Open During Renovations...

It was a crisp 22* F (-5* C) and the local Starbucks had a small walk –up window open for hot drinks and food. There were three baristas closely tucked inside with a space heater, coats, gloves, smiles, music and laughter. The milk and cream station was boldly out on the icy sidewalk. Renovation had started that day, complete with piles of material visible through the windows as I walked past with my latte. Aren’t we all “Open During Renovation”? I mean, it’s not like we get to stop when it’s hard to keep going, we just get to rest a little. But we persevere through and do the work and renovation as we go.

Staying open during the construction was a brilliant plan, I stopped there for coffee because of the perseverance and good cheer of the frozen baristas. Renovations are messy. They usually take longer and cost more than you think they will. And the end result often looks nothing like you planned. Eventually though, it’s over.

sandys brain picI imagined how it works inside us – construction happening in our own renovations as we try to stay cheerful and open. I had this picture of a brain with a little walk-up window, some scaffolding, and tiny baristas doing their best with bottles of cortisol, dopamine, serotonin, pro-inflammatory mediators “What are you ordering today?”

For me, I prefer an Extra Shot of Dopamine and Serotonin, usually getting those with an order of Hope and Possibility. Laughter is my favorite anti-inflammatory*. I’ll take a Grade Latte with a double shot of Resilience!

What if that’s really how it works? Physical Therapists like to tell people to keep moving. Moving sometime hurts, or you just can’t do it “one more time”. Rest a bit, take a couple of easy breaths** and give moving easily another chance. You are stronger than you feel. You are resilient, and resiliency gets better with practice (everything does, even feeling crappy). The flare-ups and dark-downs are not permanent, though they may feel like they are when you are in the midst of them.

The Frozen Baristas at the local Starbucks may have felt like they would be stuck in that little walk-up forever, the charm may have worn off as they lost feeling in their fingertips… but the newly polished store is once again fully open and shining!

What will you order today?

* Poetic license. It’s not quite that simple…

** Why Breathing? Persistent pain and challenges that go on too long can make it hard to feel or pay good attention to your body. You may have become accustomed to the tension and guarding you’ve used for so long that you don’t realize anymore that you are doing it. It’s become normal. Or maybe you’re not bracing or guarding anything at all – but to keep going through your own renovation you’ve stopped feeling or even being aware of a part of you, you’ve “put it somewhere else” so that you could keep going. Both of these are great short-term tools – but they aren’t supposed to be permanent! Breathing mindfully can help you take an imaginary walk to and through parts of yourself that need some kind awareness and timely attention.

Why Should You Come to Neil's Course?

This is an update of a blog we posted last year....  It's exciting that we didn't have to change much, as Neil will be returning to Entropy in July 2016!!  If you missed him last year, don't miss him again!  Neil O'Connell will be popping across the pond this July to hang out in Chicago, and come have a chat at Entropy Physiotherapy.  Sandy and I have invited Neil to come and help us understand how to not just read, but interpret 'evidence' correctly.  You don't have to go far into Twitter, Facebook, or any number of blogs to see 'evidence' thrown around to support a chosen view.  But how can you tell if the evidence is sound?  Reading the whole article is a good place to start, but understanding what makes a study strong is a whole other level.  Neil will help us understand how to tell if that study is any good, if it can support the claims the conclusion makes, and how to apply the study to true 'evidence based practice'.


Also, there will be a headstand competition...  Neil kicked my butt in Buenos Aires (I will NEVER again underestimate my opponent), and he totally called me out by name on CynicalPT's blog. So in case you needed another reason to come have a great weekend at Entropy, you can see the rematch of the year:  Dr. Neil O'Connell vs. Sarah the PT in a headstand challenge! I've had another year to train....  So this one will be epic.


You can sign up now and reserve your spot!  We're keeping the course small, so there's plenty of time for arguing/debating the finer points of evidence in the world of PT!

See you there!!


And Neil, I've been practicing.... IMG_2528

What to Look for When You're Looking for Help with Pelvic Pain

Pelvic Pain can be hard to deal with.  The amazing amount of information (both good and bad, accurate and inaccurate) can be overwhelming.  How do you wade through everything and find the help that is right from you? Here are a few suggestions that you may find helpful.  Remember:  If you feel scared or hopeless, you’ve just not yet found the right person to help you.

Medically Induced Healthcare Issues

Healthcare can do better....

This weekend I had the good fortune to attend  a wonderful course, Comprehensive Management of Bowel Dysfunction.  As a pelvic health physio, patients with gastrointestinal, digestive, and bowel issues are always challenging.  And the fact of the matter is, if you ask your patients (even the ones coming to see you for their knees), they’d tell you about their bowels.

sitting on table

As much as I love talking about bowel issues, one of the most profound things that I experienced in this class was a completely comfortable, completely pain-free vaginal and rectal exam.  That’s right, even the rectal exam.


It got me thinking about what my patients go through on their quest for health.  The exams they experience, the things that they are told about their condition, and the testing they must endure are unfortunately unhelpful.   Many patients will come into the clinic ‘worse’ after visiting their physician for a recheck, or after undergoing ‘further testing’. Why are the examinations and tests people are put through making them worse?






In our clinic, we’ve started referring to these as ‘medically induced conditions’.

scary doctor

We unfortunately see this often.  Patients traumatized following their medical interventions or hospitalizations or physical therapy treatments.  Why does this continue to happen??  Is it necessary to ‘get worse before you get better’?  Is it necessary to endure further testing?  Here are some thoughts and questions for patients and clinicians to ponder.  I hope it makes clinicians (physios, physicians, anyone touching a patient ever) reflect and reconsider their actions/suggestions/prescriptions.  I hope it makes patients speak up if they’re being hurt.


  1. If you poke anything hard enough, it’ll probably hurt.  This goes double for poking into any orifice.
  2. Poking something hard enough to make it hurt won’t necessarily tell you what to do to help that person.  Especially if the person has already told you, ‘it hurts if this bit gets poked’.
  3. Testing should be done to help rule out red flags, or to help direct the plan of care.
  4. Patients should understand why they’re having a test, and understand how the results will impact their plan of care.cartoon
  5. Clinicians should take the time to make the healthcare experience better.  Make the patient comfortable.  Take the time to explain what you’re doing.  Take the time to answer the questions.  Pay attention to verbal and non-verbal indications that what you’re doing to them is causing pain.
  6. If a patient says ‘ouch, that hurts’, or they’re squirming on the table, stop hurting them.  Take a minute and reflect on what might be happening, and why in spite of your perfect technique this patient is not feeling better.
  7. If a patient isn’t getting better, doing whatever you’re doing harder, deeper or more often isn’t likely the answer.

I have a hopeful heart, that even when patients have negative healthcare experiences, the healthcare practitioners are basically good people with good intentions.  There are a lot of us who also fancy ourselves to be wonderfully qualified:  specializations, advanced degrees, conference and course attendance trying to acquire  new knowledge, new skills, and new evidence to educate those patients.  Professional development (heck, learning in general) should be life-long.  However that knowledge should not replace common sense and good manners.

Your Vagina is Awesome….

Even after 3 kids.  Even after menopause.  Even if you didn’t know how awesome it is.  

As a pelvic health therapist, it amazes and saddens me that in 2014, women are still ashamed, self-conscious, and confused by their lady bits.


I’d like to address a few of the myths and inaccuracies that I’ve heard, in and out of the clinic…



1)   It can be a challenge to see your vagina.  – The vagina is essentially a hallway from your uterus to the outside world.  It’s a hallway that can stretch.  A lot.  If you can see your vagina without trying, you might want to see a physician…  Vaginal prolapse can happen, and it would need to be addressed.

2)   The parts you can see vary much from person to person.  And I’ve never seen an ugly one. -  The first thing most of us run into if we’re to take a peek at our genitals is the labia majora. If we separate those, we’ll be able to see the labia minora, clitoris, as well as the vaginal opening.  These bits do change with arousal, childbearing, and age.  If you’re curious about what ‘normal’ is, I recommend the documentary The Perfect Vagina.  

3)   The vagina is not the same as your pelvic floor. – The pelvic floor muscles are a group of muscles that are located in the bottom of your pelvis, spanning from your pubic bone, to your tailbone, and out to each ‘sits bones’.  The pelvic floor has 3 openings for us ladies:  (starting from the front) An opening for our urethra to urinate, an opening for our vagina (for sex and childbirth), and finally our anus for defecation.  The pelvic floor also plays a role in respiration and core stability.  Bladder, bowel, and sexual function can all be impacted by pelvic floor muscles that are not functioning up to par, which brings us to my next point.

4)   Having a baby can greatly impact the function of your pelvic floor muscles.  There’s much to say about this…

  1. If you give birth vaginally, you’re pelvic floor muscles stretch more than any other muscle at any time in your life.  It is one of the wonders of the world that a woman can pass a child through her pelvic floor, and more often than not, regain fairly good bowel and bladder control quickly, and resume sexual activity in as little as 6 weeks.
  2. If you give birth via C-Section, you did not get the ‘easy way out’.  Studies show that pelvic floor dysfunction (bowel, bladder and/or sexual dysfunction) are just as high in women 12 months after a C-section as they are in women who have a vaginal delivery.
  3. Some women recover more quickly than others.  Some women just think they’ve recovered.  There are several common things that women experience after childbirth, such as incontinence or painful intercourse.  These are certainly common, but should not be considered ‘normal’, and therefore ignored.  There is much to be done to improve these symptoms, and I’d seek out a qualified pelvic health therapist to get an assessment as soon as possible.

5)   Even if you haven’t had a baby, it’s ok to get help for pieces that don’t seem to be working as well as you’d like. - Sometimes things aren’t as good as you’d like.  Yep.  I’m talking about sex.  Lack of enjoyment, lack of desire, lacking the ability to have orgasms…  These can be more complicated, but not impossible to address.  Identifying the different pieces that may be contributing to the situation is key.  There are physical, medical, mental and emotional issues that can contribute in various ways to sexual dysfunction.  Understanding what your bits are, and what they’re supposed to be doing can go a long way in decreasing fear and anxiety relating to sexual dysfunction/lack of enjoyment.



If you find yourself in a situation where you don’t love your vagina, get help.  Don’t assume nothing can be done, and don’t suffer in silence.  If you’ve not had a physical lately, I’d recommend you check in with your gynecologist.  If you feel like you can’t talk to them, or feel like you’re not being heard, don’t give up.  We’re happy to offer some suggestions on a starting point for you to start your journey to better sex.

Oops! What to do for embarrassing issues...

The need for pelvic health for men and for women is getting more attention, including a recent blog post from the Women’s Health Foundation that talks about Accidental Bowel Leakage (ABL).  It is great to have more discussion about what is “normal” and what can be done to get or stay healthy.  Physical Therapy plays a huge role in health care as the best option for muscle and body awareness training.  

The post by the Women’s Health Foundation outlines the basics of bowel health and emphasizes that 90% of people can be helped with lifestyle changes in diet, bowel habits and retraining the pelvic floor.   But, what if some of these changes actually cause worsened problems or don’t adequately address the issue?  There is more that can be offered through a visit to a pelvic health physical therapist, think of us as all of the above PLUS unique and individual education.  A pelvic health physical therapist provides all of the above information and is trained for including a careful internal assessment of the pelvic floor to make sure that you have good control and awareness of the pelvic musculature.   We also check to make sure that you can relax the muscles.   Biofeedback may be helpful for learning a general awareness, but it does not replace a qualified internal assessment.  Your difficulty may be more complex than simple activation of the muscles and could require sensory retraining and/or desensitization as well as coordination.

colon pic

A specially trained pelvic health physical therapist also has the ability to work with retraining of functional bowel habits with specialized techniques such as the use of a rectal balloon catheter for sensory-motor reeducation and provide individually designed home exercises, toileting postures and functional activities geared specifically to regain function.


Finally, pelvic health physical therapy can also address other factors related to bowel disorders including stiffness of the spine and thorax which increase intra-abdominal pressures, mobility and pain issues of the abdomen and pelvis as well as coordinated care of urinary dysfunction (which is also closely correlated).  Education on fiber and water may not be as simple as just increasing consumption as this can cause pain and bloating in many instances.  Increasing exercise may also require intervention to help the knees, hips or back move much more efficiently to achieve these goals.  The great news is that a physical therapist can provide this care and integrate the education into treatment and work closely with the medical team for truly integrated care.


If you are a physical therapist interested in advanced bowel care, we have the course for you!

Physical Therapy Comprehensive Management of Bowel Dysfunction

September 12 – 14, 2014

Instuctors:      Susan C. Clinton PT, DScPT, COMT, MHS, OCS, WCS

Susan George PT, DPT, MS, OCS, WCS

Prostatitis - Can Pelvic Floor Physical Therapy Help?

Prostatitis is one of the most common diagnoses that men are given if they’re having a new onset of pain “down there” or urinary issues.  ‘Prostatitis’ literally means ‘inflammation of the prostate’.  There are two basic types of prostatitis, acute and chronic. Identifying which kind is present is important in determining the best course of treatment.  

Acute bacterial prostatitis is an infection of the prostate.  Like any other infection, symptoms can come on suddenly, including chills and fever.  Other symptoms might include pain in the bladder or when urinating.  Acute bacterial prostatitis is best treated by your doctor with antibiotics.


Chronic prostatitis has a few manifestations. First, chronic bacterial prostatitis is characterized by gradual onset, and recurrent urinary tract infections.  The other is chronic pelvic pain syndrome or nonbacterial prostatitis.


Most men who begin to experience discomfort or dysfunction in their nether regions will head to their doctor to remedy the situation.  As stated earlier, if the pain or dysfunction is caused by an infection, medical intervention is necessary. However, there are times where the medical intervention does not end up relieving the man of his pain or during the course of medical intervention it is determined that there is not an infection present.  So what can be done for the patient with pain but no infection?


This is the type of ‘prostatitis’ where pelvic physical therapy may help.  Physical therapists are experts in treating pain, and identifying ways to manage or eliminate it.  Chronic pelvic pain syndrome is a condition where a man may or may not have any inflammation in his prostate.  Or if he does, it may or may not actually be contributing to his complaints of pain or dysfunction.  Understanding the behavior of the pain, as well as the function of the anatomy in the area (low back, pelvic floor, hips, bladder, bowel and sexual function) can help develop a better understanding as to why the pelvic pain is persisting.  Understanding all of the potential contributors to a man’s complaint of ‘pelvic issues’ is key to providing the most effective intervention.


There is a fourth type of prostatitis called ‘asymptomatic inflammatory prostatitis’.  This type of prostatitis doesn’t have any symptoms of pain or dysfunction, but ‘signs of inflammation are found when the patient is being evaluated for something else’.  If there are no symptoms, and no infection, there does not need to be any treatment for this condition.


Anytime a patient (male or female) comes to me with 'chronic UTIs', I always ask if they were confirmed with a culture.  I've seen too many people get treated for 'repeated' infections with no cultures.  Does the person have burning with urination and frequency and the patient and doc are assuming infection?  And if there is pain due to something else (pelvic floor dysfunction, non-relaxing pelvic floor, etc), a painful bout of urination could make that pelvic floor freak out more. Or if they're already sensitized to pain in that area, then an infection (which hurts)  could contribute to ramping up any symptoms in that area.  Often prostatitis is more often an assumption than an 'I had a positive test for prostatitis'.  A guy has pelvic pain, he is almost certainly going to be diagnosed with pudendal neuralgia or prostatitis, with very little differential diagnosis done.






Acute Bacterial ProstatitisAcute Infection!  See doctor, get medication and everything should be fine. Chronic Bacterial ProstatitisRecurrent infections, antibiotics still likely to help, but may take longer
Chronic ProstatitisCharacterized by pain and discomfort.  I wonder if this is really ‘inflammation of prostate’ or if it is a pain syndrome blamed on the prostate.  Antibiotics don’t usually help, maybe Pelvic PT can! Asymptomatic Inflammatory ProstatitisNo symptoms to complain of, but inflammation if found incidentally.  Not typically treated.



If infection has been ruled out or treated, but symptoms of pain or dysfunction persist, consider consulting with a skilled pelvic floor therapist.  A skilled pelvic floor therapist can assess your pelvic floor muscles for tenderness, ability to contract and relax, as well as assessing other potential contributors to your pain.  Physical therapists can also help with function.  Unfortunately most of the advice I found online for men experiencing pelvic pain were to just avoid all things that might exacerbate their symptoms, like sitting or riding a bike.  While I don’t suggest doing things purposefully to exacerbate pain, understanding the cause of the pain and addressing it will allow you to keep doing the things you love.


What does healthcare really cost??

  This morning a potential patient called to cancel her evaluation, because Entropy Physiotherapy is a cash practice, and not covered by her insurance.  It surprises me how much this still stings.  We created Entropy Physiotherapy to provide expert care at an affordable, transparent price.  So I decided to do a little recon work, and see if our efforts to make good care affordable were successful.

I called my insurance company to verify my benefits.  I got through to a representative fairly quickly, but it still took me more than 25 minutes to have him answer 4 simple questions:

  • What are my in-network PT benefits?
  • What are my out-of-network benefits?
  • How do they know if in-network PTs are any good?
  • Do I have different deductibles to meet for in and out of network services?


He had to go look up some of the info, but I actually ended up getting a lot of good  answers.  I’ll do all of the math on another post, but the good news is I have coverage to some degree in and out of network, after meeting my deductible.  The bad news is that in-network ($1000) and out-of-network ($2000) deductibles are separate.

For any readers who don’t know, the appropriate deductible needs to be met before the insurance company will pay anything.  So I’d be having $1000 come out of my pocket, even if I stayed in-network.  That’s a hefty chunk of change.  This led me to 2 more questions:

  • How does an insurance company choose the physical therapists to send their members to?
  • How long will I be in treatment before I meet my deductible?


The nice man at my insurance company could only answer one of those 2 questions.  He said that any provider could go online and fill out the paperwork to become an ‘in-network’ provider.  There is a process, but nowhere is ‘interview’ or ‘review of CV’ listed.  They appear to check and make sure you’re a real person with a license to practice.


I wasn’t’ terribly surprised by this, because Blue Cross Blue Shield of Illinois recently implemented a ‘tier’ system for reimbursement, which currently only applies to private physical therapy practice.   Clinics are arranged into tiers based not on outcomes, or on patient satisfaction, but rather how many visits they saw patients on average.   I’d like to think that my therapist would make the best decision for me for my outcomes.  But the hands of the therapist may be tied by how many visits my insurance would be willing to pay them.

As for the cost of a visit, he had no idea.   He did suggest I see a massage therapist.  And that he thought it was great I running, because it would make my knees stronger, which would help my hips

I decided to find out just what a Physical Therapy evaluation would cost me if I hadn’t met my deductible….

I called 3 different Physical Therapy clinics that were in-network for my insurance.  As a consumer, I’d like to know what I’m paying for any product or service.  As a PT, I’m painfully aware that I’ve had several jobs where I had no idea what my patients were being charged for my services.    So just how much is a Physical Therapy evaluation?  Nobody had any idea.  I was told it would depend on what needed to be done. …  I said just an evaluation….  They still said they didn’t know, but they could guesstimate for me.  Answer from Clinic #1:  $327, but likely I’d only be responsible for $275 after the insurance discount.  Answer from Clinic #2:  $300-$400, but likely only $150 after insurance discount.   Or $114 if I paid cash).  Answer from Clinic #3:  $250-$350, and we should know in about a month what my financial responsibility would actually be.

I’m asking as a Physical Therapist and as a consumer:  Why can’t we find how much a treatment will cost?  There doesn’t seem to be anything else I consume where the price is a complete mystery.   I know how much my dinner is going to cost, as well as how much the bottle of wine will cost.  I know how much my haircut with Ryan is going to cost, and because he’s awesome, I’m willing to pay a little more than I would for a haircut elsewhere.  All very upfront, and I can make my decisions based on what I can afford and what I find value in.  How do we expect patients to accept a randomly selected therapist and sign papers stating that they will be responsible financially for anything that insurance won’t cover (without knowing what services cost, or what insurance will or won’t cover).  In my opinion, we shouldn’t expect anybody to agree to be financially responsible for an unknown amount, and consumers of healthcare shouldn’t accept that ambiguity.


Men Have Pelvic Floors, Too…

I’ve considered myself a ‘pelvic floor therapist’ for about the last decade.  That’s a long time, but it’s amazing how little the public and the medical community knows about this area of physiotherapy.  Many people have heard about “Kegel exercises’, usually in relationship to preventing urinary incontinence after childbirth.  In fact, I’m usually called a ‘Women’s Health Therapist’.  Not very fair to all of the gentlemen who’ve been sent to me over the years for various pelvic issues…  

In an article currently ‘in press’, Andrew Siegel, discusses the benefits of Pelvic Floor Muscle Training  (PFMT)(what Kegels really are) for male pelvic issues. The pelvic floor is a group of muscles that run from the pubic bone in the front, all the way back to the coccyx  and sits bones, and are instrumental in bowel, bladder, and sexual function.  The pelvic floor muscles are skeletal muscles, just like our biceps and quadriceps.  And like all skeletal muscles, exercises can be done to improve the strength, tone and coordination of the pelvic floor muscles.

So what might happen if these muscles get stronger or more coordinated?  It’s been found that pelvic floor muscle exercises can improve symptoms of Stress Urinary Incontinence, Overactive Bladder, Postvoid Dribbling, Erectile Dysfunction and Ejaculatory Dysfunction.

PFMT can help decrease or eliminate stress urinary incontinence (SUI) by increasing the tone, strength and endurance of the pelvic floor muscles.  As a result, the external urinary sphincter (which lives in the pelvic floor and helps maintain continence as the bladder fills) becomes stronger, and the reflexes that help all of us maintain continence become more robust.  Improving the tone of the pelvic floor (and indirectly impacting the strength of the guarding and cough reflexes) can assist not only in SUI, but also with post-prostatectomy UI.

Overactive Bladder (OAB) is the presence of urinary frequency, urgency, and nocturia with our without urge incontinence.  There are many factors which can contribute to that ‘gotta go’ feeling.  Once infection and prostate issues have been ruled out, there’s a good chance that learning how to manage your bladder with PFMT will be an effective choice of treatment.  There is a muscle surrounding the bladder called the detrusor.  This is a smooth muscle that should be relaxed while the bladder fills, while the sphincters and pelvic floor contract gently to maintain continence.  (Imagine holding a water balloon closed with your fingers).  Then, when the time is right, you go to the bathroom to urinate.  You would relax your pelvic floor, and the detrusor would contract to squeeze the urine out.  (Now imagine letting go of the balloon, and squeezing all of the water out).

Sometimes, for various reasons, that bladder will start to contract inappropriately, giving an urge to void.  Sometimes it’s because we’ve ingested bladder irritants, sometimes it’s because the pelvic floor doesn’t know how to let go, or sometimes the detrusor has just been trained to contract too often.  You can use your pelvic floor to retrain the detrusor by reinstating the natural rhythm of ‘pelvic floor relax/detrusor contract-pelvic floor contract/detrusor relax’.

Post-void dribbling is an issue that arises from time to time for men, which is the loss of urine immediately or shortly after completing urination.  The male urethra is much longer than the female urethra, and sometimes urine will become ‘stuck’ in the urethra.  Using the pelvic floor, one can learn to successfully expel urine completely to avoid post-void dribble.

Now, let’s talk about sex.  The penis (to quote the article) ‘is a marvel of engineering’.  It has the ability to increase its blood flow by a factor of 40-50x over baseline.  Without going into too much detail, there are many factors that contribute to erectile difficulties.  Blood flow is one of these factors.  For a successful erection, followed by a successful ejaculation, having a healthy pelvic floor is very helpful.


Wow!  Then why aren’t Pelvic Floor Muscle Exercises recommended more often?? Part of the reason may be the medical culture in our country.  Lifestyle improvement measures and exercise programs may be recommended, but as with any other area of our lives, not always easy to follow through.  Medial professionals tend to recommend a surgical or pharmacological intervention, which may at first appear to be the ‘quick fix’ patient are looking for. Another obstacle is that these exercises are frequently done incorrectly, as physicians don’t have the time to properly instruct patients and pamphlets have been found to be ineffective in teaching proper technique.  This article was a lovely summary of how pelvic floor muscle training is beneficial for some male pelvic issues.


There are some situations when pelvic floor exercises may or may not be able to help.  How might one decide if pelvic floor muscle training will be helpful?  First, see your physician for an assessment if you have any sudden changes in bowel, bladder, sexual function, or begin to experience unrelenting pelvic pain.  Your physician can assess your general health, and run necessary tests to rule out any ‘red flags’.  If the physician cannot find anything that needs to be addressed, like an infection, then physical therapy is a great option.

A trained pelvic floor physical therapist will be able to assess a person’s complaints (incontinence, decreased ability to empty bladder, fecal incontinence, pelvic pain, prostatitis), as well as assess the function of the pelvic floor:  ability to contract, ability to relax, strength, sensation and coordination.  It’s important to asses the person as a whole, not just how the pelvic floor works, but how does it work in conjunction with breathing, posture, as well how these things impact a patient’s symptoms and communicate these findings back to the physician.   Doing PFMT correctly is the first step in determining if PFMT will be beneficial for you.  Learn to do them properly by finding a pelvic floor physiotherapist .


Part of an Interdisciplinary Team

When Should Health Professionals Refer a Patient to Women’s (and Men’s) Physical Therapy? Thanks to the great job by the LA Times there is renewed interest and increased visibility around the too-often taboo subjects of peeing, pooping and sex.  It’s not necessary to suffer these problems in silence or shame, and there are qualified professionals who can help you find the care, support and courage you need. You can recover your health!

What is this special kind of Physical Therapist?

Physical Therapists who specialize in pelvic health are a key component of an interdisciplinary team.  We do a musculoskeletal screen of the spine, pelvis, legs, check on breathing and coordination, PLUS we know how (and when) to do an internal pelvic examination to determine how the internal pelvic muscles are doing.  It’s not all about Kegel’s  - a healthy muscle can contract AND relax. If the problem is an unrecognized/unaware pelvic contraction then there is a need to learn to lengthen/relax and recover the nuance and bounce of the pelvic muscles.  Specialized Pelvic Health therapists also understand how complex pain is, and respect that pain in the pelvic area comes with additional complexity.  We can do our evaluations and treatments with pain science underpinning our treatments and help to calm a sensitive nervous system.  (No Pain and Plenty of Gain).

How would you know WHEN to refer a person to a Women’s (and Men’s) Physical Therapist?

Part of a routine examination gives the clues:

  • Urinary Incontinence (Stress or Urgency/Frequency)
  • Pain in the genitals
  • Pain with intercourse
  • Unresolved Hip/SI pain in the absence of pathology
  • Fecal Incontinence
  • Back/hip pain in pregnancy
  • Heaviness or pressure in the perineum (Pelvic Organ Prolapse)

Any of these problems should be evaluated by a specialized physician, typically a Urogynecologist, Urologist or Gynecologist.  Once pathology is ruled out, the next step should be a Physical Therapist that specializes in pelvic health.  That’s a bold statement – read on!

Sex should never hurt – there are a variety of reasons why it might, and pain neuroscience education combined with careful graded exposure to tissue stretch and fitness, manual therapy and consultation with a qualified sex therapist if needed will help restore not only tolerance to sex, but the enjoyment and glorious benefits associated with orgasm.

It is not normal to leak urine, although it is common and 1 in 3 women report this problem. Stress incontinence and Urgency/Frequency respond to education and training.  Physical therapists can design a program to regain control and restore function.  Some more information is here and here.

It is not normal to leak stool either, or to be constipated.  Bowel health can be a bit complicated and we typically work closely with a physician to ensure bowel health and interdisciplinary treatments. We’ve addressed this previously here.

Pain in the perineum is to be taken seriously and treated (labia, testicles, penis, vaginal or rectal pain).  After a good evaluation by an MD to rule out pathology, you should come to see a pelvic health therapist.  We know that pain is 100% a protective response that may not have as much to do with the tissue health as we think.  There’s a patient education book underway that will address pelvic pain from a biosphyscosocial perspective – which is what the pain science literature is pointing to as the most effective way to treat pain.  In the mean time, we love this video.

Low back, hip or SI pain that isn’t responding to treatment may involve a coordination issue that includes the internal pelvic muscles.  Normal movement is a combination of multiple systems and sensory awareness, the pelvic muscles are important in this symphony of motion.  If things aren’t getting better, consider an internal pelvic evaluation to see if the pelvic musculature is coordinated, supple and able to both contract AND relax.

There may be a strong sense of hesitation to talk about these things – by the health professional and by the person experiencing it…  but since we can make a difference in a persons most basic necessity of life – don’t hesitate to refer!

Where would you find a qualified therapist?

The American Physical Therapy Association and the Section on Women’s Health have locators to find qualified therapists in your area.  There are growing lists in Canada, the UK and Australia as well.  If there isn’t a qualified provider in your area it may be worth a phone call or consultation with the closest you can find.  We can help, often we will see measurable change in 2 or 3 weeks.

You're not broken...

Pain stinks. But we will all likely have to deal with it at some time in our lives. Understanding pain, and understanding that you're not likely broken can be a very powerful pain reducer.[embed width="320" height="240"][/embed]

Learn more here:

Bronnie Thompson authors the wonderful HealthSkills blog and has a word for people who are experiencing pain:

For a visual look at what is going on with Pain, the TedX talk from Professor Lorimer Moseley is a classic.

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What can we do to help?

How would an orthopedic Physical Therapist know when to refer a patient to a Women’s (and Men’s) Physical Therapist? This question came up on Twitter today and we think it is a great one.

Part of a routine orthopedic physical therapy examination should include checking for common Red Flags:

  • Incontinence of bowel or bladder (Stress or Urgency/Frequency)
  • Pain in the genitals
  • Sexual dysfunction including pain with intercourse
  • Unresolving Hip/SI pain in the absence of pathology
  • Back/hip pain in pregnancy
  • Heaviness or pressure in the perineum (Pelvic Organ Prolapse)

If a Medical Doctor has already seen the patient and pathology is ruled out, the next step should be referring this patient for a consultation or treatment with a Physical Therapist that specializes in pelvic health.

What is the difference?

A physical therapist who specializes in women’s and men’s health will be able to do an internal pelvic assessment that may include:

  • Coordination of the pelvic muscles and the ability to contract and relax.
  • Tissue mobility, the pelvic muscles should be non-painful.
  • A detailed history of bowel and bladder function and habits.
  • Assessing the ability to integrate the pelvic muscles in normal activities.
  • Reassuring the patient that it is never normal to have pain during sex, incontinence can be helped by a well-designed program, and it is never normal to leak.

Where would you find a qualified therapist?

The American Physical Therapy Association and the Section on Women’s Health have locators to find qualified therapists in your area.  There are growing lists in Canada, the UK and Australia as well.  If there isn’t a qualified provider in your area it may be worth a phone call or consultation with the closest you can find.

Sexual Dysfunction…. There is help!!

SexProblemCirclesDefining sexual dysfunction:  Sexual dysfunction or sexual malfunction is difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including physical pleasure, desire, preference, arousal or orgasm. …

Our sexuality is an intimate and private part of our lives.  Messages from media, friends, and partners combined with complicated cultural and societal norms come together to form our assumptions about sex. It is something we don’t often freely discuss.  This is especially true when bits and pieces aren’t working how they should.

Sexual dysfunction can be a difficult topic to broach with health providers.  Understandably, the sterile lights, thin walls, and chaos of a doctor’s office can discourage an already sensitive topic.

That is why we created Entropy Physiotherapy.  We have created a warm, welcoming space that invites dialogue about sexuality.  The truth is many men AND women suffer from sexual dysfunction.  We recognize this and it is something we address daily here at Entropy!

So how can physical therapy help you to regain your sex life?

The definition of sexual dysfunction is broad, and there are many different factors that may be impacting your sexual function.  Emotional, hormonal, physical and psychological influences can all impact your sexual function.

We understand you may be surprised to know that physical therapy works with people just like you who for one reason or another aren’t experiencing sex in the way that they should.  A physical therapy treatment with Sarah or Sandy will include an assessment of the pelvic muscles.  We are confident that we can help you to restore normal muscle function by identifying, relaxing, and retraining  any muscles or groups of muscles that are short, tight, in spasm or otherwise not behaving nicely.


By Anne Shea, SPT


shamed puppyShame:(Noun) A painful feeling of humiliation or distress caused by the consciousness of wrong or foolish behavior – loss of self-respect or self-esteem. Used to reprove someone for something they have done or failed to do.

(Verb) Causing another to feel shame, embarrassment, loss of esteem.  To cause someone to feel inadequate.

Shame Culture: refers to social conformity of behavior being maintained by the individuals’ fear of being shamed.

What does this have to do with Physical Therapy? Did you notice that part where it calls shame “A painful feeling” and how shame is both a verb (we do it to others) and a noun (we feel it in our selves). We internalize the feeling of pain and dysfunction as if it is our fault, that we have done something wrong.

I think this is a subtle and insidious thing but that you’ve heard it before: • when someone hurts their back “What did you do to it?” or “what did you do wrong?” • when there are incontinence issues “I have a weak bladder” or “Are you doing your Kegels (are you doing them right? Often enough?)” • with painful sex “you need to relax more” or “it’s all in your head” • If you would just _________ then you would be better.

The internal sense of being inadequate or “not good enough” is a powerful thing that gets in the way of well being. Feeling ashamed of your own self (body, thoughts and actions) can be a challenge on the road to recovery.

And it’s one that we can work with. We can • Acknowledge that you have been brave to seek help, maybe talking with many professionals before you found us. • Create an atmosphere that is open and supportive of your challenges. • Physical Therapists can help you move with ease, get your function back and teach you how to maintain the quality of life that you desire. But we can’t do it all, we work with quality health professionals who are able to support your efforts to reclaim the important things in your life.

At Entropy Physiotherapy we are working to create a Rehabilitation Center that takes into consideration all of the contributions to the your experience, and treat the socially delicate issues complicating incontinence and sexual dysfunction with grace and respect for the difficulty faced by the individual. With pelvic health and persistent pain we are aiming for empathy – and we recognize that the shackles of shame are as varied as the expressions of an individual pain experience. Happily we have Angela Coleville here to aide in the journey to well being.

We promise to be courageous and kind,


Happy New Year! Now about those resolutions...


crossing the finish lineHappy New Year!  It’s the first day of 2014….  Have you set any New Year’s Resolutions?? More often than not, resolutions include:  eat better, lose weight, and be healthier…


These are admirable goals, and most of us do need to strive to be healthier.   However, many would agree, that the same resolution will be set again next year.  Why?  We all face our individual barriers, run into our own obstacles, and sometimes life just gets in the way.


Entropy Physiotherapy and Wellness is here to help!


Common difficulties in meeting fitness goals include:  pain, not having fun, and not being sure how to go about meeting those goals.


We can help with all of those obstacles!


  •  Pain is not a normal result of exercise, and you really should be feeling ‘good’ while you’re going your work out.  Yes, you may be sore later, but you should also be able to function the next day!
  •  Is leaking urine keeping you from running or participating in aerobics or kickboxing class? There’s help for that!  There's help for the high level athletes that leak too.  If your goal is the intensity of CrossFit we get it, and we can keep you powerful and dry too!
  • Lack of motivation or shyness of going to the gym can also be a barrier.  Or financially, committing to a gym can be daunting.  There are so many, low-cost, enjoyable activities that you can do at home or outside, by yourself or with some motivated friends.  We are here to get you to your best and help you reach your goals.




Think of us like the ‘Genius Bar’ for your body.  Many aches and pains that people attribute to age, weight, or just being ‘normal’ aren’t actually normal or due to age or your weight.  Come talk to us about your goals, and we can help you get there.


Below Your Belt: Unlocking the Mysterious Box

Last Friday, we had the honor of hosting the Women's Health Foundation for a Girls' Night Out.  The topic?  The Mysterious Box below our belts.  The Women's Health Foundation is the most passionate champion for women's pelvic health in the country, and there's a lot to be said about keeping the pelvis healthy.  Many people already know about the Total Control Program, but there is more to pelvic health than continence! Friday, we were able to talk a little bit about the sensuous side of the pelvis.  I gave a talk on the Anatomy and Physiology of Orgasm.  I was given 15 minutes, and overestimated the amount of stuff I could say…  So if anyone wants to chat about orgasms, stop by Entropy and we can work something out...

Lucky for the full house, I was followed by the energetic Rachel Fiske, who took us through some gentle yoga, helping the group increase our pelvic awareness.  Her talk, 'The Key to the Home of the Goddess', was the perfect balance of movement and education.  I also learned my new favorite pelvic floor contraction cue:  Imagine a little kiss.  Much more inviting than 'contract like you want to stop the flow of urine'.

The evening ended with the eloquent Elsbeth Meuth, educating us on how to 'Boost Your Yoni Health with Tantric Infused Practices'.  We spent a glorious 25 minutes becoming aware of our pelvic energy, and that awareness can infuse the whole body with increased sensitivity and appreciation.

The Women's Health Foundation does know how to throw a great party:  wonderful food and wine, fun women who are looking to learn, and a program that encompassed different aspects of our pelvic awareness, health, and enjoyment.  My only question is:  When do we get to do this again?

Special thanks to the Women's Health Foundation for including Entropy Physiotherapy in this wonderful night!!



Understanding Pain - In less than 5 minutes

Pain is an experience most of us will have at some point in our life.  Thankfully, the scientific understanding of pain has improved drastically over the years.  Unfortunately, there are still lots of misconceptions and misunderstandings about what pain is and what to do about it.  Here's a short, fun clip that might help you think a little differently about pain. [embed width="320" height="240"][/embed]

Stuck. Stiff. Glued together. Painful. - How can manual therapy help?

Stuck. Stiff. Glued together. Painful.

Those are pretty typical words for the sensation that your body just isn’t moving as easily as it should. That’s about the time most of us look for help to get back to our normal comfort. Make no mistake, moving easily is normal.

What can be done to improve the way you feel at rest and in movement? There are a few parts to the best answer:

1) Education: It’s important to understand the context of what is limiting you from moving or being comfortable. That is what a well-constructed evaluation and some specific pain and biology education will do. We will work together to determine what you need and come up with a plan to get you to your goals and a life without limits.

2) Movement Therapy: You will need to move. This can be so much fun, and needs to be something you enjoy. We can help you explore high quality movement options like Yoga, Tai Chi, Dance, BIG exercises, Eric Franklin imagery/movement, Walking, Running, Swimming… you get the idea? It’s movement. The type that works best for you is individual. We will find something you like.

3) Manual Therapy: Sometimes we need someone else to nudge the stuck spots and help to carefully get us back to moving. There is a place for well-trained and carefully selected manual therapy.

Manual therapy is a general term for any therapy applied with the hands. How are you supposed to figure out what is best, among all of the different types of manual therapy that are marketed under specific names?

kitten in hands • It’s comfortable and you move better/more when you are finished. • You aren’t bracing or guarding or in pain while it is happening. Really. You don’t have to hurt to get better and experiencing pain doesn’t make you more tough. There are easier ways to achieve your goals than paying for someone to help you practice protective responses! • You can measure progress. By how you feel, by how you move, by how long you can sit, by having sex without pain – if what you are doing is helping, you should be able to see change. We aim for measurable change that you can see somehow in the first few visits!

What do we have to offer at Entropy along the lines of specific techniques we have been trained in? • Myofascial Release: Find the stuck spots and apply gentle pressure until the stuck spot changes. It’s a non-forceful technique that means it isn’t a test of your endurance or pain tolerance. This technique is not terribly different than what some people would call craniosacral mobilization. • Visceral Mobilization: Find the stuck spot theory applies here too – also non-forceful and no more mysterious than the movement that happens when you breath. • McKenzie Technique: Looks at movement patterns and limitations, uses a common sense and rational approach to correcting stuck spots. • Self-treatment Techniques. This is the most important of all. It is likely that what we do with our hands is not as important as the opportunity that it creates – so that you learn how to move with ease again, with less fear of the movement or activity, with less pain, with more comfort. And most importantly, just like brushing your own teeth or hair, we want you to be able to learn to do this for yourself.

When do you need Manual Therapy? When moving is stiff, stuck or difficult and you need some well-trained hands to help you get back to your own comfort. We think that’s important.