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How can we Quickly Make a Diagnosis of Complex Pelvic Pain Patients?

Today we get the opportunity to hear from Herman & Wallace faculty member Elizabeth Hampton PT, WCS, BCIA-PMB! Elizabeth has been kind enough to offer her insights about the diagnosis of pelvic rehabilitation patients. Join Elizabeth at Finding the Driver in Pelvic Pain this November in Houston, TX in order to learn evaluation tools for complex pelvic pain clients!

Having taught for Herman and Wallace since 2006, I have a few observations that have been consistent over the years. Clinicians want their clients to get better, so much so that they are ready to jump in to treatment before having a solid problem list and validated findings. I can understand this: after a 3 day course we have clients Monday morning at 8 a.m. who have been waiting for us to take this course so we can get them better! We had better be smart ASAP! But what do we do when we are treating symptoms rather than understanding the primary, secondary and tertiary factors in their condition?

Finding the Driver in Pelvic Pain is a course that is a foundational first step in screening the pelvic pain client. It is a great place to start. I developed the course because there was no evidence based comprehensive factors that had been established as fundamentals for screening a pelvic pain client.

The other thing I have learned after teaching Pelvic Floor Function, Dysfunction, & Treatment – Level 2B for 9 years is that the majority of clinicians who take this intermediate level course cannot perform a precise vulvar and intrapelvic muscle mapping assessment. Close your eyes and pretend you are mapping a client’s left iliococcygeus: can you place your finger in the proper orientation and know 100% you would be palpating it? Indeed, this takes training and repetition. Internal pelvic floor muscle mapping is a key part of the Finding the Driver screening system.

What do you do when you have a pelvic pain client on your schedule and a 45-60 minute slot? How do you screen findings and get the plan of care within such a short period of time? Finding the Driver is a comprehensive pelvic floor and musculoskeletal screening to rule in or rule out drivers of the pain from all sources including spine, pelvic ring, neural entrapment, intra-articular hip, load transfer, biomechanics and motor control. There is a clear flow to the screening process and an emphasis on how to organize that information, as we know with pelvic pain, it is the copious amount of information that is the challenge. We have two case studies with either participants or clients of a local Physical Therapist who come in and we go through the entire screen, prioritize treatment and provide that treatment during the course. The participants walk away with clear clinical reasoning for their treatment and prioritization of treatment as primary, secondary, and so on. The goal of the course is to help the clinician sort through the extraordinary amount of information we gather on our pelvic pain client and organize it in a way that we can explain to the client as well as create our plan of care. Treatment is not linear, as we are frequently treating many aspects at the same time. However being able to organize the information is key in designing that plan of care. For example, with a prone knee bend that reproduces labial pain, we find that the genitofemoral nerve is causing referred pain. However that referral may be due to constipation, irritable bowel, inguinal entrapment due to hernia surgery, intra-abdominal adhesions due to endometriosis, osteitis pubis or facilitated segment at the upper lumbar spine. How do we tease that out? How do you sequence nerve glide, visceral work, soft tissue mobilization, joint mobilization and dietary components for colonic motility? The treatment with all of those components are very different indeed. Finding the Driver is a hands on course with systematic screening tools and, with case studies, we go through treatments appropriate to that client. The focus is on what we, as physical therapists, can do to understand the drivers.

At the last Finding the Driver course in Milwaukee, WI, we had two case studies in pelvic pain. One client reported chronic psoas and adductor tightness with deep left sided pelvic pain. As a professional aerialist, she was extraordinarily flexible and demonstrated positions of tightness that concerned her, which included lateral splits with her hips in slight horizontal abduction and extension (yes, yikes!) When she reported that her adductor felt tight in this position, I explained it was because it was trying to keep her leg attached to her body! She was 9/9 on the Beighton scale and had severe multidirectional instability in her hips, impaired load transfer through her pelvis, respiratory dysfunction with efforts at pelvic floor and transverse abdominis contraction, as well as repeated choice of activities that were profoundly provoking. Interestingly, she was better at load transfer during handstands (bilateral or unilateral) vs. in standing and we discussed her course of treatment addressing the primary, secondary and tertiary aspects of her condition. Another client had severe labial pain, and despite multiple abdominal and intravaginal surgeries, her symptom onset was 4 months prior. She certainly had visceral, postural, joint restrictions, movement dysfunction and many other factors. But her primary driver was a labral tear in her hip and she needed surgery. After surgery, her pain was 100% resolved and in her post op rehab, the other factors could be addressed.

It is safe to say that it can be difficult to perform a comprehensive screen in 45-60 minutes on ALL clients. We all know that many of our clients need to tell their story and because of fear or previous negative history, we may choose as clinicians how to spend that session to best honor the needs of the client. That being said, Finding the Driver is a course which provides a solid start in differential diagnosis so you can drill down into more specifics on subsequent visits.

Verbal Instructions and Pelvic Floor Contractions ...
Visceral Therapy in Rehabilitation

Upcoming Continuing Education Courses

Pelvic Floor Level 2A - Grand Rapids, MI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Mary Free Bed Rehabilitation Hospital

Pelvic Floor Level 1- Kansas City, MO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Centerpoint Medical Center

Oncology of the Pelvic Floor Level 1 - Grand Junction, CO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Urological Associates of Western Colorado

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Virginia Hospital Center

Pelvic Floor Level 2B - East Greenwich, RI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: New England Institute of Technology

Pilates for the Pelvic Floor - Livingston, NJ (Rescheduled)

Apr 18, 2020 - Apr 19, 2020
Location: Ambulatory Care Center- RWJ Barnabas Health

Genital Lymphedema

Apr 24, 2020

Pelvic Floor Level 1- Canton, OH (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Aultman Hospital

Pelvic Floor Level 1 - Rochester, NY (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Unity Health System

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Michigan Medicine

Lumbar Nerve Manual Assessment and Treatment - Madison, WI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: University of Wisconsin Hospital

Pelvic Floor Level 2A - Winfield, IL (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Trenton, NJ (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Robert Wood Johnson Medical Associates

Athletes & Pelvic Rehabilitation - Minneapolis, MN (Rescheduled)

Apr 25, 2020 - Apr 26, 2020
Location: Viverant

Sacral Nerve Manual Assessment and Treatment - Fairlawn, NJ (Rescheduled)

May 1, 2020 - May 3, 2020
Location: Bella Physical Therapy

Pelvic Floor Level 1 - Fayetteville, AR

May 1, 2020 - May 3, 2020
Location: Washington Regional Medical Center

Pelvic Floor Level 1 - Boise, ID (Rescheduled)

May 1, 2020 - May 3, 2020
Location: St Luke's Rehab Hospital

Pediatric Incontinence - Duluth, MN

May 1, 2020 - May 3, 2020
Location: Polinsky Medical Rehabilitation Center

Yoga for Pelvic Pain - Online Course

May 2, 2020 - May 3, 2020

Pregnancy Rehabilitation - Corvallis, OR

May 2, 2020 - May 3, 2020
Location: Albany Sport & Spine Physical Therapy

Coccydynia and Painful Sitting - Boston, MA

May 2, 2020 - May 3, 2020
Location: Marathon Physical Therapy

Pelvic Floor Level 1 - Bay Shore, NY (SOLD OUT)

May 11, 2020 - May 13, 2020
Location: Touro College: Bayshore

Pelvic Floor Level 2A - Crown Point, IN

May 15, 2020 - May 17, 2020
Location: Franciscan Health System