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The Good, The Bad, The Internet: Pelvic Health Phy ...
The Good, The Bad, The Internet: Pelvic Health Phy ...
The Good, The Bad, The Internet: Pelvic Health Physical Therapy
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All right. Good evening, everybody, and welcome to the Augs at PMRS Fellows Lecture Series. I'm Christopher Hoyer, the moderator for today's webinar. Today's webinar is titled The Good, the Bad, and the Internet. Pelvic Health Physical Therapy. Our speaker today is Dr. Katherine Miles, who serves as the lead pelvic health physical therapist at Walter Reed National Military Medical Center, faculty of the Female Pelvic Medicine and Reconstructive Surgery Fellowship Program, assistant professor for obstetrics and gynecology at the Uniformed Services University of Health Sciences, as well as a selected White House medical unit consultant. Dr. Miles earned her doctor of physical therapy degree from Washington University and St. Louis School of Medicine and is a board-certified clinical specialist in women's health physical therapy and credentialed clinical instructor through the American Physical Therapy Association. She has a particular interest in the clinical application of the biopsychosocial model for pelvic and sexual pain conditions as it relates to the neuromuscular and movement systems. Just some quick last-minute reminders. This presentation will last approximately 45 minutes, and the last 15 minutes of the webinar will be dedicated to questions and answers. Before we begin, I'd like to review some housekeeping items. This webinar will be recorded and live-streamed. Please use the Q&A feature of the Zoom webinar to ask any questions you may have, and use the chat feature if you have any technical issues. The AUG staff will be monitoring the chat and will be able to assist. So without further ado, I'd like to introduce Dr. Katherine Miles. All right. Thank you so much, Dr. Hoyer. I'm Katherine. I just want to say good evening, everyone, and thank you for coming out. I know tuning in on a Tuesday night at 8 p.m. Eastern time is not the easiest thing to do, and I just feel super honored and grateful to be here, and I hope everybody walks away with one new novel thought, theory, fun fact, something to bring back to clinic, come next week after the holiday, spark some discussion with your colleagues, look at things a little bit differently, and basically when people came to me asking about a lecture, they said if I could present on what is ideal pelvic health physical therapy, like what to look out for. So in that, I'm going to be talking about the good, the bad, the Internet things, rumors, you know, things that people may have already heard about, so please keep the questions coming in. We'll have tons of time at the end to go over it, and I also have my business email on the last slide, so if there's any questions, you can always hit me up at a later date, and we can talk offline. Okay? So without further ado, we're going to get started about the good, the bad, and the Internet. Okay. So first, I, Katherine Miles, have not, nor my spouse or partner or immediate family members have any disclosures or financial interests, anything relating to this subject matter, and also the views here are those of my own and do not reflect the military or the Department of Defense. So our objectives for today, I'm going to describe the basic components of a pelvic health physical therapy examination, identify the role of pelvic health physical therapy as a part of a multidisciplinary team, develop a professional toolkit for your patients with pelvic floor dysfunctions, and understand how to find a pelvic health physical therapist in your area. So sometimes we're like, physical therapy for my what? Right? So pelvic health physical therapy is a subspecialty that was established in the 70s, and it started more on the OB side of the house more in terms of the birthing process, postpartum rehab, things like that. And now it's expanded to treat men, women, children, patients transitioning. So we did have a name change from the section on women's health to the Academy of Public Health. So in case you're looking online, you'll just notice a little change there. And what we do is we look at musculoskeletal and neuromuscular components of bladder, bowel, sexual function and pelvic pain. So commonly treated diagnoses and symptoms that we do see include things like urinary and fecal incontinence, urinary and fecal voiding dysfunctions, pelvic organ prolapse, pelvic pain, pain with intercourse. And I just put pictures here just to show we're going to look at the pelvic floor muscles from a couple different viewpoints, just to get a better visualization of it, especially coming from a musculoskeletal perspective. Not necessarily with all the surgical planes, things like that, but maybe looking at how we look at the pelvic floor and its function. So what does the pelvic floor do? So there's three main functions that we commonly think of. So one is it's supportive. So it acts as a hammock for all of our pelvic organs. And it helps in terms of responding to that increased abdominal pressure. It also is responsible for sphincteric control of the bladder and the bowels, as well as sexual function. So it helps with arousal, erection. And then we also know, with literature coming out, it's very important in terms of force regulation. So we see this in terms of the COPD population, the spinal cord injury population. We're noticing there's a relationship between the respiratory diaphragm and pelvic floor diaphragm that they need to move in a good synergy, and they need to be synchronous in order for good sitting balance, productive coughing, and again, accepting that intra-abdominal pressure appropriately. And so here we're looking at the muscles from the bottom up. And I put this in here because over the years, giving lectures, a lot of people sometimes forget about the superficial pelvic floor muscles can also be a primary pain generating source. And they should also be considered when we're doing pelvic pain exams, if someone's having urethral pain, sexual pain, things like that, knowing their orientation can be really helpful. So if we look over here on the right hand side, we have the female pelvic floor. And you can see along the ischial bone here, we have the ischiocavernosis. We have the bulbospongiosis, and the superficial transverse perineal muscle, and a lot of people are familiar with that with Oasis and things like that. But along these muscles, a lot of times I find in my patients that there can be tension or trigger points that can be contributing to their pelvic floor dysfunction. This is now a bird's eye view, and I put this just to give us a little bit more of an understanding how maybe the articular surfaces can affect pelvic floor function. So a lot of times, if we look over here on the right hand side, again, you see that pubic symphysis, if there is any sort of rotation, dislocation, laxity, which what we do see with pregnancy, polytrauma, leg length discrepancies, things like that, that can also be a pain generating source for patients with clitoral pain, pain with arousal. Same thing in the back. If you look down here towards the sacrum and the lumbar spine, that SI joint can also affect the pull of some of those pelvic floor muscles, and I'm sure, you know, with our very hyper mobile patients, sometimes we're trying to catch different symptoms here and there. Stabilizing these muscles can sometimes also help the pelvic floor function and stabilizing those bones. And here, this is one of my favorite infographics. I think it's just a really nice, direct, concrete way, right, because a lot of times we see so many different pictures of the muscles with different names. I love how simple this is, right? So again, just for orientation, we see the pubic bone at the bottom, we see the sacrum in the back, and just knowing that your muscles are labeled from where they're starting and where they're going, right? So the puborectalis starts at the pubis, loops around the rectum, pubococcygeus, same thing, starts at the pubis, attacks to the coccyx, same thing with the iliococcygeus. And these three together are called the levator ani complex. There are more muscles that are still part of the pelvic floor complex, okay? So the coccygeus is really important when we're thinking about our postpartum patients, right, with pelvic pain. Your patients with tailbone pain, we see that a lot. Patients who are maybe having that really deep hip pain that's not going away, can sometimes be in the piriformis. And the piriformis and the operator internus, those are two hip external rotators, again, same thing with the pelvic floor. But what's interesting about the operator internus is I feel like I see a lot of patients with dyspareunia, where it's like a singular, like trigger point, a lot of times you can release it in the office, and the patient's like, oh, my God, he finally found, you know, that pain with intercourse that we've been chasing around with like diagnoses of endo and things like that. So just to test that muscle, you can go ahead to your internal exam, and you can hook that finger around, right, either to the 10 o'clock or two o'clock, have your patient resist into some hip abduction or lateral rotation, and you'll feel it pop into your hand. Okay. So I'm also going to just try dropping some clinical pearls as we go along, just to take back to clinic too. So now getting into the meat and the potatoes of pelvic health physical therapy. And I put this picture, this is a picture from Pinterest. And it says, may your coffee, pelvic floor, intuition and self appreciation be strong. And I put a little asterisk right next to coffee, because of course, that's one of our loved and most hated bladder irritants, you know, that we talked about in clinic, and I just thought this was a very funny infographic. Okay, so getting started with what pelvic health physical therapy is not, I would say, again, over the past 10 years or so, I normally have patients and providers, you know, doctors, nurses, everyone says, Could you just give me a handout? Could you just give me a handout that I could just give my pain, and that would be it. And I really wish that was the case. And a lot of times right now on the internet, there are so many different programs, PDFs, they're selling for, you know, 2999 to 9999 a pop. A lot of times, they're just trying to get like your email, and you end up being on their district list for a long time. And again, a lot of times, there's good information in that I think information is key. I don't necessarily think that one size fits all, right. So I am a huge believer in getting out lots of information. So if that PDF is full of information, that's wonderful. I would just be wary of buying or recommending any sort of one size fits all packet. I've also seen that in different areas where everybody just gets one packet, regardless of diagnosis. And this is start with this. And then we'll see kind of where we end up. And then sometimes the symptoms can get worse, because they're actually doing things that can aggravate or flare their symptoms. So again, just because someone has, you know, mixed incontinence, there could be so many different contributing factors, by doing the same exercises and things like that, it can actually get worse. So just something to think about. We're also not Kegel instructors, believe it or not, I feel like a lot of times, patients come and they say, Oh, you're going to teach me all about Kegels or Kegels. And I would say, a lot of times, we do introduce different types of pelvic core muscle contractions, relaxation, things like that. And of course, if that's something that we need to do, I could totally see it as part of an assessment or treatment, I would say even today in clinic, two of my patients, we have never done Kegels, right, because there's a lot of different things that we can work on. modifications, the lumbopelvic complex, looking at the spine, things like that. So just knowing that doing Kegels all day will not cure everything. And the reason why I bring this up is because a lot of times, you know, I would say probably the second most thing I get asked is, I just give me a handout is, what's your favorite biofeedback device? Right? Like, can I just give someone, you know, the LV biofeedback, and can't they just do that all day? They could, right? I actually had someone yesterday who did that, and their symptoms didn't change because their muscle strength had nothing to do with their symptoms. And it's actually interesting, there are literature and studies out there right now, that show that pelvic core muscle strength is not indicative of the absence of a pelvic floor dysfunction. So just because you have a really strong contraction, doesn't mean the muscles moving appropriately, doesn't mean you have enough length, doesn't mean that the tone is okay, doesn't let you know anything about trigger points, anything like that. So just because you have really strong muscles, doesn't mean they're working right. Right? So I also like to tell people, sometimes you see like these really buff guys with, you know, a six pack and great biceps, but they can't push a wheelbarrow, right? They can't help out on the farm and stuff like that, like, just because they're pretty muscles doesn't mean they're functional. And the last thing is, we're also not psychotherapists. I see a lot of times patients get referred to various pelvic health therapists, and I have friends all across the country. And a lot of times, because sometimes providers just feel stuck, or they don't know what, you know, what they don't know. And they're like, Well, I don't know what I can do for you. So I'm going to send you to pelvic floor, right? And a lot of times, these patients can have anxiety, depression, and it's really hard to kind of narrow down what their goal is. So they just get sent to us. And there's a couple issues with that. So one, it's really tough, because pelvic floor health, pelvic health physical therapy, we have a very high no show rate to begin with, it's documented all the literature based on how intimate our exams are, how sensitive the diagnoses are that they're coming to us for. But then also a lot of times, patients have no idea what to expect. And I can't tell you how many times patients are in my office, and I'm like, Okay, so what brings you in today, and I've done a whole chart review, we've gone over all this stuff, and they don't know. So if they don't have a goal, they have no idea what they're doing there. That makes it a really tough place to start. So one thing that I would like to ask and make a charge for is, before the patient leaves the clinic or goes to physical therapy, they should kind of know what their plan is, you know, saying, Oh, we're going to treat this with exercises, or, you know, you could just say like, there are exercises, lifestyle modifications, things like that you can work on, especially if there's a patient with a whole host of things with let's say, it's urgency, pain, leakage, you know, the whole gamut, just saying, you know, what expectation management can be very helpful in terms of what you expect with public health, and from your side of the fence as well. And then what to expect when you're referring, right? So in terms of counseling, so I want to help everybody figure out what what what happens once they get to us, right? So when you do see public health, physical therapy, there's three main things that happen, right? So one is the biopsychosocial assessment, where we go through the history of present illness, lifestyle and modifiable factors. And I can't stress this enough, I would say probably the number one question that is the most helpful, and it seems very simple and obvious, is onset. So a lot of times when these things happen, and I tell everyone, the public board does not work in a vacuum. When did your symptoms start? Right? So a lot of times, it'll be Oh, it happened after kiddo number three. But sometimes it's, you know, when my dad got diagnosed with cancer, or with the with the pandemic, how many of my patients are now coming to me, and all their symptoms started 2020 2021. And a lot of times that'll tell us what changed in their lifestyle, their training, their diet, their mood, all those things can affect their pelvic floor function. We also do orthopedic screenings, right? So we want to be checking out the lumbar spine, the hips, the knees, things like that, because that's going to affect all the movement up and down the chain. And then as well as a pelvic floor muscle assessment. So this can be done in this can be done internally, externally, with biofeedback, there's different ways that you can do it. So when you do send someone to pelvic floor physical therapy, we don't always need to do an internal exam. But I would say it should be offered. Okay. And if they don't have the equipment or the privacy for that, there is room to do an external muscle exam, right using a mirror, something like that. And then also biofeedback can help in terms of just muscle energy activity, it won't tell us anything in terms of strength, but it lets us know in terms of coordination and motor control. Okay, so what is the biopsychosocial model? So one, it's talking about biological factors, so genetic material function, structure, physiology, the immune system, response, anatomical systems, and I feel like, historically, we do a really great job working within this biomed model, right? And then there's other factors like psychological factors. So behavior, lifestyle choices, decision making, cognitions, beliefs, knowledge, emotion, affect, mental health, personality, motivation, just just another example today, right? My treatment approach for someone who is a type A marathon runner, is very different than my retired 72 year old man who likes to sit on the couch all day, right, so their approach and their, you know, gusto with exercise, I'm not gonna tell someone, oh, do as many as you can, if that's their personality. Same thing in terms of mental health, how often is it a circular loop? Where is it? Okay, is the depression causing people not to do things? Are they not doing things because of their depression? Using some motivational interviewing can be very helpful for these things. But being cognizant that these issues can also have very real effects in terms of pelvic floor function. As well as social factors. So relationships, support, family, community environment, availability of resources or lack thereof, those can all really make a difference. And so when we ask that onset, thinking of these things in the back of your mind, and there's a quote that I like here, oops, sorry, here, I don't see my mouse. So sometimes I, I lose this, but the physician should not treat the disease, but the patient who is suffering from it, okay? I think that understanding the type of patient is probably equally, if not more important than knowing what syndrome you're treating. So there's a difference between the biomedical model and the biopsychosocial model. So one of my friends, Dr. Laura Wanner, she put together this, this little chart, and I love using it, and thank her so much for letting me use it. It really just goes down, what is the difference? And I like to think of this with two different diagnoses. The one with the biomedical model, this is great for, you know, an acute issue, where you need to identify the cause, you use technology, so let's say, for instance, like a UTI, right? Someone's coming in with, you know, urinary burning, pain, urgency, things like that, you're going to try to figure out what it is, you're going to do a urine culture, your goal is to cure it, you are the expert, and the patient just kind of sits there, they go to the lab, you know, they leave their sample. And this is really great for acute conditions. And then there's also the biopsychosocial model. So let's say, kind of taking a similar, a similar presentation. So let's say someone has, you know, that recurrent UTI without any cultures, right? So these people who always have that urgency, frequency, maybe it burns here and there, but nothing's ever popping hot. A lot of times, this has to do with public form muscle overactivity, dyssynergia, lifestyle mod, lifestyle factors, things like that. So it's our job to be more of like a teacher and a coach and figure out the effects, right? So look at it more in terms of like a complex problem, do that psychosocial evaluation and restore function and improve quality of life. So especially with these, you know, very chronic issues. So let's say it's the symptoms of, you know, that, that recurrent UTI, that's not a UTI, or pelvic organ prolapse, that just won't go away. And let's say they have already had a surgery, and they've already had pelvic floor physical therapy. A lot of times, our goal isn't necessarily to fix it or have the absence of symptoms, but maybe it's how are they going to manage those on their own, right? So figuring out what contributes to that issue, and then we can kind of coach them through that. And this is going to be a very big slide, so if we can just think about behavioral tracking as its own intervention, especially in terms of pelvic floor function. I say this is probably where we rise and shine as pelvic floor physical therapists. So identifying aggravating factors. Again, very simple concept, right? But going through the list. So one, look at things that are irritating the system, whether they're bowel or bladder irritants. So again, I half-jokingly say it's everything delicious in life, right? So your coffees, teas, juices, soda pops, alcohols, things like that. See, you know, what are they currently ingesting, how much volume, timing, things like that. And then also go through stress. So also emphasizing physical and emotional stress, right? So it's not just, you know, that CrossFit, marathoner, Peloton cyclist that's having stress in that pelvic region, but also someone who is working 12 hours a day at the Pentagon, has to sit in two hours of traffic each way, you know, high stress environment, sitting on their bum all day, right? So stress can make, take a physical toll on the body. And we've already seen that people who even, you know, some of my Intel guys that just watch noxious stimuli all day, and they're bombarded with bad news and bad guys and things like that. They've shown that just exposure to that can increase pelvic floor muscle activity down there, right? So you can think about that extra tension that people can be carrying just from psychological and emotional stress. And then also in terms of physical activities. So looking at the type, duration, timing, things like that. So again, it could be something from like bending, lifting, twisting, tons of crunches, things like that. Right now, spring just happened. And guess what, a lot of people's prolapse symptoms just came back. And why did that happen? Tons of people just spent four hours in their garden, mulching, pushing the wheelbarrow, you know, that they went from doing nothing. And then all of a sudden, they're spending four hours a day, three days in a row. And you know, now they're leaking, and they feel heavy and pressure and all these things. And I just want to kind of talk through these things, because I feel like there's normally two big camps, right? One camp is the, you can't eat XYZ, you can't drink XYZ, sit ups are off the table, you know, like, oh, no more CrossFit for you. And that's one camp. And then there's another camp was like, Oh, no one's gonna change the lifestyle. So like, just do it and then like, suffer. I feel like I've heard both. And I think that there is nuance in this. And there's a lot of things that we can do in the middle. And the way to kind of mediate that is looking at again, type, duration, volume, right? So just even from a training perspective, right? So let's say, you know, they really want to garden instead of doing four hours at once, right, let's back and we're gonna talk about this with self pacing. But let's back it down, maybe, you know, 45 minutes an hour, see how you do see how your symptoms are. And we can always build off of that. Same thing with bladder irritants. I had someone last month, or the month before I'm losing track of time. It was so funny and not funny at the same time, because her number one complaint was she would always lose her urine walking into work every morning, right? So again, when did this start, they had to go back from being telehealth number two. Again, she also happened to be working in the Pentagon, it was a long commute. And then number three, she was drinking her coffee in the morning right before going. So she really don't want to eliminate it. We did some other techniques. I said, Well, why don't we just change when you're drinking it? Right? So just have your water with your pills in the morning, save that coffee for when you get to work. Lo and behold, you know, we never took her coffee away. I never said you only need drink decaf, or only low acid coffee. We literally just shifted when she drank it. And now she doesn't leak when she walks into the office every morning, right? So timing can also be a big thing, right? So like, if you're going to go for that morning run, let's do some fluid management. And then contributing factors. So looking at things like sleep, work demands, attitudes, beliefs, social support, and lack thereof. Okay, so we already addressed some of those aggravating factors. And then these are the things that can kind of like amp up or decrease some of those symptoms as well. So when you think about if someone is sleep deprived, or they're having disordered sleep, how that can affect urinary and bowel control, work demand. So sometimes there's just environmental barriers that we need to work around, or then we have to do some more of that, like time, fluid intake management, things like that. attitudes and beliefs. Sometimes patients here, they have an idea, this is what I need to fix myself. And you know, that nocebo effect can sometimes be so strong that that's what they need to, you know, go forth with more treatment. And we have to be cognizant of that. And also beliefs, right? A lot of times patients say, I really just want to make sure I don't have XYZ, whether it's, you know, a mass or a cancer or lesion or stuff like that. And sometimes it doesn't make any sense. And then you find out in their history, you know, they've had three loved ones pass away from cancer, things like that. And that just gives them so much relief. They just relax. I've seen tons of examples like this. And then the last thing, and one thing that I would say, I probably didn't get such a good appreciation until the last couple years. And I wish I knew this sooner, personally, is really focusing on the alleviating factors. Right? So the concept is building on success. So especially with our patients who have chronic conditions, prolapse, right? They've been feeling like their organs have been falling out since 1995, right? 2000. And they say, sometimes, you know, the symptoms are really bad. And the symptoms are really good. We do such a great job saying, tell me more about your symptoms. If they do have absence of symptoms, it's really, really helpful to build off those. And I think it's important to emphasize those. One, it shifts our attention. So it also shifts how we feel about it, just as an attitude and a belief. But then two, it can actually give you more insight into what's going on. And I call it the 24 hour snapshot. Again, Francis, it was a male patient today, but he has that chronic prostatitis, which is really just from pelvic floor muscle overactivity. And he only gets his flares like once a quarter, so to speak. So we had to track, you know, the symptoms then, but then, you know, the patient I had right after him, the symptoms are all the time. So instead of tracking the symptoms, we did the 24 hour snapshot, but when he had the pain relief, right? So that other patient, they had no symptoms for like a whole weekend. And I said, okay, what were you eating, drinking? What was your physical activity like? What was your mood like? Again, unsurprisingly, I also see a lot of symptoms magically disappear when they're at Disney World, even though it makes no sense when you think about how much walking and lifting you're doing, and how much fluids were pounding in the heat. But sometimes, you know, just shifting your attention from your symptoms can be really helpful. And then we also do a musculoskeletal examination. So kind of outside the box outside the pelvic floor, it's really important that we look at the pelvic girdle, right? So looking at that pubic symphysis, the SI joint, again, we can find a lot of information in terms of clitoral pain, sexual pain, position dependent dyspareunia, things like that, looking at the lumbar spine. This is also something where a lot of times I see dysfunctions in that thoracolumbar region, you know, T12, L1 to 2. And sometimes that region can really give a lot of suprapubic, or bladder pain relief. And then also looking at the acetabular joint, so the hip joints. A lot of times, especially with either super hypermobile ladies, some of that hypermobility in the hips can make those pelvic floor muscles kick in and really try to take charge and just stabilizing the hips can let the pelvic floor muscles relax, right, because they don't have to do so much. And then the opposite is true. So I also have some patients with really, really tight hips. And sometimes they need to learn how to let that go so those muscles can do their job. We also look at the movement system, right? So looking at body mechanics, ergonomics, how someone's sitting all day, how are they walking, running, things like that, putting them in the positions, not only that they're in all day, but what causes their symptoms. And I can't tell you how I had a patient this week, she only had tailbone pain when she wasn't sitting appropriately, right? So we mobilize the tailbone, we can get all the pain to go down. And you know, if she sits in a posterior pelvic tilt, and she sits on that tailbone, it ramps everything up. And all we had to do is change her office setup. So get her on a nice cushion, put some lumbar support in there, teach her how to find neutral spine, neutral alignment on those ischial tuberosities. And she's good to go. And she knows how to manage her chronic tailbone pain now. Right. So even just looking at simple things like that can be incredibly helpful. And then also doing some neurologic screening. So don't be surprised if we check out some dermatomes, some nerve tension tests, looking at balance coordination. I'd say in this setting, I don't look at lower quarter reflexes as much. I'm not in like a trauma setting anymore. And but these also give more clues into what's going on. And again, I always look at dermatomes of the abdominal region and pelvic region, because a lot of times you'll see differences in like touch, sensation, again, you can use the Q-tip, you can try the end of the Q-tip with the sharp end of the Q-tip, you can test right versus left, you can test different dermatomes. And that can also just give you a little bit better insight into not only their sensation, but their function and proprioception. And then this is a picture here, again, looking from our musculoskeletal perspective outside the box. So starting on the left hand side, you can see the quadratus lumborum, that's the muscle that goes kind of from the rib, the last rib to the top of the iliac crest can be a huge pain generator. A lot of times if you push on it can cause patients to have that sensation like they have to pee. So sometimes if someone sits a certain way all day, and there is a trigger point there, this is also where like dry needling, it's really awesome. Sometimes you can release the quadratus lumborum or the adductors or the rotators, their urgency decreases, right, so sometimes just having overactivity in this region can cause other symptoms. And again, you see the adductors here again, and one spot over from the left, a lot of times those can be contributing when we're dealing with our athletic population. And then we see on the next one, we see a lot of the hip rotators, so lateral rotators, hamstrings, these muscles, again, really important for us as PTs to clear, make sure there's no contributions, not only in terms of our runners, in terms of our hypermobile patients, make sure that they're strong enough, make sure all the alignment's okay. And then we have here again on the right hand side, the superficial pelvic floor muscles. And again, I just like keeping it there just to keep in the back of our mind that it's not all internal pelvic floor muscles. Because again, I've seen a lot of, you know, vaginismus, vulvodynia, where we can make huge changes just on a superficial external exam and treatment approach without having to, you know, go full blast with those internal muscles. And then we also do an external perineal exam. Okay, so we're looking at the skin integrity, we're looking at the dermatomes, that sensory discrimination that we were talking about, and that perineal body, right. And you guys are the experts in all of this, you know, looking at the resting position, you know, we have them contract, relax voluntarily, involuntarily, and we see what happens. Okay. And this is again, a lot of times I can see dysenergia without even doing an internal exam or anything fancy. You can just look down there, you can also have the patient use a mirror. It's a highly low tech, very effective way. So if someone says, I have no idea what I'm doing at home, right, if my muscles are going up, down, nowhere. I mean, you can get in my office right now, I used to have to, but I have a I have a mirror, handheld mirror that can swivel, and patients can check themselves in clinic. And I say go to the dollar store, just like I did. And you can check out the muscles for yourself as well. So that's also a very low tech, quote unquote, biofeedback that patients can use. And then we also do palpation of the superficial muscles, and then also looking for scar tissue, not only in terms of pain generation, but then also in terms of if there's any restrictions in mobility, which can impair pelvic floor function. And we also do an internal exam, right? So we test all the same muscles, the iliococcus, coccidius, puborectalis, and the obturator internus, I would say is a huge one for us, that hip external rotator. And then we also look at the integrity of those muscles. So the resting activity, saying if it's overactive, if there's any defects, and also trigger points, right? And there can be tender points, trigger points, things like that. And we also do pelvic organ prolapse screens. Again, every public health therapist is a little bit different. You can do it laying down, standing up. Again, I also have patients where I tell them to come later in the day. Because just again, anecdotally, I've had patients come in at 8am, and they're fine. You know, there's no issues. So I say, you know, come at two, three o'clock. And let's, let's see what's going on then in terms of the muscle activity in terms of prolapse, things like that. And this slide goes over what does a team treatment approach look like, right? So together, everyone achieves more, right team. So I would argue that in terms of a team approach, prehab is what we call in the rehab world is more important, more effective than rehab. So what is prehab? So this would be for example, there's tons of this and you know, the PT side of the house in terms of prehab for total knee replacement or hip replacement, right? So those are like the big, you know, you think of ortho surgeries, tons of evidence saying, you know, a lot of times patients, if they can do that pre PT, they afterwards, they're just off the bat running day one, right? Similar with pelvic floor, I would argue, because a lot of things that we can do on the front end, prevent issues in the long, especially if this is a chronic condition, addressing those lifestyle factors, those behaviors, ruling out any sort of avoiding dysfunctions, again, getting them on good habits beforehand. So one, we don't run into issues, but then also to just make sure that there's nothing laying around. And it's also important because a lot of times in literature, we say, oh, they went to pelvic floor, you know, once, and then they had surgery, and then they follow up. And I'd say those one offs are probably really helpful if it's just like rule out disinertia, or if you want to establish rapport, or again, in the civilian community, a lot of times in order to just get into their census, they need to at least have an evaluation and the follow ups are really easy to get in. So I could totally understand it from that perspective. Do I think pelvic floor is effective as just a one standalone treatment? Probably not. And I hate saying that, because it's really tough, you know, especially in my population, they're moving all the time. And I go, I just want one session, and it could be great, but we may be very limited. And then just knowing in terms of expectations, so neuromuscular changes. So that would be like motor control, right? Someone's coming to you, and there's a movement pattern coordination deficit, and they just don't know how to fire those muscles. It takes about six to eight weeks to get a meaningful change. Okay. And let's say there's like a forced production deficit. Let's just say those muscles are out to lunch, right? With bottomless mimosas. That's going to take three months, right? So to get changes on a cellular level with those muscles, it takes three months. So saying, oh, I did pelvic floor for three sessions, and one month, I wouldn't expect too much, maybe a little bit of motor control, maybe a lot more lifestyle modifications. You know, so when you think about, okay, do they want to give it everything they can say, probably at least three months, just to see if there's a change. Um, and then kind of go from there. And then the other thing is having a dialogue. So again, when I was a university hospital before, um, we, we do progress notes all the time. And that's something that you have to do from like an insurance based system, right? Just to keep, just to keep things getting reimbursed. Um, and that normally happens about every month to two months, depending on the insurance, but also in terms of if there's a surgical team that we're talking with, whether it's, you know, even if it's a medical team, like GI, urogyne, colorectal, um, pain management, PM&R, a lot of times they want to know like what's going on with the patient and you can totally ask and the patient can request. So either they can request a copy of their progress notes to take back. Um, I will say, um, a lot of times our notes are kind of in hieroglyphics, right? We use a lot of abbreviations. Um, maybe there's some weird words in there. So a lot of times what we can also do is a summary of care. And basically what that is, it's like a one page ditty that just goes over. This is what the patient had. This is what we did. And this is where we are. And it's a very short thing. People in our profession knows what it is. They say, Oh, can you just give me a summary of care? And that again, historically, that's what we've done a lot of times because sometimes we send progress notes to doctors and they say, I have no idea what this means. So you say, no problem. Here's a summary of care and it can all be on the same page. Okay. And then last but not least in terms of that team approach, I can't stress this enough. It's so important for the patient to clearly know what their plan of care is. It's so important for patients to know what their plan of care is. Um, cause again, a lot of times these patients can have very chronic issues. And when patients have chronic issues, sometimes there's difficulty paying attention. There may be cognitive issues. Um, again, sometimes anxiety can get in the way, or if there's very, very front loaded, heavy counseling session, they may forget certain things. Um, so sometimes it's helpful, you know, at the end, give them a piece of paper with like the three things that they're doing, whether it's, okay, you're going to take this medication. You're going to go to public for, and you're going to come back in six weeks. Right. Um, and then also like, what is your plan with them? Uh, sometimes I've seen patients where they come to me and they don't know why they're getting certain procedures, or they don't know when they're getting them. They don't really know what public for it is. They're not sure why they're there. Um, so those types of things, I feel like if we were all on the same page could be incredibly helpful. And if the patient knows what they're doing and they know where they're going and why they're doing it again, it's better compliance, better buy-in and better outcomes. Okay. And last but not least kind of going over the internet. Okay. So especially in our culture, there's a very big do-it-yourself culture here. Um, so there are so many online programs and I gotta say, there's a lot of really good content out there and there's a lot of very questionable content. Um, and the reason why I bring this up, there are so many gurus, um, masterclasses, um, zoominars, things like this. And a lot of times I've seen, you know, and I have to keep on top of this because every time, every day in clinic, there's at least one, Oh, have you heard of so-and-so and I have to look them up on social media. Um, and a lot of times they're like really fun moms with six packs. Um, sometimes they're, they have credentials and I think that's wonderful. And a lot of times there's good content on this. And then sometimes it's just a mom with a six pack and you know, they don't have any credentials. They're telling people to do these top three things to have the strongest kegel upper. And sometimes they don't make sense, or maybe it's a bunch of kegels and, you know, vacuum techniques and things like that, but that that's not necessarily the best thing to do. And also I bring this up because a lot of these online programs are kind of that like one size fits all. I did have a patient recently. She came in very insightful young woman. Um, she had mixed incontinence. She's 13 months postpartum and, you know, this makes some, it won't go away. And ever since three months postpartum, she's been doing this online program. And then she started this other online program. She was doing wonderful exercises, but she was doing exercises for someone who had weak pelvic core muscles. She comes in and they're overactive and she has a left hip involvement. So the reason why they weren't working is because the exercises weren't specific. They weren't appropriate for what she had. Um, so again, just kind of keeping that in the back of your mind. And this also kind of feeds into that home biofeedback unit. Um, there's so many on the markets and they're getting super fancy. They can be super fun. They can be great for that compliance piece. If a Kegel is what someone needs as a home exercise program. And the part of the Kegel they're focusing on is strength specifically. They could be great. Um, but again, I would argue that most people, it's not necessarily the strength of the public for, because if you think about the pelvic floor muscles are reflexive. So a lot of times those muscles need to contract before you move your arm, they contract when you rotate your pelvis, they are reflexive in nature. So kind of just doing all these volitional ones all the time, isn't necessarily probably going to get to the root of the issue. Um, so again, just keeping that in the back of the mind as well, and then also being wary of these social media support groups. Um, a lot of times it's patients and people going on there that are just kind of talking about their horror stories and things that aren't going right. So I would argue, depending on what kind of like your subspecialty is and things like that, you know, there are support groups for patients with vulvodynia, um, endometriosis, um, you know, or there's downloads. So depending on what they have to go to the actual association and get them a support group, instead of some of these dark webs of Facebook and Instagram and things like that. And then also being conscious of fear-mongering content. Um, I got an email today, believe it or not the new one. I wrote it down because I couldn't believe it. It was our mom genes causing prolapse. So apparently there's some people online, um, that are saying that your mom genes can cause prolapse. And I would argue those would have to be very, very, very tight genes. Um, but yeah, so, you know, that intro abdominal pressure can cause more sensation down there, send more signals, um, you know, just maybe cause a little bit more bulging. But I would say that it's, it's really disheartening to hear, you know, now that patients are concerned that their mom genes are causing prolapse, that doing CrossFit when they're pregnant, you know, cause everything to hurt and ache and they're broken now. Um, but someone can never do sit-ups again because they had a diastasis, like just be aware of some of those messages out there and being able to dispel that in clinic is incredible. And I also want to tell you about three other things that I'm starting to hear. Now there's different waves in our community, um, of pelvic health and these online gurus and things like that. Um, one camp we're hearing a lot of this, you know, kind of just breathe movement, right? So we talked about that coordination between the respiratory diaphragm and public for diaphragm and absolutely getting that synergistic and that synergy, the relationship between those together can be incredibly helpful. Um, but again, just quote unquote, just breathing. Um, I don't think it's necessarily going to solve everyone's pelvic floor dysfunction. I do think it can help in terms of anxiety, urge suppression, it can help in terms of pelvic floor muscle relaxation. Um, but I would just be wary of that cause that's one camp out there right now. Another one is, you know, that strongest Kegel ever, you know, get this biofeedback device. Let's do, you know, let's get that really strong glute. You know, there's all these like, but what is it like at, what was it? Guts and butts or something. I, I got another email the other day about that. Um, you know, people are trying to get all this extra tone and get all this stuff down there. Everyone wants to tone, tone, tone those muscles. You know, they want to sit on these chairs that provide electromagnetic energy, um, East and things like that. That's also not evidence-based. Um, so I'd also look out for those and then also way out in left field or having a huge influx, um, from the sports community now saying that cables are useless. So we also now have this big influx from the orthopedic and sports world that are saying, why go to public health physical therapy? If you just get everything strong, like in terms of your hips and your abs, you won't have any pelvic floor dysfunction. And I would argue that that may be, you know, for that very high level athlete where there's no other issues. They've never had kids abdominal surgeries. They don't have any diabetes, you know, heart issues, things like that. They're at the appropriate BMI. You can probably help a lot of people, you know, kind of what we call bulletproofing those muscles. Um, but I would also just be very wary of that camp as well. So when your patients got into the community and you hear anything, things coming back, you might have a little bit of more of awareness now and you can counsel them appropriately. So depending on where you are, and I'm assuming everyone's all over the place. Um, how do you find a public health physical therapist or public for physical therapist? So our national association is the American physical therapy association, the APTA. And so in our association, anybody who is doing public for physical therapy, um, you can enroll in this directory and basically we're classified by our zip code. So it's our name, it's where we're located and this is open to the public. So I included the link here. You just go to the link, you type in your zip code and you can find people. And there's a little scroll bar and you can say how many miles out you're willing to drive or go to. Um, the other thing too, especially with insurance, the other way to also do it, you know, would be once you, if you can find someone in the area, that's great. Sometimes you can't, and maybe you need to find someone that maybe has only taken one class. Um, but maybe they have a pulse on public health. Um, your insurance company should know, and then just make sure your patient calls the clinic itself. So the clinic would be aware, right? If they have any public health physical therapist there and things that you can talk to with your patients when they do find someone is finding the right fit, right? So this is a very intimate, um, profession and treatment modality. So things to look out for with, there is a vast spectrum of education and experience. So some of our alphabet soups just to be aware of, um, classically it's a PT degree. And right now there's masters and doctorate levels. So you can see that with the lettering and then there's also certification and then board certification. So certification, you can get either like an OB focused one or pelvic focused one. Um, and then there's also board certification. So there's different levels of education and testing. And then another thing I would say probably even more important than necessarily the alphabet suit behind your name is the diagnosis. Um, I have some colleagues where that is the person I want my pain patients going to, or that is, you know, the trans health PT that I want them going to. Um, so knowing what diagnoses those PTs really shine in that, that I would say is paramount. Um, cause there are some PTs where they only treat incontinence, like they only treat urinary incontinence. They don't do anything with bowels. Um, so just kind of being aware of that can be really helpful. And then also personality, right? So finding someone that matches that because all patients are different, right? How treatment approaches are different. Um, so sometimes a really peppy bubbly person and someone was not, you know, the most affect go out, may not be a good fit or age, things like that. Um, gender, those things can all also affect, you know, that personality and that rapport. So just to be cognizant and also treatment frequency and plan. So something to look out for classically PT, you know, I think of going two to three times a week for 12 weeks. Um, again, probably not the most necessary, right. And that's, that's a huge economic and time burden, um, for the patient. A lot of times PTs, you should be able to get results, you know, seeing them once a week, once every other week, um, you know, it could be as little as once a month, but making sure that, you know, they aren't just going three times a week, um, and just getting biofeedback, something like that, or, you know, and, and telling them also in terms of expectations, right. So go to public for PT for three months, right. And see if there's a change and then we can have that discussion. And then also looking at the length of assessment and treatment sessions. And unfortunately, a lot of this is dictated by the insurance companies now. Um, so a lot of times, like if they could only get reimbursed for 25 minutes, you bet your bottom dollar, it's going to be a 20 minute visit. Um, so sometimes it may be worth, instead of going to a 20 minute visit, three times a week and not getting any results, maybe spending that, you know, 50, $60 co-pay and just spending that $100, you know, in a boutique clinic once a week might be worth it, right. Cause the co-pays are going up, reimbursements going down. There's a huge thing going on, um, with our specialty right now. So being able to know some of this backstory can be really helpful when your patients come back to clinic. And now last one, I always talk about the tools for your toolkit, right? Um, so four big things we're going to talk about tracking, self pacing, patient resources, and professional development. Okay. So tracking, we already talk about that. So in terms of bladder, bowel, pelvic pain, prolapse, things like that. Um, again, looking at contributing factors. So physical activity, mood, uh, fluid food intake. Um, so generally just making a list of things to monitor patients can keep track on their phone. I'm pretty old school. Um, especially when I deal with like my peds patients, things like that, I print out a calendar and you make a legend, right? So like a star is a bowel movement, right? Or an X is leakage. Um, and then having that as that like thousand foot view, and you can see when the symptoms happen, you can see if they're still having their cycle. Um, it can kind of track to see if there's any correlation there as well. Okay. Other types of tracking. I did put the links for these as well, in case anybody wants to look at these. Um, this one I thought was the easiest bladder diary that I could find the nice thing with it. Um, kind of like a blessing and a curse is this one doesn't need to measure how much fluids coming out. So you don't have that bladder hat. So if someone doesn't have access to it, um, this is great. You kind of put, is it large, small, medium? How much are you going? Um, but what I do like about this one besides some of the other ones is that this also includes foods. So especially if you're having that painful bladder syndrome, things like that, um, seeing if there are different triggers. Okay. And then also here on the right-hand side, you can also see what activity they're doing. So we do know that with bladder diaries and bowel diaries, that we do see at least a 30% improvement in some of their complaints just by tracking alone. Um, so even thinking about this, instead of just like a headache for someone to complete, but look at as a type of intervention, um, a lot of times just being mindful of what we're doing, what we're eating and drinking, we can get improved outcomes. Okay. And normally when I give a bladder or bowel diary, I also give a handout with normative values, right? So what is normal bladder function capacity? Um, how long does it take to avoid things like that? And also defecatory posturing. So that way, when someone's doing this, they don't have a lot of questions and getting more anxious. They'll say, oh, this is where I am compared to this. And even that in itself is going to be an insightful moment and can be really helpful. And this one here is a bowel diary. Um, again, here, I also like that it has, um, not only in terms of incontinence, but also has smearing and it has the Bristol chart. Um, and this is just one part of the diary and it has medications, comments, things like that. And again, in terms of bowel diaries, I tend to do them longer than my bladder diaries, just because of how the GI system works. Um, but this is a really helpful diary to use. And then last but not least in terms of activity and self pacing. Um, and I want to talk a little bit about self pacing. I put the PDF link at the bottom here, because a lot of people never really heard of this before. This is incredibly helpful for those chronic conditions, prolapse pain, um, where your patient's like, Oh my God. And it's like, I never get relief in my symptoms, right? A lot of times these are the same patients, those boom bust patients, right. Where they are on the couch for six days. And then all of a sudden they wake up one day, you know, it's 65 degrees outside. They feel wonderful. They do all their grocery shopping. They clean the entire house. Um, you know, they plant for the harvest and then they're out, they're exhausted. Their symptoms are back. You see this a lot with fibromyalgia patients, hypermobility patients, pain, prolapse patients. So basically what self pacing does is it creates a new baseline. So let's say we know that, let's say it's standing, right? So a lot of times patients will get pain or pressure prolapse with an hour of standing. So instead of standing for an hour, we cut that by 50% and we say, okay, let's start with 30 minutes. Cause then we know for sure that they're, they're going to have less pain. And if they win at that, if they get that win at 30 minutes, then we can increase the minutes from there slowly and gradually. Right? A lot of times it's very difficult. I would say this is probably the hardest part because we also have to check our egos a little bit. Um, and I got to say, I had a brachial plexus injury and I had to check myself. Um, you know, I want to, and I'm a PT, right? I love working out. I love being very active. Um, and putting myself through this, it was incredible. So again, going back to 50% and then tacking on the time while we still have symptom relief. Cause the name of the game of self pacing is to have the same level of energy all day long. So that prevents the boom and the bust, right? So we're trying to optimize this even love, even level of energy and not have giant crashes. Okay. So not only is it same amount of energy, but also same symptom resolution is the goal. Okay. And then in terms of your toolkit and things that you can watch or tell patients to look at, um, these are four things, um, that I found tremendously helpful. So the first one is a YouTube is called pain explained in five minutes. It's a cute little cartoon. It's one of those little infographics where they talk and they draw at the same time. It includes pain science. It is at like a fifth grade reading level. Um, incredibly helpful for the chronic pain population. Again, similar vein, why public pain hurts. Uh, this is put out by Adrian Lowe and his group. This is wonderful. It's a little book that you can hand to a patient. Again, this, I think it's at a three to fifth grade reading level, um, tons of cartoons, pictures, but patients get it. Um, and this one's specific to pelvic pain. So before it's like, why, why does pain hurt? Um, and then they broke it into different body parts. And this one's really helpful. There's also one called healing pelican abdominal pain by Amy Stein. She's a physical therapist. And what's nice with this one is it's almost like an algorithm. So it says, okay, you know, here's the major concepts and then try this out if this works. And then you go from there. And this is actually something I use a couple of times because I work in a military setting and I had someone in Korea at the time and they had no help and they were just lost. Um, they had access to this book. Um, there are eversions as well, and they were able to, you know, call that they were able to pinpoint their pain. So before is giant pelvic pain. Um, and then we got it localized and then we could kind of train it from there. Um, but this is also really helpful. And then last but not least, there's also a book called the interstitial cystitis solution. This is also put out by, um, cozy and she's a PT and it's nice because it takes that thousand foot view. It talks about lifestyle exercises, things like that, and then things that patients can do on their own. And again, these are all great resources. And then looking at professional development, if this is something that you're interested in, where you have more questions about, um, from the musculoskeletal side of the house, we do have things within our academy of public health. Um, we have free webinars and I encourage if you're a nerd like me and you like to hit a webinar, you might be listening to me while you're doing dishes, kind of like what I do. Um, they have webinars on incontinence, pelvic health, prolapse, movement, system impairments, um, affirming gender surgeries, post-op outcomes. I mean, there's trauma informed care. Um, I would say get them while you can. When the pandemic came out, a lot of associations put out free content. Um, right now they still have some, they don't have as many as they did two years ago, but this is a great resource. And then number two, there's also the McKenzie Institute where they look at mechanical sources of low back and pelvic pain. This is something that is also really helpful in terms of triaging and screening things. Um, so they do have, I think one or two specific to pelvic and bladder pain. Um, and it was really eyeopening. So again, ruling out that thoracolumbar region to see if that affects any bladder dysfunction, pelvic pain. Um, and again, I use this all the time in my clinic, it's really effective. And again, this can also be a hands-off over telehealth, um, just great free resources. Perfect takeaway for today is consider pelvic health physical therapy, right? Um, refer early and often consider, you know, their education experience level, what diagnoses they treat, right? First and foremost, and make sure when your patient's going there that they should be getting that full biopsychosocial and physical assessment. Okay. And ruling out behavioral and musculoskeletal involvement, and then considering PT as prehab and as rehab. But then again, considering if you really want those really good post-op outcomes, doing some prehab sending to behavioral health, right? We know that treating anxiety and depression beforehand also gives better post-surgical outcomes. Um, so kind of front-loading that. And then again, in terms of treatments, teamwork makes the dream work. And one size does not fit all or most. Okay. So just being aware that if you just have one handout in your clinic, and this is something that you give to all of your patients, just be wary of that. Um, and that our treatments, we should try to make them a little bit more active than passive. So get some buying at the patient's moving and grooving, and there'll be more independent and they'll be able to take care of themselves for the long run. Okay. And that's a wrap. So again, I'm Dr. Miles and I have my email here, my email at the end. So feel free to take a screenshot, shoot me a line. I'm available. Thank you, Dr. Miles. We appreciate it. That was a wonderful presentation. I think we have time for just one quick question. You really, really shared a lot of great resources with us this evening, a lot of PDFs and websites specifically. You had a lot of, uh, to talk about different, uh, things to be weary of, um, regarding the internet. Was there any specific like phone related applications or apps that you feel like you trust, um, in order to, uh, utilize, um, for behavior tracking instead of just the PDFs or the, uh, um, the, uh, the calendar or legend? Yeah. I mean, so unfortunately I'm probably very low tech to be totally honest. Um, there are a lot of apps out there where patients can track them themselves. Um, there's voiding tracking, there's bladder tracking, things like that. The only issue that I have heard from some of my colleagues is that it doesn't link up with the provider. Like there's not like an interface where the provider can see it too. Um, but again, that question, it's a little bit outside of my wheelhouse since I'm still very low tech calendars and legends. Yeah. Can't go wrong. All right. Well, on behalf of logs, I'd like to thank Dr. Miles and everyone for joining us this evening for a full list of upcoming webinars. Please visit the OGS website to sign up. But everyone have a good evening. Thanks.
Video Summary
In the video lecture "The Good, the Bad, and the Internet: Pelvic Health Physical Therapy" by Dr. Katherine Miles, she discusses the importance of pelvic health physical therapy in treating conditions related to bladder, bowel, sexual function, and pelvic pain. Dr. Miles emphasizes the biopsychosocial model in assessing and treating patients, highlighting the need for a comprehensive examination of the musculoskeletal and neurologic aspects of the pelvic region. She provides lifestyle modifications that can help improve symptoms, and emphasizes the importance of a team treatment approach and clear communication with patients about their plan of care. The lecture also addresses the prevalence of online programs and resources related to pelvic health, advising listeners to be critical when seeking information. Dr. Miles provides recommendations for tracking symptoms and self-pacing to manage conditions, as well as resources for patient education. The lecture aims to educate healthcare professionals about pelvic health physical therapy and its application in clinical practice. The video transcript highlights the importance of addressing specific muscles and areas of the body in pelvic health physical therapy, such as the quadratus lumborum and pelvic floor muscles. The speaker emphasizes the need for external and internal exams, along with a team treatment approach. They also discuss the prevalence of online programs and offer recommendations for patient education resources. Overall, the lecture aims to provide a comprehensive understanding of pelvic health physical therapy and its role in clinical practice.
Keywords
pelvic health physical therapy
bladder
bowel
sexual function
pelvic pain
biopsychosocial model
musculoskeletal
neurologic
lifestyle modifications
team treatment approach
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