Amy is a 37 year-old female referred by her gynecologist to outpatient physical therapy with primary complaint of urinary and fecal incontinence after giving birth 12 months ago. After performing appropriate screening tests for other medical diagnosis, he referred the patient to physical therapy for evaluation of the pelvic floor with diagnosis of incontinence. The patient reported that she wears an adult pad daily. She stated that she “leaked urine” when she coughed, sneezed, jumped, lifted items, and stood up from sitting. She stated that she experienced “small fecal accidents” when running long distances. Patient reported that she has been doing “Kegel exercises” for the last 9 months as instructed by her gynecologist, but feels her symptoms have become worse. Can physical therapy help her?
Many physical therapists are not aware of what pelvic physical therapy consists of and who it can help, so before we look at how to help Amy, let’s examine how it all started and how it is practiced today.
Pelvic physical therapy has been around longer than many people are aware. The Section on Women’s Health of the American Physical Therapy Association was founded by Elizabeth Noble in 1977 under the original name of “The Section on Obstetrics and Gynecology”. It has evolved over time, with the scope of practice for more than 3,000 members growing to include abdominal and pelvic health concerns of women, men and children: incontinence, pelvic/vaginal pain, prenatal and postpartum musculoskeletal pain, osteoporosis, rehabilitation following breast surgery, lower back pain, lymphedema, conditions specific to the female athlete, fibromyalgia, chronic pain, wellness, and exercise. In 1995 members voted to change the name to Section on Women’s Health to mark the specialized education required to address women’s physical therapy needs. In 2011, the organization updated its mission and vision statements to recognize members who also treat males affected by incontinence, pelvic pain, fibromyalgia and osteoporosis.
It can be challenging to sum up what pelvic physical therapists do and what they treat daily. We are musculoskeletal experts in the areas associated with the pelvis (coccyx, sacroiliac joints, sacrum). We treat issues involving the vulva and vagina, penis, scrotum, and colorectal regions. We treat urinary and fecal incontinence, and many different pelvic and genital pain issues. We treat urge incontinence. We treat pregnancy and post-pregnancy issues such as helping pregnant women prepare for an easier delivery, back pain and pubic symphysis dysfunction, and rectus diastasis. We treat issues with pain with or preventing intercourse.
There are many different methods and techniques used to treat pelvic floor problems. As with any other physical therapy plan of care, a comprehensive evaluation must be completed. This includes medical history, signs and symptoms, postural examination, assessment of strength and coordination of the pelvic floor, and pain assessment. Depending on the type of background of the physical therapist (including experience, education, and preferences) and treatment setting (or policy of the company) assessments can vary. There are some physical therapists who focus on orthopedics who do exams without assessing the pelvic floor internally. There are others who focus heavily on assessing the pelvic floor muscles and associated areas first and later transition to daily functional activities and return to sport or recreation.
There are several ways to treat pelvic floor dysfunction. Most therapists use a variety of methods and approaches on patients. Some common treatments are:
- Education – Most patient will need to learn more about the anatomy and physiology of their pelvic floor and how components work. They may need to be educated in daily habits such as intake of bladder irritants, bowel routines, stress management techniques, and the importance of exercise compliance. Interventions involving the use of behavioral programs are among the least invasive approaches to address urinary incontinence/pelvic pain and have no adverse complications. Critical aspects of a successful behavioral program include education of the patient and caregiver, availability of the staff and consistent implementation of the interventions.1
- Manual therapy – Hands-on techniques such as trigger point reduction, soft tissue mobilization, and stretching are used both internally (vaginal and rectal) and to external tissues such as glutes. There is a growing number of studies showing that manual therapy is effective in the treatment of pelvic floor dysfunction.2
- Pelvic floor exercises – Contraction and relaxation exercises in order to achieve increased strength, endurance and coordination of the pelvic floor muscles. Patients are also instructed in breathing and timing techniques to maximize effectiveness.
- Biofeedback – This is a tool that enables patient to see on a screen how the pelvic floor muscles are working. This can be done with internal probes (vaginal or rectal) or external sensors.
- Electrical Stimulation – Can be used with internal probes (vaginal or rectal) or external electrodes. This is used to increase strength, increase endurance, reduce pain, and to relax overactive tissues.
There are many ways to become a “pelvic physical therapist”. You are not required to do any specific training beyond that which makes you a physical therapist. Many physical therapy schools offer some education in this specialty, however most physical therapists feel it is not enough to feel confidently treating this patient population. Some therapists work with other experienced pelvic physical therapists and learn skills on the job. There are some educational providers that offer courses, with a few that have certifications. The Section on Women’s Health (SoWH) has developed the Certificate of Achievement in Pelvic Physical Therapy (CAPP-Pelvic) to certify that a physical therapist has completed a comprehensive education, training and testing program for the management of patients with diagnoses of pelvic health dysfunction, such as urinary incontinence and pelvic pain.
The CAPP is awarded to physical therapists who complete the required courses of training in pelvic physical therapy, pass written and clinical testing requirements at each level and successfully complete and “pass” a written case reflection. Another option is from Herman and Wallace. The certification is called the Pelvic Rehabilitation Practitioner Certification (PRPC). This certification is awarded to those therapists who successfully apply to sit for the exam and receive a passing score on the computer-administered multiple-choice examination. Clinicians who earn this certification may amend their professional title and all accompanying documentation (CV, business cards, resume) with the letters “PRPC” to distinguish themselves as an expert in the field of pelvic rehabilitation.
You may be wondering how it worked out with Amy. The plan of care included strengthening exercises, internal manual resistance to increase awareness of contraction of the pelvic floor and increase pelvic muscle strength, perineal biofeedback, patient education, and home exercise program. After 6 visits the patient reported dramatic improvement. She was able to eliminate the use of an adult pad at work and home. She continued to wear a pad during exercise, and reported that she rarely has accidents. Her Pelvic Floor Impact Questionnaire results decreased from 103 to 33. The scores range from 0 to 300, with lower scores indicating a lesser effect on her quality of life as it relates to incontinence. Her “PERFECT” score increased from 2/5 pelvic floor muscle strength of 4/5, endurance from 2 seconds to 8 seconds, ability to perform 4 maximum contractions to 7 maximum contractions, ability to perform 4 repetitions of full contractions and full relaxations in 10 seconds to 7 repetitions of full contractions and full relaxations in 10 seconds, and overuse of co-contraction of the transversus abdominis to appropriate co-contraction of the transversus abdominis, and absence of involuntary pelvic floor muscle contraction with coughing to appropriate involuntary pelvic floor muscle contraction with coughing. This reflected and increase in pelvic floor strength, endurance, and coordination. Standing and seated posture progressed from a forward head, forward shoulders, increased lumbar lordosis, and anterior pelvic tilt to unremarkable, which allows for optimal recruitment of pelvic floor muscle contractions. She returned to running 3 miles for 3 days per week with reports of mild urinary accidents during running averaging once day per week, and had not experienced a bowel accident in 4 weeks.
Patients who present with non-functioning pelvic floor have symptoms pain, incontinence or both. Understanding the role of the pelvic floor, as well as how to examine pelvic floor dysfunction, is vital in the treatment of pelvic floor dysfunction.3 The need for pelvic physical therapists seems to be increasing as awareness of this specialty has grown and the scope of our practice has expanded.
- Messelink B, Benson T, Berghmans B, et el. Standardizatin of terminology of pelvic muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn. 2005; 24:374-380.