Ramona Horton, MPT is a pelvic physical therapist who teaches for Herman & Wallace Pelvis Rehabilitation Institute. She is passionate about the impact of visceral and fascial components as they relate to functional activities.
If you share my curiosity about the impact of viscera on your patient's function, then you'll enjoy this interview as much as I did.
Connect with Ramona on twitter @PelvicViscera. Enjoy!
Let’s start this off at the beginning of your day. What do you usually have for breakfast?
During the week always the same thing, a small serving of mixed raw nuts. I am a protein gal the nuts manage to fill me up and give me a good slow burn until lunch time.
What led you into the wonderful world of Physical Therapy?
My own knee surgery at the age of 16 combined with the fact that a career in the medical field was the only thing that attracted me. I was contemplating the nursing field, and took a job as a CNA in order to get exposure to health care, rehab just became the obvious choice.
How did you get interested in Pelvic Dysfunction? And, how did this lead into your passion for Visceral Mobilization?
My PT training was through the Army-Baylor program, I was all in for orthopedics and sports medicine until October of 1990. I gave birth to my second child, an adorable but behemoth 9lb 9oz baby boy. His delivery, a VBAC (vaginal birth after cesarean) was very traumatic on my pelvis, I sustained pudendal nerve injury and muscular avulsion. When I queried the attending OB-GYN about my complete lack of bladder control his response <insert righteous indignation here> and I quote “do a thousand kegels a day, and when you’re 40 and want a hysterectomy, we’ll fix your bladder then.” As for the desire to study visceral mobilization, that reflects back to my PT training through the US Army which was 30 years ago, when the MPT was just getting started. It was an accelerated program to say the least, we received a master's in physical therapy with 15 months of schooling. Given the very limited time line, which included affiliations and thesis, the emphasis in our training was on critical thinking and problem solving, not memorization and protocols which in 1985 was not the norm. I can still hear the words of our instructors “You have to figure it out, I am not going to give you a cook book”.
Following my initial training in the field of pelvic dysfunction 1993, as I started treating patients I had a problem, I could not wrap my head around how I was to effectively treat bowel and bladder dysfunction….without treating the bowel and bladder? I knew that there was more to this anatomy than just pelvic floor muscles and the abdominal wall, but at the time that is what was being treated. Once I started learning VM principles and applying the techniques to my patients I saw a vast improvement in my outcomes. I realized that the visceral fascia is a huge missing link in this field and that somewhere along the line the physical therapy community forgot one simple fact. We are not hollow, the visceral structures attach to the somatic frame through ligaments and connective tissue and have an influence on the biomechanics of said frame.
Why is the adoption rate of Visceral Mobilization so low amongst Physical Therapists who aren’t pelvic specialists?
Most likely several reasons, first they do not deal with dysfunctions that have visceral structures involved the way pelvic health therapist do. The second being a paucity of higher levels of evidence on the effectiveness of VM for musculoskeletal conditions. The third and most difficult issue to deal with is the broad based claims that VM can be an effective treatment for issues ranging from acute trauma to emotional problems. One website called VM “bloodless surgery”. The problem simply is when anyone purports their technique to be a virtual panacea for all that ails mankind, without adequate evidence to back up the claims, the clinical world raises its collective antennae. These critical remarks are coming from a practitioner, published author and educator in the VM field. The reality of evidence based medicine is talk is cheap, research is not.
Could you share an anecdote/story of the effects Visceral Mobilization in clinical practice?
A male patient many years ago that was experiencing constant right flank pain that made physical activity almost impossible and the pain increased during urination. He had been evaluated by the chief of the urology department at the medical school and was sent to me for biofeedback with a diagnosis of pelvic floor dysfunction and bladder-sphincter dyssynergia based on urodynamic testing. His symptoms began 3 years earlier while experiencing hematuria, most likely due to a kidney stone but that had not been confirmed. His exam revealed clear cut muscular guarding with tissue changes in his right psoas, quadratus and gross restriction of the renal fascia. I went rogue, and did not initiate the biofeedback, instead treating his restricted renal fascia which encompasses the ureter. He returned for his first follow up about a week later reporting that 3 days following PT evaluation and initial treatment, while urinating he experienced a strong sensation in the area that I had been working felt a rush and had immediate resolution of all pain. The best part is what he told me next “trust me, this was not a placebo effect because I thought you were a quack” reporting that he was quite irritated that I had not initiated the biofeedback as his urologist had requested and he was planning on cancelling his follow up appointments and going to another therapist. He was so pleased with the outcome, that he wrote a letter to the CEO of the hospital about his experience, encouraging them to assist in furthering my field of study.
You’ve just traveled back in time and are sitting face-to-face with your 25 year old self. What advice would you give yourself?
Learn to get over it
Fascial Mobilization has been another touchy topic for some Physical Therapists. Why do you believe Fascial Mobilization is such an important aspect of clinical practice?
Most importantly because fascia is ubiquitous, it is EVERYWHERE throughout the body and it contains a vast neurological network to include nociceptors, mechanoreceptors and proprioceptors just to name a few. The fascia was that stuff that we all dissected out of the way in anatomy lab so we could learn the assigned structures that soon would have a pin with a number stuck in it that we needed to know for a lab practical. We need to move beyond the “myofascia” and understand that the fascial system has multiple layers in the body starting at the panniculus which blends with the skin, the investing fascia surrounding muscles and forming septae, the visceral fascia which is by far the most complex and the deepest layer of fascia, the dura surrounding the central nervous system. All fascial structures, regardless of layer or location have their origin in the mesoderm of early embryologic development.
Why do you think there are more cases of Endometriosis today than 10+ years ago? Given the hormonal component (estrogen dominance) involved, how do you counsel your patients on what you can do for them, and what they can do for themselves?
I am pretty straight with these patients about their options as far as hormone suppression goes, surgery, pain control and fertility. I also advise them to take a very good look at their household and eliminating endocrine disruptor chemicals in their environment.
Favorite books & authors? (these don’t have to be PT-related, but they certainly could be…)
I am hooked on The Outlander Series by Diana Gabaldon
Tell us about your relationship with Herman & Wallace. How did this start? And, what are the biggest challenges to creating a course?
I did my initial pelvic dysfunction training with Kathy Wallace and Holly Herman in 1993. While attending a course on pudendal neuralgia in Seattle in 2007 Kathy Wallace was there as well. We got talking about our practices and as the topic of VM came up, when she learned of my level of education on the subject, she asked me to consider writing a course for H&W.
For me, the biggest challenge is trying to decide what information to leave out. I am terrible about trying to cram in way too much content, too many techniques and too many clinical pearls in a limited amount of time. Students can only absorb so much, and I have a tendency to overwhelm them with information.
If you could have dinner with any famous individual who is no longer with us, then whom would you choose? Why?
Sorry, I can't pick one. For me, the great dinner would be with Jesus, Mohammed, Gandhi and the Buddha and I would ask them how they feel about mankind killing each other in their name and how we can make it stop.
Ramona, thanks for this great interview!
Connect with Ramona Horton on twitter @PelvicViscera
Hope you got as much out of this interview as I did.