Behavioral Assessment & Treatment of Pelvic Floor Disorders

                                       (This is the BCIA approved course on

          biofeedback for urinary incontinence, pelvic pain, etc.)

45 Hours of CE Credit / Course Fee $550    
Presented by Richard A. Sherman, Ph.D.

The link for purchasing this course is at the bottom of this course description.

Concept and Objectives:

This course is set at the level of a typical 3 credit post-licensure, introductory level course. The course is targeted to licensed / certified clinicians such as psychologists, counselors, physical therapists, social workers, nurses, and physicians as well as to graduate students. Students learn by watching audiovisual lectures provided on CDs, reading assignments both from materials provided on the CD and standard texts, and interacting with their instructor via e-mail. They answer short essay questions after each lecture rather than taking exams. Previous students have found that this course takes between 45 and 95 hours of work to perform.           

This course provides a basic understanding of pelvic floor functions and structures along with clinical etiologies of pelvic floor disorders treated by behavioral interventions. Provide sufficient information on research supporting behavioral interventions, and clinical protocols for behavioral interventions to bring health care providers to the point where they have the knowledge base needed to provide these interventions to their clients within their scopes of practice and expertise after the providers gain hands-on experience by working with experienced practitioners. You may wish to contact the Foundation for information about hands-on training.

Learning objectives: The course objective is to provide the depth of knowledge in pelvic area A&P, psychophysiology, biofeedback equipment, and training techniques which clinicians require to perform psychophysiologically oriented assessments and biofeedback and other behaviorally based interventions for pelvic floor disorders. This information is crucial to effectively adding these techniques to a clinician’s practice.

This course is designed to help you (the student):

Summarize the psychophysiological processes and anatomy underlying each

                  pelvic floor condition covered in the course.

Use psychophysiological recording and biofeedback devices record and

                  display psychophysiological information about musculoskeletal

                  functioning of the pelvic floor.

Control the biofeedback display to optimize learning to correct patterns of

                  muscle  tension in the pelvic floor.

Use psychophysiological recording equipment to assess patients with pelvic

                 floor  musculoskeletal dysfunctions.

 Use biofeedback equipment to apply specific interventions tailored to each

                   muscle related pelvic floor condition covered in the course.

Use behavioral techniques learned in the course to assist patients in

                  controlling muscle related dysfunction patterns causing specific

                  pelvic floor problems.

Format: Interactive distance based home study supported by e-mail chats after each unit is completed. The CD based lecture portion of the course is presented through a series of audiovisual lectures profusely illustrated by power-point slides. You start the course whenever you wish and work at your own pace. You will receive CDs containing both the audiovisual lectures and a copy of the slide sets upon which the lectures are based so you can make notes on your copy of the slides as you attend the lecture. After watching each lecture and reading the corresponding material in the assigned texts, protocols, and articles, you will answer a brief series of essay questions. The answered questions are then e-mailed to the instructor. You and the instructor will discuss each unit via e-mail chat after your answers are assessed. Ample opportunity for personalized discussion of questions, plans, etc. is available.

Computer and Computer Knowledge Requirements:  Anybody with a modern computer and a bit of basic understanding of computer operation (at the level of being able to send e-mails) can play this course with minimal problems. You must have a computer (a) containing a CD read or RW drive, (b) capable of connecting to the internet and running a typical internet program, (c) containing/running a modern word processor such as Microsoft word or Word Perfect, (d) the capability to play sound (e.g. music) from a CD (has speakers and appropriate software which normally come with any modern computer), and (e) a slide viewing program such as Power Point (you can probably get a slide viewing program free off the internet if you don’t have one). Any modern (e.g. built within the last ten years), IBM style computer running Windows 98 and more recent platforms (e.g. XP) should be able to do this. Speed, hard disk size, and RAM are not factors for computers in the above category. Dozens of students have used recent Apple products (MACs etc.) for the course but some have had difficulty hearing the lectures and seeing the slides simultaneously. You need to have a working internet connection (normally through an internet service provider – ISP), know how to communicate via e-mail including either how to send an MS Word / Word Perfect attachment or how to cut and paste text from a word processor into an e-mail message. You need to be sure your computer’s speakers are on so you can hear the lectures. You may want to test your computer by checking to be sure it can play music from a CD.

Reading:

Required: (Cost of the texts is not included in the course fee.)

a. Schwartz M and Andraskik F: Biofeedback a Practitioner’s Guide. All of section VIII (elimination disorders), Guilford Press, New York, 2003. ISBN 1-57230-845-1

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

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

Optional:

a. Dorey G: Conservative treatment of male urinary incontinence and erectile dysfunction. Whurr Publishers, Phhiladelphia & London, 2001.  ISBN 1-86156-302-7.

(Note: If you work with males, it is very worth your while to get this small book!)

b. Newman D: Managing and treating urinary incontinence. Health Professions Press, Maryland, 2002.  ISBN 1-878812-82-3 (Very good book but you can get similar material from the two required texts.)

c. Brubaker L and Saclarides T: The female pelvic floor. F.A. Davis, Philadelphia, 1996.  ISBN 0-8036-0075-5  (Excellent book but you can get similar material from the two required texts.)

Topic Overview:

 (A detailed list of subtopics with reading assignments is at the end of this outline.)

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

Getting started:

Purchase the text books on your own (usually on-line book sellers are far less expensive) and purchase the course from the Foundation. Just go to our web site to pay by credit card or send a check in US funds to the above address. See below for discount information. You can begin at your convenience and progress through the course at your own pace.

Schedule: Begin the course any time you want to and proceed at your own pace.

Payment and discounts: The course costs $550 (exclusive of the texts). You can purchase the course via credit card on our web site (behavmedfoundation.org) or by mailing a check in US funds made out to the Behavioral Medicine Research and Training Foundation to the letterhead address.

Discount for this course if you already took the Foundation’s general biofeedback or urinary incontinence courses:  People who have taken either the Foundation’s general biofeedback or urinary incontinence courses can take this pelvic floor course for half price ($275). People who took general biofeedback courses from other groups can not have a discount because we have no realistic way to judge how much of the information was provided.

Discount for taking the Foundation’s general biofeedback course: The Foundation offers a BCIA approved, distancecourse in general biofeedback. Because of the tremendous overlap in information between this and our general biofeedback course, we offer our general biofeedback course to people taking the pelvic floor course at ½ price ($275).

Group discounts: Contact the Foundation for details.

CE Credit: This is a continuing education, not an accredited, course. CE credits are given through (1) the state of California’s Boards of Psychology and Behavioral Sciences (Approval # PCE1895); (2) The National Board of Certified Counselors (Provider # 6270), and (3) the California Physical Therapy Association. Psychologists, counselors, physical therapists, and clinicians from other professions should have little problem getting CE credit for this course as many states recognize the above approvals. The Foundation is always willing to help individuals get CE approval.

Certificate of Training:  The Foundation will issue a certificate of training in behavioral treatments of pelvic floor disorders at the completion of this course only after the participant provides evidence of at least ten hours of hands-on training using a biofeedback device for treatment of urinary incontinence.

BCIA credit: This course meets or exceeds BCIA’s (Biofeedback Certification Institute of America) requirements for the didactic portion of their “pelvic muscle dysfunction biofeedback” certification.

Refund, cancellation, & CD replacement policies:  Full refund until the CDs are mailed to you. After the CDs are mailed, there is no refund at all as the Foundation has committed its resources to you. A course would only be cancelled due to an extreme emergency on the part of the course instructor or the Foundation. In the highly unlikely event a course is cancelled, you would receive a full refund. There is a $20 charge to replace lost course CDs.

Faculty:The course is taught by Richard A. Sherman, Ph.D. Dr. Sherman has been performing behavioral interventions including biofeedback for pelvic floor disorders including fecal and urinary incontinence for over 25 years and has trained dozens of clinicians (including nurses, physical and occupational therapists, and psychologists). He is a professional psychophysiologist with extensive training (his PhD is in biology / physiology) and has over 30 years of experience in the field. He has clinical and research publications in urinary incontinence in addition to over 130 other books and publications. Dr. Sherman is dean of the psychophysiology doctoral program at the University of Natural Medicine and has held numerous positions at the Association for Applied Psychophysiology and Biofeedback (AAPB) including president. His CV is on the course CD and is also available upon request.

Practicum and mentored biofeedback training:This course covers only the didactic portion of the material required to be competent in performing behavioral interventions for pelvic floor disorders. It is crucial that everybody intending to perform behavioral interventions for pelvic floor dysfunctions (1) hands on training in use of the biofeedback devices, (2) observe patients being treated for those dysfunctions of interest, and (3) receive mentoring while performing initial interventions. For BCIA (Biofeedback Certification Institute of America) certification in “pelvic muscle dysfunction biofeedback” in addition to a course in anatomy and physiology, 4 hours of practicum training in use of biofeedback equipment and observation of patient treatment are required along with 48 hours of mentored biofeedback. The mentoring consists of 30 hours of clinical training in EMG and behavioral interventions, 12 hours of direct clinical supervision, and 6 hours of case conference.

You may want to contact us for information about getting this crucial training and mentoring.

Limits to the depth of information provided by this course:

Anatomy and Physiology Course:Anyone intending to perform behavioral treatments of pelvic floor dysfunctions needs to know the basic elements of human anatomy and physiology (A&P). For example, the effects of stress, hormones, bone remodeling, bone disorders, etc on the dysfunctions to be treated can’t be covered in sufficient depth in this course. BCIA requires an undergraduate A&P course for certification. We offer a BCIA approved, distance based A&P course which emphasizes the material you need to know to enhance you competence in providing behavioral interventions. Information about the course can be found on our web site.

General Biofeedback Course: This is not a course in general biofeedback. Thus, although you will learn all you need to about the correct application of muscle tension and pneumatic biofeedback to the pelvic floor. But you will not learn (a) how to perform other types of biofeedback such as temperature and breath control training which may be needed if the person is vasoconstricting so much or breathing so incorrectly they can’t attend to what you are trying to do due to anxiety, etc. or (2)  associated behavioral techniques such as relaxation training which may be needed to reduce levels of anxiety so high the patient can’t learn the skills you are trying to teach or may be so tense all over they may not be able to control the pelvic floor. Thus, if you haven’t had a general biofeedback course, you may want to take one. The Foundation’s general biofeedback course is available at half price to people taking this course.

Pain Course: This is not a general course on pain assessment and intervention from a psychophysiological perspective. This course provides an overview of psychophysiological pain assessment and intervention sufficient for you to do a competent job assessing and providing interventions for simple pelvic floor related pain problems but it doesn’t have the depth to give you an overall picture of how pain in other parts of the body relates to the pelvic floor, etc. This means you won’t know enough at the end of this course to competently assess pain problems referring to or influencing the pelvic floor. Nor will you know the overall elements of pain assessment and intervention. If you are going to work with pain in the pelvic floor, you should consider taking a course in pain psychophysiology.

Detailed Contents of each topic with associated audiovisual talks and readings

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

a. 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

b. 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

c. Prostate conditions

Optional Dorey ch 4

d. 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           

 a. Introduction to biofeedback (definitions, history, overview of modalities, concepts of feedback and control in biological systems, principles of human learning as applied to biofeedback)

b. 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)

c. Biofeedback and distress (stress and the biopsychosocial model of illness, stressful life events and the risk of illness, psychophysiological reactions to stressful events)

d. 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 Audiovisual Lecture 4

5. Assessments and interventions for urinary incontinence

Audiovisual Lectures 5.1, 5.2, 5.4, 5.6, and 5.8

Protocols and patient handouts on CD           

a. 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

b. Physical assessments

c. Urodynamics

d. 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)

e. Exercise and Surface EMG based pelvic floor training

f. 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)

g. EMG instrumentation options (sensors, SEMG instruments, home training devices)

Laycock & Haslam 10

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

i.  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. and 6.2

Schwartz & Andrasik 27 & 29

Laycock & Haslam 20 - 22

a. 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)

b. 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

a. 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)

b. Pelvic pain syndromes unique (mostly) to males: (prostatitis, orchialgia, penile pain, prostatodynia, perineal pain, testicular cancer related pain, proctalgia fugax)

Optional Dorey ch 6

c. 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

a. Overview of erectile dysfunction

b. Assessment

c. 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 files on CD entitled “PFD BCIA ethics document” and “additions”.

End of course description and outline.

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Behavioral Medicine Research and Training Foundation
6576 Blue Mountain Road
Port Angeles, WA 98362

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