Behavioral Assessment & Treatment of Pelvic Floor Disorders

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in partnership with the
Behavioral Medicine Research & Training Foundation

Non-profit Scientific & Educational Organization 91-1948669 operating under Section 501c3 of the US Internal Revenue Code 6576 Blue Mountain Road, Port Angeles, WA 98362

Course Description and outline for:
Introduction to Behavioral Interventions for Pelvic Floor Disorders
45 Hours of CE Credit / Course Fee $750

Presented by Richard A. Sherman, Ph.D

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 the course web site, watching movies demonstrating recording techniques and interviews, reading assignments both from materials provided on the web site and standard texts, and interacting with their instructor via email. 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. It provides 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):

  1. Summarize the psychophysiological processes and anatomy underlying each pelvic floor condition covered in the course.
  2. Use psychophysiological recording and biofeedback devices record and display psychophysiological information about musculoskeletal functioning of the pelvic floor.
  3. Control the biofeedback display to optimize learning to correct patterns of muscle tension in the pelvic floor.
  4. Use psychophysiological recording equipment to assess patients with pelvic floor musculoskeletal dysfunctions.
  5. Use biofeedback equipment to apply specific interventions tailored to each muscle related pelvic floor condition covered in the course. 6. Use behavioral techniques learned in the course to assist patients in controlling muscle related dysfunction patterns causing specific pelvic floor problems.

DISCLAIMER: Completion of this continuing education course is strictly for educational / informational purposes and does not imply competency, proficiency, and/or experience. The course completion certificate is not a clinical certification nor a license to practice.

Format: Home study supported by e-mail chats after each unit is completed. The lecture portion of the course is presented through a series of audiovisual lectures profusely illustrated by power-point slides and movies. The course is accessed from the course web site. The audiovisual lectures are on power point slides. You will hear the instructor’s voice while viewing the power point sides. The lectures are between 1 ½ and 2 ½ hours in length. Reading assignments parallel the lectures. After watching the lecture and reading the assigned supporting files, you will answer a brief series of short essay review questions (which are in the review questions file on the course web site). 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. There is no need to complete the discussion with the instructor before proceeding to the succeeding lecture & chapters. It is expected that all review questions will be answered correctly and completely by the student. Any questions answered incorrectly or incompletely must be discussed and/or corrected. You will have at least one real-time meeting with the instructor via a web based program such as “go to meeting” during which you will interact around your new skills.

Accessibility: Hearing impaired people can view the slides only as virtually all of the material presented in the lectures is typed onto the slides. Visually impaired people can concentrate on the verbal lectures as the slide material is repeated in the lecture accompanying each slide.

Accessing course materials: All course materials are available on the course web site. When you purchase the course, you will be given instructions for accessing the course web site immediately.

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) capable of connecting to the internet and running a typical internet program, (b) containing/running a modern word processor such as Microsoft word or Word Perfect, (c) the capability to play sounds such as music (has speakers and appropriate software which normally come with any modern computer), and (d) 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 or Windows 8) 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 however they frequently have more difficulty playing the course materials than PC users do.

If you are using a MAC type of computer, you must have a current version of “quicktime”. If you do not have it, you can download it for free from the web.

Prerequisites & professional training requirements: You should have had undergraduate courses in general biology and general psychology prior to taking this course. If you haven’t had them, contact us before registering. You will do much better in the course if you have already taken our “introduction to psychophysiology” and “Anatomy and Physiology for Behavioral Clinicians” courses. This course is intended for licensed / certified clinicians. None of the instructional material offered will provide you with the clinical skills needed to apply the psychophysiological assessment and interventional techniques you will learn in the clinical environment unless you are already a trained clinician.

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.)

Faculty: The course is given by Dr. Richard Sherman, Ph.D He is certified by BCIA, approved by BCIA to teach the general biofeedback certification course, and currently teaches A&P, Pelvic floor disorders, pain, and other courses. He is a professional psychophysiologist with extensive training (his Ph.D is in biology & psychology), has nearly 30 years of experience in the field, and has published over 130 books, chapters, and articles (mostly in peer reviewed journals). Dr. Sherman is Director of the psychophysiology doctoral specialization at Saybrook University and has held many positions within the Association for Applied Psychophysiology and Biofeedback including president. Full CV available upon request and on the course web site.

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.

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

Note that in accordance with BCIA requirements, this course includes at least the following number of hours of education in the following topics scattered through all of the lectures: Applied Psychophysiology & Biofeedback 6 hours; Pelvic Floor Anatomy 6 hours, Surface EMG Assessment of Pelvic Floor Musculature 6, Clinical Practice Procedures 6 hours; Clinical Disorders I, Bladder Dysfunction 6 hours; Clinical Disorders II, Bowel Dysfunction 6 hours; Clinical Disorders III, Chronic Pelvic Pain Syndromes 6 hours, Ethical considerations 3 hours.

1. Overview of behavioral assessment and intervention for pelvic floor disorders:

(About three hours of instruction including interaction with the instructor.)
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 1

2. Anatomy and Physiology of the Pelvic Floor

(About six hours of instruction including interaction with the instructor.)
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 (About six hours of instruction including interaction with the instructor.) Audiovisual Lectures 3.1 – 3.6 Movie 1 on CD 2 (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

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 (About two hours of instruction including interaction with the instructor.) 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 (About six hours of instruction including interaction with the instructor.) Audiovisual Lectures 5.1, 5.2, 5.4, 5.6, and 5.8 Protocols and patient handouts on CD 1 Movies 2 and 3 on CD 2

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 (About six hours of instruction including interaction with the instructor.) Audiovisual Lectures 6.1 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 (About six hours of instruction including interaction with the instructor.) 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 (About five hours of instruction including interaction with the instructor.) 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 (About two hours of instruction including interaction with the instructor.)

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 (About three hours of instruction including interaction with the instructor.) 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”.

11. You aren’t quite done yet.
Please fill out the Foundation’s course and instructor evaluations. When all requirements have been successfully completed, your course completion certificate will be e-mailed to you and BCIA will be informed that you completed the course.

Administrative Information

Schedule: You can start the course whenever wish to within six months of the purchase date and work at your own pace as long as you complete the course within one year of purchase.

Duration of course validity: You must begin the course within six months of the purchase date and complete it within one year of the purchase date. Courses not completed by that time are void and must be repurchased if still available. No refunds are provided for courses not completed within one year of purchase.

CE Credit : Saybrook University is regionally accredited and approved by the state of California to grant degrees. These are continuing education, not university accredited, courses. CE credits are given through (1) the state of California’s Board of Behavioral Sciences (Approval # PCE1895); (2) The National Board of Certified Counselors (Provider # 6270), and (3) the Behavioral Medicine R&T Foundation is approved by the American Psychological Association to sponsor continuing education for psychologists. The Foundation maintains responsibility for this program and its content. Saybrook University is regionally accredited and approved to grant degrees by the state of California.

BCIA: This course is accepted by the Biofeedback Certification International Alliance for both certification and recertification.

Purchasing courses: Courses can be purchased from Biofeedback International Resources by clicking the Buy Me button for the specific course HERE.

Full refund will be made until the students are given access to the course website.

After getting access to the course website, there is no refund at all, as Saybrook University and the Foundation have committed their resources to you and you have access to all of the course materials.

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.

Scholarships: Saybrook University and the Foundation give scholarships consisting of 25% off the cost of the course(s) to (a) students and professionals (e.g. clinicians, coaches, teachers) from emerging nations and (b) full time graduate students in developed nations.

Course updates: Updates to all courses are placed on the course web site as they are made. Students are informed when updates are available.