Thank you, Jennifer. That was a great introduction. Thanks for having me. As Jennifer said, I've been a PT for quite some time. My original background was in neuro, and then I spent some time in PEDS, and eventually orthopedics and sports medicine. And after some time, I did start my private practice when women started asking me, oh my gosh, what's going on down there? I said, hold that thought. I'll get right back to you. And I took a bunch of courses, and CTS was born. So I've been helping women ever since. My only disclosure is that I am the owner of CTS, where I have a staff of 10 PTs and an additional 12 women of support staff. We do have one male physical therapist on staff who treats some of our female clients for orthopedic injuries, but his practice is the male clients. So we have a pretty good sized practice here in San Diego. Our learning objectives today are simple. I just want everyone listening to be able to identify some disorders in which physical therapy can help treat, explain kind of what a session of pelvic PT entails so your patients aren't so terrified when they show up in our offices, and then be able to discuss three treatment techniques, some commonly used biofeedback techniques. And I want y'all to be able to find a physical therapist near you. So I'll teach you some ways that you can search. This is a short list of commonly treated disorders. We see lots of laxity issues, including pelvic organ prolapse. We'd love to see these women as soon as we can, postpartum, or as soon as the problem is evident in an ideal world. We'd love to see them preoperatively and postoperatively as needed, but before things get too difficult for them to manage on their own. We treat all kinds of various incontinence issues. When I started in this specialty, I thought bladder issues were going to be my primary clientele, but alas, it's actually defecatory disorders and all kinds of pain conditions. When it comes to when do you refer, as I said earlier, we prefer sooner rather than later, especially for pain patients. Opioids are clearly not as prescribed as often, which we're of course excited about. So pelvic PT and PT in general should be considered a first line when it comes to treating pain clients. We do have a lot to offer and we have none of the horrible side effects that opioids have. When we first see a client, we go into a detailed history of everything. This can lead to our first appointment being over an hour for some of our clients. We comb through every bit of their history from their medical history, family history, what's going on in their social and support systems, and then habits. We actually ask about everything. I know some of my fellow colleagues, my fellow urogynes, really are limited on time and you can have your patients fill out a lot of the forms and diaries, but it's tough to get all that history in. So sometimes we're able to comb through a little bit more with our patients than a lot of our physicians might have time for. We ask about diet and hydration and lots of habits, urination and bowel movements, but not just frequency, but their Bristol scale, the amount of effort, their position, their technique. We really go through, whether it's sleeping or exercise habits, and we try to warm them up with all those questions. Once we do have them warmed up, we ask them about their sex lives too. As awkward as that can be, we really do get into details. Again, we talk about frequency, pain, positions, lubrication. We love the details of all of their habits and medical history because it gives us clues on how to best coach them back to health. I mentioned diaries. We love diaries and we love them almost as much as we love pelvic floor exercises. Diaries help our patients become aware of their habits and we become aware of their habits. We define goals. They learn a cause and effect relationship to their habits and it gives them benchmarks to show improvements. If they fill it out honestly, sometimes clients are shocked about how much they drink or maybe how little they drink or how much they leak or how little they sleep. Again, diaries give us clues to fine tune our treatments. We have diaries for just about everything. Once we do our medical history, which is usually a large portion of our exams because it gives us so many clues as to how we're going to start treatment, we do start the physical exam. When I say physical, we get very physical. We're looking at posture, but also functional postures and range of motion. We do screenings to clear the lumbar spine, sacroiliac joints, and hip joints for contributing factors. Many, many times we find hip pathology or lumbar pathology that can contribute to those bladder and bowel functions. We examine the abdomen, looking for scars and trigger points and muscles, and we'll do a visceral exam. We also look for diastasis rectus, and we'll get into a little bit of that a little bit later. We get into a detailed pelvic exam, internal and externally, and we'll get to that in more detail in a little bit. We also check on different things that you may not be aware of, especially when it comes to adverse neurotension on sciatic nerves, thoracic and lumbar, and pugendal nerves, nerves that need to be mobile, especially when it comes to our pain patients, but that can also contribute to bladder and bowel urgency and frequency. As I mentioned, we examine the viscera, looking for mobility of organs. All organs should have a certain mobility, and we can sense restrictions, especially after trauma or surgeries. And then we get to functional strategies. We really analyze different habits that they have, habits that they have when they're lifting their newborn, or how they toilet, or how they breathe in different postures. Whether we're working with a postpartum mom of three, or a NOLI Pilates instructor, it's imperative that we look at all these different areas to figure out where to take our exam a little bit further, but also how to treat them best. When I mentioned a detailed pelvic exam, we are looking at all these different muscles. We test muscle strength, as well as mobility, and we're looking for trigger points, but we're looking at the UGT, the urogenital triangle, versus the levator ani. We can observe externally, but we really feel, for the most part, that internal palpation gives us much better clues as to how they use their pelvic floor in excursion, their ability to contract, their ability to relax and let go, and also testing for symmetry. We can test lift, we can test their ability to squeeze. We're testing sustained 10-second, maybe 30 or even 60-second contractions, as well as quick flicks. We're looking for endurance. We're looking for volitional contractions versus reflexes. And we really take this exam, depending on what the diagnosis is or what the functional need is for this patient, we may take it to different postures. Typically, I think most pelvic exams are done in supine, but we might have to do things in sitting on a commode or standing or even in a squat. We can also assess pelvic floor activity versus via biofeedback. We can see things on a real-time ultrasound now or examine things on surface EMG or pressure EMG. But surface EMG is really a sum of muscle activity, and plenty of clients cheat with pressure or surface biofeedback. And so, that's why we really do like internal palpation. We really feel like it's the most reliable assessment for strength and coordination. And certainly, it helps us sense pain in some of those patients as well. So, back to our abdominal exam. We, as PTs, definitely test for diastasis rectus. There's lots of new things happening in the literature and demonstrating the connections between diastasis rectus and other pelvic floor or pelvic issues. Diastasis may be mild and may not contribute to much of anything. Or some of our patients may be just at risk for body image changes. This is that postpartum pooch we see sometimes. But they also are more susceptible to pelvic girdle pain, sacroiliac joint, or pubic synthesis pain. There's more of a correlation for pelvic organ prolapse, stress incontinence, and low back pain. So, years ago, we used to think just the width of the diastasis was most important. But now, Diane Lee, a physio up in Canada, has also studied the importance of the depth, also the density of the tissue, and more importantly, what you can do with it. Can you transfer the load from one side of your pelvis to the other, even though you have a diastasis rectus? Or if you do have a diastasis, how we can help repair that to perhaps improve your symptoms of stress incontinence, pain, or pelvic organ prolapse? I mentioned we analyze posture and body mechanics. There's a huge correlation between posture and pain. We know our chronic pelvic pain patients, and that's the little picture depicted on the left, they typically come in kind of slumped, holding their muscle patterns, holding their breath. And we know that can lead to chronic pelvic pain. And we know that can lead to chronic pelvic pain. There's lots of different postures. There's postpartum mom posture. There's kind of a military posture. We're in a military town here. So, we actually see that. And those postures can affect how they use their muscles and how their organs are affected. And again, affecting things like prolapse and incontinence. So, PTs really do analyze posture, and not just in standing, but also in sitting and functional postures. You know, how they lift their baby, how they push their stroller, how they get the groceries out of the car. Especially if that's when they're leaking or if that's when they're having pain. So, once we've gotten their history and completed our physical examination, we really start on treatments as we're going through our history. And we are huge in education, educating our clients. And you do the same thing. We just tend to have more time as PTs. We educate on everything. We go over the anatomy and physiology of why they may have the condition that they have. But we also have handouts on everything. Everything from the neck and urge suppression, the toileting, where to find help with smoking cessation, how to exercise regularly, sleep hygiene habits. We really do educate on every detail. And what's nice about working with PTs is we do tend to see them more often than they get to see their physician on average. And so we can reinforce all the education that you've already done and then get into the details of why they need to change their habits or how to change their sleep habits so they can sleep a little longer and improve their symptoms. And we also at times may even refer to other practitioners to help us out, especially when it comes to things like work-life balance and sleep and pain. We're huge fans of also cognitive behavioral therapies and usually have some psychologists that work closely with us. But we may also do things like just refer to an orthopedic surgeon to follow up on that severe low back pain or herniated disc or a pulmonologist to even help with a sleep study. Part of our education is education on regulation. We're huge fans of regular bowel and bladder habits. So we educate in proper hydration. Our magical formula is usually half an ounce of fluid per pound of body weight. Half of that hopefully being water. And then we educate on fiber so that we can get their bowels regular to hopefully help their bladder to become more regular. But we also let people know that irritants are a problem. Gas producing foods can be painful and to avoid constipating foods. So again, this is all part of our education and getting into the details of their bladder and bowel habits. We are also educating on medications and supplements. What we find especially for our bowel and bladder patients that are led more towards the extremes. They also have extreme habits of going on and off medications that or supplements that I call the roller coaster. And this is just a short list of things our clients take for bowel movement regulation. But they start and stop so frequently that irregular use can even lead to more issues or just frustration for lack of improvement. So we're neither really promoting or prescribing, but we do educate our patients on why their physicians have prescribed such things, questions to ask or even how to use them. There's so many combinations and they tend to take one supplement to counter the effects of another or they take them because their neighbor told them or their grandma told them or they read it on the internet. But we constantly remind patients of side effects of their medications and usually just defer them back to their physician to discuss this. They tend to have a little bit more time to discuss all these things with us during our sessions. But really we want to defer back to our referring physicians, but get our patients to use their medications and supplements as prescribed. So I mentioned body mechanics already, but toileting mechanics are extremely important for our clients. We go through the basics, the basics of promoting regularity and scheduling, which may or may not be with those supplements and hydration. But toileting posture is also super important. I'm a huge fan of the squatty potty. It's one of those things that I wish I invented because I think I sold millions. But it's super helpful for bowel regularity. And really getting people scheduled reduces anxiety for things like fecal incontinence and bladder irritability. But it also improves constipation. We go through in detail how to use proper posture and toileting techniques. We like wide knees and elbows on knees. So that's why we're a huge fan of the squatty potty or things like nature's platform or just squatting. So again, we ask how our patients are toileting and then ask them actually show us. So demonstrate just as they would sitting on a chair. In our clinic, we also have commodes that we can move around. So we can really get the angles right for patients, especially if they have other issues. We're a huge fan of knees above hips. But if they've had a total hip or a total knee, that might be more difficult for them. So we might want other props or work on other postures with our patients. So again, we really get into the details of their mechanics. For bowel movements and for voiding, we really like relaxed techniques. Or maybe for bowel movements, a little push on initiation. We teach them, you might hear your patient saying, my PP said, do belly big, belly hard, or blow as you go, as you bear down. And again, we analyze how these techniques work best for your patients. And everyone's different. So we may say belly big for belly hard for some people, but may need to teach other people how to manually support their perineum or their rectocele. We want to get them out of the habits of straining and out of the habits for prolonged sitting, which may lead to other things, including hemorrhoids and other painful conditions. We are physical therapists. So most of us really, really like manual therapy techniques. And this may include joint mobilization, whether that's the lumbar spine or pubic symphysis, we may need to mobilize these type joints, or we may need to stabilize them with belts or tape. We're big fans of kinesio tape or other types of tape to help stabilize certain joints. We're big fans of visceral mobility, and we'll get into colon massage a little bit later. We can mobilize nerves. And then there's lots of different soft tissue techniques. And one thing I want to mention when it comes to manual techniques, physical therapists learn on each other. So we know exactly what these techniques feel like. We don't get medical models when we go to our coursework. So we know what it's like to get these pelvic exams. We know exactly what it feels like when nerves are stretched too much or mobilized too aggressively. But we also know we can perfect our techniques by working on each other and getting great feedback from each other. So I just think that's a unique way to learn is really working on each other. Every PT has their own bag of tricks. So the list that I have up right now is just a short list of many options. But in addition to using all these manual therapy techniques for us, working on our clients, we also like to teach them self-mobilization techniques if they need it. And then of course, have exercises piled on top of these things so that once things are mobilized, we can really keep them moving and progressing forward in their therapy. So we're just going to go through a few of those techniques. And this is an example of just one soft tissue technique called skin rolling. It's courtesy of Stephanie Pendergrass and Liz Rummer, who are fantastic PTs, who have taught us a lot about mobilizing nerves and also mobilizing the soft tissue. And we can skin roll just about anything. But I wanted to let you know that this is we really get in there and do mobilize the tissue of the perineum around the vulva. Skin rolling is all done externally, but we also do a lot of internal techniques. We go through lots of trigger point releases in different areas of the body. These techniques are somewhat dated. This goes back to Travell and Simons. But we use lots of variation on these techniques. And this is to go through all those trigger points of the pelvic floor, especially for our pain patients, but also our urgency patients. So if you're ever thinking about that, or if you're ever thinking of a client who may have an overactive pelvic floor, and for some of our urogynes, Botox is a viable treatment, we can tell you exactly in detail which muscles are most overactive. Is it really the coctygeus? Or is it the anterior aspect of the puborectalis muscle? Or is it the obturator internus more related to that lumbar pathology? And we can do these techniques. I mean, this is an example of internal trigger points. The trigger points are also external. We'll do trigger point releases on the iliopsoas and affect not just the psoas, but digestion and breathing and just how they feel and get their abdomen moving just by doing psoas releases. So trigger point releases can be done on any muscle. It's just a matter of which muscles are most provocative, especially of pain and urgency or frequency. So a few other techniques we might use. Feel's massage dates back, Dr. Feel was actually a urologist. And he was doing feel's massage actually to affect chronic prostatitis way back around World War II. Now we use the same techniques. And we do use this on our male clients, not so much for prostatitis on the prostate, but we're stroking through various pelvic floor muscles, specifically levator ani, coctygeus, and obturator internus. And we might even get in there to the piriformis. And either going with the grain of the muscle or maybe cross fibers to really calm these muscles down, improve circulation, decrease trigger points, and just improve the overall mobility of the pelvic floor muscles. For the most part, this can be done vaginally. But this picture is definitely showing a rectal position. And although we do, we're limited on our male clients, we'll definitely do this rectal. When our patients are having rectal pain or coccyx pain, this is also a technique we can use to mobilize the coccyx in addition to the feel's massage. And we do that rectally, either in side lying or in a supine position as depicted here. I think what one soft tissue technique that gets a lot of press is colon massage. So we do this often in our clinic, especially for constipated patients. It's also known as the magic poopy rub. It's fairly effective for facilitating movement in our constipated clients. It's not a standalone modality, but it can really help. It's used to decrease pain and discomfort associated with gas and constipation and bloating. There's many variations of this technique. So this is just what I'm doing on one of my more constipated clients. But our techniques vary in depth and pressure along which meridian and in visceral manipulation. We are very organ specific, but this is specifically for our colon. And there are some studies showing improvement in colon massage, especially in our pediatric clients, our MS population. And again, just for most of our constipated clients. So we do this often in our clinic. And sometimes our patients just come in and request the magic poopy rub because when they've tried everything else, this is very stimulating for the bowels. Biofeedback is a great technique that our physical therapists use. But I just want to remind people that biofeedback isn't just surface EMG. But biofeedback is really about getting input, whether it's visual, auditory, or tactile cues. So even our pelvic exam is somewhat of a biofeedback. Using mirrors can be a biofeedback. But we also do surface EMG. Some of us will do rectal balloon treatments. We here at CTS use real-time ultrasound. And in some places, I know some hospitals, the PTs also have use of their anal rectal manometry. So biofeedback typically isn't a standalone treatment, but it can really, really help with a variety of conditions, especially our bladder and bowel continence issues. So surface EMG is done either with a vaginal or rectal sensor, or we can simply put external sensors on the perineum. And that's typically what we do here. For one, in an outpatient clinic, it's most cost effective. The rectal and vaginal sensors can cost up to $75 a sensor. And so that cost is prohibitive for some of our clients. So the external sensors can work just fine in many cases. We can get a great baseline. We can teach our patients quick flicks. We can put them on a work rest program and also work on endurance. And having these patients get this visual is incredible for some of our patients. But some of our patients are so goal and number oriented they can also get hung up and just want to cheat. So the downfall of surface EMG and some other biofeedbacks is in order to see the little line move they will substitute with their gluteals, their hip rotators, their abdomen. And a lot of times we'll put an extra sensor on their abdominal muscles to make sure they're not over contracting their abdomen. But there aren't enough leads to put sensors on the abdomen and their glutes and their inner thighs. So we're constantly teasing that out and coaching them along the way. When PTs are doing the surface EMG we're typically in the room with them the whole time coaching them along the way to not substitute and not cheat with their other muscles. But this can be extremely effective for stress incontinence, urgent incontinence, fecal incontinence, and constipation. For our pain patients we're actually, we might see a high baseline but we also are, they may have a poor ability to contract those muscles. So sometimes they have a falsely low baseline. So we teach them the ability to contract and then teach them the ability to relax again. So it can work well for our pain patients as well. Another form of biofeedback is our pressure biofeedback. This is, you know, taken, designed after the original perianometer for Dr. Cagle designed. For some of our patients they like this better than the surface EMG because they like the sense of squeeze. Especially for our prolapse and incontinence patients. There are great home units available that people can purchase that are not that expensive. But again, substitution is the biggest downfall. And I would say breath holding is another downfall. So we want patients to learn how to isolate and contract their pelvic floor muscles. But not at the expense of holding their breath or getting the contraction by contracting their abdomen or their glutes. But again, if this is how I need to get my patients to do their pelvic floor home exercise program, then I'm fine with them using a home biofeedback unit. And some of them now have apps that they can use as well. So in the last couple years at our clinic we've also started using real-time ultrasound. Our friends in Australia have been using real-time ultrasound for quite some time. But we just got our units last year because they can be kind of pricey. But this is another great form of biofeedback. And what I learned is that we can really sense, we can really teach our patients the appropriate contractions and how to avoid balfalva and bearing down by showing them in this type of picture versus an EMG picture what their bladder is actually doing. So on the left there's a transabdominal viewing. And in that picture that contraction was great, the pelvic floor went up. And then the next contraction is bearing down. And then this third contraction, still on that left side of the screen, my client does a balfalva. And you can see the squeeze laterally. So they're getting more of a lateral squeeze versus the pelvic floor lifts. And on the right side of the screen we have a transperineal view. And again we can see what their pelvic floor is like at rest. We can get a great contraction and relaxation. And then what it's like when they bear down or what it's like when they balfalva. So this really helps us fine-tune our cues for our patients. And in some of my patients, especially some of our elderly patients, we don't really, some of them are just not comfortable with having internal work done or even having vaginal or perineal sensors placed on their perineum. Which is fine because in this case, especially the transabdominal picture, I can get a great picture of what's going on inside and a great picture of what's happening with their pelvic floor without having to do an internal pelvic exam. So we are huge fans of real-time ultrasound. We can also use real-time ultrasound to see what's happening in their diastasis rectus and possibly retrain the transverse abdominis and in an appropriate contraction so that our patients can actually form more tension along their linea alba and improve their core stability. So we'll use a real-time ultrasound transabdominal looking down at the pelvic floor, transperineal, but also transabdominal just for looking at examining diastasis rectus. Rectal balloon therapy is also something we use especially for our bowel urgency and fecal incontinence patients. We also find it helpful in some cases of constipation. Not all PTs have the means of doing rectal balloon therapy, but it is an option. Clinically, we want to examine when our clients get their first sense of fullness and we've seen first sense at 30 cc's, but we want people to train them down to their first sense of 10 cc's. We're hoping to improve that first sense of awareness especially in our fecal incontinence patients, but in some of our patients where their rectum may not be as flexible, we're also gradually getting them to improve their urge control and improve the flexibility of their rectum by using rectal balloons to improve compliance and flexibility. We can start by expanding the 50 cc's and then growing to 70 to maybe a hundred to hopefully a hundred and fifty cc's. Again, we do this most often with our fecal incontinence patients, but if anal rectal manometry isn't available, we can get a good sense of what their rectal capacity is, whether they may have a mega rectum or if we keep filling and they're not sensing or they have an inflexible rectum and we can work on stretching that with these balloons. Again, not every PT has this in their clinic, but it is available and if you're interested, I'm sure you can convince your PTs to learn how to do this because it can really facilitate treatment in fecal incontinence and even fine-tune treatments in constipation, especially when we train expulsion techniques. We use a 50 milliliter balloon and by the way, we always fill with air, but we've even trained in expulsion techniques in varying various positions. Typically, this is done in side-lying, but we've even taken our patients into sitting on a commode to really get into retraining their expulsion to have a complete bowel movement, but just another form of biofeedback that is a possibility. We also use various modalities in our clinic. I think modalities are most often used to decrease inflammation. They may also be used in the case of heat and ultrasound and therapeutic light or low level lasers. They may be used to promote circulation and healing and even help manage pain and for a lot of our patients, they can use modalities that are available at home as well. So again, lots of stuff out there for your patients to purchase, whether it's the old-fashioned Penn's unit or cold cone, especially for our patients that may have had more pain syndromes or burns due to radiation or our oncology patients. There are lots of options for our patients. One of those modalities is electrical stim. So we have our old-fashioned Penn's unit, which again, home units are available for our clients, but we also have interferential, which is just a little more comfortable type of electrical stim. We usually do that in our clinic, but we can also use neuromuscular re-education units. For our urge clients, we may use a lower hertz. Think kind of along the lines of PTNS for your clients. For strengthening, we're using about 50 hertz. And again, these sensors can be vaginal or they can be rectal. And we're prescribing the electrical stim to really supplement their home exercise program of pelvic floor muscle exercises. And really, most of the studies out there show that combined therapies work best, right? So not just biofeedback or not just electrical stim, but biofeedback with electrical stim with lots of home exercises. Your patients may come back to you and say, my therapist told me to breathe. Well, breathing is really important and how patients breathe is really important. The diaphragm is a huge muscle responsible for not only breathing, but also in part to control stabilizing postures, regulating thoracic and abdominal pressure systems, and certainly helping with GI function and even blood pressure. We can improve GI and bladder function in various ways just by quieting the sympathetic, right? Fight, flight, freeze, by quieting their breathing techniques, or maybe we need to stimulate certain breathing patterns. Breathing works not just the diaphragm, but the abdomen, abdominal muscles, and the intercostals. So when we give or prescribe your patient's diaphragmatic breathing, we're not just having them lay around and breathe. We may start them in the supine position that's pictured here, but we want to promote this breathing pattern in sitting as well, when they're driving, when they're working, when they were having a bowel movement, and also in standing. If they're trying to quiet their urge, then slowing their breath down and doing great diaphragmatic breath is a great way of quieting their nervous system and then quieting their bladder. And because we breathe more than we do anything, it's really important that we do this well. And I can't tell you how many times I've analyzed patients and other PPEs out there and just noticed that their patients walk in the door and they're holding their breath the whole time, especially our pain clients and our urgency frequency clients. So it's not just about breathing, but it's breathing in different postures and different techniques. When we talk about exercise, although we love Kegels, we love pelvic floor muscle contractions, we do a lot of other things. So we're working on their abdominals in a very functional way, making sure that their transverse abdominus muscles aren't overriding their obliques. We're working on strengthening those hips because those hip muscles are so coordinated with their pelvic floor muscles, and we're working on, you know, how they move. Can they transfer loads from one limb to the other? When we talk about stretching, it's not just stretching their perineum, it's stretching, again, a lot of different hip muscles, their quadriceps, their hamstrings, their low back. I'm a big fan of nearly any exercise is a good exercise. So again, we have a huge variety of exercises to choose from. Yanda and PNF and Gary Gray and Aldo are just a few, but your patients already like to do Pilates or they used to go to yoga class or they're thinking about Tai Chi, and so we work to promote exercise, get them functional enough, get their pelvic floor strong enough, and coordinate enough so they can get back to their Pilates, yoga, Tai Chi, or cardio classes. So just to review our philosophy, we do a super thorough evaluation. Again, we started with that huge medical history and then our physical exam. We treat what we find. Those things are tight, we stretch it. If things are weak, we strengthen. If things move too much, we're trying to stabilize. And then we really try to empower our clients with education, giving them exercises that they can manage their condition on their own, teaching them how to use self-care strategies to improve their toileting habits or dietary habits, or hydration. And then our ultimate goal is, of course, to restore function. So when to refer? I mentioned this early on in our presentation. Sooner rather than later is so awesome for us. So think postpartum checkup or pre-op visits, especially if you know it's a more complicated client. We definitely see patients post-operatively, but sometimes we see them months post-operatively. And what we hear is, man, I wish I would have known about this before I had surgery. So post-op might have been better. Definitely refer your pain clients as soon as they're complaining of pain, because the sooner we get them, the easier it is to transition them out of pain. Of course, your pelvic organ prolapse clients. And then don't forget about your specialty populations. We really want to see our oncology patients. Whether it's breast cancer or cervical cancer, we really feel like we have things to offer these clients, especially when it comes to pelvic floor health. Your neurology patients, Parkinson's and MS patients could really use the referral. And as I mentioned, of course, our prenatal clients. And just to remind you, we're here to support you and back up what you do. So we just want to make everyone's job a little bit easier. So how do you find us? So the easiest thing is if you're in a rural area where you may not have already met your local PT, you can simply Google, quote, pelvic floor physical therapy, quote, and put in a zip code or a city. You can also find practitioners on any of the sites I've listed here. The Women's Health is our national organization. Pelvic Rehab, Herman and Wallace is an educational platform. And Pelvic Guru also offers a listing. And really just reach out to your local clinic and get to know them. And that way you can also be on the same team, right? So we can support what you do and make your job a little bit easier. So what to look for in a pelvic PT? You can certainly look for years of experience, but you should also look for a couple things. Private rooms. So pelvic PT should be done in private rooms. We have eight private rooms here. Gyms are great, but I can't do an exam behind a curtain. So make sure clinics have private rooms. Your PT should be comfortable with both vaginal and rectal exams. You can ask your PT what kind of biofeedback they do so you know if it's real-time ultrasound or you know they are comfortable with rectal balloons or maybe they're just comfortable with surface EMG. Exercise preferences that you may have, but also that you may have, that your PT may have. PT visits last in general anywhere from 30 minutes to an hour and a half to maybe two hours if they're doing a huge exercise program. And that's not usually where we start, but some of our more complicated patients may be here for a while. We may see patients in the beginning once or twice a week and then hopefully we get them down to once a month to manage their condition. There are different credentials that PTs may have. I am just the PT, but there are people that have masters and doctorates. You may see the initials WCS, which is a women's clinical specialist. There's also orthopedic clinical specialists. And then PRPC is Pelvic Rehabilitation Practitioner Certification. So there are lots of credentials out there. And then what we might need from you is great lines of communication. We may want to share information with with you or we might need information from you. Imaging, hormonal management, we may have medication questions on medication just because the PT or the patient may not tell you everything. Sometimes we may just get down into those details. So we may just pick your brain and need more advice on how to treat particular clients. But anyway, I want to thank you for having me. We'll open it up to questions, but thanks to Augs and then all the local practitioners for helping us out. So I will stay on the line for questions. Thank you, Cindy, for your presentation. We do have a few minutes for questions. You can submit your question for Cindy in the questions box on the left-hand side of the window. While we wait to hear from some of our participants for questions, Cindy, one of the things that I'd like to just kind of pick your brain about is when you have a patient who might be a candidate for pelvic physical therapy, what would you like us to communicate with them before they visit with you on the first visit? I try to tell them, you know, definitely expect to have an exam and some internal work because I think sometimes that can make patients a little anxious. But is there anything else that you want us to communicate with patients before they meet with you? You know, I think what typically happens in our clinic is when patients call and you can ask them, you know, call and they might also have extra forms. Kind of like the forms that your clients fill out in your office. Again, back to the diaries and questionnaires. And so that'll give them kind of a hint of where to start. But I would also empower them with, and don't worry, you don't have to do an exam that you're not comfortable with. Especially when it comes to the anxious client or a client that's in pain. And especially those two categories. They also have a pretty significant history of trauma. So we may not do an internal vaginal or rectal exam the first visit. Because if we sense that, you know, we don't want to force that on them. And we want to give empower them to say no. That being said, we'll encourage it when the patient is ready. But I would say, you know, you should feel comfortable going there. And a lot of our clients just open up to us about everything. But you can also do things like wear comfortable clothes. Be ready to exercise. Little things like that can be helpful too. Okay, thank you. Just gonna pause for a few more minutes to see if any questions come in from our audience. And again, thank you for having me. I had this last slide, it's just a list of references. But there are some great organizations on there. You know, to find a PT or to get more information about pelvic PT. Thank you. We do have a question. One of our participants wanted to know if there was a brand you recommend for surface biofeedback or real-time ultrasound. I think what's best is to try out a few. So in our clinic, we do use the Prometheus biofeedback, which has been great. And that, I would say, is probably the most common. But if you're in a hospital-based setting, you can also see what Urogyne is already using or Urology is using. And you might be able to tag team with them. But Prometheus, I would say, is probably the most common in surface biofeedback. And then as far as real-time ultrasound goes, we have a sonocyte machine because we have 10 therapists. So our equipment is heavily used. And I went with them only because they are military grade. And that's what we need here, because we're really hard on our equipment. But again, Prometheus just came out with a great affordable unit. And I would see what's easiest and what's most portable, because you're going to be schlepping those units around your clinic. So I would call a few different places and see what works best as far as what fits your clinic, what price fits your clinic, what warranties are like, because they do get a lot of use in our clinic. And then there were two questions that were fairly related. One of the participants wanted to know what your thoughts about home simulators were. And then if you had a brand for home e-sim or biofeedback units that you would recommend. So with electrical sim, first, I just want to emphasize that you want to really, really make sure that their vulvovaginal tissue is super healthy, and that the treatment is absolutely pain-free, and that their muscle connectivity to the vaginal or rectal sensor is really good. Because otherwise, those vaginal sensors can slip around. So we, again, use a Prometheus stim unit. But in case of, let's say, a postpartum mom with kind of a roomy vagina, if you don't have great muscle contact, you're not going to get a great response from the patient. So I always make sure that it's okay to use in the clinic first and do it a few times. They need to have really great sensation. And then again, their skin condition needs to be really good. So I don't, I don't typically prescribe home stimulus as much as I would say, hey, home biofeedback, there are a bazillion online right now. I mean, it's really popular. You can put Kegel Exerciser in Amazon, and at least five of them will pop up. So again, it goes by price and really what the client's going to use. So, you know, clients just have to try them out. But I don't have one in particular I use. I defer back to my patients, especially because of price. With the electrical, the electrical sim units. There, if you go through some of the companies, they may have kind of a rent to own program. So that's a possibility. But again, it's going through, you know, probably Prometheus, and I don't know of any other ones that have a rent to own, but that's an option. But as far as surface EMG goes, I am not aware of an affordable surface EMG units. So the home units out there are pressure biofeedback, which is fine. But it's just a little different than surface EMG, but you get a better sense of squeeze. So some clients like that better. Thanks. Thanks. Do you use any vaginal dilators? And if so, what role do they play in your practice? Oh, yes, that is a great question. We use definitely we use a ton of vaginal dilators. I can't believe I forgot that my apologies. Um, especially for pain patients. We use it for straight up dyspareunia vaginismus. And we also use it a lot for trigger points. So there's vaginal dilators, and there's also a pelvic wand, kind of a curved wand. And again, especially for trigger points, we want our patients using this stuff on their own. And then dilators, there's the hard plastic dilator, which is great that come in graduated sizes. But and that's most affordable for most people. Laura Berman has one out. That's kind of like those little stacking those little Russian stacking dolls. But that can be really affordable, too. Um, but it's harder to find. And then, um, there are some silicone dilators out there. And what we like about those is that sole source makes them you can sit on them, they're a little pricier, but they're more bendy, so they can be much more comfortable. And in our age of multitasking, sitting on a dilator, and working from home can be a huge advantage because dilators don't work unless you use them. So we definitely use them to improve muscle flexibility. And then like I said, it decreased trigger points and managed pain. Great question. Thank you. Awesome. Thank you so much. So it looks like we're out of time. On behalf of the Oggs Education Committee. I'd really like to thank you, Cindy, and to everyone who's joined us this evening. Our next webinar is titled teaching in the operating room and will be presented by Dr. Stephen Swift on June 12. Thanks so much, everybody.

Cindy Furencia

physical therapist

pelvic floor therapy

private practice

disorders

biofeedback

early referral

thorough evaluation

collaboration