Course Title: Department: Instructor: Credits:

NR540 - Behavioral Assessment & Treatment of Pelvic Floor Disorders Health Sciences Richard A. Sherman, PhD - - Vita 3

1. Schwartz M and Andraskik F: Biofeedback a Practitioner’s Guide. All of section VIII (elimination disorders), Guilford Press, New York, 2003. ISBN #: 1572308451

2. Laycock J and Haslam J: Therapeutic Management of Incontinence and Pelvic Pain. Springer, New York, 2002. ISBN 1852332247 (soft cover).

3. Compendium of articles and protocols provided on the course CD.

1. Dorey G: Conservative treatment of male urinary incontinence and erectile dysfunction. Whurr Publishers, Phhiladelphia & London, 2001. ISBN #: 1861563027
   (Note: If you work with males, it is very worth your while to get this small book!)

2. Newman D: Managing and treating urinary incontinence. Health Professions Press, Maryland, 2002. ISBN #: 1878812823 (Very good book but you can get similar material from the two required texts.)

3. Brubaker L and Saclarides T: The female pelvic floor. F.A. Davis, Philadelphia, 1996. ISBN #: 0803600755 (Excellent book but you can get similar material from the two required texts.)

1. Overview of behavioral assessment and intervention for pelvic floor disorders including a brief discussion of credibility.
2. Anatomy and Physiology of the Pelvic Floor
3. Principles of applied psychophysiology biofeedback as applied to the pelvic floor
4. Know what is normal before you try to fix it
5. Assessments and interventions for urinary incontinence
6. Assessments and interventions for bowel dysfunctions
7. Principles of pain assessment and intervention from a psychophysiological perspective
8. Assessments and interventions for pelvic pain syndromes
9. Assessments and interventions for erectile dysfunction
10. Ethical considerations in performing behavioral assessments and interventions for pelvic floor disorders

1. Overview of behavioral assessment and intervention for pelvic floor disorders
   Elimination disorders treated with biofeedback assisted behavioral therapy, history of biofeedback and behavioral modalities used for pelvic floor disorders, assessing credibility of behavioral interventions for pelvic floor disorders, etc.
   
   Audiovisual Lectures 1.1 and 1.2 – Introduction
   Audiovisual Lecture 1.3 – Assessing Credibility
   
   (Note that people who have taken the Behavioral Medicine R&T Foundation or UNM’s courses in either pain assessment or general biofeedback are exempt from lecture 1.3)
   
   Laycock & Haslam 1
   Optional Newman 1 and 2
   PFD biofeedback chapter file on CD

2. Anatomy and Physiology of the Pelvic Floor
   Audiovisual Lectures 2.1 and 2.2

1. Anatomy and physiology of pelvic floor structures (pelvic floor muscle, bones, diaphragms, sphincters, smooth vs. striated muscle)

Laycock & Haslam 2, 5, 28 - 30
A&P of the male lower urinary tract
Optional Newman 2 and 3
Optional Dorey ch 2
Anatomy of the penis / physiology of erections

2. Urological A&P (urine storage and maturation, bladder anatomy, normal bladder storage and emptying, somatic and autonomic enervation)

types of urinary incontinence, dyssynergia
Laycock & Haslam 3
differences between male and female urinary incontinence
Optional Dorey Chapter 5

3. Prostate conditions

Optional Dorey ch 4

4. A&P of digestive structures and processes, stool continence, defecation, somatic and autonomic enervation.

Laycock & Haslam 20 - 22
Optional Newman 5

3. Principles of applied psychophysiology biofeedback as applied to the pelvic floor
   Audiovisual Lectures 3.1 – 3.6
   
   (Note: Anyone who took the pain or general biofeedback course given by either the Behavioral Medicine R&T Foundation of the UNM is exempt from this section.)
   
   PFD muscle tension exercise file on CD

1. Introduction to biofeedback (definitions, history, overview of modalities, concepts of feedback and control in biological systems, principles of human learning as applied to biofeedback)
2. Surface EMG Instrumentation (terms and concepts, sources of artifact, sensor placement including skin preparation, distance between sensors and typical sites, EMG factors affecting assessment and interpretation such as fat, posture, etc., signal processing and feedback displays)
3. Biofeedback and distress (stress and the biopsychosocial model of illness, stressful life events and the risk of illness, psychophysiological reactions to stressful events)
4. Neuromuscular relaxation training (techniques assisted by EMG biofeedback such as autogenic training, hypnosis, meditation, etc., integrating relaxation into daily life, overview of other psychophysiological modalities used for neuromuscular relaxation such as heart rate variability, thermal biofeedback, EEG, GSR, etc.)

4. Know what is normal before you try to fix it
   Lack of understanding normal levels and patterns of muscle function, patters and rates of urination, defecation, lubrication, erection etc. has led many people to think they are abnormal and many therapists to try changing a normal system resulting in abnormal functioning and pain.
   
   Audiovisual Lecture 4

5. Assessments and interventions for urinary incontinence
   
   Audiovisual Lectures 5.1 and 5.2
   Protocols and patient handouts on CD

1. Overview of physiological basis for and testing for urinary disorders (varieties of bladder disorders such as stress and urge incontinence dyssynergia, etc., overview of medical diagnostic procedures, urodynamics)
   
   Schwartz & Andrasik 26
   Laycock & Haslam 4, 6, and 16
   Optional Newman 6

2. Physical assessments

3. Urodynamics

4. Surface EMG pelvic floor muscle assessment (vaginal and rectal surface EMG placements, infection control, protocols for evaluation, baselines, phasic and tonic muscle testing, endurance, dyssynergia testing, data interpretation)

5. Exercise and Surface EMG based pelvic floor training

6. Treatment options not involving biofeedback
   
   Laycock & Haslam 8 , 9, 11 – 15, 17 - 19
   Optional Newman 7, 8, 9, and 10
   Optional Dorey chapter 8
   
   Exercises, Cones / weights, Electrical stimulation, Lifestyle changes, Bladder training for urge incontinence, Medications for urge incontinence, Pads, Appliances, Penile clamps, Prosthetic devices, inserts, Plugs, Surgery, Fluid Control, Skin care for incontinence dermatitis, Intermittent self-catheterization, and Artificial urinary sphincter (d 83/4)

7. EMG instrumentation options (sensors, SEMG instruments, home training devices)
   
   Laycock & Haslam 10

8. Preparation for clinical practice (patient education in biofeedback and relevant A&P, patient intake, communication with other health care providers)

9. Medical and behavioral treatment modalities – urologic (neuromuscular reeducation and exercise assisted by vaginal/rectal SEMG and other SEMG placements for bladder disorders – uptraining, downtraining, coordination training), other behavioral techniques including urge suppression techniques, bladder retraining, electrical stimulation, etc., non-behavioral techniques including drugs, surgery, electrical, physical interventions, etc.)

6. Assessments and interventions for bowel dysfunctions
   
   Audiovisual Lectures 6.1 and 6.2
   Schwartz & Andrasik 27 & 29
   Laycock & Haslam 20 - 22

1. Physiological basis for and testing for GI disorders (GI disorders including fecal incontinence, constipation, dyssynergia, irritable bowel syndrome, and colonic inertia, medical diagnostic procedures including manometric and defocograraphic evaluation and transit time studies)
2. GI Medical and behavioral treatment modalities (neuromuscular reeducation and therapeutic exercise assisted by vaginal/rectal surface EMG and other EMG placements for bowel disorders including uptraining, downtraining, coordination training, and bowel sensory awareness training, other behavioral methods specific to bowel disorders, non-behavioral interventions including surgery medications, physical interventions)

7. Principles of pain assessment and intervention from a psychophysiological perspective
   
   Audiovisual Lecture 7.1 – 7.7
   (Note: Anyone who took the pain course given by either the Behavioral Medicine R&T Foundation of the UNM is exempt from this section.)
   
   Physiological basis of pelvic pain disorders (psychophysiological basis of pain, basic pain mechanisms related to pelvic pain, pain – stress – muscle tension relationships, trauma)

8. Assessments and interventions for pelvic pain syndromes
   
   Audiovisual Lecture 8.1, 8.2, & 8.3
   Schwartz & Andrasik 28
   Laycock & Haslam 23 - 27

1. Physiological basis of pain syndromes related to pelvic floor dysfunction (chronic pelvic pain syndromes including vulvodinia, proctalgia fugax, levator ani; co-morbidities including irritable bowel syndrome, fibromyalgia, interstitial cystitis)

2. Pelvic pain syndromes unique (mostly) to males: (prostatitis, orchialgia, penile pain, prostatodynia, perineal pain, testicular cancer related pain, proctalgia fugax)
   
   Optional Dorey ch 6

3. Medical and behavioral treatment modalities for pelvic area pain (neuromuscular reeducation, posture, dietary counseling, drugs, surgery, physical interventions, sexual history taking and counseling)

9. Assessments and interventions for erectile dysfunction
   
   Audiovisual Lecture 9

1. Overview of erectile dysfunction
2. Assessment
3. treatment

(1) alternative (electrical stimulation, herbs, acupuncture)
(2) drug based (antianxiety, vasodilators)
(3) surgical (repair or replace)
(4) behavioral (education, counseling, fantasizing, exercises, biofeedback, life style)

10. Ethical considerations in performing behavioral assessments and interventions for pelvic floor disorders
    
    Overview of ethical principles of biofeedback as well as practice limitations and referral guidelines.
    
    Audiovisual lectures 10.1 and 10.2
    Read file on CD entitled “PFD BCIA ethics document”