MOBILITY ASSESSMENT, TINETTI (POMA)
• SIX MINUTE WALK TEST
• STROKE IMPACT SCALE
• TIMED UP AND GO (TUG)
• WOLF MOTOR FUNCTION TEST

SPINE 

• NECK DISABILITY INDEX (NDI)
• OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE
• P.A.C.T SPINAL SORT
• FABQ
• QUEBEC BACK PAIN DISABILITY SCALE
• ROLAND MORRIS QUESTIONNAIRE
• MCGILL PAIN QUESTIONNAIRE

ORTHOPEDIC 

• DISABILITIES OF THE ARM, SHOULDER AND HAND (DASH)
• LOWER EXTREMITY FUNCTIONAL SCALE (LEFS)
• SHOULDER PAIN AND DISABILITY INDEX (SPADI)
• UPPER EXTREMITY FUNCTIONAL SCALE (UEFS)
• SF-36
• WOMAC
• PENN SHOULDER SCORE
• ASES

ADL’S & HAND

• BARTHEL INDEX OF ACTIVITIES OF DAILY LIVING
• PATIENT SPECIFIC FUNCTIONAL SCALE
• 9 HOLE PEG TEST
• HAND GRIP STRENGTH TEST

OSWESTRY LOW BACK PAIN DISABILITY QUESTIONNAIRE

Official scoring:

Raw scores to correlate with official modifiers:

BERG BALANCE

** If you are interested in finding out more about ortho, neuro, balance, vestibular (and other) modifier PDFs, please leave your name and contact email for us! Thanks!

Heather Edwards has been practicing as a pelvic physical therapist near Asheville, NC for the past 8 years. She has been a presenter on the topic of Women’s Sexuality at the Flourish Women’s Convention in Cherokee, NC. She is a Pilates instructor and a yogi as often as she possibly can be. In her “free time” she chases around her two little boys and creates ridiculously tedious projects for herself (like calculating all of the possible outcomes for g-code scores and designing logos).

Female Pelvic Anatomy:

Basic Information -

 Diane Lee PDF: Understanding Back and Pelvic Girdle Pain – with basic anatomy

Interactive Anatomy: The 3D Vulva

***New Addition (2/17/13) 360 Degree View of the Pelvis – Muscles, Nerves, Arteries and more!

A funny, but thorough description: Women’s Health Magazine – Female Reproductive System Explanation

Anatomy of the Female Pelvis for Dummies

** Great info to know!    Muscles of the Pelvic and Perineum, Origin, Insertion, Action, and Nerve

Beyond Basics:

** Check this out!! PDF Download with Dissection pics too : The Neuroanatomy of Female Pelvic Pain – Springer

Diane Lee PDF: Neuromuscular Anatomy

Abstract:  Neuroanatomy of the female abdominopelvic region. Pelvic pain syndromes.

 Standardization of Terminology of the Pelvic Floor: (c/o Herman and Wallace):

 Anatomy of the Pelvic Floor and Stress Continence System

Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures and Pelvic Organs

PDF: Contemporary views on female pelvic anatomy  (2005)

Abstract/Shortened Version: Facts and Myths about the Pelvic Floor

 Functional anatomy of the pelvic floor

Slideshare Presentation: Anatomy of Female Reproductive System

Male Pelvic Anatomy: 

Basic Information:

WebMD Male Reproductive System

A funny, but thorough male description: Women’s Health Magazine and the Male Reproductive System

Anatomy of the Male Pelvis for Dummies

Beyond Basics: 

Abstract: Dynamics of Male Pelvic Floor Contractions with US Imaging

Neuroanatomy of the male pelvis in respect to radical prostatectomy including three-dimensional visualization 

Links to Pictures:

The TIPNA website – Collection of  Pelvic and Pudendal Anatomy Images 

Pudendal Hope Website- Anatomy Section 

Videos:

Basic Vaginal Prolapse Video Link

** New Addition (2/5/2013). Excellent 3D Pelvic Anatomy, Part 1

***New Addition (2/17/13) 3D Pelvic Anatomy, Part 2

** New Addition (2/5/2013). Pelvic Cadaver Anatomy – Male and Female

** Very well Done! Anatomy of the Inguinal Region (Drawings)

Basic Anatomy of the Bony Pelvis and Pelvic Floor Musculature

Anatomy of the Pelvis- Everything You Need to Know:

Female Bony Pelvis:

Female anatomy – plastic model:

Surface anatomy of the abdomen:

Pelvis – Sex differences:

Book Recommendations:

The Pelvic Floor

What an exciting year for Pelvic Guru! I started Pelvic Guru in mid-2012 with the goal of providing good information, injected with humor at times, regarding anything related to pelvic health. The amount of support and engagement on this site and associated social media platforms for Pelvic Guru has been incredible and unexpected. Tens of thousands of you have tuned in at pelvicguru.com and the Facebook and Twitter sites!  I’m looking forward to adding more valuable information from the top experts in the field in 2013. Stay tuned! Happy Holidays to all and thanks for the support! ~ Tracy Sher, MPT, CSCS

This post provides a collection of the most popular Pelvic Guru posts of 2012. You may want to bookmark this page! If you like this, please share this link with others as well. Please remember to sign up at the top of this link and feel free to share suggestions for what you want to see in the upcoming year.

TOP POSTS – Blog, Facebook, Humor, Videos, and Twitter (by views, comments, and shares)

Top 6 Blog Posts – the most views and shares:

Eggs Released During Ovulation

Toilet Talk: Things You Should Know But Probably Don’t

Pelvic MRI: Can You Identify the Structures?

Pudendal Neuralgia: There is Hope!

Is Your Pelvic Pain Related to What You’re Eating?

GYN Cancer Recovery Advice

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Best Humor/Comic Posts on Pelvic Guru Blog and Social Media: 

_________________________________________________________________________________________________

Facebook  Links:

He Who Sits the Most Dies the Soonest

Higher Vitamin D Levels are Associated with a Decreased Risk of Pelvic Floor Disorders in Women.

A Lesson In Female Anatomy

Pain is an Opinion

How Exercise “Really” Prevents Low Back Pain (Probably)

Moseley and Hodges Pain and Motor Control Presentation Review – (3 parts, start here)

Outdated Pain Theories

The 4 Mythys About Strengthening Your Abs

Facebook  Videos:

Pain and Lorimer Moseley:

Anatomy of the Pelvis:

Top 10 Things You Didn’t Know about Orgasm:

The Science of Pain

A New Strategy for Treating Neuropathic Pain:

Mystery of Chronic Pain- Great Explanation

On a Lighter Note: How One Hurts the Coccyx

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Top Tweets that were Retweeted:

• Don’t force your children to go to the bathroom “just in case” or just out of convenience too often. This presents two challenges: 1. The bladder and nervous system are very sensitive. If your child goes to the toilet without an urge regularly, the bladder will become sensitive to that threshold; and they will feel the urge to go more often. 2. This behavior is easily carried with them into adult years with potentially unnecessary episodes of urinary urge, frequency, and hassle. * There are obviously times when the decision to use the toilet early is advisable.
• Did you know that the average healthy adult should be able to wait 2-4 hours to urinate? Can you wait that long? The most common thing I hear “but you don’t understand, MY bladder is so small. I have to go every 30 minutes…”. Generally, there are easy ways to train your bladder to wait longer. As indicated in the prior point, you may have had habits for many years that predisposed you to believe your bladder was small and unruly. Remember, don’t go to the bathroom just in case (NO JICs). Your bladder is constantly storing urine. So, if you go early, you will likely urinate, but this does not mean it was time to go yet.

• 
• Urinate when you wake up in the morning. Your bladder needs to get “flushed” out. The rule of waiting 2-3 hours to urinate does not apply here.
• Don’t sit on the toilet for greater than 10-15 minutes at a time. This increases risk for hemorrhoids, worsening of pelvic organ prolapse, and more pelvic floor issues! On a related note, NO STRAINING with bowel movements. When you strain, there’s a significant amount of pressure placed on the pelvic floor and surrounding structures. So, sitting for greater than 10-15 minutes + straining = unhappy and unhealthy pelvic floor.
• Women- remember to always wipe front to back (after urinating or having a bowel movement). This reduces the risk of introducing bacteria and other bad elements into the vagina and urethra.
• If you feel a bulge or a “golf ball” at/near your vagina or rectum or you need to use your hand to help with bowel movements, you possibly have some form of a pelvic organ prolapse. Other symptoms can include increased urinary or bowel urge, constipation, and a pressure feeling worst with standing up or straining. You can discuss this with your gynecologist, family physician, or pelvic physical therapist. You are NOT alone. This is common, but patients feel very embarrassed to share. But there is help for this.

• Do you like to wear Spanx, shapewear, girdles, or pantyhose?  They are totally slimming, right? Guess what? They can also impede your pelvic floor muscles from fully relaxing when you urinate or have a bowel movement. When you sit down on the toilet with your slimming designer fashion, make sure to slide them all the way down as close to your ankles as possible. This way you can relax your pelvic floor and allow for best chance of fully emptying your bladder or bowels.
• Have you ever read a magazine that told you to try to stop your flow of urine to check to see if your pelvic floor muscles are strong? Well, it’s technically one way to check, but it’s not good for you! Some of my patients thought they were supposed to do this every day on the toilet as part of a Kegel exercise program. No, no, no. This can cause all sorts of issues.
• If you experience bowel or bladder issues- such as constipation, irritable bowel, painful bladder syndrome/interstitial cystitis, urinary urge or frequency- there’s hope!  There’s a high likelihood that you can modify your diet or fluid intake and make significant changes. For example, did you know that caffeine and alcohol can increase urinary urge? I have also seen many cases of constipation drastically improve with proper diet modifications. Take this seriously!
• As a general rule, adults should not need to get up in the middle of the night to urinate. As we age and get to 60+, urinating one time during the night is normal. Oh, and pregnancy is also an exception. Two easy tips: 1. Limit fluid intake to little or nothing 2 hours before bedtime. 2. If you feel an urge to go in the middle of the night, see if you can fall back asleep and resist that urge to get up. On a safety note, if you do wake up to go to the bathroom in the middle of the night, please make sure you have a well-lit, clear path without furniture, uneven rugs, or toy soldiers in your path.

If you found these tips helpful or want to share more, please leave a comment and sign up to follow us. Pelvic Guru also welcomes and receives great comments and updates on the Facebook page.

Blog post (copyright pending) by: Tracy Sher, MPT, CSCS. - Pelvic Physical Therapist, Faculty for Herman and Wallace Pelvic Rehabilitation Institute, Founder of Pelvic Guru, Consultant and National Speaker.

The egg (ovum) is only viable for pregnancy for 24 hours after its release.  However, if sperm were already present at the cervix or in the uterus before ovulation occurred, pregnancy could take place. Sperm typically remain viable for about 72 hours. This is why there can be a “window” of time around ovulation when a woman can achieve pregnancy.

Women’s Health Mag ‏‪@WomensHealthMag

Taking aspirin may reduce your risk of the 5th-leading cause of cancer deaths in women: ovarian cancer ‪http://ow.ly/eui0P 

Science Index ‏‪@ScienceIndex_

‪http://scienceindex.com  Constitutive promoter methylation of BRCA1 and RAD51C in patients with familial ovarian cancer… ‪http://dlvr.it/2KkYs6 

Symposier Ob/Gyn ‏‪@SympoOBGYN

Economic Impact of Ovarian Cancer Treatments, Annual cost of bevacizumab in the adjuvant treatment of ovarian cancer ‪http://bit.ly/HAKG70 

T.E.A.L.WALK ‏‪@TEALWALK

Ovarian Cancer fact of the day: pap smears do not check for this disease! Check out our website to see which tests do: ‪http://bit.ly/SLHuom 

ChemoBabe ‏‪@chemo_babe

a daughter remembers her mother, lost to ovarian cancer. a legacy of speaking up. guest post. ‪http://www.chemobabe.com/2012/10/deviance-and-righteousness/ … ‪#pinkwashing

Trish Rubin ‏‪@brokerbabe_nyc

RT ‪@VNSNY_News: Three Questions Help Detect Ovarian Cancer – ‪http://bit.ly/QCR6Sn 

Everyday Health ‏‪@WomensCancer

Ovarian ‪#cancer risk factors you need to know about: ‪http://bit.ly/Rjj1Yr 

Cancer News ‏‪@cancernewsdaily

New Drug May Be Effective Alternative For Patients Whose Ovarian Cancer Is Resistant To Currently Available Drugs ‪http://dlvr.it/2HRqvz 

OvarianCancerCanada ‏‪@OvarianCanada

HPV vaccine helps prevent cervical cancer, NOT ovarian cancer. Learn what every woman should know: ‪http://bit.ly/Qdl4PM 

In the current issue of the journal Physical Therapy, Wang and colleagues describe the characteristics of patients (and their pelvic floor diagnoses) presenting for outpatient physical therapy. 109 outpatient clinics participated in this data collection and included information about 2452 patients. The system used for collecting data is FOTO (Focus On Therapeutic Outcomes), and you may have heard the results of this research presented at the most recent Combined Sections Meeting of the American Physical Therapy Association. The results of the study include that most of the people presenting to the clinics for pelvic floor dysfunction were women (92%), and that many reported a combination of urinary, bowel, or pelvic pain symptoms. The authors found a mean patient age of 50 with a standard deviation of 16. Most patients reported symptoms as chronic (74%). You can see from the following chart that is adapted from the article that subgroups of patient populations were noted, and the categories used for reporting include urinary disorders, bowel disorders, and pain (not all subgroups of combinations of pain are included in the chart below.) In general, 67% of the patients reported urinary dysfunction, 27% reported bowel dysfunction, and 39% reported pelvic pain.

Breakdown of Diagnoses and Subtypes

This study delivers valuable information about who is showing up to outpatient clinics and receiving care for pelvic rehabilitation services. There are certainly reasons for which patient data may not have been captured, such as patients voluntarily choosing the portions of the data collection to complete. Although the authors attempt to extrapolate epidemiological incidence of male versus female pelvic floor dysfunction compared to population samples, we have to keep in mind that there are several confounding factors that can influence such attempts. Firstly, it is difficult to obtain accurate data for prevalence of pelvic floor dysfunction in either men or women when varying criteria and definitions are utilized and when symptoms are known to be underreported. It should also be taken into consideration that patients will attend a clinic for a program of rehabilitation when there is awareness on the part of the patient or the referring provider that a particular program exists. In other words, there is still a lack of awareness that pelvic rehabilitation providers are available, that there is a broad scope of what we can evaluate and treat, and that we treat both men and women for pelvic floor dysfunction. This brings us to the fact that not as many rehab therapists treat men, and therefore such a service is likely not being promoted and utilized to its potential in a community clinic.

Although this research targets outpatient physical therapy clinics, regardless of the setting or of the discipline involved in care of patients with pelvic rehabilitation, the use of outcomes data is critical. Some insurances will not reimburse for rehabilitation unless outcome data is collected. It should be a common practice to include at least one outcome tool in evaluation and in the discharge planning process. As pointed out by the authors of this research, the use of computerized systems for medical records allows increased access to patient demographics, diagnoses, and information about treatment. It is terrific to see pelvic rehabilitation highlighted in the Physical Therapy journal, and hopefully the inclusion of pelvic floor dysfunction in mainstream publications will continue to improve awareness of these diagnoses and to further normalize the dialog about such conditions.

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** This article (by Holly Tanner) originally appeared on September 12, 2012 on The Herman & Wallace Pelvic Rehabilitation Institute’s website. Permission received to showcase this article.

Herman & Wallace provides continuing education courses for physical therapists, occupational therapists, nurse practitioners, and other rehabilitation professionals seeking evidence-based training for treating pelvic floor dysfunction and related conditions of the pelvis, hip, and spine. Explore the options below to learn more about our continuing education seminars.

Check out the blog at H & W: http://hermanwallace.com/blog
To see all of the courses offered go to: http://hermanwallace.com