I'm just going to give it a few more minutes as we let the participants kind of roll in. Okay. As I actually have 559 Central Standard Time. I'm going to give it one more minute, Colleen. Okay, well, given that it's a couple minutes in, I think we should start. So welcome to the AugZero Gynecology Webinar Series. I'm Dr. Louiki Gou, the moderator for today's webinar. Today's webinar is titled How Physiatry and Neurogynecology Interconnect, and our speaker today is Dr. Colleen Fitzgerald, who is a board-certified physiatrist and an attending physician and professor in the Department of OBGYN, the Division of FPMRS, and the Department of Orthopedics and Rehabilitation and Urology at Loyola University. She serves as the medical director of the Health Sciences Campus Clinical Research Office, the medical director for the Chronic Pelvic Pain Program, the research assistant for the Division of FPMRS, and she's the assistant dean of medical student research. Dr. Fitzgerald's areas of clinical expertise and research include chronic pelvic pain, pelvic floor myofascial pain and dysfunction, pelvic girdle pain in pregnancy and postpartum, musculoskeletal medicine, pelvic floor disorders, and pelvic rehabilitation. She is the past co-chair and scientific committee member of the World Congress on Low Back and Pelvic Pain. She's an active member of our very own OGGS organization, and in 2021, she was awarded the Loyola Medicine Healthcare Hero Award and acknowledged for the past five consecutive years as top 10% faculty by the Loyola Wolf and Kettle Teaching Award. So for logistics, so everyone knows, the presentation's going to run around 45 minutes, and the last 15 minutes or so of the webinar, we will direct to question and answers. Before we begin, just some quick housekeeping items. OGGS designates this live activity for a maximum of one AMA PRA Category 1 credit. To claim your CME credit, you must complete the evaluation following the completion of the webinar. As you guys probably know, the webinar is recorded and live-streamed, and it will live on the OGGS e-learning portal, sort of for posterity. And please use the Q&A feature of the Zoom webinar to ask the speaker questions, and we're going to answer them at the end of the presentation. And if there are any technical issues, please feel free to use the chat feature. OGGS staff is going to be monitoring the chat, and we can assist. So without further ado, Dr. Colleen Fitzgerald. Thanks so much, Christina. It's so nice to be here, and really an honor to present within the seminar series. So I'll go ahead and get started. I hope this works. Let's see. These are my disclosures. I'm a co-investigator for the PLUS NIDDK Consortium, an editor for UpToDate, and an expert witness. But today, mainly what we're going to do is try to understand how PM&R and urogynecology really share in the patient goals of functional recovery and quality of life, to describe some of the opportunities that we have for unique collaboration across our specialties, especially for female pelvic health, but then how we can build interdisciplinary clinics as well, and just give some examples of that. I'd like to differentiate today just kind of how you refer to PM&R and why you refer to PM&R versus pelvic floor physical therapy, which I all know that you know so very well how to do. And then to really kind of dive into some of the musculoskeletal contributions for female pelvic health beyond the pelvic floor, which is where I really think PM&R can play a big role on your teams. So my specialty is awesome, I think. You know, we are a four-year non-surgical specialty that focuses on the treatment of what we call impairments. It's kind of an old word. Another old word is disabilities. We're really shifting now from thinking about not disability, but ability. But primarily what we do is take care of patients with neurologic and musculoskeletal diagnoses, although some of my partners in PM&R care for cardiac rehab patients, chronic, you know, deconditioning, burn rehabilitation, cancer rehabilitation. So we really cross multiple specialties. And I think that what we do very well and what we train in is the team approach. And that means that we are a part of a greater rehabilitation team with not just physical therapy, but occupational therapy, speech pathology, psychology, social work, nursing. We really come together, and that's kind of how I trained to be a part of a team. So it was sort of a natural thing, I think, for me to be a part of the urogynecology team. Our focus is really on quality of life and maximizing function. That's what we do, no matter what the diagnosis. That may or may not include decreasing pain, at least in a lot of what I do it does. But many of my colleagues are dealing with chronic pain. They're dealing with other complex rehabilitation diagnoses. But you can see the tagline here for the other great organization that I'm a part of, the AAPM&R, which is that we're physicians adding quality to life. But I think that I align so well with urogynecology because we are like-minded, at least in our goals for patients, for quality of life and function. And though you train surgically and I train non-surgically, we're there together to really get the best outcome we can for our patients. So I just wanted to talk about my track a little bit and some old pictures here. But I did medical school and residency training at Northwestern, and that's where Christina and I actually met. What was great there is that I was exposed to the largest rehabilitation hospital in the country. At the time, it was called the Rehabilitation Institute of Chicago. And I spent the summer between first and second year medical school there on an externship and really just kind of fell in love with the specialty. So I was lucky to be exposed to it early on. I've been in clinical practice now for 22 years, and I spent the first 12 where I trained. And I think what was awesome now, the rehab institute is called the Shirley Ryan Ability Lab. Again, you know, with the focus on ability, I have many colleagues still there. But we were able to build a women's health rehabilitation program there. And that was when I really got excited about how I could make a difference. I started out in orthopedic inpatient rehabilitation. I moved on to outpatient musculoskeletal with sports medicine and really just got referred a ton of female patients, mainly because my partners at the time were all men. And I think by default, I ended up seeing a lot of the female patients and started getting a lot of referrals for pelvic pain. So I actually met Dr. Miller and Dr. Brubaker and Dr. Ketton early on in my career. I actually co-called Linda Brubaker, believe it or not, and asked to give a talk. I gave a talk at their division conference, and I started seeing patients with them in 2001 for a few years when the Rehab Institute and Loyola had a relationship. But then I formally moved to Loyola 10 years ago. I've been here 10 years to join the great clinical research team and urogynecology division here. I've been a member of AUGS since that time. It's been awesome. I've been a part of the musculoskeletal writing group through AUGS, and there's a recent publication. Ingrid Harms-Hernandez actually was the lead author of that, and that was a great experience. And more recently with Christina, helped work on the postpartum consumer text for AUGS, which has also been a great opportunity. And I've been doing clinical research for the last 14 years. So I started out a pure clinician. I had a ton of questions when I got into clinical practice about the pelvis, especially. And because of that, I applied for the BIRCWH at Northwestern, the K-12, and oh gosh, I think it was 2008. I was on the BIRCWH for four years, then I transitioned to Loyola where I did a K-23, and now I'm a part of the U01, the plus consortium that I mentioned among many other wonderful grant opportunities. So, you know, of course, like, you know, how you end up doing things in any of our specialties is the great mentorship that brings you to the place you are in that moment in time. And on the left-hand side is a picture of myself, much younger, and Dr. Joanne Smith. And Joanne was the attending I was assigned to when I did that externship. She was an amazing physiatrist. She passed away last year, but she taught me how to do a pelvic floor muscle exam. She taught me how to examine a sacroiliac joint, and she was cheering me on, and I believe still does even now, to really do right by women's health rehabilitation and PM&R, and was very, very supportive when I moved over to Loyola 10 years ago. And Linda, I mean, from the moment I met her said, you should see patients with us. We need you. We believe in you and your specialty. We understand physical therapy already, but we know we can benefit from PM&R. She was a formal mentor to me on my K-12 and my K-23, but has been just an incredible friend and mentor along the way for everything I've done. So without these mentors, I'm not sure that this interconnectedness, Christina, actually would have really happened. So I'm very, very grateful to them and to all my partners then and now. I think the key to success, and hopefully you can see this with the people on the side, is really that we have a shared respect within our division here. I think anything the urogynecologists say surgically, I believe in, and I think they believe in me as I assess patients. We have the same goals around patient care, but the same prioritization around scholarly activity. So when Dr. Miller became OGS president, we all supported her as much as they all supported me when I became president for the International Pelvic Pain Society. We sort of placed really high value on our overlapping expertise, and it just is in everything we do. And I think it's really worked well because I'm totally integrated within the Department of OB-GYN. It's actually my primary department here within the division of urogynecology. Obviously within OGS, I go to all your meetings. It's an amazing opportunity, but I'm also fully integrated in the training of the residents and the fellows. And in my prior institution at Northwestern, I trained the PM&R residents a little bit, the OB-GYN residents, but here they're with me every day, the OB-GYN residents and the urogyne fellows and the urology residents when I have the opportunity. So I'm really grateful, and I think we've been successful because of that real integration. And we're friends. We're friends and we're partners. We believe in each other. And I think that's been why this collaboration has worked so well. We have a great infrastructure here. We're really fortunate. We have the clinical research office, which I help run now that supports the nurses in research, the coordinators, the biostats core. We believe in both team science and team medicine. This is an old picture here with Alan Wolf and Linda Brubaker, Mary Tolke, who is our research nurse. And the work that we do with microbiology, I've even actually adopted within my care of pain patients. So it's been really awesome. And as far as team medicine, we don't just refer each other patients and then individually see them. We sometimes do that, but a lot of the time we're actually seeing patients together in our multidisciplinary clinics. And so we go in together as physiatrists and urogynecologists and see the patient, evaluate the patient, whether it's in the multidisciplinary pelvic floor clinic, the mother's wellness clinic, which is a pregnancy and postpartum clinic, or within the chronic pelvic pain program. And we're fortunate that many other specialties join us in those clinics, colorectal, GI, physical therapy, and minimally invasive gynecologic surgery within the pelvic pain clinic. So I really think it works because we're fully integrated. So when should you refer to PM&R? I wanted to put this up front and center, and there's a lot of bullets here, but I think many of you know, not a lot of physiatrists do a pelvic floor exam. I do, and I've trained everyone, every physiatrist I've worked with to do it. I've been able to recruit another physiatrist to our team here at Loyola, but I think that's okay. I think if you need greater diagnostic clarity and understanding, the broader musculoskeletal or neurologic contribution other to pain or pelvic floor disorder, make the referral. Even if the PM&R doc does not do pelvic floor evaluations, they can help you because we train in complexity and we train in every age group. There's pediatric rehabilitation all the way to geriatrics, and we train in the biopsychosocial approach. So I really think, you know, there's not a complicated patient that we can't sort of work with you on. It's sort of, we train in complexity. Also if you need help with pain management, whether it's pharmacologic medication or injections or non-pharmacologic, that's where we would step in to help out our physical therapy colleagues, for example. Musculoskeletal ultrasound is a great tool that a lot of physiatrists, including my recent partner, Dr. Benes, has trained in, and that can really be helpful diagnostically and therapeutically for injections. If you have questions around assessing or maximizing a patient's functional capacity, PM&R should see them. I mean, we really can help you do this both preoperatively and postoperatively. If you're having trouble getting the patient to return to exercise, if a patient fails physical therapy, these would be great reasons to refer to PM&R. And honestly, I think I joined the specialty when we were at the end of the line. I liked that. I actually liked kind of taking over where other doctors left off, but I think what's been amazing is that now I'm more at the beginning of the line, at the front line with you. And I think that PM&R can be way more effective if we're there at the beginning. So the sooner you consult, I think don't wait until they've had, you know, a year or two of physical therapy, get PM&R involved sooner is what I would say. And this website is how you can actually find a PM&R doc in your area. So I can make sure everyone gets these slides. Also physiatrists train and how to write a really detailed physical therapy prescription, including pelvic floor. So rather than just PT evaluate and treat, we're going to write exactly the diagnoses sort of by level of importance, what we want the, you know, hopefully physical therapy to focus on based on our diagnosis and beyond Kegels, which I know, you know, already, but honestly beyond the pelvic floor. I think that's where we can really make a difference. This is a great picture of our team with Dr. Benes. I was so happy when she joined and, you know, really serves as my main PM&R partner here at Loyola. But Dr. Petko, our chair, super supportive and the entire team. And then, you know, when you see a patient and you do an exam, I always said it's such a win when urogynecology diagnosis myofascial pain, it's huge, right? But I think you think that, and then end of story perhaps, but I think it, and then I'm thinking about all these other things in the differential. So I'd like to train the residents and the, you know, the fellows to think about why do the muscles hurt? You know, there's gotta be a reason and sort of assessing what else muscularly can be affected. What other parts of the core are either in pain or not functioning properly? What parts of skeletal or joint in the differential should we think about? Is there an SI joint dysfunction? Is there a lumbar contribution or a hip contribution to pain? And then always we're thinking about the neurologic system. So for example, if someone has an L5 radiculopathy, they have buttock pain and they typically have pelvic floor myofascial pain on that same side. So, and then many of you know, anyone who has endo or irritable bowel, or of course interstitial cystitis, they have pelvic floor myofascial pain, the great majority. And I think this, the concept of visceral somatic and how then that secondarily impacts these other musculoskeletal pain generators, I think is really important. So I see a patient with pain and this is what I'm thinking. And I think that's what most PMNR doctors would do. You know, we also would weigh in on musculoskeletal imaging and what's needed. Is it a plain x-ray that might diagnose some of these things like a separation, an osteotis pubis, a coccyx injury? We can use the ultrasound to diagnose the separation, which is beautiful. I mean, in pregnancy, this is ideal, but then we use MR a ton. We can diagnose sacral stress fractures, herniated discs, I mean, tears and muscle. It's really great. But I think working with you on sort of what's the necessary musculoskeletal imaging test that will help is important. And we, you know, I'm going to get into the slides later on the exam. The musculoskeletal exam is the mainstay of our diagnostics, you know. So we do that first before we jump into imaging, but hopefully we would help you throughout that continuum to help a patient. You know, I love this picture because it really shows how the pelvic floor muscles, you know, this group knows very well what they do, but that they connect the musculoskeletal pelvis from the anterior to the posterior components. And they are a source of pain like any other skeletal muscle in the body, potential source, but really, and I hope that everyone can leave here today thinking this, that they are the floor of the core. And so we can't just think about them in isolation. We really have to think of them more globally in the whole patient and the whole musculoskeletal system. There's a lot of great data and a lot of it's old actually, but just kind of coming to the forefront now that co-activation of pelvic floor and abdominals is kind of the normal recruitment pattern actually. So I always say to the students, you know, when you take your first step, the first muscle group to kick in is the pelvic floor, but then that's quickly followed by transversus abdominis co-contraction, for example. And then one feeds off the other. So if pelvic floor works right, the other core muscles work right. And also another really cool study looked at, well, if you're in like neutral spine, we call it in rehab, where you kind of have really good posture, you're going to activate your muscles better. And so you cannot just do pelvic floor without thinking about these other things. And hopefully PM&R would help you with that. And then there's sort of this idea of core instability. And that sort of means like a balance between the global muscles on the outside and the local muscles on the inside, like the pelvic floor. And these statements here sort of say, when you have a problem with the global muscles, it will challenge core stability, but it will affect the local. So there has to be this beautiful balance. We call it motor control in rehab and excessive use of one will lead to strain in another. So it's not just enough to look at the pelvic floor itself. We really have to look at the entire core as a whole. These are some really cool slides. They were originally thought through by some colleagues of mine in the Netherlands where they talked about this idea of core and especially with the pelvis. And there being two components to pelvic like lumbopelvic stability, one being form closure which is just like basically how the bony pelvis just naturally comes together, right? We know that the SI joints, for example unless you're pregnant, don't move that much. And the pelvis is a nice unit held together by joints and by ligamentous structures. But the force closure is really probably more key than anything else as it relates to lumbopelvic stability. And that's not just pelvic floor but all the other core muscles that then allow for true stability when we're doing a task or we're doing an activity. This is another awesome study. All my friends originally in the Netherlands didn't like to talk about the pelvic floor. They like to talk about everything else because I don't think they really wanted to do vaginal exams unlike the urogynecologist. And Dr. Poole Goodsword who did this study, it was super cool because she started to really, she's also there and started to really get them to think about how the pelvic floor actually is a key component of core and how it impacts the SI joint, for example. So this study was done in cadavers. They removed the pelvic floors and replaced the muscles with springs. And they basically looked at male cadavers and female, tighten the springs and then looked at what happened to the SI joints. And only in the female cadavers did the SI joints tighten up or get more stable, if you will, when the pelvic floor was activated. So it was kind of the beginning of saying, hey, we should really be looking at this more closely. And then early on, we were doing these studies when I knew Christina at Northwestern, we were saying kind of the same things. We were finding all these things in patients. If they had a pelvic floor muscle problem, they had all these other musculoskeletal findings. But we actually did a little study taking chronic pelvic pain patients. And we found not only in this, you can see here, did they have pelvic floor pain compared to controls who didn't have pain, but they had significant findings almost on every single musculoskeletal test we did. And that was cool. That was kind of saying, hey, listen, it's not, these things are connected. And I'm still constantly trying to make this case to my orthopedic colleagues, but I think we're making some game now that we're building the research. And then we were also told early on, this is a finger, this is a little pressure ergometer. I did this study with Frank too. And some of you know Frank, he's also in Chicago, but I also did it with a couple of engineers that helped us make the device. And we used it to assess pain pressure threshold in women with pelvic floor myofascial pain. And basically found that the women, just like we find on physical exam, but we finally had an objective measure for it, that women who had pain could not tolerate the pressure and women who did not have pain could tolerate way more pressure. We all have a level that we can't tolerate pain anymore when someone presses hard enough. But this is the first study to say, you know, there really is something there. And it's not just if you press on everyone's pelvic floor, it hurts. So that got us excited. And then so excited that we did this follow-up study and I'm looking at all of the data now. This was a part of my K23 where we're actually measuring EMG muscle activation in concert with pain pressure threshold. This is a picture of a, this is the device now, the updated device where we have a little EMG, surface EMG electrode on the end of our finger when we do a pelvic exam. And this is us measuring a Kegel. And then with pressure, just looking at if there's, so this is a normal patient who didn't have pain. When I placed pressure, this red here, she did not have higher activation or over-activation of pelvic floor. So trying to look at lots of different ways we can objectively examine pelvic floor. I think when we think of patients, now I'm moving on to this concept of the core again. And, you know, this is me pregnant years ago, but, you know, pregnancy is a real time. Like there's certain times in our lives when we have more musculoskeletal disease and more core disruption. Pregnancy is one of them. I mean, you can naturally see like the hyperlordosis, the muscles have to significantly stretch. And I think I have a good picture here. I think this one speaks a thousand words, right? What's happening to the core during pregnancy? The pelvic floor has to stretch too, as does the rectus abdominis muscles to support the growing uterus. But the other thing that's happening is we can't breathe properly. And the diaphragm, the ceiling of the core is also affected. So we did these studies looking, oh, and because of this women who are pregnant, you know, have SI joint pain, also called pelvic girdle pain. And this is pain right here in the SI joints, worse with movement, probably prevalent in about 20% of pregnant women and maybe 50% if you include lumbar spine disease. But I did a really cool study in the Birch. Just try it again, this concept of connecting like the external musculoskeletal pelvis with the internal pelvic floor. And I took women who had no pain in pregnancy and women who had pain. It was a very small study, but I basically just did pelvic floor muscle exams on that. And all the women with external SI joint pain had significant tenderness of their pelvic floor muscles, whereas the women who didn't have pain did not. And that was really cool study where we also were able to show in a separate publication that the women with pelvic girdle pain, even after controlling for pelvic floor muscle strength had more urinary incontinence. So small study, but pretty significant association there. And then the core gets hit again with labor and delivery, sort of no way out of it. These are beautiful pictures showing stretch of pelvic floor, Delancey's awesome work, the pubovisceral tears, the ongoing rectus abdominis diastasis, which a hot debate about this in the rehabilitation literature now, but these are the things now we have even more damage to the core. And then we move from this stage in our lives onto middle age or later life musculoskeletal problem on top of that, developing things like osteoarthritis, osteoporosis related fractures. I mean, any of you, I mean, I'm 52, we all have these problems. So tendonitis, bursitis, and we know that low back pain, the highest prevalence is actually in women in middle to later life. And spinal stenosis in particular, osteoarthritis and degenerative disc disease that affects the nerves of the lumbar spine is a leading cause of musculoskeletal disability. So we did a study at Loyola, kind of, again, I wanted to say, okay, if we take middle-aged women, not pregnant women, this is actually under review right now with IUJ, but it's great study we did with Urogyne, women who are middle-aged, actually, we looked at 177 women and the women who reported symptoms of low back, hip, or pelvic girdle pain were far more likely to have pain on vaginal exam and significant association again here, especially compared to women who did not have that history. So, you know, and I'm not the only one who's been thinking like this, but there are others even separate from pain who have looked at this as it relates to urinary incontinence. And these are some awesome studies with great end sizes. This one was 1400 women in Japan, women who had urinary incontinence were way more likely to experience just pain in general and specifically low back pain than those without. In Korea, they had a similar finding, a significantly higher relationship of low back pain and disability in women with urinary incontinence. And another study where musculoskeletal diseases globally, not just low back pain, were more associated with voiding symptoms than those who did not have musculoskeletal disease. So I think there's pretty good evidence out there and I'm just sharing bits and pieces of it quite honestly to support this concept that the musculoskeletal system even beyond the pelvic floor, I'm sorry, even, yeah, even beyond the pelvic floor really impacts pelvic floor disorders as a whole. This one was shocking to me. This is a huge study. It was published in 2006 in Australia. Paul Hodges has done some great work. Almost 40,000 women retrospective study, they found actually that low back pain was more strongly associated with incontinence than obesity or physical activity. And it was a very, very well done retrospective cohort study. So obviously we're well aware about obesity and physical activity, but I think this concept of musculoskeletal disease is not as well known even though there's some good literature out there to support it. And then I love this one. This was a more recent study. I think it was 2016. They just, they took women and wanted to look at the effects of core stabilization exercises where they weren't doing pelvic floor therapy, but they really believed the pelvic floor muscles were engaged and they wanted to look at low back pain and urinary incontinence and how that core stability program affected it. And the women who did a more specific program like this that targeted the pelvic floor, so you can see nothing was internal, but really focused on core stability, they were more likely to have improvements both in incontinence as well as chronic low back pain, which is pretty cool. So because of these studies and many others and the fact that I've had the great fortune of being involved in the PLUS network, we are now doing a prospective observational study, many of you know, called the Rise for Health. But within that study, we're doing an in-person assessment where we're bringing some of the community participants in for an examination. And I've been really fortunate to help lead the musculoskeletal component of the in-person assessment. And I wanted to share this with you because I'm the only physiatrist in this group. I'm so honored. And there's a lot of urogynecology colleagues within this group. And I think what I have felt is that they've really believed in this. They've believed in the questions around musculoskeletal health and bladder health, so much so that we've been able to move forward with this in-person assessment, which I'm so excited about. So this is really where we're gonna do a series of musculoskeletal testing to assess core stability, function, and pain. And we're gonna correlate it with the survey data that we have in the population that comes in. So I'm gonna show you some of this. This core stability testing has been validated. Some of my rehabilitation colleagues have done it. And we're looking at core stability four ways. The first way is this one with the single leg splot test where this is me, of course, and Dr. Miller took these pictures of me. And again, I'm middle-aged and I could do it. So we had a lot of debate about, well, kind of, but we had a lot of debate about, oh my gosh, our patients won't be able, or participants, that is, won't be able to do it. And really, we've had some exciting preliminary results in another study, but I think we're excited to see this actually happening. So the first part is having a woman stand on her strongest leg and see if she can do it and bend her knee. The second part is doing a supine bridge where she lifts the pelvis and then lifts one leg at a time for five seconds on both sides. Then we have her do a side bridge or like the side plank, which you know is not so easy. First with her knees, just the knees, then with the knees straight, then with one leg up. And in order to kind of pass the test, they have to hold it for five seconds. And then the final part is doing like a prone plank. And I can tell you, I mean, I examined someone today who was 62 years old and she got a perfect score on this. So, and this one, you know, it's basically prone on the arms and not only lifting the pelvis, but with lifting one leg and alternating legs at a time. So we're doing that test. We're also examining the lumbar spine, but we decided to do what's called the seated thump test. And some of you remember the old days of the straight leg raise, but this is kind of a better straight leg raise. And we're assessing for the presence of pain when the participant leans forward and we dorsiflex the foot. And we're looking for basically low back and leg pain in this test. So that's exciting. And then we're doing a series of tests looking at both the pelvic girdle and the hip. We're examining sacroiliac joints for tenderness. We are examining the anterior superior iliac spine for tenderness as well on both sides. And then we're also, I'm sorry, I don't think we have the picture of this, examining the pubic synthesis. So that's great. That was well described in Meister's paper including that as part of a pelvic floor exam. And then the hip testing we're doing, the Faber test is flexion, abduction and external rotation. We're assessing for pain with this maneuver on both legs. And then one more that I don't think is here that I included called the Fader. So basically the opposite of Faber. In addition, we're provoking the sacroiliac joint with a test called the pelvic girdle pain provocation test. This is a really easy test where we flex the hip and knee and push vertically down and ask the participant if it's painful or not. And finally, we're doing a test of function where we're asking the participant to do the active straight leg raise it's called. We have her lift the leg and we ask her if it's difficult. And if she says it's difficult, that's a positive test. And then we go on to actually compress the pelvis to see if that difficulty is improved. That sort of is, if you think about it, us facilitating the core. So it's a test that's been well validated in women with pelvic girdle pain. So those tests are really exciting and we're so, I'm just so thrilled as a physiatrist again to be a part of that group and to weigh in on the musculoskeletal function. We're also doing a test that's been validated called the short physical performance battery which is a series of tests that give us an assessment of a participant's ability to hold standing positions with their eyes open. It includes balance testing, gait speed and a chair stand test. And this actually has been shown to be correlated with urinary incontinence in the geriatric population but we're actually doing it across age groups. We're using this as one of our primary outcome measures for function. So excited to include that as well in the musculoskeletal assessment. So I think I'm actually early and that's fine. I, you know, hopefully I made a strong case especially in the second half of the presentation about the importance of the musculoskeletal system and finding your local PM&R partners to collaborate to be your clinical partners in care and urogynecology in addition to your awesome physical therapy partners. I mean, I can't speak more highly of the physical therapists we have in Chicago, at Loyola, throughout the Chicagoland area but I think there's some incredible physiatrists across the country that could really assist you as well. And hopefully I've made a good case about the musculoskeletal system beyond the pelvic floor. That's what we spent all of basically 2001 writing about. And this is the paper that was published in urogynecology on the assessment of the pelvic floor and the associated musculoskeletal system. So it's awesome. If you had to look at one reference, this would be it for including a lot of those things I just talked about in the slides and the corresponding references for that. But these are some old pictures. I mean, I had a lot of fun going through old pictures of my colleagues in urogynecology. And I just really wanted to thank you for inviting me to sit at your table. It's really an honor to work with all of you and this is how you would reach me if you needed me at Loyola. So thank you so much for your attention tonight. Thanks so much, Colleen. That was amazing. I want to remind the audience that if there's any questions to put it into the Q and A. I actually have a question. I'm in the process of editing a book with some international colleagues and there's an entire chapter dedicated to pre-dental neuropathy and neurophysiologic testing. Can you talk to us a little bit about neurophysiologic testing? Like, do you do EMG? Like, how does that play into... Because there's all this stuff dedicated in that chapter to this. And I just feel like we don't really use that as much here in the U.S. Or maybe I'm just... I think, you know, Christina, we were super excited about it, like in, you know, 20 years ago, even 10 years ago, right? And Dr. Kenton led an awesome course on it. And, you know, I think most of the early graduates of Loyola's program, especially trained in this, right? From a pain perspective, it does not help us at all. I mean, it's not diagnostic at all from a pain perspective. And I think that because there's really not normative data around its use in pelvic floor disorders, specifically urinary incontinence, I think that's where it's been sort of put aside in the U.S. Because I don't think diagnostically it's helping us as much as we had once hoped. You know, the pudendal nerve gets blamed for pelvic pain a lot. And certainly, pudendal neuralgia is in the differential diagnosis. I sort of, I have this bias where I think that the pelvic floor muscles are creating, especially with myofascial pain, creating pudendal neuralgia in a great majority of women. Because when we treat their pelvic floor, their pudendal neuralgia gets better. So, I mean, there's some data out there, you know, about Nante's criteria for pudendal neuralgia. There's some data out there on doing diagnostic blocks, guided blocks for making the diagnosis. But we really lack in good studies around how to assess the pudendal nerve. I don't know if I'm answering your question, but I think it's great. I think there's a chapter, because the chapter probably at least will highlight what we do know, and sort of the opportunities or the gaps in our knowledge related to pudendal. Because I think there's a lot more to do. Yeah, no, thank you for that. I don't see any other questions. I actually have a patient that I'm going to send to you. I did a sacrospinous hysteropexy, and I legitimately think we got the pudendal nerve, because, you know, it pierces right through there. She met all Nante's criteria, and we took it down, but she's still struggling. So. You know, it's interesting. So, for a while, for like the last couple of years, we were working with radiology, looking at, you know, making the diagnosis of pudendal neuralgia on MR, like with MR neurography. And I know at Northwestern, you have that capability. In fact, the radiologist who was here is now at Northwestern doing it. And, you know, it was amazing what we saw. It was amazing. And, you know, we are still looking at that data just retrospectively in about 50 women, because the majority of the time, it correlated with our clinical exam, which is kind of new to the literature. But I can definitely get you in touch with the radiologist that we worked with, and she's there. And, you know, it might be helpful, actually, in just making you feel better about if that's really true or not. Yeah, she's been working with our excellent PTs and making a ton of progress. Yeah. But I think just for the sake of kind of, it was a pretty, you know, it was immediately after surgery that it happened. You know, I think that would be maybe cool to do with the MRI I mentioned. Yeah. Yeah, I'll get you her contact information. I think there's kind of a rage and pain in looking at that, but I think we're still, the jury's still out about if it perfectly correlates with sort of our clinical exam, and then sort of what to do with it. Because then when we would do pudendal blocks on these women, they wouldn't necessarily get better, even though there was significant inflammation on T2-weighted image, you know, so. Interesting. Yeah. Well, on behalf of AUGS, I'd like to thank you, Dr. Fitzgerald, and everyone who joined us today. And then just a quick reminder, make sure to register for our upcoming webinars. We've got one on August 23rd, all about the urethra, and on September 21st, the microbiome of genitourinary tract diseases. So again, thanks very much. Thank you. Thank you so much for having me. Have a great night, everybody. Thank you.

physiatry

neurogynecology

collaboration

musculoskeletal conditions

pelvic floor disorders

core stability

research

referral