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It’s a question I’m sure every pelvic pain patient prescribed PT has
thought about. Currently, there is no standard of care for pelvic pain
PT. So unfortunately, patients get PT ranging from good to mediocre to
inadequate to a complete waste of time. The hope is that when patients
begin to push for the best standard of care, change will occur. The
problem is that the majority of patients have no idea where the bar
should be set when it comes to pelvic pain PT. Going into it they get
very little, if any, information from their prescribing physicians, who
themselves often have little knowledge of the treatment.
This brings us back to the original question: What is a “typical good
pelvic floor PT session like?” With this post, we plan to answer that
question by giving a play-by-play description of both an evaluation
appointment at our clinic and a typical follow-up appointment.
Before we go any further, however, you’re likely wondering who the
heck we are to presume to set the standard for pelvic pain PT? Well, for
one thing, over the past decade we’ve focused solely on the treatment
of patients with pelvic pain, both women and men. Plus, during that
time, we’ve worked extremely hard to educate the PT community and the
general medical community about pelvic pain PT (click here to get to
know us better). But the most important claim we have is that we know
what we do works because our patients get better!
Now, back to the question at hand. Below is the reader question that sparked this post.
Question:
I’m curious as to what a typical good pelvic floor PT
session is like. I went to PT for a while to treat my pelvic pain, but
I’m not sure it made a difference. The PT didn’t really explain
anything—the only thing I heard was that I have some tight muscles, but
that seems pretty vague to me. My PT sessions consisted of about 20
minutes of conversation, then I got up on the table, was guided through a
leg stretching exercise, then my belly was massaged for a bit. From
there I got undressed and had about 15 minutes of vaginal massaging.
This never varied.
Answer:
Evaluation Appointment
At the evaluation appointment, the first thing we do is interview the
patient. What we’re after is the patient’s full pelvic pain history.
Among the questions we ask are:
When did your pain start? What does it feel like? Where is it
located? What exacerbates your pain? What alleviates your pain? How does
it affect these three functions: Urination? Bowel movements? Sex? What
activities does your pain limit? What kind of work do you do? What
doctors/other PTs have you seen? Have you had any diagnostic procedures
done? What past treatments have you had? What medications are you
taking?
It’s important that the interview not go over 15 minutes! That’s
because we want to make sure we have enough time to get our hands on the
patient. That’s how our time and their time is best spent. So after 15
minutes, whether we’ve gathered all of the info we need or not, we ask
the patient to undress and hop up on the table. We leave the room to
give the patient privacy and time to get situated and comfortable. If
there is still info we need from the patient—and there always is—we will
simply continue the conversation as we begin evaluation and treatment.
The evaluation is the actual hands-on work that we do on the
patient. The goal is to begin to uncover the contributing factors of
each impaired area.
We choose where to begin based on what we’ve already learned from the
patient. Because we’re limited by time—the evaluation appointment is a
one-hour appointment—we must prioritize. So, we’ll pick selective things
to work on during that first appointment. We want to tackle the areas
causing the patient the most pain first.
While every patient’s pain is its own unique puzzle, there are two
areas we will always check out on evaluation day. These are a patient’s
connective tissue mobility and their internal pelvic floor muscles.
We’ll access the latter either vaginally with our female patients or
rectally with our male patients.
During the internal exam we are on the lookout for hypertonic (tight)
muscles, trigger points, and a gauge of the patient’s pelvic floor
motor control and function. Plus, we will palpate the peripheral nerves
to identify irritability. As for the connective tissue, it’s a rare day
that connective tissue is not involved in a patient’s pelvic pain. In
fact, we go through the connective explanation every single time we have
a new patient.
In case you’ve never gotten an explanation for how connective tissue
contributes to pelvic pain or you need a refresher, this is our schpeal:
“Connective tissue becomes tight as a result of underlying dysfunction
in muscles, nerves, organs, or joints. As a result, there is reduced
blood flow and the tissue becomes hyper-sensitive. Therefore, it becomes
difficult and painful to manipulate. If we don’t fix it, it’s going to
continue to contribute to the underlying impairments in corresponding
muscles, nerves, organs, or joints, and the pain cycle will continue.”
So, in the evaluation appointment, we definitely examined the
patient’s connective tissue mobility and their pelvic floor, plus other
areas we were able to get to that we believed were contributing factors
to their pain. Ultimately, between this first appointment and the next
appointment or two, all areas on the patient will be evaluated from the
ribs to the knees, back and front.
An Explanation
One of the things that bothered us in the reader’s question was this
line, “They didn’t really explain anything—the only thing I have heard
is that I have some tight muscles, but that seems pretty vague to me.”
We don’t ever want our patients not knowing why we’re doing what
we’re doing! Throughout the treatment session, we explain to them what
we’re doing and why.
If your PT is not giving you these kinds of explanations, it’s
important that you ask for them. Asking her will not only bring you up
to speed, it’ll force her to develop a plan, and not just treat you in a
scattered, directionless way. And do not accept a half-hearted
explanation that what she’s doing “decreases muscle tightness.” Your PT
needs to be able to tell you why she thinks the tightness is there, what
she thinks is causing it, and what she’s doing about it.
On top of explanations throughout, at the end of every appointment we
give our patients a briefing on what we did, what we found, and what
our expectations are. For instance, we’ll say something like, “So I
worked on such and such trigger points today, they’re still there, so
basically I don’t expect your pain to change until these start to change
more. For the next four weeks, I’m only going to focus on this area and
if I can’t get things under control I’m sending you for trigger point
injections.”
A Typical Pelvic Pain PT Session
At the beginning of a typical PT session, we walk into the room with
the patient dressed. We question the patient for two minutes at the
most. Just as on evaluation day, time is precious. We only have one
hour, so we want to begin manual therapy on the patient as soon as
possible. If we don’t get all of the info we need in two minutes, then
we’ll just continue the conversation once we begin treatment.
One bit of info we want to get from the patient is a description of
their symptoms after their last treatment. We especially want to know
how those first two or three days were after treatment.
This is important for a few reasons. For one thing, oftentimes we will
focus our treatment for the day based on what their response is and what
is bothering them the most. For another thing, it allows us to educate
our patients about reasonable expectations. For instance, based on their
response to the question, we’ll explain why they were sore (if they
were). Or why their pain was better or worse.
Also, from looking at the chart before the patient comes in, we’ll
have a few very specific questions to ask. For instance, if it’s a
patient who is having pain with sex, we’ll ask whether sex was possible
since their last appointment.. If it was, we’ll want to know if anything
was different about the experience. We’ll want to know whether the pain
was less in intensity, less in duration, or in a different area.
After our two minute chat, we’ll leave the room so that the patient
can change and get situated on the table. When we come back into the
room, we’ll tell her or him what we’ll be doing during the appointment
and why.
The first thing we’ll do during treatment is to treat the patient’s
connective tissue. (If you aren’t familiar with connective tissue
manipulation, click here to read more about it.) The reason we do the
connective tissue manipulation first is that it makes it easier to treat
underlying trigger points, it calms the nervous system down some; it
increases blood flow to the area; and it relaxes the pelvic floor a bit.
For the most part, there are four rungs to the ladder of pelvic pain
treatment. They are: working out external trigger points, working out
internal trigger points and lengthening tight muscles, connective
tissue manipulation, and treating at structural abnormalities. However,
the last, treating structural abnormalities, is only incorporated when
it applies. So during a typical appointment, we are focused on these
strategies.
Typically we spend about half the appointment on connective tissue
manipulation and external trigger point release (external work), and
half the appointment on internal trigger point release and muscle
lengthening (internal work). An appointment lasts for one hour. And
patients either see us twice a week or once a week.
So that’s what we do during a typical PT appointment. What we don’t
do during an appointment is: We don’t ever leave our patients alone in
the room hooked up to a tens unit or to a biofeedback machine or
performing exercises with an aide. When it comes to the successful
treatment of pelvic pain, what works is manual, hands-on treatment, so
that’s what we do.
Also, we don’t use a cookie cutter, one-size-fits-all approach to
pelvic pain PT. Not only will every patient’s treatment be different,
but a specific patient’s treatment will change and evolve from
appointment to appointment!
And, we don’t spend precious time cheerleading our patients through
stretches and strengthening exercises. While we do arm patients with
therapeutic home exercises from day one, like pelvic floor drops, we
don’t spend more than a few minutes teaching patients how to do them. As
for stretching and strengthening exercises, they do have their place;
when pain is either completely gone or way down and when trigger points
are gone, and the muscles are either tight or weak. That’s the time, and
the place for them is when the patient is at home.
So, now that we’ve given you a rundown of what we believe is a good
pelvic pain PT session, we’d love if you’d share your experiences with
us and our readers! Do your PT sessions differ from what we’ve
described? If so, in what way/ways?
Please either leave any questions or comments you might have in the
comment box or email us at: blog@pelvicpainrehab.com. We’d love to hear
from you!
Be well,
Steph and Liz
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