The key to healing pelvic floor dysfunction and ultimately living a pelvic pain-free life is finding a physical therapist that knows what she’s doing. That’s not to say that a good PT is the only piece of the puzzle, but in my mind it’s the most important piece. A good PT is able to see the big picture of your pelvic pain, while at the same time focusing in on each and every small detail. Think of her as the CEO of your company, “Pelvic Pain Be Gone Inc.” If she’s good, put your trust in her and prepare to start reaping the dividends of healing and health, if she’s bad, fire her on the spot, and get to work recruiting another.
But how do you distinguish the good physical therapists from the bad? After all, because of the complicated nature of pelvic floor musculoskeletal dysfunction (PFMD), there is no standard protocol for PTs to follow. True. But luckily there is a list of (PFMD) physical therapy DOs, just as sure as there is a list of (PFMD) physical therapy DON’Ts.
Below is that list of DOs and DON’Ts.
Disclaimer: While I am an expert at feeling pelvic pain (boy, am I good at that!) And am quite good at getting physical therapy. (My trigger points can be released with the best of ‘em!) I’m no expert on matters concerning administering physical therapy for pelvic pain caused by PFMD. That’s why the information below is based on the research of a handful of pelvic pain superstars, namely Jerome Weiss, M.D., Stephanie Prendergast, MPT, Julie Sarton, DPT, M.P. FitzGerald, M.D. and Rhonda Kotarinos.
Physical Therapy DOs:
• Your PT should know how to internally treat your pelvic floor via your vagina and your rectum; common internal treatment techniques are: trigger-point release, myofascial release, proprioceptive neuromuscular facilitation, strain/counter strain and contract/relax. (I ask my PT to describe which techniques she’s administering while she is treating me internally just so I can get a sense of what’s going on and what feels like what.) • Your PT should be looking outside of the box, so to speak. Yes, your pelvic floor muscles are in spasm. But, your PT should also be: assessing your bony pelvic structure and the alignment of your pelvis and spine; manipulating your connective tissue in key areas like your abdomen and inner thighs with strategies such as “skin rolling,” and softening and releasing any scars you may have from surgeries or C-sections. • Your PT should have knowledge of the Pudendal nerve and its pathway, and should be treating it if it is an issue. • Your PT should have knowledge of the nervous system as a whole because other nerves besides the Pudendal nerve influence the pelvic floor. On top of that, some women have pelvic floor neuropathic pain due to other issues with the nervous system. So, your PT should know how to integrate central nervous system calming techniques into your therapy. • In addition to working internally, your PT should also be working on you externally as more than 30 muscles attach onto the pelvis and many times these muscles have set the stage for the dysfunction internally. • A good PT will teach you how to self-treat. Self-treatment is another important piece of the recovery puzzle. The patients that respond best to PT are the patients that also self-treat. • A good PT will also stress the importance of integrating appropriate exercise into your life. Specifically, core strengthening and stretches are important. But, she will be mindful that integrating exercise varies according to patient presentation. The key is when to get a patient to start exercising—if done too soon or too aggressively, it can flare a patient. • If muscle spasm is present, a good PT will tell you NOT to do Kegels! You do not want to contract muscles that are already contracted. Once a patient's muscles are lengthened and relaxed enough, then Kegels can be integrated with an overall exercise routine. • A good PT is plugged into a network or team of other key practitioners. A good working relationship with a knowledgeable physician is a plus as it provides for more comprehensive care. For example, trigger point injections can be coordinated with physical therapy. In addition to having a relationship with a physician, a PT should be able to pass along names of other practitioners such as acupuncturists, pain specialists, pain psychologists, sex therapists and compounding pharmacists. A multi-disciplinary approach is a must! • A good PT is resourceful; she’ll help you figure out what kind of cushion you can use to make sitting as painless as possible, she’ll give you the low down on the best self-treatment tools, such as dilators and foam rollers. • A good PT is a good listener. At every visit she asks about your progress, she wants to know what is making you feel better and what is making you feel worse. • A good PT is a good detective; she is constantly on the case trying to figure out what exactly is causing which layer of your pain. • A good PT will be able to assess certain behaviors that are detrimental to your recovery; she might tell you to avoid certain activities, like jogging, until you’ve reached a certain point in your recovery. • A good PT should be up on all of the latest PFMD treatment options and research. • A good PT isn’t afraid to refer you elsewhere if her treatment isn’t working.
As I mentioned in my last post, a “good” PT isn’t always easy to find. In fact, the pool, while it’s beginning to grow, is still relatively small. I’m fortunate enough to live in Southern California, a hub for PFMD treatment and research; however, I saw five different PTs before I found “the one.” And while I was embroiled in my PT search, I had a few pretty awful experiences with therapists that purported to be experts in “women’s health.” One such PT would spend 45 minutes of my hour-long sessions teaching me to breathe. One day all of the deep inhaling and exhaling had me seeing stars and I nearly fainted! So, in addition to the research literature I mentioned above, I’m including my own experiences with bad PTs into the following list of PT DON’Ts.
Physical Therapy DON’Ts
• A PT that is hesitant to work on you internally most likely doesn’t know what she’s doing. (I once saw a PT that I practically had to beg to work internally, and when she did, she spent only about 15 minutes a session on internal work—just long enough to flare my muscles and irritate my nerves.) • A PT that is constantly trying to sell or rent you different gadgets is likely more interested in her businesses’ bottom line than your pelvic floor. • If a PT accepts medical insurance, she should know how to work within the insurance system. (I once had a PT who coded my diagnosis incorrectly and kept notes that did not adequately represent my progress. As a result, my insurance company stopped paying for my treatments.) • If a PT is only administering Biofeedback for your pelvic floor spasm, give her her walking papers. If Biofeedback is used at all, it should only be used to educate a patient on how tightly she is holding her pelvic floor and should be mixed with techniques integrated for relaxation. • If a PT, or any other practitioner for that matter, boasts that they have developed a one-size-fits-all treatment “protocol,” run for the door! There is NO standard protocol for treating PFMD; each patient presents with her own unique issues and symptoms, a PT should develop tailor-made treatment strategies for each of her patients--strategies that are open to trial and error. • A PT should not try to psychoanalyze you. • A PT should never blame you for your pain. • A PT should be able to connect with you on a personal level, she should be sensitive and empathetic to your situation, if she is not, she may not be "the one." • A PT that is unable to communicate effectively with the other members of your team is a liability to your treatment.
Communication is key to the patient/therapist relationship. In addition to knowing what your PT should be doing, you should know what questions she should be asking you. To give you an example of the kinds of questions your therapist should ask you at your very first evaluation session, take a look at the following list of questions that Julie Sarton, D.P.T, included in a recent article she wrote on the topic:
• Can you connect a particular event with the onset of your pain? • Have you had prior injuries, such as falls on your tail bone? • Do you have injuries from prior surgeries or childbirth? • Have you ever been abused? • Do you participate in sports such as gymnastics or ballet? • What is your occupation? Does your occupation call for you to sit for long periods, as with computer work or dentistry? • What are your daily activities? • Do you have pain during or after sexual intercourse? • Do you have urinary hesitancy or frequency? • Do you have a history of constipation? • What makes the pain better or worse?
If you are conducting your first PT search, or if you have decided to can your current PT and conduct a search for a new and improved version, print out this post, and use it to interview potential PTs for the job. Before you settle on a PT, ask her the following questions:
• What techniques do you use? (Run through the list of techniques listed above—if she isn’t familiar with them, move onto the next candidate.) • Do you perform both internal and external work? (Remember, you most likely need both.) • Have you had courses in physical therapy for pelvic floor musculoskeletal dysfunction? For pelvic pain treatment?
I hope I’ve covered all of the bases in this post. If any of you have anything else to add, please do so in the “comment” section. Also, if you are currently being treated by an awesome physical therapist for your pelvic floor pain or if you know of an awesome PT, please leave her name and contact info so that readers in her area can give her a call.
You are an incredible woman and I am so thankful to have found your blog. Once I read all of your posts I look forward to reaching out to you in more detail, but in the meantime I want to be sure to share the contact info for my PT who has been an incredible part of my tx team. Please feel free to share this info as you see fit. Thanks for sharing - it is so nice to know I am not alone. The last 22 months has been a really tough journey (Interstitial Cystitis and Pelvic Floor Dysfunction) and there seems to be no end in sight. Your clear determination has given me the extra bit of strength and hope I needed this weekend. Hope you are well.