In the United States, estimated direct medical costs for outpatient visits for chronic pelvic pain (CPP) is more than $2.8 billion per year.1 In a 2017 study in the Clinical Journal of Pain by Sanses et al, a detailed musculoskeletal exam of clients with CPP can assist both physicians as well as physical therapists in differential diagnosis and appropriate referrals for this population.
Evaluating a client with pelvic pain requires a skill set that includes direct pelvic floor as well as musculoskeletal test item clusters. The prioritization of which depends upon many factors including clinician discipline, experience, specialty vs. general setting, as well as client history, presentation and goals. In addition to the direct pelvic floor assessment, there are additional key musculoskeletal screening tests that are an essential part of a pelvic pain assessment. New this year, my course Finding the Driver in Pelvic Pain will incorporate the use of Real Time Ultrasound in neuromuscular assessment and re-education of the pelvic floor and abdominal wall during the Sunday morning lab session.
Peery et al (2012) noted that abdominal pain was one of the most common presenting reasons for an outpatient physician visit in the United States. Abdominal pain is one of the many complaints that our clients may report requiring differential diagnosis including urogynecologic, colorectal, musculoskeletal, visceral or neurogenic causes. Lower abdominal quadrant pain may denote serious emergent pathology. Clinical findings, physical exam and client symptoms in addition to smart differential diagnosis must be used to determine if the abdominal pain is musculoskeletal in nature. Direct access requires physical therapists to perform a skilled initial screening for abdominal pain in order to determine if it is abdominal wall versus a visceral origin. Physicians are fluent in ruling out emergent pathology but may not be familiar with musculoskeletal tests for non-emergent pathology. Assessment of bowel and bladder function and habits are essential to perform. This blog specifically addresses three physical exam tests that can be performed as part of abdominal wall pain screening. According to Cartwright et al, the location of the abdominal pain should drive the evaluation.
Carnett’s test is a simple clinical test that assesses abdominal pain response when a client tenses their abdominal muscles. A positive Carnett’s sign denotes the origin of symptoms within the abdominal wall with a negative tests suggesting intra-abdominal pathology. The test is performed in supine, the clinician gently palpating the area of abdominal pain and has the client lift their head and shoulders off the table. Conditions such as myofascial trigger points, scar and muscular pain would be flared with palpation of the contractile tissue with activation of the abdominal wall muscles. If the pain is due to visceral origin, appendicitis for example, the pain would remain unchanged with palpation with head lift. Although some perform Carnett’s test by lifting both legs off the table, this method may cause unnecessary pain in clients with poor lumbopelvic control. (Figure 1) The head and shoulder lift option is felt to be comparable method of performing Carnett’s test.
Blumberg’s sign is most commonly used to rule in appendicitis, peritonitis or a visceral driver of right lower quadrant pain. The test is performed by the clinician applying deep pressure over McBurney’s point (Figure 2) with an abrupt and rapid release of pressure. Although there are anatomical variations in appendix location, pain reproduction is consistent with a positive test and immediate referral to the ER is indicated.
Thoracic dysfunction, including disc herniation, can result in abdominal pain.2 In thoracic discogenic driven abdominal pain, symptoms would likely be exacerbated by coughing, sneezing, spinal flexion and activities that would increase spinal loading. A simple screening for this is seated thoracic traction. If the client reports reduction or resolution of symptoms with traction, further musculoskeletal tests including regional movement and PIVM testing could be implemented to rule in or rule out need for diagnostic imaging.
In the Herman Wallace course “Finding the Driver in Pelvic Pain” participants learn a comprehensive musculoskeletal screen including abdominal, neural mobility and conductivity, pelvic ring, pelvic floor and biomechanical contributing factors to pelvic pain. Evidence based test item clusters are defined, along with their diagnostic accuracy, for all associated systems in order to outline a comprehensive screen for pelvic pain clients. To learn more about musculoskeletal screening for pelvic pain, check out faculty member Elizabeth Hampton PT, DPT, WCS, PRPC, BCB-PMD’s course Finding the Driver of Pelvic Pain, which is next offered Jun 28, 2019 - Jun 30, 2019 in Columbus, Ohio. We are fortunate to have Dick Poore, President of The Prometheus Group present on Sunday June 30th for technical support for the Real Time Ultrasound portion of the course.
1. Sanses et al. "The Pelvis and Beyond: Musculoskeletal Tender Points in Women with Chronic Pelvic Pain". Clin. J. Pain. 2016 Aug. doi: 10.1097/AJP.0000000000000307
2. Papadakos et al. "Thoracic Disc Prolapse Presenting with Abdominal Pain: Case Report and Review of the Literature". Ann. R. Coll. Surg. Engl. 20019 Jul. doi: 10.1308/147870809X401038
Earlier diagnosis is clearly a huge need for patients with pelvic floor dysfunction. Many patients suffer with their symptoms for years before even hearing the words “pelvic floor,” or realizing that a pelvic floor physical therapist may be able to help. For interstitial cystitis, one large survey article found fewer than 10% of patients with the condition had been correctly diagnosed with IC, even after years of symptoms and visits with multiple doctors.
Even after being diagnosed, patients still don’t learn about how the pelvic floor can be causing or exacerbating their symptoms. In one study of our interstitial cystitis patients, 46% learned about the importance of the pelvic floor on their own and sought out treatment independently, while nearly half felt they were referred by their physician to physical therapy far too late, as a ‘last resort.’ This is despite the fact that many of these patients had seen five or more physicians and physical therapy is considered the most proven treatment for IC by the American Urological Association.
Physicians, orthopedic physical therapists, other practitioners, and patients themselves need a simple, proven way to identify pelvic floor dysfunction to help patients find pelvic floor physical therapy earlier in their medical journey.
In a large survey of our patients with confirmed pelvic floor dysfunction, we examined what symptoms and medical history was most closely correlated with pelvic floor dysfunction. Any screening questionnaire would ideally be able to identify a wide variety of pelvic floor dysfunction, including patients with chronic pelvic pain, pelvic organ prolapse, orthopedic pain with a pelvic floor component (low back, hip, groin), urinary urgency/frequency, and/or bowel dysfunction.
While these patients all had different medical diagnoses, many symptoms were common across the patient population. The most common were pelvic pain (84%), urinary urgency, frequency, or incontinence (81%), orthopedic pelvic pain (71%) and symptoms that worsen with prolonged sitting (68%).
Based on the survey results, we created the Cozean Pelvic Dysfunction Screening Protocol to screen for pelvic floor dysfunction and published the results in the International Pelvic Pain Society (2017). The goal was to correctly identify more than 80% of the patients with pelvic floor dysfunction (sensitivity). For ease of use by both practitioners and patients, the questions were phrased so they could be answered with a simple ‘yes/no’ (as a check box). If patients answers ‘yes’ to 3 or more of the questions, pelvic floor dysfunction is highly likely.
In a model like this, we would expect a normal (bell-shaped) distribution curve of answers from patients with pelvic floor dysfunction. Some patients will score on the high end, others on the low, and the majority would be clustered in the middle. This is what we observe with use of the questionnaire, as seen by the trendline in the blow graph. Most patients with confirmed pelvic floor dysfunction cluster in scores between 3 and 7, with a few scoring at 8 or higher. Less than one out of ten patients with pelvic floor dysfunction score below a 2 on the questionnaire and would not be captured by this measure.
Specificity: 91%. More than 90% of patients with confirmed pelvic floor dysfunction were correctly identified by this screening protocol. Additional testing is required on a general population without PFD to determine the specificity of the questionnaire.
Average: 5.2. Of patients with confirmed PFD, the average score according to this screening protocol was 5.2 with a median score of 5 and a mode of 6. This is in line with what would be expected with a normal distribution curve.
We hope this 10-question survey is able to help patients with pelvic floor dysfunction be diagnosed earlier - whether by their physician, other physical therapists, or themselves – and seek pelvic floor physical therapy earlier in their medical journey. Please feel free to use the printable version of this protocol with your patients or in working with local practitioners.
Nicole Cozean will be teaching the course Interstitial Cystitis: Holistic Evaluation and Treatment in Princeton, NJ from April 6-7, 2019.
Nicole Cozean is the founder of PelvicSanity physical therapy, in Orange County, California. Nicole was named the 2017 PT of the Year, is the first physical therapist to serve on the ICA Board of Directors, and is the award-winning and best-selling book The Interstitial Cystitis Solution (2016). She is an adjunct professor at her alma mater, Chapman University and teaches continuing education courses through the prestigious Herman & Wallace Institute.
I’m Elizabeth Hampton PT, DPT, WCS, BCB-PMD and I teach “Finding the Driver in Pelvic Pain”, which offers practitioners a systematic screening approach to rule in or rule out contributing factors to pelvic pain. This course helps clinicians to understand and screen for the common co-morbidities associated with pelvic floor dysfunction, like labral tears, discogenic low back pain, nerve entrapments, coccygeal dysfunction, and more. Importantly, it also coaches clinicians to organize information in a way that enables them to prioritize interventions in complex cases. I've noticed that there are some questions that course participants frequently have as they talk through common themes in their care challenges and wrote this blog to share some clinical pearls you may find to be helpful for your own practice or as an explanation to your clients.
Here are some of the most common questions that I get when teaching Finding the Driver in Pelvic Pain:
1) Question: How do I even start to organize information when a client has a complex history and I am feeling overwhelmed?
I write down a road map with key categories: Bowel and bladder; Spine; Sacroiliac Joint/Pubic Symphysis; Hip; Pelvic floor muscles; biomechanics; respiration; neural upregulation; whatever details can be fit into ‘big buckets’ of information. I use it to both organize my thoughts for my notes, as well as educate the client as to what my findings are and the design of their treatment program.
2) Question: How do you get your clients to do a bowel and bladder diary?
I am proud to say that I can talk anyone into a 7 day bowel and bladder diary because I tell them how incredibly helpful it is to understand the way their body responds to what they eat, drink, and daily habits. It’s my secret weapon to snag clients to start connecting with their body and listening to their details, educate about defecation ergonomics and what happens in multiple systems when there is pelvic floor overactivity. It’s a great teaching tool that facilitates self-reflection and how their self-care choices impact their body’s behavior.
3) Question: How do you educate clients about pelvic floor function so they don’t focus so much on Kegels?
Pelvic floor muscles do three things:
They contract gently, or powerfully, with no discomfort, and totally normal breathing; PFMs should have the same kind of nuanced control like your voice does: they should be able to do a gentle contraction, like a “whisper” or a powerful contraction, like a “shout”, depending on the task position and intent.
They relax fully and completely when the body is resting in support, or they should be able to relax to a supportive level when they are needed posturally. Relaxation should be its own celebrated event!
They should be able to relax and gently lengthen.
Faculty member Elizabeth Hampton PT, DPT, WCS, BCB-PMD is the author and instructor of Finding the Driver in Pelvic Pain, a course designed to help practitioners utilize differential diagnosis in evaluating pain. Join Dr. Hampton in Portland, OR on July 27-29, 2018 or November 2-4, 2018 in Phoenix, AZ.
Dr. Nicole Cozean was just awarded the IC/BPS Physical Therapist of the Year by the IC Network, one of the largest patient advocacy groups for interstitial cystitis! Today she shares her treatment approach for this complex dysfunction. Join Dr. Cozean in San Diego on April 28-29, 2018 to learn everything there is to know about interstitial cystitis.
Interstitial cystitis (IC) is a chronic pelvic pain condition characterized by pelvic pain and urinary urgency/frequency. IC is frequently accompanied by other symptoms1, including painful intercourse, low back or hip pain, nocturia, and suprapubic tenderness.
While pelvic floor physical therapy is the most proven treatment for interstitial cystitis, most patients require a multi-disciplinary approach for optimal results. The majority are forced to develop this holistic approach on their own, but one of the most valuable things a physical therapist can provide is assistance in creating their own unique treatment plan. The American Urological Association has released treatment guidelines for interstitial cystitis, and potential treatments fall into several different categories. It is important to note that most treatments aren’t effective for the majority of patients, so a trial-and-error approach is needed to find the right balance for each patient. Tracking symptoms with a weekly symptom log can be a powerful tool to optimize the individual treatment plan.
Oral medications are primarily used to reduce pain.Anti-depressants can dampen the nervous system, decreasing the severity of pain reported. Anti-histamines have also been shown to be effective in reducing the pain and symptoms of interstitial cystitis, perhaps because of their ability to reduce inflammation and break the cycle of dysfunction-inflammation-pain (the DIP cycle). Some patients require opioid painkillers for adequate pain control.
Urinary tract analgesics can provide temporary pain relief for some patients, but cannot be taken consistently because they thicken the urine and strain the kidneys. Some patients find success using these medications (Azo, Pyridium, Uribel) during severe pain flares.
The only FDA-approved oral treatment for interstitial cystitis is Pentosan Polysulfate (PPS, Elmiron®). This is commonly prescribed to patients after an IC diagnosis, but has been shown to be effective in only 28-32% of patients. It also requires a long time (often 6-9 months) to build up in the system and take effect, and many patients stop taking the drug before they could see effect because of side effects (including hair loss) or cost. Unfortunately, many patients lose more than a year after their initial diagnosis waiting to see if Elmiron will work for them, when it is unlikely to provide complete relief.
Antibiotics should never be prescribed for IC in the absence of a confirmed infection.
Bladder instillations deliver numbing medication directly to the bladder through a catheter and can provide temporary pain relief for some patients. If these are effective, they typically are repeated at least weekly as symptoms return. Some patients don’t tolerate the catheterization well, finding the procedure causes more pain than it prevents. Typical bladder instillations consist of Lidocaine, Heparin, or a combination of the two.
Another route of treatment works by artificially stimulating the nerves the innervate the bladder and pelvic floor.Percutaneous tibial nerve stimulation (PTNS) directs electrical impulses from the ankle up through the pelvic floor. This is an outpatient procedure typically performed weekly for a course of 12 weeks. A more permanent option is implanting a device under the skin of the buttock to target the sacral or pudendal nerve root directly.With this procedure, the patient is given a ‘trial run’ with an external device to see how it performs. If significant improvements are noted, the device can be permanently implanted.
Many patients see marked improvement in their symptoms with a home care program. Deep breathing or meditation can calm the nervous system and reduce the amplifying effect of an upregulated nervous system. A stretching regimen targeting the inner thighs, glutes, abdomen, and pelvic floor can relax muscles and reduce nerve irritation in the region. Self-massage can find and eliminate the trigger points that are causing symptoms. Home tools like a foam roller can address external trigger points, while patients can be taught internal self-release with the help of a tool like the PelviWand or another tool.
One of the most common misunderstandings about IC centers on the ‘IC Diet.’ In fact, there’s no such thing. While nearly 90% of IC patients report that diet influences their symptoms in some way, the scope and severity of dietary triggers varies greatly between patients. There are a few common culprits - coffee, tea, citrus fruits, artificial sweeteners, tomatoes, cranberry juice - but no guarantee that a patient will be sensitive to all (or any) of these. Many patients read about an ‘IC Diet’ online after receiving their diagnosis, and are convinced that they need to cut out a huge portion of their diet.
Instead, they should be doing an elimination diet focused on identifying their trigger foods.With this approach, they eliminate most of those common culprits and see how it affects their symptoms.If they notice an improvement, they can gradually add foods back into their diet, one at a time, until they see symptoms increase again. This allows patients to identify their specific trigger foods.
Our advice for IC patients is simple - avoid your trigger foods and eat healthy. It doesn’t have to be any more restrictive than that.
There are also several supplements that have shown benefit for patients, either in clinical trials or anecdotally. Prelief (calcium glycerophospate) is an antacid that may reduce the consequences of eating a trigger food. L-Arginine is a semi-essential amino acid that facilitates blood flow and vasodilation; in clinical trials it was shown to be effective for nearly 50% of patients in reducing pain and urinary symptoms. Aloe Vera pills are used by many patients, and thought to help replenish the bladder’s protective layer. Finally, a combination of supplements known as Cystoprotek is also a common supplement taken by IC patients, combining anti-inflammatory flavonoids with molecules that may reinforce the bladder lining.
Acupuncture has been shown to provide relief for pelvic pain patients2, with 73% of men with chronic prostatitis (either identical or closely related to IC) reporting improvement. These men received two treatments weekly for six weeks, focusing around the sacral nerve. Women with pelvic pain and painful intercourse have also reported improvements in pain with 10 sessions of acupuncture3.
Cognitive-Behavioral Therapy (CBT) has been shown to help reduce pain in conditions as diverse as cancer, low back pain, and pelvic pain. In pelvic pain, ten one-hour sessions of CBT was shown to provide significant benefit for nearly half of patients4. Supportive psychotherapy was also shown to have benefits for pelvic pain patients.
A multi-disciplinary approach provides the best results for patients. Physical therapists, who see our patients regularly, can be a great resource in suggesting additional treatment options. The American Urological Association IC Guidelines can be an important resource in guiding patients to other options and developing their unique treatment plan.
For additional patient resources available for download, feel free to visit The IC Solution page.. In our upcoming course for clinicians treating interstitial cystitis (April 28-29, 2018 in San Diego), we’ll focus on the most important physical therapy techniques for IC, home stretching and self-care programs, and information to guide patients in creating a holistic treatment plan.
1. Cozean, N. "Pelvic Floor Physical Therapy in the Treatment of a Patient with Interstitial Cystitis, Dyspareunia, and Low Back Pain: A Case Report". Journal of Women's Health Physical Therapy. 2017
2. Chen R, Nickel JC. "Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome"Urology. 2003 Jun;61(6):1156-9; discussion 1159.
3. Schlaeger, J, et al. "Acupuncture for the Treatment of Vulvodynia: A Randomized Wait‐List Controlled Pilot Study". Journal of Sexual Medicine. 30 January 2015. https://doi.org/10.1111/jsm.12830
4. Masheb, et al. "A randomized clinical trial for women with vulvodynia: Cognitive-behavioral therapy vs. supportive psychotherapy". PAIN® Volume 141, Issues 1–2, January 2009, Pages 31-40
I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).
From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).
People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.
Let’s talk briefly about Trauma Informed Approach
This is a (person), program, institution or system that:
The Tenets of Trauma Informed Approach
Trauma Specific Interventions
Types of trauma are varied but I usually treat survivors of emotional, verbal, sexual and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgement). Since most of my clinical experience include sexual and medical trauma survivorship, I try to reframe these experiences as potential Post Traumatic Growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.
First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation and other mechanisms of coping with the trauma. Have a plan ready for these patients.
Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:
After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Making healthy boundaries (with patients and others), taking time to decompress, creating healthy ritualistic behaviors, mindfulness/relaxation and somatic release (like yoga, massage or working out) is crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.
Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my new course implements evidenced based trauma sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma Informed Approaches of Safety, Trustworthiness and transparency, Peer support, Collaboration and mutuality, Empowerment, voice and choice and Cultural, historical and gender issues.
Join me in Trauma Awareness for the Pelvic Therapist, next available this March in Albany, NY.
Recently, a note was left at my doorstep by the wife of an older gentleman who had chronic male pelvic pain. His pain was so severe, he could not sit, and he lay in the back seat of their idling car as his wife, having exhausted all other medical channels available to her, walked this note up to the home of a rumored pelvic floor physical therapist who also treated men. The note opened with how she had heard of me. She then asked me to contact her about her husband’s medical problem. It ended with three words that have vexed me ever since…we are desperate.
Unlike so many men with chronic pelvic pain, he had at least been given a diagnostic cause of his pain, pelvic floor muscle dysfunction, rather than vaguely being told it was just a prostate issue. However, the therapists that had been recommended by his doctor only treated female pelvic dysfunction.
My first thought after reading the note was, “I bet shoulder or knee therapists don’t get notes like this on their doorstep.” My next thought, complete with facepalm, “THIS HAS TO STOP! Pelvic floor rehab has got to become more accessible”.
Pelvic floor therapists see men and women and even transgenders. They treat in the pediatric, adult, and geriatric population. They treat pelvic floor disorders in the outpatient, home health and SNF settings. They treat elite athletes and those with multiple co-morbidities using walkers. They can develop preventative pelvic wellness programs and teach caregivers how to better manage their loved one’s incontinence. This is due to one simple fact: No matter the age, gender, level of health or practice setting, every patient has a pelvic floor.
The pelvic floor should not be regarded as some rare zebra in clinical practice when it is the workhorse upon which so many health conditions ride. It interacts with the spine, the hip, the diaphragm, and vital organs. It is composed of skin, nerves, muscles, tendons, bones, ligaments, lymph glands, and vessels. It is as complex and as vital to function and health as the shoulder or knee is, and yet students are lucky if they get a “pelvic floor day” in their PT or OT school coursework.
I call for every therapist, specialist, and educator to learn more about the pelvic floor. Here are some steps you can take today toward eliminating the need for such a note to be written.
Contact every PT clinic, every SNF, every doctor, every nurse, every chiropractor, every acupuncturist, every massage therapist, every personal trainer, every community group and let them know! If you have already told them, tell them again. Send a one page case study with your business card. Host a free community health lecture at the library or VFW hall. Keep the conversation going. Reach out to your local rehab or nursing school programs and volunteer to speak to the students. Feature pelvic health topics in your clinic’s social media stream. Get on every single therapist locator that you can so people can find you. Click here to go to the Herman and Wallace Find a Practitioner site.
The guys really need your help. You literally may be the only practitioner around that has the skills to treat these types of problems. Yes, the concerns you have about privacy and feeling comfortable are valid. But, you are not alone in this. Smart people like Holly Tanner have figured all that stuff out for you and can guide you on how to expertly treat in the men’s health arena. Sign up for Male Pelvic Floor or take an introductory course online at Medbridge. If you have only taken PF1, it’s time to sign up for Pelvic Floor Level 2A: Function, Dysfunction and Treatment: Colorectal and Coccyx Conditions, Male Pelvic Floor, Pudendal Nerve Dysfunction. Reach out to other pelvic floor therapists that treat men and ask for mentorship.
Good news! Not every pelvic floor course requires you to glove up and donate your pelvis to science, so to speak. Yes, there are several external only courses you can take that do not have an internal examination lab. Click here and look under “course format” to see a list of external only courses. If you treat in the outpatient, ortho, or sports medicine arena, consider taking Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System or the Athlete and the Pelvic Floor .
If you treat in the Medicare age population, work in skilled nursing, or home health, join me in New York on May 21-22 for Geriatric Pelvic Floor. It is an external course and we cover documentation and self-care strategies extensively for incontinence and pelvic pain in older adults across multiple settings. Older adults with pelvic pain, like the man in the back seat, are at risk for being diagnostically ignored. We will address biases, such as “prostato-centric” thinking, ageism, and the ever-present “no fracture no problem” prognosis given to seniors who sustain a fall, but are left with disabling soft tissue dysfunction.
Sorry, but it sounds silly. It’s like saying you offer a “Knee Day” in your program. Replace it by including the pelvic floor into Every. Single. Class…anatomy, ther ex, neuro, peds, geriatrics, and even cardiopulmonary!
As the baby boomer population grows, pelvic floor disorders are expected to rise significantly (download a free white paper on pelvic floor trends here). Are you preparing your doctorate students to be competent screeners of pelvic floor dysfunction? Pelvic floor rehab is becoming the gold standard of first line treatments for pelvic dysfunction. Are you giving your students the skills to be competitive in a job market that recognizes pelvic floor rehabilitation as standard of care? Bias is learned. Excluding the pelvic floor in your student’s coursework or presenting it as a niche specialty subtly reinforces this bias.
Reach out and ask your local pelvic floor therapists to guest lecturer throughout the program. Send your instructors to pelvic floor courses. Encourage your students to take Pelvic Floor Level 1 in their last 6 months of coursework. Offer a clinical rotation in pelvic floor rehabilitation. Include case studies and patient perspectives on pelvic dysfunction, such as A Patient’s Pelvic Rehab Journey.
Thanks to the champions of pelvic floor rehab education, we’ve come a long way. The good news in this story is that this man’s doctor recognized early that he had pelvic floor muscle dysfunction and recommended that he see a pelvic floor physical therapist. The bad news-it took 2 years before he could find one. The ball is in our court, therapists. Let’s do better. Until there are no more men in the back seat, we still need to #LearnMoreAboutThePelvicFloor.
Congratulations to Dr. Sarah Capodagli, DPT, our featured practitioner of the week! Dr. Capodagli owns and operates CorrEra Physical Therapy, and she is in the process of expanding her practice in Buffalo, NY. We were curious to hear more from her about running a practice in Buffalo, and Sarah was kind enough to write in. Thanks, Sarah!
Although Buffalo is considered the second largest city in the state of New York, we often operate like a small town. We value community and for just about any business, the best marketing tool is word of mouth. If you need a new roof, new car, or a good doctor, well, ask around and I guarantee that you will find someone who “knows a guy,” to help or advise. I cannot speak for every city, though when I think of Buffalo, NY, I think of family. When you see your family in need, you help.
A few years ago I was working in a large oncology hospital and one of my primary roles was running the pelvic floor rehabilitation program for men living with or being treated for prostate cancer. I loved this work; however, I saw greater need in our community for not only the proper conservative care and treatment, but also for the information about pelvic health to be shared more publicly with men and women. Although opening my own clinic in a suburb of this “City of Good Neighbors” was not always the plan, when given the opportunity to grow into my own practice by a chiropractor friend, I jumped at the chance and have never looked back. It was a big jump, but for me, the fear of regret in never trying was so much worse than the fear of failure.
The greatest challenge was in actually starting my practice and beginning to educate the community and physicians. In a larger metropolis there is more awareness of this specialty and referrals come more naturally when conservative options are made known to patients. In the beginning I reached out to a mentor, utilized many tools available on the Herman & Wallace website, held free community events, and spent my first few months focused on networking. Once introduced to some fabulously conservative docs, birthing professionals, and physical therapists who were aware of the benefits of pelvic floor rehab, I really started to see the growth. I became an advocate for patients – a navigator in this sometimes confusing and frustrating system. People want conservative options and when happy patients return to their physicians with improved symptoms and quality of life, well, now your reputation establishes you as one of the “go-to” practitioners in the community.
Though patience and persistence are crucial in this process of growth, I’m also a firm believer that, as Dr. Francis Peabody stated, “the secret of the care of the patient is in caring for the patient.” This belief is what sets me apart, and in a small community this is what really matters. One of my favorite books is The Go-Giver by Bob Burg and John D. Mann. I always want my practice and the growth of my business to reflect the strategies of value, service, influence, and authenticity emphasized in this story. In a community where community is valued, I truly believe that if you stay teachable and positive, the care you put into your practice will always pay off.
The following post comes to us from Herman & Wallace faculty member Tina Allen, PT, BCB-PMD who teaches many courses with the institute. Tina's new course, Manual Therapy Techniques for the Pelvic Rehab Therapist, will be debuting this October in San Diego, CA.
As a physical therapist who has been treating pelvic floor dysfunction for 20 years, the patient who still impacts me the most happens to be the second patient I ever treated. The patient was a 22 year old woman who, before she even was referred to me for pelvic pain, had already seen 14 medical providers and experienced 10 procedures including a hysterectomy. She had been told by more than half of her providers that this pain was “in her head”, that “she needed counseling”, and that there was no reason for her pain. With 4 years of clinical experience at the time, I felt discouraged and wondered how I was going to help her. Then I remembered that no one else could look at her muscles and biomechanics like a PT could.
I started out by educating her about the muscles “down there”, observed how she moved with her daily tasks and then I completed her seemingly first ever muscular evaluation of the perineum. After 6 sessions of down training, muscle reeducation, manual therapy, strengthening of her hip and teaching her how to self mobilize the tissues of the perineum, she reported a pain level of 3/10- the lowest her pain level had been since she was 13 years old! Of course, she asked why it took so long for her to be referred to PT.
While this felt like an extreme story to me at the time, I now know that this is still the reality for many of the clients that we work with as pelvic floor PT’s. This experience set up the aspiration for me to have medical residents in my clinic with me to teach them what PT can do for patients and so that the residents can better evaluate their patients. As pointed out in research in the Journal of Graduate Medical Education, residents in obstetrics and gynecology do not feel adequately prepared to manage the care of women who have chronic pelvic painWitzeman & Kopfman, 2014. Specifically, residents reported negative attitudes towards patients with pelvic pain, and feelings of not having enough time to address their patients’ needs. When asked about how they preferred to learn more about care of patients with pelvic pain, the residents were interested in one-on-one clinical teaching as well as use of diagnostic algorithms. At this point in time I have medical residents with me at least 2 days per month. It’s a start!
So, what does a typical day look like with a 1st year OB/GYN resident in your clinic?
First, I always do my best to let my clients know in advance that a physician will be with me that day. The patient can always decline but most patients are accommodating. I have found that most of our patients want to advocate for themselves and others by having that physician with us in our session to teach them about how PT has helped them.
I spend the first 30 minutes when the resident arrives by bringing out the pelvic floor muscle model and explaining the function of all the muscles and how those muscles impact function. I also describe how this function is impacted by fascia, the muscles of the trunk, biomechanics and mind/body connections. Then we start seeing patients. After I have reviewed the patient’s current status, we begin our session. The patient is asked to give the resident their history and medical history. It’s been wonderful to watch my patients teach the residents and to hear the patients be able to explain their condition including procedures and functional restrictions.
The residents will then be instructed to palpate and learn about restricted tissues, observe how the patient uses their pelvic floor muscles, core, trunk and legs with their daily tasks. The residents have the opportunity to observe how we progress the patient’s self care in therapy.
While the session may start with the resident feeling frustrated that they are not able to be seeing their own patients or preparing for their tests, it usually ends with the resident asking when they can come back to the clinic to learn more about what we do and how we can help patients.
I urge all of us to reach out and invite physicians, PA’s, ARNP’s, midwives, naturopaths and nurses into our clinics to learn. With a little advanced planning we can get patients the help they need as soon as possible.
Witzeman, K. A., & Kopfman, J. E. (2014). Obstetrics-Gynecology Resident Attitudes and Perceptions About Chronic Pelvic Pain: A Targeted Needs Assessment to Aid Curriculum Development. Journal of graduate medical education, 6(1), 39-43.
Herman & Wallace Pelvic Rehabilitation Institute faculty member, Ginger Garner PT, L/ATC, PYT, will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more. Read below as Ginger shares why the voice is a linking science.
Your voice can be the key to your success. Forbes magazine’s #3 habit in an article, Five Habits of Highly Effective Communicators, is “Find your own voice.” London’s think tank Tomorrow’s Company declares in a recent report on efficacy in business leadership, “Having a voice really matters for employees today.” The director of the Involvement and Participation Association (IPA) and vice-chair of the London-based MadLeod Review on employee engagement says, “Voice is extremely important because there are many changing business concepts and one of the essential ones is trust. Our voice is one of the things we really need to change old management paradigms and build trust in an organization.”
If you are an instructor, teacher, educator, therapist, or all four, having a voice is synonymous with having a job. You can’t do your job without a voice. And yet, we don’t spend much time thinking about vocal physiology, much less how to maintain and even improve it.
The most powerful change agent or therapeutic modality you have - is your voice. Yet, the voice is often overlooked as a therapeutic tool. Think of how important it is for someone giving a TED talk to have good vocal quality, for example. Now consider how important it is for others, like you, who may have to speak for hours on end each day. The vocal folds must be cared for just like we attend to the mind and body during postural yoga practice or movement therapy.
What were the other findings of the report?
The power of the voice cannot be ignored, particularly for those who have allergies, respiratory issues, or struggle to make a powerful impact or to establish themselves as an effective team member or thought leader. Oftentimes, the voice is the single variable that holds us back from making the success we are seeking in our work. US News World and Report states,
“Whether you are an aspiring leader or in a support role, developing your communication skills can impact your success. First, let’s take a look at the complexities of communication. It's more than the words you use. It's how and when you choose to share information. It's your body language and the tone and quality of your voice.”
Psychology Today and National Public Radio have recently reported on the relationship between vocal quality and job success and effectiveness. Both agree that speech rate, tone of voice, facial expression, and diction have a great deal of power to make or break effective communication. If tone doesn’t match facial expression, for example, neural dissonance occurs, which erodes trust, increase skepticism, and cooperation.1 In fact, warm vocal tone is a sign of transformational leadership, which generates “more satisfaction, commitment, and cooperation between team members”.2 Changing pitch increases therapeutic potential and improves the chances of your being understood by colleagues, especially when diction is congruent with emotion.1 Additionally, training mindfulness during public speaking can improve prefrontal cortex activity, which allows for improved social awareness, mood-regulation, decision-making, and empathy.4 Vocal awareness and training can slow your pace of speaking, which is shown to deepen others’ respect for you and simultaneously calm anxiety, traits which are bridge-building and healing for all relationships, business and personal.
MISTY is a not-for-profit organization and event dedicated to teaching others about therapeutic yoga.
Ginger’s workshop, “Vocal Liberation,” will introduce techniques for developing and preserving the voice, including projection, quality, longevity, and therapeutic impact through fusion of nada yoga and ENT physiology, which Ginger has developed over her career in public speaking and vocal performance. Want to learn about therapeutic yoga at MISTY? There’s still time to join Ginger and a host of other talented speakers and therapists. Learn more and register at http://www.homyogaevents.com.
Use of affective prosody by young and older adults. Dupuis K, Pichora-Fuller MK. Psychol Aging. 2010 Mar;25(1):16-29.
Leadership = Communication? The Relations of Leaders' Communication Styles with Leadership Styles, Knowledge Sharing and Leadership Outcomes. de Vries RE, Bakker-Pieper A, Oostenveld W. J Bus Psychol. 2010 Sep;25(3):367-380.
Short-term meditation training improves attention and self-regulation. Tang YY, Ma Y, Wang J, Fan Y, Feng S, Lu Q, Yu Q, Sui D, Rothbart MK, Fan M, Posner MI. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17152-6.
The following insight comes from Herman & Wallace faculty member Peter Philip, PT, ScD, COMT, PRPC, who teaches Differential Diagnostics of Chronic Pelvic Pain: Interconnections of the Spine, Neurology and the Hips for Herman & Wallace, as well as the Sacroiliac Joint Evaluation and Treatment course. Peter has been working with pelvic dysfunction patients for 15 years, and he has some insights and advice for male practitioners who are nervous about treating female patients.
As a male treating female patients suffering with pelvic pain, many considerations must be taken to ensure that the patient is comfortable partaking in the patient/clinician relationship. As clinicians treating the most intimate of pain, we all must be highly aware of the sensitivities that each of our patients has as it relates to their genitalia. Many patients wish to maintain their modesty while simultaneously wishing to eliminate that which is ailing them. It is common that the observation, and contact to the pelvis and genitalia be a component of our patient’s evaluation and subsequent treatment in order for an accurate diagnosis to be made. So, in order to best protect our patients and ourselves it will behoove us to take a few simple steps.