Pelvic Health PHODA - What is it and how can it help?

Finding the “right” areas to address when working with any patient is a challenging task for a health care provider. What is important to that patient? In what area can we work to make progress so that there is a meaningful change and impact for that individual? When the patient is open, shares, and can pick out a specific activity or experience in which they would love to engage in again or for the first time all I must do as the provider is listen. But what can I do when the patient cannot articulate their goals because there are too many things, or it has been so long that all they want is for the dysfunction or pain to end?

That is when I use the Pelvic Health PHODA (Photographs of Daily Activities). Sandy first gave me the idea to create a PHODA for pelvic health after we discussed the original version during a course by Cory Blickenstaff. She had been wanting to have one for several years but had not yet found the opportunity to create the cards. A little while later I found myself stranded on my way back to the clinic from my home in Northern Michigan just after Christmas. My car broke down and instead of going to work for the next few days I headed back home until I could find an alternate route to Chicago. When I told Sandy about being stranded she said, “Work on PHODA”.

To begin I did some research on what versions of the PHODA exist and how they are used. It has been validated for use on patients with high and low levels of Kinesiophobia (Trost et al, 2008) where the modified version was used. This version has 20 photographs compared to the 100 in the original version. There is also a version that was recently validated for use with the pediatric population (Verbunt et al, 2015). This version looked at activities specifically important to youth with musculoskeletal pain and how harmful they perceived certain activities.

During my search I found the modified version, the original was by Kugler et al, for download on-line. My impressions after un-zipping, installing, and using the file were not positive. The background is a horrid mustard-yellow, the pictures are small and outdated, and you have to use all 40 images in order to complete the test. The experience was off-putting with the nauseating color scheme and the repetition of similar images that all had to be placed on a scale.

What I envisioned was a tool that would allow patients to pick images out that resonated with them, how ever many they would like, and then lay them out in terms of easiest to hardest. This then serves as a tool for the clinician to focus treatment and for the patient to zero in on what they are looking for from physical therapy. So I set about finding pictures of a variety of daily activities that patients have reported loving, hating, or wishing they could do that thing.

When I use them with patients I say, “Here are some photographs of activities. Please pick out ones that appeal to you. Then place them from no difficulty to very challenging based on your reason for coming to physical therapy. I don’t care how many you chose but I would like at least one at each end of the spectrum. Then we will talk about why you chose each card.” I want them to feel free to pick 2 or 54 cards. Then I can use their own choices as a guide for treatment.

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Eventually I would love to validate these cards and their specific use for the treatment of pelvic dysfunction. Bronwyn Thompson, PhD, MSc (Psych) 1st Class Hons, DipOT, Registered Occupational Therapist has a great article on validating PHODA for use in New Zealand.  For now I use them in conjunction with other outcome measures using the photos to gain insight and target my treatments to best serve each individual who comes through the door.

Hannah Mulder is a 3rd year DPT student from Rosalind Franklin University, doing an amazing job of applying research to her practice, as well as making excellent snacks for the courses at Entropy.  If you're interested in a set of your own PHODA for the Pelvis cards, you can buy a set now!!



Trost Z, France C, Thomas J. Examination of the photograph series of daily activities (PHODA) scale in chronic low back pain patients with high and low kinesiophobia. Pain (03043959) [serial online]. February 2009;141(3):276-282. Available from: CINAHL Complete, Ipswich, MA. Accessed January 22, 2018.

Verbunt J, Nijhuis A, Goossens M, et al. The psychometric characteristics of an assessment instrument for perceived harmfulness in adolescents with musculoskeletal pain (PHODA-youth). European Journal Of Pain [serial online]. May 2015;19(5):695-705. Available from: PsycINFO, Ipswich, MA. Accessed January 22, 2018.

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS: The Photograph series of Daily Activities (PHODA). CD-rom version 1.0. Institute for Rehabilitation Research and School for Physiotherapy Heerlen, The Netherlands, 1999

HealthSkills Blog

Another EPIC story... Jilly Bond shares her experience from WCAPP 2017

From Entropy - Thanks to Jilly for sharing her thoughts on attending the 3rd World Congress on Abdominal and Pelvic Pain in Washington DC this past October. If you're interested in applying for an EPIC scholarship, please stay tuned for more details!  We have 2 events coming up in 2018 to support his fund.  We will have another EPIC event with Lorimer Moseley in Victoria, BC May 4, 2018.  We are also grateful and excited to announce that Paul Hodges has joined the party!  We will have an EPIC event with Professor Paul Hodges in Chicago at Entropy on March 2, 2018.  We hope to see you there!

Reflecting with distance

When I look back on my career I’m pretty sure that attending the World Conference on Abdominal and Pelvic Pain 2017 in Washington, DC, will have been a turning point for me. An idle conversation with a colleague about the wealth of international knowledge we wished we could access spurred me on to find out if there was funding available. I didn’t really consider that it might happen.

Without Entropy Physiotherapy’s EPIC scholarship in collaboration with Lorimer Moseley, it would have remained a pipe dream. I submitted my entry at the end of a long day in the clinic and crossed everything hoping that I’d get chosen. I was sure that I couldn’t appreciate the value of attending this conference until I was there, and I wasn’t wrong. The sheer volume of knowledge disseminated was vast; from presentations of evidence supporting concepts I was somewhat familiar with but in far greater depth and complexity, to basic brain science that was a real challenge to understand. At one point I asked a physio I was sat next to if this was a “normal” conference for her, or if she was also as blown away by the level of clinically relevant evidence presented and by such a wide array of experts in the field. “Oh yes, this is pretty normal for us. But I’m still amazed, isn’t the body incredible?!”. I’m a regular attendee at our national conferences, but this was truly a world-class event.

It was also an exhausting and exhilarating week – American conferences start early, and events go on late into the night. However, it was at the fundraisers and PT pub nights that I had the most fruitful conversations, where other clinicians and researchers as passionate about pelvic pain as I am shared how they had interpreted the day’s evidence into clinically useful ideas. Names that I have been reading since University were standing around me wanting to talk about what they’d heard, their thoughts, experiences within research and what they thought I needed to be thinking about and reading. These short interactions had a profound impact upon me. I grabbed breakfast with a keynote speaker, unawares, discussing the importance of psychoimmunology over our pastries. I had an amazing conversation whilst walking to the pub with Paul Hodges about how we can personalise treatment, and how we could begin to integrate that into an evidence-based model. At a coffee break, I discussed practical applications of interval training for vagal nerve stimulation with the team who had spent 15 years discovering how and why this could be useful to visceral pain. Over cocktails, I talked about how we could apply graded motor imagery and motor planning to bladder pain, with a researcher currently studying brainy changes who was also interested in the potential of this challenge. And I had a deeply impactful conversation with Shelly Prosko over Dim Sum on the importance of therapist self-care, that has made me take up Yoga. People were enthused, wanting to discuss pelvic pain, and were willing to share their knowledge. I’ve added countless people to my lists of those I follow online, those who I go to for help and solid evidence, and have benefitted from these supportive relationships already through professional mentoring.

A few months on I’m still returning to my notes to process all the concepts I’ve learnt and marveling in the access to experts that the conference provided. Putting together some blog summaries of the week for my colleagues in the UK and worldwide that couldn’t attend has really helped me to reflect and identify my learning points from the conference into the following themes:

-        There are complex changes in the motor cortex, sensory cortex, and salience network in those with chronic pelvic pain

-        Pelvic pain occurs with multiple and overlapping comorbidities, we have to think about them concurrently in treatment

-        The convergence of visceral pain creates a widespread pain state – the “widespreadedness” of pain is important and may denote a phenotype

-        Psychoimmunology is important - brainy pro-inflammatory pathways reduce downregulation of the distal inflammatory response in many pelvic pains

-        Autonomic changes are important – Bladder Pain Syndrome involves a vagal nerve dysfunction we can affect with interval training and myofascial pain involves a sympathetic vascular dysregulation

The harder part is then how you employ this knowledge. It’s all well and good having an intense learning experience and meeting some incredible members of our research community, but the important bit is how we apply this to clinical practice and help our patients. A few months on from the conference I can reflect now that it’s had a dramatic effect on my clinical work. I’m using tools I did before but with a greater understanding for the mechanisms by which they may work. I’ve started to play with different methods of creating motor and sensory retraining in patients with significant pain. Where I would previously have focussed on building a supportive, therapeutic relationship to allow me to get to the point where it was tolerable to perform manual therapies in order to affect change, I’m now working alongside my patients in the initial phases to build and modulate their motor and sensory awareness in order to produce a more meaningful response to manual treatments. It’s a subtle change but I’m already finding that my manual therapy feels more effective and efficient. All of my pain patients are also now completing interval training, to whatever level is appropriate for them. This has prompted me to engage them in physical exercise much earlier than I usually would in my treatment plans, challenging my previous ideas that it would limit the benefit of manual pelvic floor work by “getting everything tense again” using maladapted strategies – quite the opposite, they’re all improving and they’re enjoying themselves whilst they do! And finally, I’m explaining things more clearly to patients because I understand them more fully.

I’ve also spent some time going through the literature discussed and adding it into the professional development courses I run in the UK for physiotherapists so that the reach of this conference can be maximised. The conference has had a deep impact on my understanding of pelvic pain, the treatments I provide for my patients, and where I look for evidence and learning. I would encourage anyone interested in pelvic pain to attend the world congress, thankfully next time it may be closer to home for me in the UK. Without the EPIC Scholarship from Entropy Physiotherapy and Lorimer Moseley none of this would have happened, I can’t thank them enough for supporting me to attend what was a pivotal moment in my career. See you at the next conference!


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Thanks again to Jilly for her blog!  You can find out more about her amazing work on her website, or find her hopefully attending more international conferences.  We are certainly excited to spend some time with her!

EPIC people doing EPIC things! Wynne's Experience

EPIC people doing EPIC things! Wynne's Experience

Wynne Tezak is a physical therapist in Alpena Michigan (way up in the boonies). She is obsessed with, ahem, specializes in pelvic health. Through extensive community education she has been able to lure many unsuspecting citizens into taking control of their own bodies and health. Thanks to the EPIC scholarship Wynne and her fabulous PTA Sarah Schnell were able to attend the World Congress on Abdominal and Pelvic Pain, where they filled their brains to the brim and made valuable connections with leaders in the field. 

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Goat Yoga - by Kelly Newman**

Though Kelly has left us, she's not forgotten...  Here's her blog on her (almost) experience with Goat Yoga.

Chronic low back pain is a huge problem in the United States, and despite our best efforts, we haven’t really found an effective treatment for it… until now.  Allow me to introduce the latest health and wellness technique: GOAT YOGA.  It is yoga… with goats.   

Why do so many people have chronic low back pain? It’s obvious.  It’s because they aren’t doing enough goat yoga.  “Can’t I do regular yoga?” you ask.  NO. NO. ABSOLUTELY NOT.  It’s not rocket science, people!  It’s clear that the health benefits are from the pitter patter of tiny goat hooves on your aching back. Trust me, if you don’t have a furry grass-muncher sniffing your ear while you down dog, you’re not doing it right. 

Downward goat - kelly

The theory is...

the goats have the perfect body weight to fur ratio to stimulate your muscles…and stuff.  And also relax them if that’s your problem.  While it’s true that nobody has checked out these claims “scientifically”, I can tell you that I am 100% certain that goat yoga will cure you.  If it doesn’t, you probably aren’t committed enough to goat yoga.  

To get the maximum healing properties out of goat yoga, you should go at least four times per week for the rest of your life.  Goats from the farms of Wisconsin are best, but any regular old goat will do in a pinch.  Just don’t expect as good of results.  Make sure the goats are in a healing mood.  If the goats aren’t in a healing mood, you need to come back later when they’re ready to radiate positivity.  

Make sure your instructor is GOAT YOGA certified.  If they are not, you will get nothing out of the class and probably feel worse for a long time, possibly forever.  Make sure you ask to see their Goat Yoga certificate for the 18 courses they had to take to become a Goat Yoga instructor.  If they try to tell you that they don’t need the certification to release a goat into a field while you’re doing yoga, they are SERIOUSLY MISLED and you need to get away before all of your discs slip.   

goat savasana - kelly

By the way, I am a certified Goat Yoga instructor and would love to take your money I MEAN CURE YOUR BACK.  Sign up now!



PS: Goat Yoga actually does not make any of these claims and I made this whole thing up.  Goat Yoga is probably really fun and silly!! Try goat yoga if you want, or don’t.

**It came to my attention today that I prematurely called her 'Dr. Kelly Newman'.  My apologies for this error.  I do know that Kelly has completed all of the didactic and clinical work for graduation, as well as passed her boards and secured her first job as a physical therapist with a clinic that will not disappoint her.  We're super proud of her ability to critically think, and not be seduced by things like certifications and 8-step training programs.  So, Kelly, we're really proud (even though you're not a doctor just yet) of what you're going to contribute to our profession.  Please continue to have fun, love what you do, and DTS. Love, Sarah and Sandy

I didn't know what to expect - Nate's time at Entropy

Note from Sarah- Today is the first day in 2 months that Nate Mancillas won't be heading to work at Entropy.   We will miss him, and this post made my eyes water just a bit. Luckily Ryan Smith will be there to soften the blow...  Here are Nate's thoughts on his time with us at Entropy.  

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Screen Shot 2016-03-14 at 10.06.34 AM

From Nate:

When I first began my clinical at Entropy Physiotherapy I didn’t know what to expect. If I had to guess before I began I would have thought my experience would just be anatomy, internal manipulations, and incontinence. While my time here did entail some of those things, it was so much more

I was able to attend continuing education courses that I felt were just as, if not more in some cases, beneficial than days spent in the clinic. I got to interact with world-class therapists and researchers and learn from them first hand. I was given the opportunity to network with them and connect with them outside of a clinical or conference setting.

I was given the best education on pain science a student could ask for. I learned the what, where, when, and why, and how of pain in my 10 weeks. I admit I still have a long way to go on pain science, but this clinic has taught me I need to educate others on pain, which is an awesome starting point.

Beyond all of these great things, I got to learn from two of the best physical therapists in the world. The way Sarah and Sandy run their business, treat their patients, and represent the profession of physical therapy is among the best I have ever seen. They treated me with respect and kindness. They were never condescending and always willing to answer my questions. I haven’t even mentioned how funny they are, but I never went a full day without a good laugh.

With all this glowing praise, you might think this was a cakewalk, but it was quite the opposite. I had my lines of thinking challenged and anything I would say had to be backed up by evidence. If I could not provide this evidence, I would need to do a bit of digging on the topic and come back with a suitable answer.

I would not trade my time at Entropy for anything. Even though I am sad to leave, I know that my time here has been invaluable and I am a better physical therapist walking out than I was walking in. Thank you Sandy, Sarah, and Ryan. I’m sure I will see you again.

Follow Nate on Twitter!  @NateMancillaSPT