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.
Although awareness of pelvic rehabilitation is growing, patients who are referred for pelvic rehabilitation usually have more questions than the average patient about attending therapy. This can mean that you as a provider are burdened with a lot of phone calls or emails that go something like this: can I come to the clinic if I’m on my period? what are you going to do? are you familiar with my condition? how long will it take to get better? Consider how often these questions occur with patients who have knee pain, or headaches, and you may find that pelvic rehab is perceived by patients as quite unique from other types of rehab. How can you avoid trying to find time in your busy clinical schedule to tackle these additional communications? You can start by educating your front desk to handle patient care questions related to pelvic rehab, such as the following frequently asked questions:
It is likely that the patient will ask to speak directly with the therapist, so you can first encourage your support personnel to politely inquire if there is something he or she could help in answering. Create a list of conditions along with a brief description of its definition, and a few examples of skills that a pelvic rehab provider has to offer. Your support staff can also offer to mail a brochure or flyer that you create which answers some of the frequently asked questions. Providing an “FAQ” section on your website that can be referred to may also decrease some of the stress of trying to play phone tag. Make no mistake that if you DO have the time to follow-up with a patient who has a question, you may create a connection that is really important for that patient in regards to scheduling an appointment. On the other hand, if you don’t have time set aside in your day for such calls or emails, you risk having the patient not get her questions answered. A form (on your site or as a written resource) might have some of the commonly asked questions written out, and you could use the ones below as an example to get you started.
Most patients can attend a physical therapy visit without having a prescription or written referral from a doctor or other referring provider. Insurance companies, however, may insist that you have a referral in order for you or your therapist to receive payment. Even if you do not need a referral from a medical provider, your therapist may require that you have seen a medical provider for your condition. Many conditions involving the pelvis can be medical in nature and require checking for more serious conditions before coming to the clinic. It is also helpful to have a medical provider with whom your therapist can coordinate care and discuss your health as a team.
First, we will talk about what concerns or symptoms you have. Your therapist will also look over any forms you filled out to learn more about your history. The exam will be discussed with you so that you can have any questions answered. Your therapy exam may include general movement like bending forward and backward, seeing how you move your body, and specific tests of your joints, muscles, and nerves. For pelvic rehabilitation, an assessment of your pelvic muscles internally (through the rectum or vaginal canal) may be valuable.
Your therapist may use surface EMG (electromyography), a form of biofeedback. This may involve placing some sticky sensors on your body so you and your therapist can get a better idea of how you are coordinating muscle activity in the abdomen or pelvis. Biofeedback means that you will be able to get information about how your muscles are working, and in therapy this is often displayed as graphs or bars on a screen. An internal sensor for the vaginal or rectal canal may also be used.
It is usually not necessary to reschedule if you are on your cycle, so you are welcome to keep your appointment.
Can patients benefit from a non-face-to-face treatment program for stress urinary incontinence? A recent study addressing this question was published in the British Journal of Urology International. This randomized, controlled trial utilized online recruitment of 250 community-dwelling women ages 18-70 years. Criteria was stress urinary incontinence (SUI) at least 1x/week, diagnosis based on self-assessment questionnaires, 2 days of bladder diaries, as well as a telephone interview with a urotherapist. The Outcomes tools included the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF), the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), the Patient Global Impression of Improvement, health-specific quality of life (EQ-VAS), use if incontinence aids, and satisfaction with treatment.
The participants were randomized into 2 pelvic floor muscle training groups: an “internet-based” group (n=124) and a group who were sent information in the mail (n=126). The internet-based program contained information about pelvic muscle contractions (8 escalating levels of training), behavioral training related to lifestyle changes. The internet group received email support from the urotherapist, and the postal group did not. Pelvic floor muscle training was instructed at at least 8 contractions 3 times/day. After the 3 month training period, the internet-based treatment group was advised to continue pelvic floor muscle training 2-3 times/week, whereas the mail training group were not given any advice about continued training frequency. Follow-up data was collected at 4 months post-intervention, at 1 year and 2 years. At 2 years follow-up, 38% of the participants were lost from the study.
Within both groups, the authors report that the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) showed “highly significant improvements” after 1 and 2 years compared to baseline data. Much of the improvement occurred within the first 4 months of the study “…and then persisted throughout the follow-up period.” When comparing the internet group to the mail-only group, the perception of improvement following treatment was higher. Approximately 2/3 of the women in both groups reported satisfaction with the treatment even at the 2 year follow-up. The authors conclude that the internet or mail-based exercise programs may “…have the potential to increase access to care and the quality of care given to women with SUI [stress urinary incontinence] in a sustainable way.” Additionally, not all patients will improve significantly unless they have one-on-one intervention, leaving plenty of patients who do need our direct care.
If you would like to learn more about exercise prescription for urinary incontinence, consider attending one of Herman & Wallace's many continuing education courses.
The following is a contribution from Elisa Marchand, PTA, PRPC. Elisa is the first PTA to become a Certified Pelvic Rehabilitation Practitioner! Elisa started a Pelvic Floor program with a locally-owned rehab company where she mentored 3 different PT's through the years. In that time, Elisa also taught as an adjunct with the local PTA program. Elisa works at McKenna Physical Therapy in Peoria, IL.
As a physical therapist assistant, the following should cause me to rethink my passion for and practice within women's health PT. "The SOWH is opposed to the teaching of internal pelvic assessment and treatment to all supportive personnel including physical therapist assistants." (Position Statement on Internal Pelvic Floor Assessment and Treatment: Section on Women's Health, APTA; Feb 2014) It should have stopped me from sitting for and becoming the first-ever PTA certified as a PRPC. Fortunately, this is not the case.
I want to be clear from the start; I understand the need for clear boundaries with regards to the scope of practice of PTAs. However, the interpretation of these rules can get quite muddy. In the APTA's "Guide for Conduct of the PTA", the following clarifications are made, including their interpretations:
3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge, there may be areas of physical therapy interventions in which he or she displays advanced skills...To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence.
3E. [PTA's] shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient/client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient/client status indicate that modifications to the plan of care may be needed.
Through the years of working as a PTA, I have practiced in a variety of settings. Some of these settings have allowed for a high level of autonomy (such as in my current workplace), and some have operated in quite the opposite-- where my treatments were dictated step-by-step by the PT. No matter the state in which one lives, physical therapy clinics will vary in their method of treatment and utilization of PTAs. In Illinois, where I practice, the following is the detailed description of a PTA per the Illinois Practice Act:
"'Physical therapist assistant' means a person licensed to assist a physical therapist and who has met all requirements as provided in this Act and who works under the supervision of a licensed physical therapist to assist in implementing the physical therapy treatment program as established by the licensed physical therapist. The patient care activities provided by the physical therapist assistant shall not include the interpretation of referrals, evaluation procedures, or the planning or major modification of patient programs." (http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapterID=24)
Additionally, per the APTA's Standards of Ethical Conduct for the Physical Therapist Assistant: "6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy." (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) Personally, I take this as a green light for PTA's to immerse themselves in whatever their niche or passion may be. Thus, if a PTA is following this standard, and the advances in PT call for more trained therapists with an understanding of the pelvic floor, and the appropriate oversight provided-- as in my case; what is the hold-up?
Counter to the above expectations, the Section on Women's Health's Position Statement on Internal Pelvic Floor Assessment and Treatment states:
"Any internal pelvic (vaginal or rectal) myofascial release or soft tissue mobilization techniques that would require a continuous ongoing re-evaluation and reassessment should be performed by the physical therapist and not delegated to supportive personnel including physical therapist assistants. The SOWH recognizes that therapeutic exercise, neuromuscular reeducation and behavioral retraining techniques for pelvic floor dysfunction at times requires ongoing critical decision making while at other times are relatively routine. In the routine circumstances, those techniques may be delegated. When the higher level of critical decision making is necessary those techniques should be performed by the physical therapist and not delegated to support personnel including the physical therapist assistant."
In this above set-up, PTA's are made to sound as if incapable of using any critical thinking skills. Or, at the least, able to operate with very limited critical reasoning. Furthermore, in the typical treatment of pelvic floor conditions, how is the decision-making process required for individualized treatment any different than that to the external pelvis, or the low back, or the foot for that matter?! The skill and awareness that was required in transferring a patient in the ICU when I was a new grad was in some ways more complex with more of a direct impact on a person's survival and well-being, than what I do now. Yet, how am I not qualified to do something in which I have extensive training? This seems inconsistent.
In my opinion, the PTA is more than just "supportive personnel". On the other hand, I also believe that new PTA grads may not have a place in pelvic floor PT. There are complexities within, and knowledge required of anatomy and physiology of the pelvis, which the PTA does not get from his or her program. Though doctorate students entering the PT world today also do not have much exposure to the pelvic floor, they at least have gone through a more thorough coverage of anatomy, physiology, and disease processes. Despite the differences in schooling, MANY physical therapists see their assistants as vital assets to their clinics.
One incredibly positive aspect of being a PTA is the follow-through I have with my clients. I LOVE getting to know my patients, and feel that I am allowed this luxury more frequently than PT's whose schedules may need to stay open for new evaluations. I frequently have clients say to me, "I would never have dreamed that I'd be talking about (fill in the blank) with ANYBODY!" Usually, this is after a few sessions of working together. I cherish seeing the freedom and healing that comes when people feel comfortable enough to open up their physical, emotional, and spiritual selves.
Yes, as a PTA we are limited by the scope of practice placed before us. However, I do not see that as a set of limitations that binds us to a very narrow existence. With the training one receives through continuing education such as with Herman & Wallace, the PTA can gain the necessary skills for treatment. And from this, the possibilities are endless!
With ICD-10 changes right around the corner, we thought it would be helpful to put together a bit of a cheat sheet for our pelvic health providers. Keep in mind that this is only a guide, and that you and your facility should rely upon your own knowledge and skills. We hope this list makes getting to coding proficiency a little easier!
The Centers for Medicare and Medicaid Service have a website called “Road to 10” that is very helpful for learning about all the changes that are coming up very soon, starting with “ICD-10 Basics” (they even have a countdown clock, with seconds included- no pressure!) The site has some documents for physicians, which therapists might find somewhat useful, including ones called “Common Codes for OB/GYN" or "Common Codes for Orthopedics". The Herman & Wallace Pelvic Rehabilitation Institute has created for you the Common Codes for the Pelvic Rehab Provider, For those of us in pelvic rehabilitation, the more tools that we have to make the transition easier, the better.
There are 3 main things that are going to help with this transition: 1) knowing how ICD-10 is different than ICD-9, so that you are aware of the additional choices you may need to make, 2) having a comprehensive list of all the codes to choose from, and 3) having a shorter list of codes so you don’t have to move through the entire list!
If you need a primer on ICD-10, Rick Gawenda has done a great job of providing resources, including his courses on the MedBridge website. First, we will cover some how-to about navigating the websites and the lists. Next, we will give you some hints about avoiding the pitfalls of the new system. Finally, we present a short list of some “go-to” codes for most pelvic rehab providers. For great ICD-10 info, you can also check out WebPT’s blog and other resources on their site.
As for the cheat sheet, below are some of the top codes we use in pelvic rehab. For a much longer list, and more pages of information about resources to get you ready, download the Common ICD-10 Codes for the Pelvic Rehabilitation Practitioner document.
Coccygodynia (See Sacrococcygeal disorders, not elsewhere classified) M53.3
Constipation K59.0 Excludes1: fecal impaction (K56.41) incomplete defecation (R15.0)
Constipation, unspecified K59.00
Dysmenorrhea, unspecified N94.6 (Excludes1: psychogenic dysmenorrhea (F45.8))
Dyspareunia N94.1 (Excludes1: psychogenic dyspareunia (F52.6))
Fecal incontinence R15 (Includes: encopresis NOS Excludes1: fecal incontinence of nonorganic origin (F98.1))
Functional diarrhea K59.1 (Excludes1: diarrhea NOS (R19.7), irritable bowel syndrome with diarrhea (K58.0))
Incomplete defecation R15.0 (Excludes1: constipation (K59.0-) fecal impaction (K56.41))
Interstitial cystitis (chronic) N30.1
Irritable bowel syndrome Includes: irritable colon spastic colon K58
Irritable bowel syndrome with diarrhea K58.0
Irritable bowel syndrome without diarrhea (Irritable bowel syndrome NOS) K58.9
Low back pain (Loin pain, Lumbago NOS) M54.5 (Excludes1: low back strain (S39.012), lumbago due to intervertebral disc displacement (M51.2-), lumbago with sciatica (M54.4))
Mixed incontinence (Urge and stress incontinence) N39.46
Muscle spasm M62.83
- Other muscle spasm M62.838
Nocturnal enuresis N39.44
Lower abdominal pain, unspecified R10.30
Outlet dysfunction constipation K59.02
Overactive bladder (N32.81) (Detrusor muscle hyperactivity) (Excludes1: frequent urination due to specified bladder condition- code to condition)
Pain in hip M25.55
- Pain in right hip M25.551
- Pain in left hip M25.552
Pelvic and perineal pain R10.2 (Excludes1: vulvodynia (N94.81))
Pelvic Muscle Wasting N81.84
Post-void dribbling N39.43
Primary dysmenorrhea N94.4
Sacrococcygeal disorders, not elsewhere classified (Coccygodynia) M53.3
Sciatica M54.3 (Excludes1: lesion of sciatic nerve (G57.0) sciatica due to intervertebral disc disorder (M51.1-) sciatica with lumbago (M54.4-))
- Sciatica, right side M54.31
- Sciatica, left side M54.32
Secondary dysmenorrhea N94.5
Slow transit constipation K59.01
Stress incontinence (female) (male) N39.3 (Code also any associated overactive bladder) (Excludes1: mixed incontinence)
Urge incontinence (Excludes1: mixed incontinence (N39.46)) N39.41
Vaginismus N94.2 Excludes1: psychogenic vaginismus (F52.5)
Vulvar vestibulitis N94.810
Vulvodynia N9, unspecified
The concept of patient compliance, or adherence (a more preferred term), has been the subject of many medical studies, and adherence in pelvic rehabilitation is an aspect of rehab of critical interest. Recently published results of a survey questioning providers and the public about adherence in pelvic floor muscle training offers an insightful perspective. Researchers Frawley, Dumoulin, and McClurg conducted a web-based survey which was published in published in Neurourology and Urodynamics. The survey was completed by 515 health professionals and by 51 individuals from the public. Interestingly, but perhaps not surprisingly, health professionals and public respondents placed different value on which factors related to rehabilitation contributed the most to adherence.
Data collected in the study included topics such as barriers to adherence in pelvic floor muscle training (PFMT), perception of potential benefit of PFMT, therapy-related factors including therapeutic relationship, socioeconomic factors, and issues surrounding short-term versus long-term adherence, for example. For the providers, poor motivation was rated high as a barrier to short-term adherence, whereas the patients rated perception of minimal benefit from PFMT as the most important barrier. Facilitators of pelvic muscle training included aspects of access such as having appointments outside of the typical workday, or having childcare available, transportation, and not being bored by the exercise program or feeling that the therapist has adequate training and skills.
As suggested by the authors, perhaps that most important variable agreed upon by both providers and public is that of perceived benefit. In other words, patients need to believe that the exercise program can alleviate symptoms and that what they are doing in their particular program is going to achieve positive results rather than wasting time on a home program that will not be effective. This issue is one that can be easily remedied through appropriate patient education, communication with the patient about whether or not they understand the potential value and expected recovery through program participation, and adequate training of the therapist that allows for proper diagnosis and treatment planning. The study concludes by emphasizing that health providers “need to be aware of the importance of long-term patient perception of PFMT…”
If you are interested in advancing your diagnostic or treatment planning skills, check out the pelvic floor series of continuing education courses and the many specialty courses that the Institute offers.