The Institute has welcomed occupational therapists since our founding in 2006. In addition, three OTs: Richard Sabel, MA, MPH, OTR, GCFP, Erica Vitek, MOT, OTR, BCB-PMD, PRPC, and Tiffany Ellsworth Lee MA, OTR, BCB-PMD all teach courses as members of our faculty. (Erica Vitek is also one of several OTs who holds certification as a Pelvic Rehabilitation Practitioner through H&W).
Recently, the Institute was contacted by an Occupational Therapist who has attended many of our courses, regarding a challenge she was experiencing obtaining CEUs in her state (Oregon) for courses on Pelvic Rehab and Biofeedback. In light of this, the Institute has been discussing with some of the occupational therapists on our faculty, as well as representatives of the BCIA and Marquette University, and how to spread awareness about and recognition of OT’s roles in pelvic rehab. Below, we’ve asked faculty member Erica to share a bit more about her journey and the role of the pelvic rehab occupational therapist.
As an OT student, I had a professor who brought in practicing clinicians to discuss their unique roles out in the field. Pelvic health happened to be one of the topics of the day. I was completely intrigued by the clinician, who had such passion about the role of OT in pelvic health. It became clear that helping people with impaired basic bodily functions was imperative to fulfilling life roles and participation; it was OT. I knew from that moment that I wanted to help people deal with these challenging, private issues.
In my journey, I did not immediately start out in pelvic health, but instead in an acute care hospital that had a women’s health program with a strong interest in pelvic health. A very experienced OT and her team of 2 additional OTs were doing great work in that department already. The window of opportunity opened for me to mentor with that group and I eventually was able to begin to get my own referrals and develop a robust hospital-based outpatient practice. At that time, ALL of my experience had been with OTs doing this work and I was naïve to the fact that outside of my world, most of the clinicians doing this type of work were physical therapists (PT). I asked to join a highly trained and skilled group within my health system of all women’s health PTs. Overtime, I was able to demonstrate my level of competency within the group of PTs and contribute valuable things to our organization. Herman and Wallace Rehabilitation Institute was instrumental in my quest to demonstrate competency as they allowed OTs a clear pathway for enrollment in their coursework and application for the Pelvic Rehabilitation Practitioner Certification examination. I can be proud to have those credentials to my name.
My challenges in the area of pelvic health practice have thankfully been minimal, nearly nonexistent, and it has come to my awareness in recent weeks that this is not the case for OTs around the country trying to develop themselves as pelvic health practitioners. My original OT mentors reassured me with the AOTA’s published document titled Occupational Therapy Practice Framework: Domain & Process, detailed a clear place in the role of pelvic health. This document has gone through 3 revisions over the course of its first publication in 2002. The 2nd edition was published in 2008 and the 3rd edition in 2014. I’d like to cite a few important areas of the document that I find to be helpful in an OT’s quest to demonstrate our role in pelvic health rehabilitation.
I’d first like to quote the definition occupational therapy according to the 3rd edition, “occupational therapy is defined as the therapeutic use of everyday life activities (occupations) with individuals or groups for the purpose of enhancing or enabling participation in roles, habits, and routines in home, school, workplace, community, and other settings. Occupational therapy practitioners use their knowledge of the transactional relationship among the person, his or her engagement in valuable occupations, and the context to design occupation-based intervention plans that facilitate change or growth in client factors (body functions, body structures, values, beliefs, and spirituality) and skills (motor, process, and social interaction) needed for successful participation. Occupational therapy practitioners are concerned with the end result of participation and thus enable engagement through adaptations and modifications to the environment or objects within the environment when needed. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non-disability-related needs. These services include acquisition and preservation of occupational identity for those who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction. “
As we look closer at the framework and the definition of OT, there is clear evidence that the occupational therapist (OT) has a role in the treatment of pelvic health conditions. Importantly, occupations are defined by this document as “…various kinds of life activities in which individuals, groups, or populations engage, including activities of daily living (ADL), instrumental activities of daily living (IADLs), rest and sleep, education, work, play, leisure, and social participation.” The clearest examples of the OT’s role in pelvic health occupations within this section include: 1) ADL section: toileting and hygiene (continence needs, intentional control of bowel movements and urination) and sexual activity. 2) IADLs section: sleep participation (sustaining sleep without disruption, performing nighttime care of toileting needs). 3) Achieving full participation in work, play, leisure, and social activities, requires one to be able to maintain continence in a socially acceptable manner in which they can feel confident and comfortable to fulfill their roles and duties.
Client factors as defined in this document are “Specific capacities, characteristics, or beliefs that reside within the person and that influence performance in occupations. Client factors include values, beliefs, and spirituality; body functions; and body structures.” Client factors are further identified as affecting the performance skills and participation of the clients we work with. OT’s role per definition is to “facilitate change and growth in client factors”. In order to fully enhance our client’s performance skills/participation related to change and growth in client factors, OT’s have to examine the whole person, including pelvic health impairments, which have a negative influence on performance. Within client factors, the document defines body structures as, “Anatomical parts of the body, such as organs, limbs, and their components that support body function.” Within this category, one can refer to multiple items named that relate to the care that OTs provide in pelvic health rehabilitation, including but not limited to, structures related to the digestive, metabolic, and endocrine systems and structures related to the genitourinary and reproductive systems.
Since the first email from this individual in Oregon, we have been reached by several other OTs asking about similar challenges and questions about scope of practice. Because of our commitment to honoring the AOTA’s Practice Framework, and because we believe that the great patient need that exists can be better served by having trained OTs able to treat pelvic health conditions, the Institute is working with members of our faculty and professional network to advocate for recognition of OTs in pelvic rehab and resolve confusion about scope of practice. For those interested in further resources, please check out:
American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
American Occupational Therapy Association. (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683.
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68, S1-S48.
As someone who has spent nearly two decades marketing myself, my practice, or practices for employers, I have learned a lot of skills by trial and error. One of my favorite strategies to expand my professional network is to “Follow the Patient.” By this I mean to follow the patient to a specialist consult, to a procedure, or to a referral that you helped to coordinate. This must be done with the patient in mind, first and foremost, and then also the provider and their practice environment, so as not to have that practice shut the door on you in the future. Of course, this process can look different if you are in a health network because as an insider, you will likely be more welcome and have all the right credentials in order to simply attend a patient’s provider visit. If you are in a private practice, there are sometimes more hoops and permissions to negotiate. Following are some tips I have learned about this strategy of nurturing referral sources.
Offer the idea to the patient and see if they are open to it. It might sound like this: “If you are interested, I may be able to accompany you to your upcoming appointment. Does that interest you?” It’s very important that the patient is consenting to you being in attendance at their appointment, as the visit is for them. It may be best to not promise that you can clear your schedule, or coordinate the visit, but finding out if the patient is open to the idea is the first step.
2. Check in with the provider’s office. This can be accomplished by you or by the patient. This might sound like this: “I’d like to be sure that your provider would welcome me at your appointment. Would you prefer to contact the provider’s office or shall I?” In my experience, the provider’s office will say “if it’s ok with the patient, it’s fine with us!” Typically, a patient can bring whomever they like to an appointment, so that’s not much of an issue, unless there is close quarters or some other limiting scenario. The good thing about giving a heads up is it allows the provider’s office the opportunity to know that you may be joining your patient. I was able to follow a patient into a hernia repair surgery, and the nurses were so surprised that a physical therapist was in the prep room, they asked me “does the doctor know you are here?” in which case I was able to affirm that I indeed had permission from the surgeon.
3. When you attend the visit, allow the patient to introduce you or politely introduce yourself. Then listen. This is not the time to tell the medical provider all of the wonderful things you have been doing, or all of the things you have to offer their patients. Sometimes when reporting their history, the patient will look questioningly at me to recall details, and unless I am needed to give a brief response, I like to be quiet and stay out of the story until later. This is the time for the patient and the provider to get to know each other, establish rapport, and fewer interruptions are best.
4. Be prepared to summarize your thoughts when given the opportunity to share. Typically I have found that a medical provider will at some point turn and ask me a few questions, or simply state, “Do you have anything to add?” at which point I try to make concise yet thoughtful statements about the patient’s progress, continued challenges, and the reasoning behind the referral if I was the one to coordinate it. The summary might sound like this: “The original severe pain locations have eased, function has improved in this way, and the symptom or issue that is persisting is this. I was interested in knowing if there is potentially something else going on, or if you have a recommendation towards furthering their progress.” At this point, it’s best to not get too far ahead of yourself, or put expectations in front of the patient beyond a brief summary. In other words, don’t request specific imaging or suggest a particular procedure, as this may create an imbalance in the patient’s expectations and the reality of what takes place. If the provider wants more details or thoughts from you, they are likely to ask directly. (You can also send a progress report or summary letter prior to your visit if you have specific thoughts or concerns about what is going on.)
5. Allow the visit to unfold, listen carefully and take mental or written notes. I have often found that I recall details of anatomy, medications, or suggested interventions easily and the patient may ask about the details in a follow-up visit. This type of partnership allows the patient to have “another pair of ears” and can serve as a valuable part of the rehabilitation care planning. For example, perhaps the provider said, “Let’s try this imaging, if nothing of interest shows up, continue rehabilitation for 6 weeks. If no significant progress, I’d like to see you back here within a couple of months from today.” This allows the therapist to note that a provider visit was requested at 6 weeks following the appointment.
Marketing our services, in the long run, and especially in pelvic health, is critical in sharing awareness of the role of pelvic rehabilitation. Marketing is about relationships, and the easiest way to create a relationship is face to face. “Following” a patient along their healing journey, while it may take time out of the clinic for you, is a valuable way of engaging with providers and of being part of a collaborative process. When another provider or therapist requests that I see their patient to offer another view, I find it helpful to welcome the referring therapist to join the patient as well. This can lead to valuable discussions, sharing of information, and ultimately the patient may experience more efficient care that is directed to optimal strategies.
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