Core Rehab without "Going There"

In January, H&W faculty member Elizabeth Hampton PT, WCS, BCB-PMD presented at the APTA’s Combined Sections Meeting in San Diego, CA in a presentation sponsored by the Orthopedic Section. The presentation was called “Core Rehab without ‘Going There’: Evidence Supporting Direct and Indirect Evaluation and Treatment of PFM Dysfunction.”

In her talk, Elizabeth discussed contributing factors to pelvic health and continence, including muscular, fascial, neural, biomechanical and motor control factors. She also noted a pilot study done by HW’s own Stacy Futterman, PT, MPT, WCS, BCB-PMD, which prompted a wonderful discussion about the role hip labral tears and femoral acetabular impingement has on the pelvic floor.

Elizabeth was gracious enough to share details about her presentation with Pelvic Rehab Report. Below is what she had to say about this topic.

EH: In this talk, I focused on pelvic health and continence being a distinct specialty within orthopedic manual therapy. Considering the interrelationship between musculoskeletal, urinary, colorectal and sexual function, I believe an integrative understanding of all systems is required for autonomous, direct-access physical therapists as we look towards Vision 2020. Indeed, IFOMT’s definition of orthopedic manual therapy correlates directly to the women’s health physical therapist.

In my talk, I proposed that a comprehensive pelvic health and orthopedic manual therapy evaluation is required for the evaluation and treatment of pelvic pain and pelvic health conditions. I noted (and the audience agreed) that the reality is that not all PTs will have a comprehensive pelvic health knowledge base. Key items for a pelvic pain exam have not been standardized for physical therapists that do not have training in direct pelvic health and continence evaluation and treatment methods. Barriers to clinician evaluation of pelvic floor function and dysfunction can include education, apprehension, aversion, risk management concerns and knowing how and when to include pelvic health questions during client history- taking.

One example of a lack of comprehensive pelvic health knowledge base is the therapist who instructs on pelvic floor contractions - without prior assessment by the therapist - during a clinician- designed core rehabilitation program. Without evaluation, the competence of pelvic floor muscle contraction is in question. Cueing a muscle contraction without assessment, therefore, is not a skilled intervention in and of itself.

This prompted a discussion of whether a direct pelvic floor evaluation is indicated with all clients needing core rehabilitation. We also discussed external (i.e. indirect) assessment via the Ischiorectal fossa or client’s hand on their sacrum/ischii as options for a general screening. Further research is needed to determine when direct (internal) or indirect (external) evaluation methods of PFM contraction/relaxation are appropriate.

I encouraged all clinicians to attend the minimum of a Level One Pelvic Floor course through Herman & Wallace or the APTA. Regardless of the long term clinical interest of each PT in pursuing pelvic rehab as a focus, a Level One PF course would enable each clinician to perform a fundamental history, effective bowel and bladder screening and an understanding of the anatomy of the pelvic ring, even if they chose not to perform direct PFM assessment and treatment in the clinic.

I observe that the attitude of ‘us’ vs. ‘them’ still persists between clinicians who do have women’s health PT skillset and those who do not. This attitude has the potential to impair clinical collaboration and the inclusion of PTs of other specialties into the study of pelvic health, continence and women’s health physical therapy. Our profession would be well-served to focus on meeting the needs of the clients through a comprehensive orthopedic/ biomechanical/ urogyn/ colorectal knowledge base, rather than by separating client treatment according to clinician toolbox (i.e. women’s health vs. orthopedic.)

The Description of Specialty Practice for the Women’s Clinical Specialty includes a highly-detailed orthopedic skillset. Likewise, women’s health physical therapy is a highly-specialized field within orthopedic manual therapy. Both toolboxes are required for comprehensive evaluation and treatment of clients with women’s health, pelvic health and continence dysfunction.