… But when do we need to REALLY evaluate and treat the pelvic floor muscles?
It’s interesting. When I first started practicing in pelvic health, there was a big emphasis on “the importance of the internal exam.” I would attend classes where this was REALLY pushed on us. So much so, that I actually think I likely inadvertently pressured some patients to have internal exams when they were not actually wanting to do this (As I’ve become more experienced, I’ve learned to do better, to more effectively present options to my patients and allow them to choose what they want to pursue). This strong emphasis was a response to the “biofeedback only” pop-up treatment shops. There were clinicians (and sometimes just trained technicians) who were offering “pelvic floor therapy” but really only hooking people up to machines (usually estim and biofeedback), and not actually comprehensively evaluating and treating them. Unfortunately, this is STILL happening. And it’s absolutely infuriating.
This type of response is normal– we shift because we know there’s a better way to practice, and we emphasize this better way. As time has gone on, I’ve seen an interesting backswing. As therapists prioritized internal evaluation and treatment of the pelvic floor muscles, we started to see some clinicians *only* addressing the pelvic floor muscles. This meant that contributions to pelvic floor dysfunction in the rest of the body were sometimes ignored, and the “pelvic floor centric” approach often reigned. This type of thing often still happens. So- just like before, we saw a backswing. Some clinicians and educators started highlighting that the pelvic floor muscles are part of the body– that they exist in a system, connected to other parts– and that treating these muscles effectively means considering everything else in the system that can play a role.
We truly believe that at SPH- and it’s supported in the literature. We can see that very clearly, as we look at some of these research findings.
Important Perspective Shift To Account For Interconnections
But… as happened previously, sometimes this sort of thing leads to other shifts. So, in our PT world, we’ve seen another interesting shift happen. As clinicians have realized the interconnectedness of the rest of the body to the pelvic floor muscles, this has lead to some focusing so much on the rest of the body, and leaving out the pelvic floor muscles completely. I had an interesting discussion once about this with a well-known instructor in the pelvic floor world. She had made a comment of, “When I’m working with someone with pelvic pain, I go to the pelvic floor last. I make sure to address everything else in the body first– from the neck to the feet– then I go to the pelvic floor muscles if it’s absolutely necessary.” While this approach may work for some patients well (especially if that person would prefer not to have their pelvic floor muscles directly examined or treated), it concerned me. “Why?” I asked… “Why not evaluate and treat the pelvic floor muscles while simultaneously addressing other contributors and factors in the body?”
No where else in the body would it make sense to examine everything around the problem without examining the person’s primary complaint… right? Imagine going to see someone for your shoulder pain, and having them tell you that they’re going to look at your neck, elbow, and spine… but they’ll only examine your shoulder if absolutely needed. (And this analogy works well… because the neck, elbow and spine would all be helpful to look at if a person had shoulder pain… but also… the SHOULDER).
Principles For A Great Initial Evaluation
Soooo… back to where we started. When is it appropriate to include the pelvic floor muscles? Here are the principles I teach when I mentor other pelvic floor therapists:
The initial evaluation in pelvic floor therapy should include a comprehensive evaluation of the person→ their movement from head to toe, and specific evaluations around their specific complaint (in the pelvic health world, this usually means looking more closely at the hips, spine, abdomen, and the pelvic floor muscles).
Decisions to avoid examining or treating areas should be based on the specific patient (not a global policy, nor on clinician comfort). From this, I mean that if a clinician regularly avoids examining a patient intrarectally because they just don’t feel confident in doing that– it is their job to get mentoring and training to become comfortable. This is a very different situation from a clinician who does not perform an internal examination on a patient because that patient expressed a desire to keep their examination external.
After the initial evaluation, the clinician needs to identify the patient’s story– this is the why. What is happening for this patient that is causing them the symptoms they are experiencing?
After we determine the patient’s story, we then can hypothesize about an important piece– Do I believe the pelvic floor muscles to be a primary factor for this patient? Or a bystander to a different problem? ←This important factor drives where we start our treatment.
Taking Action With Our Initial Evaluation Findings
When we determine the story, and build our working hypothesis regarding the involvement of the pelvic floor muscles, it allows us to prioritize our interventions and treat the patient comprehensively. This can look very different for different patients. For example, I might have a patient with difficulty emptying their bowels, and we determine that the primary problem is related to difficulty coordinating the muscles at the anal canal to allow for opening. I could have a similar patient with difficulty emptying their bowels, where their problem is more related to their bowel habits and the actual consistency of their stool. Our treatment approach will likely have similarities in these two cases, but where we start, and how we prioritize our interventions will be very different.
Soooo– if you’re a clinician reading this, ask yourself if you’re following those four steps with your new patients. Are you critically thinking about your patient’s case and addressing the problems comprehensively? Or are you falling into habits and protocols?
And if you’re a patient, remember that YOU are the most important member of your healthcare team. If you don’t feel like progress is happening in your symptoms, talk with your providers. Share things you’ve read or are learning about. Quality providers will be grateful for your input and use that to provide better care for you!
Have a great week!
Jessica
Resources for Pelvic Floor Physical Therapy Professionals
Online Courses, Small Group Mentoring, Patient Handouts and more from Southern Pelvic Health.