Male Pelvic Pain: What Therapists Can Do to Help End the Desperation

Recently, a note was left at my doorstep by the wife of an older gentleman who had chronic male pelvic pain. His pain was so severe, he could not sit, and he lay in the back seat of their idling car as his wife, having exhausted all other medical channels available to her, walked this note up to the home of a rumored pelvic floor physical therapist who also treated men. The note opened with how she had heard of me. She then asked me to contact her about her husband’s medical problem. It ended with three words that have vexed me ever since…we are desperate.

Unlike so many men with chronic pelvic pain, he had at least been given a diagnostic cause of his pain, pelvic floor muscle dysfunction, rather than vaguely being told it was just a prostate issue. However, the therapists that had been recommended by his doctor only treated female pelvic dysfunction.

“We are desperate”: A Call to Action for All Therapists to become Pelvic Floor Inclusive

My first thought after reading the note was, “I bet shoulder or knee therapists don’t get notes like this on their doorstep.” My next thought, complete with facepalm, “THIS HAS TO STOP! Pelvic floor rehab has got to become more accessible”.

Pelvic floor therapists see men and women and even transgenders. They treat in the pediatric, adult, and geriatric population. They treat pelvic floor disorders in the outpatient, home health and SNF settings. They treat elite athletes and those with multiple co-morbidities using walkers. They can develop preventative pelvic wellness programs and teach caregivers how to better manage their loved one’s incontinence. This is due to one simple fact: No matter the age, gender, level of health or practice setting, every patient has a pelvic floor.

The pelvic floor should not be regarded as some rare zebra in clinical practice when it is the workhorse upon which so many health conditions ride. It interacts with the spine, the hip, the diaphragm, and vital organs. It is composed of skin, nerves, muscles, tendons, bones, ligaments, lymph glands, and vessels. It is as complex and as vital to function and health as the shoulder or knee is, and yet students are lucky if they get a “pelvic floor day” in their PT or OT school coursework.

I call for every therapist, specialist, and educator to learn more about the pelvic floor. Here are some steps you can take today toward eliminating the need for such a note to be written.

If you are a pelvic floor therapist who treats men, shout it from the rooftops!

Contact every PT clinic, every SNF, every doctor, every nurse, every chiropractor, every acupuncturist, every massage therapist, every personal trainer, every community group and let them know! If you have already told them, tell them again. Send a one page case study with your business card. Host a free community health lecture at the library or VFW hall. Keep the conversation going. Reach out to your local rehab or nursing school programs and volunteer to speak to the students. Feature pelvic health topics in your clinic’s social media stream. Get on every single therapist locator that you can so people can find you. Click here to go to the Herman and Wallace Find a Practitioner site.

If you only treat pelvic dysfunction in women, please consider expanding your specialty to include men.

The guys really need your help. You literally may be the only practitioner around that has the skills to treat these types of problems. Yes, the concerns you have about privacy and feeling comfortable are valid. But, you are not alone in this. Smart people like Holly Tanner have figured all that stuff out for you and can guide you on how to expertly treat in the men’s health arena. Sign up for Male Pelvic Floor or take an introductory course online at Medbridge. If you have only taken PF1, it’s time to sign up for Pelvic Floor Level 2A: Function, Dysfunction and Treatment: Colorectal and Coccyx Conditions, Male Pelvic Floor, Pudendal Nerve Dysfunction. Reach out to other pelvic floor therapists that treat men and ask for mentorship.

If you are general population therapist, consider taking a pelvic floor course.

Good news! Not every pelvic floor course requires you to glove up and donate your pelvis to science, so to speak. Yes, there are several external only courses you can take that do not have an internal examination lab. Click here and look under “course format” to see a list of external only courses. If you treat in the outpatient, ortho, or sports medicine arena, consider taking Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System or the Athlete and the Pelvic Floor .

If you treat in the Medicare age population, work in skilled nursing, or home health, join me in New York on May 21-22 for Geriatric Pelvic Floor. It is an external course and we cover documentation and self-care strategies extensively for incontinence and pelvic pain in older adults across multiple settings. Older adults with pelvic pain, like the man in the back seat, are at risk for being diagnostically ignored. We will address biases, such as “prostato-centric” thinking, ageism, and the ever-present “no fracture no problem” prognosis given to seniors who sustain a fall, but are left with disabling soft tissue dysfunction.

If you are a PT or OT school educator, eliminate “Pelvic Floor Day”.

Sorry, but it sounds silly. It’s like saying you offer a “Knee Day” in your program. Replace it by including the pelvic floor into Every. Single. Class…anatomy, ther ex, neuro, peds, geriatrics, and even cardiopulmonary!

As the baby boomer population grows, pelvic floor disorders are expected to rise significantly (download a free white paper on pelvic floor trends here).  Are you preparing your doctorate students to be competent screeners of pelvic floor dysfunction? Pelvic floor rehab is becoming the gold standard of first line treatments for pelvic dysfunction. Are you giving your students the skills to be competitive in a job market that recognizes pelvic floor rehabilitation as standard of care? Bias is learned. Excluding the pelvic floor in your student’s coursework or presenting it as a niche specialty subtly reinforces this bias.

Reach out and ask your local pelvic floor therapists to guest lecturer throughout the program. Send your instructors to pelvic floor courses. Encourage your students to take Pelvic Floor Level 1 in their last 6 months of coursework. Offer a clinical rotation in pelvic floor rehabilitation. Include case studies and patient perspectives on pelvic dysfunction, such as A Patient’s Pelvic Rehab Journey.

The Silver Lining

Thanks to the champions of pelvic floor rehab education, we’ve come a long way. The good news in this story is that this man’s doctor recognized early that he had pelvic floor muscle dysfunction and recommended that he see a pelvic floor physical therapist. The bad news-it took 2 years before he could find one. The ball is in our court, therapists. Let’s do better. Until there are no more men in the back seat, we still need to #LearnMoreAboutThePelvicFloor.

Congratulations to Dr. Sarah Capodagli, DPT, our featured practitioner of the week! Dr. Capodagli owns and operates CorrEra Physical Therapy, and she is in the process of expanding her practice in Buffalo, NY. We were curious to hear more from her about running a practice in Buffalo, and Sarah was kind enough to write in. Thanks, Sarah!

Although Buffalo is considered the second largest city in the state of New York, we often operate like a small town. We value community and for just about any business, the best marketing tool is word of mouth. If you need a new roof, new car, or a good doctor, well, ask around and I guarantee that you will find someone who “knows a guy,” to help or advise. I cannot speak for every city, though when I think of Buffalo, NY, I think of family. When you see your family in need, you help.

A few years ago I was working in a large oncology hospital and one of my primary roles was running the pelvic floor rehabilitation program for men living with or being treated for prostate cancer. I loved this work; however, I saw greater need in our community for not only the proper conservative care and treatment, but also for the information about pelvic health to be shared more publicly with men and women. Although opening my own clinic in a suburb of this “City of Good Neighbors” was not always the plan, when given the opportunity to grow into my own practice by a chiropractor friend, I jumped at the chance and have never looked back. It was a big jump, but for me, the fear of regret in never trying was so much worse than the fear of failure.

The greatest challenge was in actually starting my practice and beginning to educate the community and physicians. In a larger metropolis there is more awareness of this specialty and referrals come more naturally when conservative options are made known to patients. In the beginning I reached out to a mentor, utilized many tools available on the Herman & Wallace website, held free community events, and spent my first few months focused on networking. Once introduced to some fabulously conservative docs, birthing professionals, and physical therapists who were aware of the benefits of pelvic floor rehab, I really started to see the growth. I became an advocate for patients – a navigator in this sometimes confusing and frustrating system. People want conservative options and when happy patients return to their physicians with improved symptoms and quality of life, well, now your reputation establishes you as one of the “go-to” practitioners in the community.

Though patience and persistence are crucial in this process of growth, I’m also a firm believer that, as Dr. Francis Peabody stated, “the secret of the care of the patient is in caring for the patient.” This belief is what sets me apart, and in a small community this is what really matters. One of my favorite books is The Go-Giver by Bob Burg and John D. Mann. I always want my practice and the growth of my business to reflect the strategies of value, service, influence, and authenticity emphasized in this story. In a community where community is valued, I truly believe that if you stay teachable and positive, the care you put into your practice will always pay off.

The following post comes to us from Herman & Wallace faculty member Tina Allen, PT, BCB-PMD who teaches many courses with the institute. Tina's new course, Manual Therapy Techniques for the Pelvic Rehab Therapist, will be debuting this October in San Diego, CA.

As a physical therapist who has been treating pelvic floor dysfunction for 20 years, the patient who still impacts me the most happens to be the second patient I ever treated. The patient was a 22 year old woman who, before she even was referred to me for pelvic pain, had already seen 14 medical providers and experienced 10 procedures including a hysterectomy. She had been told by more than half of her providers that this pain was “in her head”, that “she needed counseling”, and that there was no reason for her pain. With 4 years of clinical experience at the time, I felt discouraged and wondered how I was going to help her. Then I remembered that no one else could look at her muscles and biomechanics like a PT could.

I started out by educating her about the muscles “down there”, observed how she moved with her daily tasks and then I completed her seemingly first ever muscular evaluation of the perineum. After 6 sessions of down training, muscle reeducation, manual therapy, strengthening of her hip and teaching her how to self mobilize the tissues of the perineum, she reported a pain level of 3/10- the lowest her pain level had been since she was 13 years old! Of course, she asked why it took so long for her to be referred to PT.

While this felt like an extreme story to me at the time, I now know that this is still the reality for many of the clients that we work with as pelvic floor PT’s. This experience set up the aspiration for me to have medical residents in my clinic with me to teach them what PT can do for patients and so that the residents can better evaluate their patients. As pointed out in research in the Journal of Graduate Medical Education, residents in obstetrics and gynecology do not feel adequately prepared to manage the care of women who have chronic pelvic pain^{Witzeman & Kopfman, 2014}. Specifically, residents reported negative attitudes towards patients with pelvic pain, and feelings of not having enough time to address their patients’ needs. When asked about how they preferred to learn more about care of patients with pelvic pain, the residents were interested in one-on-one clinical teaching as well as use of diagnostic algorithms. At this point in time I have medical residents with me at least 2 days per month. It’s a start!

So, what does a typical day look like with a 1st year OB/GYN resident in your clinic?

First, I always do my best to let my clients know in advance that a physician will be with me that day. The patient can always decline but most patients are accommodating. I have found that most of our patients want to advocate for themselves and others by having that physician with us in our session to teach them about how PT has helped them.

I spend the first 30 minutes when the resident arrives by bringing out the pelvic floor muscle model and explaining the function of all the muscles and how those muscles impact function. I also describe how this function is impacted by fascia, the muscles of the trunk, biomechanics and mind/body connections. Then we start seeing patients. After I have reviewed the patient’s current status, we begin our session. The patient is asked to give the resident their history and medical history. It’s been wonderful to watch my patients teach the residents and to hear the patients be able to explain their condition including procedures and functional restrictions.

The residents will then be instructed to palpate and learn about restricted tissues, observe how the patient uses their pelvic floor muscles, core, trunk and legs with their daily tasks. The residents have the opportunity to observe how we progress the patient’s self care in therapy.

While the session may start with the resident feeling frustrated that they are not able to be seeing their own patients or preparing for their tests, it usually ends with the resident asking when they can come back to the clinic to learn more about what we do and how we can help patients.

I urge all of us to reach out and invite physicians, PA’s, ARNP’s, midwives, naturopaths and nurses into our clinics to learn. With a little advanced planning we can get patients the help they need as soon as possible.

Witzeman, K. A., & Kopfman, J. E. (2014). Obstetrics-Gynecology Resident Attitudes and Perceptions About Chronic Pelvic Pain: A Targeted Needs Assessment to Aid Curriculum Development. Journal of graduate medical education, 6(1), 39-43.

Herman & Wallace Pelvic Rehabilitation Institute faculty member, Ginger Garner PT, L/ATC, PYT, will be giving 2 lectures at this year’s annual Montreal International Symposium for Therapeutic Yoga, or MISTY for short, in Montreal, Quebec. The first is a 2-hour lecture titled, Vocal Liberation, and the second is a 4-hour lecture titled, Hip Preservation: Yoga Reconsidered, Visit http://www.homyogaevents.com to learn more. Read below as Ginger shares why the voice is a linking science.

The Voice as a Linking Science for Clinical and Business Efficacy

Your voice can be the key to your success. Forbes magazine’s #3 habit in an article, Five Habits of Highly Effective Communicators, is “Find your own voice.” London’s think tank Tomorrow’s Company declares in a recent report on efficacy in business leadership, “Having a voice really matters for employees today.” The director of the Involvement and Participation Association (IPA) and vice-chair of the London-based MadLeod Review on employee engagement says, “Voice is extremely important because there are many changing business concepts and one of the essential ones is trust. Our voice is one of the things we really need to change old management paradigms and build trust in an organization.”

If you are an instructor, teacher, educator, therapist, or all four, having a voice is synonymous with having a job. You can’t do your job without a voice. And yet, we don’t spend much time thinking about vocal physiology, much less how to maintain and even improve it.

The most powerful change agent or therapeutic modality you have - is your voice. Yet, the voice is often overlooked as a therapeutic tool. Think of how important it is for someone giving a TED talk to have good vocal quality, for example. Now consider how important it is for others, like you, who may have to speak for hours on end each day. The vocal folds must be cared for just like we attend to the mind and body during postural yoga practice or movement therapy.

What were the other findings of the report?

• Voice is the foundation of sustainable business success. It increases employee engagement, enables effective decision-making and drives innovation.
• Finding your voice involves both cultural and structural pursuit. First, we need to be culturally competent and sensitive. Only then can we provide the right process through which our voice can be heard.

The power of the voice cannot be ignored, particularly for those who have allergies, respiratory issues, or struggle to make a powerful impact or to establish themselves as an effective team member or thought leader. Oftentimes, the voice is the single variable that holds us back from making the success we are seeking in our work. US News World and Report states,

“Whether you are an aspiring leader or in a support role, developing your communication skills can impact your success. First, let’s take a look at the complexities of communication. It's more than the words you use. It's how and when you choose to share information. It's your body language and the tone and quality of your voice.”

Psychology Today and National Public Radio have recently reported on the relationship between vocal quality and job success and effectiveness. Both agree that speech rate, tone of voice, facial expression, and diction have a great deal of power to make or break effective communication. If tone doesn’t match facial expression, for example, neural dissonance occurs, which erodes trust, increase skepticism, and cooperation.¹ In fact, warm vocal tone is a sign of transformational leadership, which generates “more satisfaction, commitment, and cooperation between team members”.² Changing pitch increases therapeutic potential and improves the chances of your being understood by colleagues, especially when diction is congruent with emotion.¹ Additionally, training mindfulness during public speaking can improve prefrontal cortex activity, which allows for improved social awareness, mood-regulation, decision-making, and empathy.⁴ Vocal awareness and training can slow your pace of speaking, which is shown to deepen others’ respect for you and simultaneously calm anxiety, traits which are bridge-building and healing for all relationships, business and personal.

About MISTY

MISTY is a not-for-profit organization and event dedicated to teaching others about therapeutic yoga.
Ginger’s workshop, “Vocal Liberation,” will introduce techniques for developing and preserving the voice, including projection, quality, longevity, and therapeutic impact through fusion of nada yoga and ENT physiology, which Ginger has developed over her career in public speaking and vocal performance. Want to learn about therapeutic yoga at MISTY? There’s still time to join Ginger and a host of other talented speakers and therapists. Learn more and register at http://www.homyogaevents.com.

Use of affective prosody by young and older adults. Dupuis K, Pichora-Fuller MK. Psychol Aging. 2010 Mar;25(1):16-29.
Leadership = Communication? The Relations of Leaders' Communication Styles with Leadership Styles, Knowledge Sharing and Leadership Outcomes. de Vries RE, Bakker-Pieper A, Oostenveld W. J Bus Psychol. 2010 Sep;25(3):367-380.
Short-term meditation training improves attention and self-regulation. Tang YY, Ma Y, Wang J, Fan Y, Feng S, Lu Q, Yu Q, Sui D, Rothbart MK, Fan M, Posner MI. Proc Natl Acad Sci U S A. 2007 Oct 23;104(43):17152-6.

The following insight comes from Herman & Wallace faculty member Peter Philip, PT, ScD, COMT, PRPC, who teaches Differential Diagnostics of Chronic Pelvic Pain: Interconnections of the Spine, Neurology and the Hips for Herman & Wallace, as well as the Sacroiliac Joint Evaluation and Treatment course. Peter has been working with pelvic dysfunction patients for 15 years, and he has some insights and advice for male practitioners who are nervous about treating female patients.

As a male treating female patients suffering with pelvic pain, many considerations must be taken to ensure that the patient is comfortable partaking in the patient/clinician relationship. As clinicians treating the most intimate of pain, we all must be highly aware of the sensitivities that each of our patients has as it relates to their genitalia. Many patients wish to maintain their modesty while simultaneously wishing to eliminate that which is ailing them. It is common that the observation, and contact to the pelvis and genitalia be a component of our patient’s evaluation and subsequent treatment in order for an accurate diagnosis to be made. So, in order to best protect our patients and ourselves it will behoove us to take a few simple steps.

1. During the course of the oral history, listen to what the patient is saying. What structures may be involved at referring to the outlined region in question? Can these structures be addressed externally and without exposure of the pelvis?
2. If a pelvic examination appears to be warranted, provide the patient with an understanding of what you will be evaluating and why. How does your evaluation reflect their pain? What are your expected findings?
3. Provide the patient the opportunity to read-and-sign a waiver that explicitly states that the evaluation may include: exposing, visualization and contact to the pelvic region inclusive of internal contact.
4. Provide a means of audio-recording the evaluation and subsequent treatments. Federal guidelines dictates that there be signs on the doors of any room or office space that is recorded, and having the patient sign permission to the audio-recording further protects themselves and the clinician.
5. Always ask permission to expose, visualize, and touch when and if any of the above are to be involved in the treatment of the day. Do this every visit, every time, and prior to initiating a new maneuver or treatment strategy.
6. Sit aside the plinth. Once observations are complete, there will be nothing to visualize. Drape accordingly and allow the patient to maintain modesty.
7. Test-retest. During the course of your evaluation, there will likely be an asterisks or correlational finding. Apply your treatment, and re-test. Appropriate treatments should provide both patient and clinician immediate feedback as to the efficacy and specificity of the functional diagnosis that the clinician is making.
8. Hold the patient accountable for their actions, and importantly their corrective actions whilst not in physical therapy. Our patients may see us for two hours a week, and if they are not complicit in maintaining that which we provide their healing will be compromised.
9. As for the male/female component. Some women and men will not be comfortable with a male clinician. Many women wish to maintain their modesty and/or have been violated and will have anxieties towards contact by a male clinician. The aforementioned strategies help not only to maintain a patient’s modesty, but also provide the ultimate control of who touches them, when and where. More importantly it provides the patient the opportunity to say “no” and to cease contact at their discretion. For the male:male patient:clinician relationship there may be equally as many difficulties. Some have been violated, and many have a subconscious concern of how well they ‘size up’ in comparison. Not that a comparison would ever be made, but the underlying anxieties will often be omnipresent.
10. Be honest and sincere with your patients and yourself. If you’ve made a clinical assessment that did not produce the immediate pain relief expected, state that to the patient, and continue your evaluation. If you don’t know the exact driver of the pain, or dysfunction, refer out to a local specialist and discuss your findings so as to better address your suffering patient’s needs.

Although awareness of pelvic rehabilitation is growing, patients who are referred for pelvic rehabilitation usually have more questions than the average patient about attending therapy. This can mean that you as a provider are burdened with a lot of phone calls or emails that go something like this: can I come to the clinic if I’m on my period? what are you going to do? are you familiar with my condition? how long will it take to get better? Consider how often these questions occur with patients who have knee pain, or headaches, and you may find that pelvic rehab is perceived by patients as quite unique from other types of rehab. How can you avoid trying to find time in your busy clinical schedule to tackle these additional communications? You can start by educating your front desk to handle patient care questions related to pelvic rehab, such as the following frequently asked questions:

• Do I need a referral from a doctor?
• What will we do on my first visit?
• What is biofeedback?
• What is ____________ (proctalgia fugax, interstitial cystitis), etc?
• I have my period, should I reschedule?
• Do you do internal work?
• Will my insurance cover this?

It is likely that the patient will ask to speak directly with the therapist, so you can first encourage your support personnel to politely inquire if there is something he or she could help in answering. Create a list of conditions along with a brief description of its definition, and a few examples of skills that a pelvic rehab provider has to offer. Your support staff can also offer to mail a brochure or flyer that you create which answers some of the frequently asked questions. Providing an “FAQ” section on your website that can be referred to may also decrease some of the stress of trying to play phone tag. Make no mistake that if you DO have the time to follow-up with a patient who has a question, you may create a connection that is really important for that patient in regards to scheduling an appointment. On the other hand, if you don’t have time set aside in your day for such calls or emails, you risk having the patient not get her questions answered. A form (on your site or as a written resource) might have some of the commonly asked questions written out, and you could use the ones below as an example to get you started.

Do I need a referral from a doctor?

Most patients can attend a physical therapy visit without having a prescription or written referral from a doctor or other referring provider. Insurance companies, however, may insist that you have a referral in order for you or your therapist to receive payment. Even if you do not need a referral from a medical provider, your therapist may require that you have seen a medical provider for your condition. Many conditions involving the pelvis can be medical in nature and require checking for more serious conditions before coming to the clinic. It is also helpful to have a medical provider with whom your therapist can coordinate care and discuss your health as a team.

What will we do on my first visit?

First, we will talk about what concerns or symptoms you have. Your therapist will also look over any forms you filled out to learn more about your history. The exam will be discussed with you so that you can have any questions answered. Your therapy exam may include general movement like bending forward and backward, seeing how you move your body, and specific tests of your joints, muscles, and nerves. For pelvic rehabilitation, an assessment of your pelvic muscles internally (through the rectum or vaginal canal) may be valuable.

Will we use biofeedback? (What is biofeedback?)

Your therapist may use surface EMG (electromyography), a form of biofeedback. This may involve placing some sticky sensors on your body so you and your therapist can get a better idea of how you are coordinating muscle activity in the abdomen or pelvis. Biofeedback means that you will be able to get information about how your muscles are working, and in therapy this is often displayed as graphs or bars on a screen. An internal sensor for the vaginal or rectal canal may also be used.

(For those menstruating) Should I reschedule if I have my period?

It is usually not necessary to reschedule if you are on your cycle, so you are welcome to keep your appointment.

Can patients benefit from a non-face-to-face treatment program for stress urinary incontinence? A recent study addressing this question was published in the British Journal of Urology International. This randomized, controlled trial utilized online recruitment of 250 community-dwelling women ages 18-70 years. Criteria was stress urinary incontinence (SUI) at least 1x/week, diagnosis based on self-assessment questionnaires, 2 days of bladder diaries, as well as a telephone interview with a urotherapist. The Outcomes tools included the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF), the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol), the Patient Global Impression of Improvement, health-specific quality of life (EQ-VAS), use if incontinence aids, and satisfaction with treatment.

The participants were randomized into 2 pelvic floor muscle training groups: an “internet-based” group (n=124) and a group who were sent information in the mail (n=126). The internet-based program contained information about pelvic muscle contractions (8 escalating levels of training), behavioral training related to lifestyle changes. The internet group received email support from the urotherapist, and the postal group did not. Pelvic floor muscle training was instructed at at least 8 contractions 3 times/day. After the 3 month training period, the internet-based treatment group was advised to continue pelvic floor muscle training 2-3 times/week, whereas the mail training group were not given any advice about continued training frequency. Follow-up data was collected at 4 months post-intervention, at 1 year and 2 years. At 2 years follow-up, 38% of the participants were lost from the study.

Within both groups, the authors report that the International Consultation on Incontinence Questionnaire Short Form (ISIC-UI SF) and the Lower Urinary Tract Symptoms Quality of Life (ICIQ-LUTSqol) showed “highly significant improvements” after 1 and 2 years compared to baseline data. Much of the improvement occurred within the first 4 months of the study “…and then persisted throughout the follow-up period.” When comparing the internet group to the mail-only group, the perception of improvement following treatment was higher. Approximately 2/3 of the women in both groups reported satisfaction with the treatment even at the 2 year follow-up. The authors conclude that the internet or mail-based exercise programs may “…have the potential to increase access to care and the quality of care given to women with SUI [stress urinary incontinence] in a sustainable way.” Additionally, not all patients will improve significantly unless they have one-on-one intervention, leaving plenty of patients who do need our direct care.

If you would like to learn more about exercise prescription for urinary incontinence, consider attending one of Herman & Wallace's many continuing education courses.

The following is a contribution from Elisa Marchand, PTA, PRPC. Elisa is the first PTA to become a Certified Pelvic Rehabilitation Practitioner! Elisa started a Pelvic Floor program with a locally-owned rehab company where she mentored 3 different PT's through the years. In that time, Elisa also taught as an adjunct with the local PTA program. Elisa works at McKenna Physical Therapy in Peoria, IL.

As a physical therapist assistant, the following should cause me to rethink my passion for and practice within women's health PT. "The SOWH is opposed to the teaching of internal pelvic assessment and treatment to all supportive personnel including physical therapist assistants." (Position Statement on Internal Pelvic Floor Assessment and Treatment: Section on Women's Health, APTA; Feb 2014) It should have stopped me from sitting for and becoming the first-ever PTA certified as a PRPC. Fortunately, this is not the case.

I want to be clear from the start; I understand the need for clear boundaries with regards to the scope of practice of PTAs. However, the interpretation of these rules can get quite muddy. In the APTA's "Guide for Conduct of the PTA", the following clarifications are made, including their interpretations:

3C. Physical therapist assistants shall make decisions based upon their level of competence and consistent with patient/client values. Interpretation: To fulfill 3C, the physical therapist assistant must be knowledgeable about his or her legal scope of work as well as level of competence. As a physical therapist assistant gains experience and additional knowledge, there may be areas of physical therapy interventions in which he or she displays advanced skills...To make sound decisions, the physical therapist assistant must be able to self-reflect on his or her current level of competence.

3E. [PTA's] shall provide physical therapy services under the direction and supervision of a physical therapist and shall communicate with the physical therapist when patient/client status requires modifications to the established plan of care. Interpretation: Standard 3E goes beyond simply stating that the physical therapist assistant operates under the supervision of the physical therapist. Although a physical therapist retains responsibility for the patient/client throughout the episode of care, this standard requires the physical therapist assistant to take action by communicating with the supervising physical therapist when changes in the patient/client status indicate that modifications to the plan of care may be needed.

Through the years of working as a PTA, I have practiced in a variety of settings. Some of these settings have allowed for a high level of autonomy (such as in my current workplace), and some have operated in quite the opposite-- where my treatments were dictated step-by-step by the PT. No matter the state in which one lives, physical therapy clinics will vary in their method of treatment and utilization of PTAs. In Illinois, where I practice, the following is the detailed description of a PTA per the Illinois Practice Act:

"'Physical therapist assistant' means a person licensed to assist a physical therapist and who has met all requirements as provided in this Act and who works under the supervision of a licensed physical therapist to assist in implementing the physical therapy treatment program as established by the licensed physical therapist. The patient care activities provided by the physical therapist assistant shall not include the interpretation of referrals, evaluation procedures, or the planning or major modification of patient programs." (http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1319&ChapterID=24)

Additionally, per the APTA's Standards of Ethical Conduct for the Physical Therapist Assistant: "6B. Physical therapist assistants shall engage in lifelong learning consistent with changes in their roles and responsibilities and advances in the practice of physical therapy." (http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Ethics/StandardsEthicalConductPTA.pdf) Personally, I take this as a green light for PTA's to immerse themselves in whatever their niche or passion may be. Thus, if a PTA is following this standard, and the advances in PT call for more trained therapists with an understanding of the pelvic floor, and the appropriate oversight provided-- as in my case; what is the hold-up?

Counter to the above expectations, the Section on Women's Health's Position Statement on Internal Pelvic Floor Assessment and Treatment states:

"Any internal pelvic (vaginal or rectal) myofascial release or soft tissue mobilization techniques that would require a continuous ongoing re-evaluation and reassessment should be performed by the physical therapist and not delegated to supportive personnel including physical therapist assistants. The SOWH recognizes that therapeutic exercise, neuromuscular reeducation and behavioral retraining techniques for pelvic floor dysfunction at times requires ongoing critical decision making while at other times are relatively routine. In the routine circumstances, those techniques may be delegated. When the higher level of critical decision making is necessary those techniques should be performed by the physical therapist and not delegated to support personnel including the physical therapist assistant."

In this above set-up, PTA's are made to sound as if incapable of using any critical thinking skills. Or, at the least, able to operate with very limited critical reasoning. Furthermore, in the typical treatment of pelvic floor conditions, how is the decision-making process required for individualized treatment any different than that to the external pelvis, or the low back, or the foot for that matter?! The skill and awareness that was required in transferring a patient in the ICU when I was a new grad was in some ways more complex with more of a direct impact on a person's survival and well-being, than what I do now. Yet, how am I not qualified to do something in which I have extensive training? This seems inconsistent.

In my opinion, the PTA is more than just "supportive personnel". On the other hand, I also believe that new PTA grads may not have a place in pelvic floor PT. There are complexities within, and knowledge required of anatomy and physiology of the pelvis, which the PTA does not get from his or her program. Though doctorate students entering the PT world today also do not have much exposure to the pelvic floor, they at least have gone through a more thorough coverage of anatomy, physiology, and disease processes. Despite the differences in schooling, MANY physical therapists see their assistants as vital assets to their clinics.

One incredibly positive aspect of being a PTA is the follow-through I have with my clients. I LOVE getting to know my patients, and feel that I am allowed this luxury more frequently than PT's whose schedules may need to stay open for new evaluations. I frequently have clients say to me, "I would never have dreamed that I'd be talking about (fill in the blank) with ANYBODY!" Usually, this is after a few sessions of working together. I cherish seeing the freedom and healing that comes when people feel comfortable enough to open up their physical, emotional, and spiritual selves.

Yes, as a PTA we are limited by the scope of practice placed before us. However, I do not see that as a set of limitations that binds us to a very narrow existence. With the training one receives through continuing education such as with Herman & Wallace, the PTA can gain the necessary skills for treatment. And from this, the possibilities are endless!

Download the ICD-10 Pelvic Rehab Cheat Sheet Here!

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.

Alphabetical List of Common ICD-10 Codes for Pelvic Rehab Providers

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

The concept of patient compliance, or adherence (a more preferred term), has been the subject of many medical studies, and adherence in pelvic rehabilitation is an aspect of rehab of critical interest. Recently published results of a survey questioning providers and the public about adherence in pelvic floor muscle training offers an insightful perspective. Researchers Frawley, Dumoulin, and McClurg conducted a web-based survey which was published in published in Neurourology and Urodynamics. The survey was completed by 515 health professionals and by 51 individuals from the public. Interestingly, but perhaps not surprisingly, health professionals and public respondents placed different value on which factors related to rehabilitation contributed the most to adherence.

Data collected in the study included topics such as barriers to adherence in pelvic floor muscle training (PFMT), perception of potential benefit of PFMT, therapy-related factors including therapeutic relationship, socioeconomic factors, and issues surrounding short-term versus long-term adherence, for example. For the providers, poor motivation was rated high as a barrier to short-term adherence, whereas the patients rated perception of minimal benefit from PFMT as the most important barrier. Facilitators of pelvic muscle training included aspects of access such as having appointments outside of the typical workday, or having childcare available, transportation, and not being bored by the exercise program or feeling that the therapist has adequate training and skills.

As suggested by the authors, perhaps that most important variable agreed upon by both providers and public is that of perceived benefit. In other words, patients need to believe that the exercise program can alleviate symptoms and that what they are doing in their particular program is going to achieve positive results rather than wasting time on a home program that will not be effective. This issue is one that can be easily remedied through appropriate patient education, communication with the patient about whether or not they understand the potential value and expected recovery through program participation, and adequate training of the therapist that allows for proper diagnosis and treatment planning. The study concludes by emphasizing that health providers “need to be aware of the importance of long-term patient perception of PFMT…”

If you are interested in advancing your diagnostic or treatment planning skills, check out the pelvic floor series of continuing education courses and the many specialty courses that the Institute offers.