This afternoon, while my rambunctious little toddler was attempting (and ultimately failing!) a nap, I had the fantastic opportunity to chat with Shelly Prosko, a physiotherapist and yoga therapist in Alberta, Canada who specializes in working with individuals experiencing chronic pain (including pelvic pain!). Shelly is an all-around incredible human, knowledgeable clinician, and dynamic educator. I hope you all enjoy this interview as much as I enjoyed it!
It’s almost here! I have been working on developing a small group mentoring program over the past few months, and it is almost ready to be rolled out!
As an instructor for Herman & Wallace Pelvic Rehabilitation Institute, I have been fortunate to work with hundreds of excellent clinicians who are at various stages of their journeys into the exciting world of pelvic health. While some clinicians enter into the field with a vast network of seasoned pelvic floor experts to support them, others have the additional challenge of being an “island”–basically, being the sole practitioner in their practice, city, and for some, within a 100+ mi radius.
My goal with small group mentoring is to be a facilitator for those journeying into this incredible specialty–to help not only with building the skill, knowledge and clinical reasoning necessary to create outstanding clinicians, but also to help connect clinicians together so no one has to go at it alone.
If this resonates with you, and you’re interested in learning with me, I would love to hear from you! I created this survey to better assess the needs of those interested in small group mentoring. Please take a few minutes to complete this survey, and look out for future announcements when the program is ready for rolling out!
All the best,
“I’m in my 3rd year of PT school and will be graduating in August, super excited to be completing my final clinical with a women’s health specialist! I was wondering any pieces of advice you could give for a new grad entering the world of pelvic health? What types of jobs to look for/courses to take/etc.? “
I just received this question via e-mail from a participant at my most recent Level 1 Pelvic Floor course in Little Rock, Arkansas. (See upcoming course schedule!) As knowledge and exposure about pelvic floor disorders and pelvic PT grows, we see more and more doctoral students attending level 1 courses. And honestly, it makes me so excited about our future! These students are passionate, hungry for knowledge, and can’t wait to enter into the field and help people get better! I have mentored many students and new grads over the past several years, and this particular question frequently arises. I hope this post can be helpful for many new grads and DPT students in the future!
When students ask the questions listed above, they often are hit with well-intended, but often somewhat discouraging advice:
“You should really do orthopedics for a few years first, and then go into pelvic health.”
“I really don’t think new grads should go straight into the pelvic health specialty”
“It’s really important that you use all of your other skills first so you don’t lose them.”
While this advice often means very well–aiming to create well-rounded practitioners, I find that this can feel very disheartening to that passionate-about-pelvic-health new grad. So, in that light, my advice is often a little bit different. I find we are all biased by our own experience, and in reality, many excellent clinicians spent multiple years in different specialties like orthopedics, neuro, acute care etc. prior to specializing in Pelvic PT, so I think there is a tendency to see this as the “best path” to becoming the most skilled clinician. Of course, I am biased the opposite way– I jumped into pelvic PT immediately upon completing my doctorate, and never looked back. Of course, this has meant that I had to do some work to build upon other skill sets that were needed over the years, but this path worked well for me.
So, why am I telling you all of this, excited-soon-to-be-new-grad? Because, honestly, you can do whatever you are passionate about doing! If you want to take some time to practice in another specialty, do it! If you are just too excited and want to jump right in to pelvic health, welcome aboard! Your experience alone is not going to make you an incredible clinician. Rather, it will be your passion, your hunger for learning, and your dedication to your patients that will fuel your path. So, on that note, here are a few of my top tips for new grads entering into pelvic health!
- Choose an employer who will support your learning journey. In many ways, it has become very popular for clinics to build pelvic health programs. This is wonderful for patients (if they are committed to building good programs!) and a great opportunity for those entering the field. So, when you interview with an employer who is excited about your pelvic floor interest, ask questions to find out how much support they will give you along the way. Will they pay $$$ for your continuing education courses? Will the provide you time to work with a mentor? Will they support you by providing adequate time in your schedule for your patients (meaning, 45-60 dedicated minutes, not overlapping patients)?
- Negotiate for what you want. This is very very important. When I was first hired as a new grad, I negotiated with my employer for them to pay for me to attend 4 continuing education courses within my first year of employment. This allowed me to complete a full pelvic health curriculum within the year. Now, I realize that may seem a bit ambitious to some, but I considered this my personal “Residency” program and I felt like it gave me the jump start I wanted! So, this can mean negotiating for courses, mentoring time (get it in writing!), or even participation in an online mentoring program (like the one I plan to set up soon!).
- Find a good mentor. Of course, my perfect scenario for you involves finding a good job with a good mentor attached to it, but I realize that is not always easy to find. Reach out to local pelvic PTs in your area and connect with someone who is willing and able to be a resource to you! Of course, this can involve meeting periodically for coffee, or could be a more formal mentoring program. If the latter is the case, see point #2.
- Don’t be afraid to jump ship. If you start working somewhere and you don’t find that you are supported in the way you need to be, or you just don’t like the place you are working, it is totally ok for you to find a new job. Seriously. Life is too short to be unhappy where we spend our time.
- Be hungry for learning. I would encourage you to make a plan for attending coursework to help build your knowledge within the specialty. There are many excellent course series out there– Herman & Wallace Pelvic Rehabilitation Institute, the Section on Women’s Health, Evidence in Motion, among many others. Of course, I teach with H&W, so would love to have you at one of my classes! 🙂 Also, there are so many wonderful opportunities for learning today, outside of traditional continuing education. Read blogs (like this one!). Research conditions and diagnoses that you are not familiar with. Join social media pelvic health groups like Women’s Health Physiotherapy and Global Pelvic Physio (both facebook groups!). Attend conferences like the Combined Sections Meeting through the APTA, the International Pelvic Pain Society’s Annual Meeting or the International Society for the Study of Women’s Sexual Health’s Annual Meeting. And don’t be afraid to ask for help when you need it!
I hope that is helpful! We are so fortunate to have so many excited and passionate clinicians joining our field! What other tips do you have for those joining this wonderful specialty? What other question do you have my dear PT students?
As an educator, one of my biggest rewards is working with students and clinicians as they learn and grow in the field of pelvic floor physical therapy. This past winter, I was fortunate to work with Amanda Bastien, SPT, a current 3rd year doctoral student at Emory University. Amanda is passionate about helping people, dedicated to learning, and truly just an awesome person to be around, and I am so grateful to have played a small role in her educational journey! Today, I am thrilled to introduce her to all of you! Amanda shares my fascination with the brain and particularly the role it can play when a person is experiencing persistent pain. I hope you all enjoy this incredible post from Amanda!
Have you ever been told your pain is “all in your head?” Unfortunately, this is often the experience of many people experiencing persistent pelvic pain. Interestingly enough, the brain itself is actually very involved in producing pain, particularly when a person has experienced pain for a long period of time. In this post, I’ll explain to you how someone can come to have pain that is ingrained in their brain, literally, and more importantly, what we can do to help them get better.
Our brains are incredible! They are constantly changing and adapting; every second your brain fine tunes connections between brain cells, called neurons, reflecting your everyday experiences. This works like a bunch of wires that can connect to one another in different pathways and can be re-routed. Another way to say this is “neurons that fire together, wire together.” This process of learning and adapting with experiences is known as neuroplasticity or neural plasticity. It is a well-documented occurrence in humans and animals. If you’re interested in learning more, this is a great article that summarizes the principles underlying neuroplasticity.1
In the case of pain…. well, here’s where it gets a little complicated.
The brain has distinct physical areas that have been found to relate to different functions and parts of the body.
Those two spots in the middle that read “primary motor cortex” and “primary sensory cortex” relate to the control of body movements, and the interpretation of stimulus as sensations like hot, cold, sharp, or dull. By interpretation, I mean the brain uses this area to make sense of the signals it’s receiving from the rest of the body and decides what this feels like. These areas can be broken down by body structure, too.
In this next image, you’re looking at the brain like you’ve cut it down the middle, looking from the back of someone’s head to the front. This image illustrates the physical areas of the brain that correlate to specific limbs and body parts. This representation is known as a homunculus.
See how the hand and facial features look massive? That’s because we do a LOT with our hands, have delicate control of our facial expressions, and feel many textures with both. Thus, these areas need a lot of physical space in our brains. In this image, the pelvis takes up less space than other areas, but for people who pay a lot of attention to their pelvis, this area may be mapped differently, or not as well-defined. We know that the brain changes due to experiences, and ordinarily, it has a distinct physical map of structures. But what happens when that brain map is drawn differently with experiences like pain?
Studies suggest that over time, the brain undergoes changes related to long-lasting pain. If someone is often having to pay attention to an area that is painful, they may experience changes in how their brain maps that experience on a day-to-day basis. This varies from person to person, and we’re still learning how this happens. Here’s an example: in a recent study, people experiencing long-standing pelvic pain were found to have more connections in their brains than in those of a pain-free control group, among other findings. The greater the area of pain, the more brain changes were found.2 My point here is to provide you with an example of how the brain can undergo changes with pain that can help explain how strange and scary it can feel for some. Read on to find out how we can work to reverse this!
The process that makes pain occur is complex. It often starts with some injury, surgery, or other experience causing tissue stress. First, cells respond by alerting nerves in the tissues. Then, that signal moves to the spinal cord and the brain, also called the central nervous system. The brain weighs the threat of the stress; neurons communicate with each other throughout the brain, in order to compare the stressor to prior experiences, environments, and emotions. The brain, the commander-in-chief, decides if it is dangerous, and responds with a protective signal in the form of pain.
Pain is a great alarm to make you change what you’re doing and move away from a perceived danger. Over time, however, the brain can over-interpret tissue stress signals as dangerous. Imagine an amplifier getting turned up on each danger signal, although the threat is still the same. This is how tissue stress can eventually lead to overly sensitive pain, even after the tissues themselves are healed.3
Additionally, your brain attempts to protect the area by smudging its drawing of the sensory and motor maps in a process called cortical remapping. Meaning, neurons have fired so much in an area that they rewire and connections spread out. This may be apparent if pain becomes more diffuse, spreads, and is harder to pinpoint or describe. For example, pain starts at the perineum or the tailbone, but over time is felt in a larger area, like the hips, back, or abdomen. To better understand this, I highly recommend watching this video by David Butler from the NOI group.
He’s great, huh? I could listen to him talk all day!
Pain alarms us to protect us, sometimes even when there’s nothing there! After having a limb amputated, people may feel as though the limb is still present, and in pain. This is called phantom limb pain. The limb has changed, but the connections within the brain have not. However, over time the connections in the brain will re-route. I share this example to illustrate how the brain alone can create pain in an area. Pain does not equal tissue injury; the two can occur independently of one another.4 Pain signals can also be created or amplified by thoughts, emotions, or beliefs regarding an injury. Has your pain ever gotten worse when you were stressed?
There is also some older case evidence that describes how chronic pain and bladder dysfunction evolved for people after surgery, in a way that suggests this type of brain involvement.5 Another case study describes a patient with phantom sensations of menstrual cramps following a total hysterectomy! 6
So, can we change the connections that have already re-mapped?
Yes!! The brain is ALWAYS changing, remember? There are clinicians who can help. Physicians have medications that target the central nervous system to influence how it functions. Psychologists and counselors can help people better understand their mental and emotional experiences as they relate to pain, and to work through these to promote health. Physical therapy provides graded exposure to stimuli such as movement or touch, in a therapeutic way that promotes brain changes and improved tolerance to those stimuli that are painful. This can result in a clearer, well-defined brain map and danger signals that are appropriate for the actual level of threat. Physical therapists also help people improve their strength and range of motion, so they can move more, hurt less, and stay strong when life throws heavy things at us! It is SO important to return to moving normally and getting back to living! Poor movement strategies can prolong pain and dysfunction, and this can turn a short-term stressor into long-lasting, sensitized pain. (See Jessica’s blog here: LINK)
Of course, with any kind of treatment, it also depends on the unique individual. Everyone has personal experiences associated with pain that can make treatment different for them. We are still learning about how neural plasticity occurs, but the brain DOES change. This is how we are all able to adapt to new environments and circumstances around us! Pain is our protective mechanism, but sometimes it can get out of hand. While tissue injury can elicit pain, the nervous system can become overly sensitized to stimulus and cause pain with no real danger. This perception can spread beyond the original problem areas, and this can occur from connections remapping in the brain and the spinal cord. For pelvic pain, treatment is often multidisciplinary, but should include a pelvic health physical therapist who can facilitate tissue healing, optimal movement, and who can utilize the principles of neural plasticity to promote brain changes and return to function.
Amanda Bastien is a graduate student at Emory University in Atlanta, GA, currently completing her Doctorate of Physical Therapy degree, graduating in May 2018. Amanda has a strong interest in pelvic health, orthopedics, neuroscience and providing quality information and care to her patients.
- Kleim, J.A., Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51, S225-S239. Retrieved from: https://www.jsmf.org/meetings/2008/may/Kleim%20&%20Jones%202008.pdf
- Kutch, J. J., Ichesco, E., Hampson, J. P., et al. (2017). Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study. PAIN, 158, 1979-1991.
- Origoni, M., Maggiore, U. L. R., Salvatore, S., Candiani, M. (2014). Neurobiological mechanisms of pelvic pain. BioMed Research International, 2014, 1-9. http://dx.doi.org/10.1155/2014/903848
- Flor, H., Elbert, T., Knecht, S. et al. (1995). Phantom -limb pain as a perceptual correlate of cortical reorganization following an arm amputation. Nature, 375, 482-484.
- Zermann, D., Ishigooka, M., Doggweiler, R., Schmidt, R. (1998) Postoperative chronic pain and bladder dysfunction: Windup and neuronal plasticity – do we need a more neuroulogical approach in pelvic surgery? Urological Neurology and Urodynamics, 160, 102-105.
- Dorpat, T.L. (1971) Phantom sensations of internal organs. Comprehensive Psychiatry, 12(1), 27-35.
In continuing my video series with clinical experts, I interviewed Susan Clinton, PT, DscPT, OCS, WCS, COMT, FAAOMPT (Yes, those are a TON of initials!!) regarding balloon training as a treatment for bowel dysfunction. Susan is well-known in our profession as an expert on bowel dysfunction, and her video definitely did not disappoint!
Curious about this treatment? Check out the interview below! If you want to learn more, here are a few research articles that mention balloon training as a treatment tool (this one and this one) Hope you enjoy!
This past weekend, I had the wonderful opportunity to teach Pelvic Floor Level 1: An Introduction to Female Pelvic Floor Function, Dysfunction and Treatment to a group of 40 clinicians in Houston. I love teaching beginner pelvic health classes. First, I am extremely passionate about pelvic health (in case you didn’t notice 😉), so spending a weekend talking about my passion with people who want to learn about it is incredible. Second, I love that I get to play a crucial role in helping a practitioner advance his or her practice to include an entire area of the body that they likely have never examined before. Yep, these participants spend 3 days learning how to perform internal vaginal pelvic floor examinations. And that, my friends, tends to be a game changer.
Inevitably, over the weekend, many clinicians will have the mixture of regret and excitement in discovering that the new techniques they are learning could have helped a prior patient. And hopefully this comes with the thrill of realizing all of the current clients who are likely going to benefit when they get back to their clinics. But what about that past patient? The one they couldn’t help? The one who didn’t get better?
I’ve been there. When I was getting my doctorate at Duke, I had a professor who once told us,
“If you reach a point in your practice that you are so tied to the techniques you use that you refuse to question them or change your approach, you should retire.”
This powerful statement has stuck with me, and encouraged me to constantly question what I do, mold my approach, and strive to improve to better serve my patients. Many years ago, I worked with a wonderful woman who was seeing me to address persistent vulvar pain (Vulvodynia). We worked together for quite a while, and we saw some improvements. But she continued to have pain. I ended up sending her back to her physician, unsure of what else I could do to help her. Fast forward 2 years later, I was chatting with her gynecologist and that patient came to my mind. I asked her gynecologist if the patient was still struggling with pain, and unfortunately, she still was. That’s when it hit me: my practice had changed in those 2 years. I was a better, more experienced clinician. I had been to many other continuing education courses, and learned so much more through the patients and clinicians I had worked with.
- My manual therapy toolbox grew larger. I had attended Stephanie Prendergast and Liz Rummer’s course on Pudendal Neuralgia, and had some good success using connective tissue mobilization and neural mobilization to help my patients with vulvar pain. I had also done coursework in dry needling and found this to be a novel input to make changes for my patients with tender muscles.
- I had spent hours and hours diving deep into the pain neuroscience world. I had learned how much educating my patients about pain and integrating pain science within the interventions I provided could influence my patients positively and be a catalyst in their healing journeys.
- I had connected with some fantastic psychological professionals in the area, including a counselor who was extremely talented at helping men and women dealing with chronic pain.
So, I asked the physician if she thought the patient would be open to coming back. We called the patient, and she was. And guess what? She was thrilled that I had thought of her after those years, and wanted to help her in her recovery. And guess what happened? She got better! My approach was different. I referred her to the counselor I mentioned, and he ended up being a huge player in her healing journey. She loved dry needling and connective tissue mobilization, and felt significant pain relief from these treatments. I also took a more active approach with her, got her moving in ways that helped her body not guard from pain, and together, we helped her move forward.
So, why am I telling you this?
- If you are a clinician, I hope you go to courses, read journals, and have conversations with colleagues that challenge your practice, encourage you to change, grow and get better! And if that reminds you of patients you could have helped, check in on them! Call them up, and ask them to take a chance on you! In my experience, men and women with chronic pain will be glad that you did! They’ll be glad you want to advocate for them, help them, and that you are passionate enough to still want to make a difference for them, months or years later.
- If you are a patient who is still not better after failed treatments, try giving a clinician a second try. Send them an email and ask if they have learned anything new that may help you or want to review your case another time. You may be surprised at the results!
I want to hear from you! Have you ever seen a clinician for a second round with different outcomes? If you are a provider, how has your practice changed in the past few years? Have you helped a patient you couldn’t help before?
I want to meet you! If you are a healthcare provider, I would love to have you at a course! Check out my future offerings here! Unable to make a live course? On-demand webinars are a great option too!
Have a great week!
First and foremost, Happy Halloween!!
I am thrilled to have the opportunity to present TWO webinars over the next few months with Therapy Network Seminars! The first, “Introduction to Pelvic Floor Rehabilitation” will be next Thursday, 11/5 8:00 – 9:30 p.m. EST and will provide introductory information about pelvic floor anatomy and function, common diagnoses related to pelvic floor dysfunction, basic information on what pelvic PT really involves, how to screen for pelvic floor dysfunction in YOUR patients, AND most importantly, how you can begin to integrate the pelvic floor into treatment the very next day!
Then, on 12/10 8:00 – 9:30 p.m. EST, I will be presenting on “Pelvic Floor Dysfunction in the Adult Athlete.” This webinar will dive deeper into the role of the pelvic floor in stability and will explore the relationship between the pelvic floor and the other deep stabilizers around the pelvis. We will also discuss how to integrate the pelvic floor and the diaphragm within functional core stabilization, common diagnoses related to pelvic floor dysfunction in the adult athlete, and specific key components to be addressed for women returning to athletics postpartum.
I am super excited to be presenting these webinars, and I hope some of you will join me!!
Register today for the early bird discounted rate of $31!!