buy valium Prana Physical Therapy Blog | Prana Physical Therapy accutane
Appointments: 571-527-9192


What If Sex Hurts? Interview with Sandy Hilton, PT, DPT


I recently interviewed Sandy Hilton for the July issue of BossFit Magazine on the topic of sex from a Pelvic Health perspective. You can find that story here (the entire issue is devoted to sex – check it out!)

Sandy shared so much good information with me, and since the magazine articles are under 500 words I had to pare it down. I wanted to share the entire interview with you here. Enjoy!

Tell us about yourself:

I am a Doctor of Physical Therapy and have been practicing since 1988. I am the co-owner of Entropy Physiotherapy and Wellness, serving Chicago to restore hope and movement in those dealing with persistent pain, incontinence or painful sex. I serve as the Director of Programming of the Section on Women’s Health of the American Physical Therapy Association and am a member in several international organizations dedicated to providing top-notch health care.

What are some reasons that men and women might find sex to be painful?

Over 1 in 7 people experience pelvic pain and roughly 90% of those will have painful sex. There are multiple causes of pelvic pain in men and women. If it hurts in your pelvis, groin, belly, genitals or the hips during or after sex, you should see a physician for a good evaluation! Find a pelvic health specialist in your area, look for Urologists, Urogynecologists or Gynecologists who are experts in pelvic pain and sexual dysfunction. Common causes that we see in the clinic are related to stiffness of the muscles of the pelvic floor (those that you tighten when you do a Kegel), sensitive nerves in the area (from injury, repetitive use like long bike rides, following an infection or even sudden onset with no tracable cause), back pain and gut problems. Diagnosis like Vulvodynia, Dyspareunia, Pudendal Neuralgia, Prostatitis and Painful bladder Syndrome may all result in pain in the perineum and painful sex. Many endure this pain for years and treatment can be delayed by delayed diagnosis, insurance limitations or being incorrectly told that there is no help available.

What type of treatment can physical therapy offer for these issues?

Physical therapists provide essential care in eliminating painful sex. The right treatment plan starts with a thorough evaluation that includes your history, your goals and a full movement screen, check your strength and coordination and importantly, test the muscles and movements inside and around the pelvis.
It’s pretty common in painful situations to have a “non-relaxing pelvic floor”. We teach you to be able to tell when your pelvic muscles are contracted/held tight and how to relax those muscles again. This is the opposite of doing a Kegel contraction. Strength is important, but to be strong you need to be fluid, supple and coordinated.
Pain neuroscience education is an essential part of comprehensive treatment. Understand how the pain system works will give you daily reassurance and hope that the movements and function you have lost will come back with careful, coordinated treatment. We teach you to understand pain and ultimately, to change your pain. Part of this is learning to do Graded Imagery and Graded Exposure, tools that train your brain and your body (we really can’t separate those things!)
Other treatments may be using biofeedback (EMG) to show you on a screen the activity of the pelvic muscles, the use of dilators or vibrators for tissue stretch or relaxation, instruction in Mindfulness/Meditation and movement re-training that may include Yoga, Feldenkrais or Franklin Method exercises.

How long does it take to see progress?

I expect to see change from one visit to the next. It’s going to take some time, but really, you should see and feel measurable improvement each week. I think it’s faster to make change if you get to treatment quickly! I’d love to see people within the first 6 weeks of their condition rather than they typical “I haven’t been able to have comfortable or pleasurable sex for 5 years”. That’s way too long to wait before getting help!

What if the OB/GYN says the patient doesn’t need physical therapy (or says they need surgery?)

Some physicians don’t know what physical therapy can do to help. They may think that physical therapy for pelvic health is just teaching kegels – and I agree that wouldn’t be helpful for pelvic pain. When the doctor understands that physical therapy is a great way to get the brain, mind and body doing better, to bring the pain response down and restore healthy motion to the irritated parts, then they often are agreeable to a trial. If it isn’t a life threatening condition then a qualified pelvic health physical therapist is a sensible first try! See the Section on Womens Health “Find a PT” to locate one near you.

Besides pain, what are some other reasons that folks might avoid sex?

Incontinence will certainly play a part in wanting to avoid sex. Pelvic organ prolapse is another condition that may make it uncomfortable to have sex. For both men and women there may be changes in hormonal levels that make sex not interesting, not comfortable or you may be concerned with changes that come with age. There is help for many of these things, often with coordination between your MD and the physical therapist.

What if a patient says, “I had surgery to “fix” my problem, but I still have pain, why?”

Pain is a protective response that has to do with if your brain thinks the area where your hurt is in need of defense! If you’ve had a surgery and the pain persists, it may be less about what’s happening in the area and more about protecting it – this is all outside your conscious awareness, it’s a pretty cool system and we would die without the ability to feel pain. BUT – if you are stuck in pain, then you need to get to someone who can help you figure a path back to well being. It takes training the brain and the painful area both! There is hope. We wrote a bit about it here.

Anything else you want to mention about sex?

Sex and intimacy are an important part of life. It helps us to feel connected, wanted, appreciated and it is great for your pelvic muscles. Orgasms are helpful for staying healthy!

Thanks so much, Sandy, for sharing your expertise. You can find Sandy on Twitter at @SandyHiltonPT


Top 10 Tips for Opening A Cash Based Practice


I was asked this morning to write down my top 10 tips for what to avoid when starting a cash based practice. Since I always prefer to think in terms of positive ideas, I’m answering here with my top 10 tips of what TO do! I hope that this list is helpful:

1) Get really clear on your UVP and mission. Live it, breathe it.

2) Work with an attorney to set up your articles of incorporation, LLC, and all legal documents.

3) Obtain professional liability insurance.

4) Research your location. Talk to other business owners in the area.

5) Keep overhead low.

6) Negotiate a situation where you pay only for the time you are actually using the space.

7) Build relationships with everyone in the neighborhood where your office is located.

8) Do trades with personal trainers and massage therapists so they can get a feel for what you do (and refer clients that are appropriate).

9) Start at a pace comfortable for you (keep your day job and start with one day a week, or one patient a week, or whatever is financially a good decision for you).

10) Have a website (even if it’s simple).

I love to help other therapists start their journey toward being an owner. If you found these tips to be valuable, you might want to check out my Webinar, Starting a Cash Based Practice. I cover these topics and more, to help you get on the path to building your ideal practice.

You Spin Me Round (Like A Record)

Ann bio photo-1

You Spin Me Round (Like A Record)

On a recent Saturday morning I woke up and turned over to grab my phone to see what time it was. All of a sudden WHOOMP, the whole world flipped upside down. “Uggggghhhh”, I moaned as I lay there motionless, trying to explain to my husband what I was wailing about. Vertigo.

Unfortunately, this wasn’t my first experience with Benign Paroxysmal Positional Vertigo (BPPV). I had my first bout with BPPV over 20 years ago, under the same circumstances (went to bed fine, woke up in the morning and turned over to discover the whole world flipped upside down.) At that time I had no idea what was going on. At least this time I did.


BPPV is the most common disorder of the inner ear’s vestibular system. 2.4% of people will experience it in their lifetime. Let’s first talk about the name of the disorder.

Benign indicates that it is not life threatening and generally doesn’t progress.

Paroxysmal indicates sudden onset of symptoms.

Positional refers to the fact that the symptoms usually occur with changes in head position.

Vertigo is a spinning sensation.

How does it happen?

Our vestibular organs in our inner ear consist of the utricle, saccule and 3 semicircular canals. The semicircular canals detect rotational movement of the head. When the head rotates the fluid exerts pressure against the cupula, the sensory receptor at the base of the canal. The receptor then sends impulses to the brain about the head’s movement.

BPPV occurs when the otoconia (tiny crystals of calcium carbonate that are a normal part of the inner ear’s anatomy) detach from the otolithic membrane in the utricle and collect in one of the semicircular canals. When the head is still, the otoconia settle. When the head moves, the otoconia shift. This stimulates the cupula to send false signals to the brain, producing vertigo and triggering nystagmus (involuntary eye movements). See more here.


Image here

 What causes it?

The most common cause of BPPV in people under 50 years old is trauma. About five years ago, I wiped out skiing and hit my head hard (I was wearing a helmet, thank goodness). I sustained a concussion and took a nice trip down the mountain in the ski patrol sled. Following that incident, I developed BPPV and had treatment that resolved the issue. Any impact to the head can cause BPPV, and anyone who has suffered a concussion should be evaluated for it.

In folks over 50, the cause is generally unknown. It might possibly be caused by age related degeneration of the otolithic membrane.

Sometimes the cause of BPPV is a virus affecting the ear and causing vestibular neuritis. Less commonly, it can be related to Meniere’s disease.

Ugh! What does it feel like?

BPPV most commonly occurs when going from sitting to lying down, when turning over in bed, or when looking up. The sensation of vertigo (spinning) can last from a few seconds to a minute, and can make you feel nauseous. Typically, only one side is affected, and you will feel the vertigo when turning to one side or looking up in a certain direction (hence the “positional” in the name).

How is BPPV diagnosed?

Clinically, BPPV is diagnosed by looking for nystagmus (involuntary eye movements) and vertigo when the head is placed in certain positions. This is called the Dix-Hallpike maneuver. Sometimes lab work may be ordered to rule out other causes of BPPV.

How is it treated?

When BPPV strikes, you will want to get rid of it as soon as possible (it’s that miserable). Medications are not effective in treating BPPV, as they mask the symptoms and can sometimes cause more harm (I was prescribed Meclizine, a motion sickness medication, which I didn’t take).

The most common treatment is a Cannalith Repositioning Procedure (CRP), usually called the Epley Maneuver. This treatment can be performed by a physical therapist or an ENT who specializes in vestibular issues. You will be taken through a series of four movements that move the otoconia back into the utricle, where they no longer stimulate the cuppula.

You should always have this condition evaluated and treated by a physical therapist or ENT, but I will share the steps of the Epley Manuever here:





Wait 24 hours before you perform the full sequence again.

It can be uncomfortable to go through this maneuver because it first puts you in the position that brings on the vertigo, and then you often feel the vertigo again during the repositioning. The procedure is often effective the first time, although it may need to be repeated for complete relief from symptoms. Some patients are given vestibular exercises to do at home as a follow up.

Happily, I can report that my symptoms were almost 100% resolved after doing this maneuver 2 nights in a row. The unfortunate news is that BPPV recurs in 1/3 of patients after 1 year, and in 50% of patients within 5 years. At least I know what to do if it strikes again!

Have you ever experienced vertigo? What do you do for treatment?




Creating Your Cash Based Practice

Over the past few years I’ve received countless emails, Tweets and phone calls from therapists with questions about starting and running a cash based practice. I’ve had the privilege to work one on one with some excellent therapists who are now venturing out on their own with this practice model; but, I can only help so many people at a time that way.

I’m excited to launch my first Webinar designed to help you create the practice of your dreams. Thinking Outside the Box: Creating Your Cash Based Practice was designed to answer your questions. Whether you’re starting a new 100% cash based practice, transitioning from an insurance based to cash based practice, or looking to add cash based services to your existing practice, you’ll find what you need here.



To your success!

Interview with Pedro Borrego: A Revolutionary Clinic Model


Interview with Pedro Borrego


Last week on Twitter a conversation started about Walk In or Urgent Care Centers for physical therapy, and quickly progressed to this question:




Talk to about that – he’s doing it in Spain.

We had a great conversation of over 195 comments, which led me to believe it would be well worth interviewing Pedro to find out more about what he is doing. In 1993, Pedro started the first physical therapy clinic in his town in Spain, and has grown it into a business which serves as a revolutionary clinic model for those of us in the US. I have known Pedro through social media and email for about 2 years now, and I am blown away by what he has done. I hope you enjoy the interview!



Q: First, Pedro, tell us about the education process in Spain to become a physical therapist.

A: Spain has become one of those countries in which physiotherapy education has improved since I went to University: I got my degree in 1992, a three years education in a recently established program in University of Salamanca. At that time the University didn’t offer a Master or Doctorate, so I got a foreign upgrade in General San Martin University (Argentina) and finished my first Masters degree in Healthcare Management. Nowadays this permits to me to teach as professor in the main private Distance University (UDIMA). In 2006 I reached my doctorate degree and I am preparing today a new doctoral thesis to fix the degree about physiotherapy in pelvic floor infectious and not infectious chronic diseases based in biofeedback.

Before I got my PT degree, most of PTs in Spain were also nurses, as their education program was linked to that profession. Nowadays, the evolution from 3 to 4-years education degree leads on to an independent PT Grade and direct access to Doctorate and Master Degrees.

Q: How long have you been practicing?

A: At the very first time I was sure I didn’t want to be ordered or directed by an obsolete system. Although I prepared a public examination to succeed to what it was supposed to be my first job in the National Center for Disabled Patients (and I got it!) I decided not to agree to the offer and open in 1993 Fisiomed, the first Physical Therapy center in Salamanca owned by a PT. Its 22 years now.

Q: What got you interested in physical therapy as a profession?

A: Well, it wasn’t what PT offered as a profession but as an aim to discover new perspectives in Healthcare areas, particularly in PT.

Q: Tell us about your clinic. Where is it located? How long have you been in business? Do you own the space or rent?

A: Fisiomed was open in 1993 initially as a renting place with 60 square meters in Salamanca Downtown (Spain): an office, waiting room, bathroom, two separate treatment rooms and a small gym. No one could foresee a new and bigger clinic 3 years later and just half a mile away. Today, a 500 square meters centre offers Physiotherapy, Orthopedic Surgery, Ophthalmology, Podiatry, Aesthetic Surgery, Speech Therapy, Psychology, and 3D-4D ECO imaging for pregnant women.

Q: Explain the model of the clinic. What other healthcare providers work with you? Are you all part of the same business? How do you all work together? Are the other HCPs contractors?

A: The clinic is sustained in two main business models adapted to Spanish laws: self-employed and LLC (limited liability company). Health Ministry only allows HCPs to practice as a self-employed in the field related to your university degree, but LLC raises the views to work with other HCPs. And that’s what I did: LLC was founded by just one associate as CEO… and the same one a self-employed in PT.

The offers came quite soon: A surgeon leading the aesthetics procedures in Madrid but born in Salamanca, was impressed by the new Center, and then we signed the first contract.

All administrative staff and Physical Therapists are hired directly by the LLC, and they work as employers.

The others HCPs can choose between three open models: they are self-employers which lend a service to the LLC by renting a limited space by a fixed but flexible schedule by week (monthly payment), a percentage in benefits, or both systems. We make a market survey before we close the agreement and we value the proper model based in the specialty and interests of both LLC and HCP. We never duplicate two same HCPs unless they come as a team (like Orthopedic Surgeons do) but hiring the PTs allows me not to have to apply that rule in that unit.

But all HCPs in the clinic, including hired ones, are free on their professional decisions and duties under a manager’s baton to make things work properly, helped by administrative staff and a complex computer program which controls agendas, payments, percentages, patients, clinical history, providers, stocks, and logistics. The success doesn’t come from that, but from a personal and humane treatment and careful relations with patients and providers.

Q: What is the payment model in Spain? Do people use health insurance? Private or government funded? How do you get paid for treatment?

A: Private clinics work directly with patients. Most of them, like FISIOMED does, attend patients which use their private health insurances. Some of them, like members of the National Police or the Army, use their government funded insurance companies according to yearly accords with public statements like Ministries or regional/local public boards. The insurances pay monthly according to fixed rates accepted by providers.

We do also receive patients from traffic crashes who don’t have to pay anything at all as we are in an agreement with National Insurance Union managed by a web-based app that register the accident, the injuries suffered by driver and occupants, authorizations for clinical procedures (Ortho, PT, Xray) and assure the applicable payments coming from the insurance of the involved vehicles.

Q: In what way are each of the HCPs paid? Percentage? Salary? Per patient?

A: It depends on the model we fixed: renting pays a monthly amount, percentages goes from 20 to 35 % of rates, and mixed model reduces the rent and percentages to minimum with variable sums in each months depending on HPC activity. PTs and office staff receive a fixed salary.

Q: How do you market your clinic and services?

A: The beginning was costly higher than now, but marketing and publicizing is a must to be on the crest of the wave. It has obviously been a radical change in this, as 20 years ago there were no Twitter or Facebook, but our main power is our own patients.

Q: Do physical therapists need a physician referral to see a patient in Spain?

A: No. We do receive patients in a direct access system. This changes if we talk about insurances or Public Health. Reimbursements are compulsory justified by physician referral; insurances allow referral from any medical specialty; Public Health requires a referral from rehab-physicians except from Primary Care which referrals to physiotherapy come from PC Physicians integrated in the called PC Team.

Q: What has been the biggest surprise about this whole venture?

A: ¿Positive or negative? ;) Let’s mention the first choice: the daily satisfaction to lead a team whose work turns into results in a better life for our patients.

Q: Where do you see the business heading in the next 5 years? Any big plans?

A: My head is continuously working and we are right know involved in both projects about computer assisted exercise program and iris laser aesthetic treatment to be included in our services. We just want to keep our MVV set and offering our best to patients and team members.

Q: What is the best piece of advice you can give someone who wants to start this model of business?

A: Be yourself, set your goals, never underestimate your rivals, and have a head for everything you decide to do.


Thanks so much to Pedro for taking the time to answer my questions. What do you think about this clinic model? What questions do you have for Pedro? Please leave comments and questions below.


Mailing List Sign Up!

Social Media


109 S. Alfred St
Alexandria VA, 22314
P 571.527.9192
F 866-936-3598

cialis online