If you are familiar with the work of Diane Lee, you may have noticed the term “driver” used throughout descriptions of patient assessment techniques. One definition of “driver” is “a factor that causes a particular phenomenon to happen or develop.” When it comes to a patient’s pelvic dysfunction, we know that there may be a dramatic number of factors driving the symptom, so what is the value of trying to determine the level of significance of various factors?
Let’s imagine that we meet a female patient who presents with pelvic pain, urinary incontinence, and difficulty holding back gas. In addition to providing a thorough subjective interview, screening for underlying medical conditions requiring attention, examining her neuromusculoskeletal system, and learning more about her daily habits, we need to figure out the best place to start with her care. What if, even though this particular patient has only experienced one major episode of leakage (after which all other symptoms started) you complete the exam to find that she is holding her pelvic muscles tense continuously? Perhaps you share this observation with the patient, only to hear her say that she is “so afraid of leaking again that she keeps her muscles tight to prevent it.” This type of rehabilitation sleuthing can help us get to the heart of the matter with our patients, regardless of the presenting complaints. For example, if we can educate this patient about the potential negative consequences of her fear of having another embarrassing episode (fear leads to muscle guarding which leads to pelvic pain and potentially dysfunctional voiding) then her thoughts can positively contribute to the other therapeutic recommendations we make.
Other examples may include meeting a patient with pelvic dysfunction whose true “driver” is a kyphotic thoracic spine that compresses the abdominal organs, or a habit of wearing pants with a waistband so tight that bowel function is compromised (true story), foot pain that creates increased loading on the now painful side of the pelvis, or even emotions and thoughts such as fear and shame. I’m sure you can think of many other examples based on your own clinical experience. If you are a newer therapist, or perhaps wish to work through further examples of not only how to evaluate but to treat for finding the primary contributors to a patient’s dysfunction, check out Pelvic Rehabilitation Institute faculty member Elizabeth Hampton’s continuing education course that focuses on this Finding the Driver in Pelvic Pain.