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  • Writer's pictureFiona McMahon

What Does Pelvic Floor Physical Therapy Look Like?



Fiona McMahon PT, DPT, PRPC


Hello! If you’ve made it to this page, I am guessing you are considering pelvic floor physical therapy. It can be a strange place to find oneself, and I’m hoping that this blog can provide a little background on what to expect. I want to take a moment to acknowledge how difficult pelvic floor dysfunction can be, as well as to congratulate you for taking the time to explore solutions to get you feeling better. You may be wondering, is pelvic floor physical therapy right for me? What are the sessions like? In this blog, I will introduce you to what most pelvic floor treatments look like at Ember Physical Therapy, but if you have specific questions regarding your condition, don’t hesitate to call for a free 15-minute phone consultation: 551-244-1186 or email me at Fiona@emberphysicaltherapy.com


So What Does the First Visit Look Like?


On your very first visit, you and I will spend a good amount of time talking. It may seem surprising because, in most healthcare settings, providers usually will have to rush through history taking, but at Ember, we have the luxury of taking time to truly understand your condition, how it affects you, as well as any relevant health history that could be contributing to your pelvic floor dysfunction. I have spent my career listening to patients who have spent hours in doctors’ offices, not feeling heard. Part of my guiding philosophy is that truly feeling seen is the first step in healing. Beyond having a chance to understand you and your health history, a thorough subjective interview also allows me to zero in on what may be driving your symptoms and to decide on the most important elements to check out during your physical exam.


After we have had ample time to discuss what you are experiencing, when it started, and most importantly, how it affects you, we will start the pelvic floor physical therapy exam. This can be the point at which folks can be understandably nervous. A typical pelvic floor exam involves checking the muscles of the pelvic floor both internally and externally for tightness, spasms, weakness, and coordination. This is done as gently as possible with a gloved lubricated finger. This exam can tell me so much about what may be causing your symptoms by getting a true sense of how your pelvic floor muscles are functioning.


As with every single aspect of what I do in physical therapy, consent, and comfort are my top priorities. Sometimes, folks are just not ready for the pelvic floor exam, (if you think you are in that boat, no worries, you have really good company). If you are not ready for the pelvic floor exam, we can spend our time evaluating the many other parts of the body that affect the pelvic floor. Did you know that posture, visceral mobility, and hip strength and mobility all can greatly affect the pelvic floor? For folks that aren’t ready for a pelvic floor exam, this can be a great place to start and can go a long way towards establishing the drivers of your pelvic floor dysfunction. These aspects of the physical exam are so essential that I include them in many of my evaluations of the pelvic floor even if a patient is comfortable with an internal examination. The role of the hip in pelvic floor function could be a whole other blog, and it will be. So stay tuned!


Once we have both your history and our results from the physical examination we are ready to rock and set to work creating your own bespoke rehab plan. I strongly believe that cookie-cutter approaches to injuries and dysfunction do us a disservice. Yes, I could have and have had two patients that present in the exact same way but require two separate plans of care based on how the stresses and responsibilities of their lives affect them. For some folks, working on stretching an overactive and spasmed pelvic floor through manual treatment in clinic and specialized homework at home is just the ticket; yet for others, they may need neuromuscular re-education to teach them to move throughout their day without clenching their pelvic floor in response to stress or heavy physical exertion. Though these two patients may present with the same symptoms, the causes of those symptoms are different, thus they require specialized and thoughtful care.


At the end of your very first visit, you should leave with a good idea of what is going on, how we are going to treat it, as well as a general estimation of how long it should take to feel better. I take time at the end of our very first treatment to discuss exactly what we will be doing in subsequent visits and why doing these treatments are essential. It is so important to me that you leave treatment feeling confident in your next steps.


How Do You Treat Pelvic Floor Dysfunction?


Prior to starting Ember Physical Therapy, I was lucky enough to work as a mentor and manager as well as a staff physical therapist at a busy pelvic floor physical therapy practice in Manhattan. What I took from training many many many budding physical therapists, is we are all so different, and a phrase that I was constantly telling my mentees is that we all have different toolboxes, meaning physical therapists may approach the same condition in different ways. That’s why it is so important to make sure you have the right physical therapist for you and why I think it is so important to offer free phone consultations so my patients can get to know me and feel assured that I am their “right fit”.


So how did I curate my toolbox? It’s a combination of evidenced based practice and nearly a decade of treating complex pelvic pain. Evidence-based practice involves keeping my practice up to date by reading the latest scientific publications on the treatment of pelvic pain and constantly attending continuing education classes, conferences, and seminars on pelvic floor dysfunction. I have been around for long enough to see big changes in our understanding of pelvic pain treatment and had I not kept my eyes on the latest research, I would have missed out on so much!

My clinical experience has been honed by nearly a decade of treating complex pelvic floor patients. This experience has allowed me to hold close to the modalities and interventions that provide the very best results and move away from the interventions that are a little lackluster.


Manual or Hands-on Interventions


Before we talk about exactly what manual therapy entails, I think it is really important for us to talk about trigger points and myofascial restriction and how they can affect the pelvic floor. The concept of trigger points has been around for a long time, even though they are currently very zeitgeisty in the world of health and wellness with all sorts of new massagers like the theragun entering the market. Trigger points are bands or lumps that are hyperirritable (think angry), within a muscle. If you have ever had a knot in your shoulder/neck that made you jump in pain when it was touched you know what a trigger point is. You may also know that the pain from that trigger point may not just reside in your shoulder, but it may travel or refer to your head causing a headache or radiating pain down your back.


The pelvic floor muscles can develop trigger points just like the muscles of our neck and back. The pain from trigger points in our pelvic floor can remain within the pelvic floor, but it can also refer to other structures. I have included a list of referral sites below, adapted from Pastore et al, cited in the sources. The journal article from which this list is cited is a free open-access paper, so if this interests you, check it out! The full citation is in my sources.


Bulbocavernosus- can cause perineal pain and pain in urogenital structure, including pain with penetration and clitoral pain

Ischiocavernosus- can cause perineal pain and pain in urogenital structure, including pain with penetration and clitoral pain

Transverse Perineum- Pain with penetration

Levator Ani (anterior portion)- Painful urination, bladder urgency, and frequency, pain with penetration

Levator Ani ( posterior portion)- Pain with penetration and bowel movement

Coccygeus- Sitting pain, pain with bowel movement, and sensation of intestinal fullness


In addition to pain symptoms, a short, restricted, or tight pelvic floor is actually a very weak pelvic floor in most cases. Pelvic floors with muscle spasms or general tightness oftentimes do not have sufficient range of motion to allow them to produce strong and effective contractions. In cases of weak and tight pelvic floor muscles, we must work to restore length prior to commencing strengthening exercises, like Kegels. In the absence of pain or even alongside it, we can see issues like urinary incontinence, urgency, frequency, and hesitancy, as well as bowel issues like incomplete defecation and leakage with a tight and spasmed pelvic floor.


Neuromuscular Education


Sounds fancy right? And it is, but it’s also fairly straightforward and simple. It is the answer to the question, “After I’m done with physical therapy, what keeps my symptoms from coming back?” Neuromuscular education is a broad treatment modality that is used across different disciplines in physical therapy, from teaching a survivor of a stroke how to rise from a chair independently to teaching the office worker with a sore neck how to sit in a more ergonomic fashion at work.


In the pelvic floor world, neuromuscular education is a huge part of what we do and forms a crucial part of treatment regardless of the individual practitioner’s treatment philosophy. At Ember, I use neuromuscular education in many many ways with the goal of fostering pain-free pelvic floor function, reduction in sympathetic nervous system tone, and reducing the need for future pelvic floor physical therapy.


The first step of pelvic floor neuromuscular education is to teach the pelvic floor what “relaxed” feels like, what an effective contraction (kegel) feels like, and what an effective “push” for bowel movements feels like. In folks with pelvic floor dysfunction, these movements can sometimes be difficult and it is not uncommon for folks to believe that they are pushing effectively for bowel movements when they are actually closing their anal sphincters. This is known as paradoxical contraction. By taking time to “teach” the pelvic floor how to contract and more importantly, relax when it needs to, you can reduce any holding patterns or clenching that can generate pelvic floor dysfunction in the future.


We can also take neuromuscular education (NMRE for short) a bit further and address the nervous system in terms of desensitization of overactive nerves to keep them from sending as many pain signals. The pain science behind this type of treatment is complex and requires its own blog; however, in the broadest of terms, when folks experience pain for a prolonged period of time, the threshold for the nerves responsible to send pain signals will lower. What this means, is that stimuli that might not have been considered painful previously will be interpreted by the brain as painful. We call this phenomenon allodynia. Physical therapy can use techniques to quiet or down-train the nervous system to reduce the perception of pain in the body.


We also teach techniques to activate the parasympathetic nervous system, which is responsible for the rest and digest properties of the body. It is the inverse to the sympathetic nervous system (fight or flight). Lower parasympathetic activity has been associated with many chronic pain conditions. By learning practical techniques to improve parasympathetic tone, you can help your body enter a state where it can heal and digest. Again chronic pain is a topic unto itself so keep an eye on the blog for more!


Strengthening


It’s so much more than kegeling! This is where I want to appeal to the folks who may have been very diligent about their kegel routine, but found no improvement. Kegels are really helpful to teach our bodies where our pelvic floor is, but for most of us, we require more complex training to be able to meet goals like running without incontinence, being able to jump and dance without the feeling of prolapse and so much more. We’ve touched on the fact that strengthening on an overly tight pelvic floor is not productive, but in cases of pure pelvic floor weakness, strengthening the pelvic floor alone is akin to learning to spell and then expecting to be able to immediately get an A+ on a 5 paragraph essay. Yes, isolated pelvic floor strength and awareness can be an essential building block to recovery, but it usually requires more sport/task-specific training.


Let’s look at the example of someone who leaks a bit when they lift something heavy. When we pick up something heavy, say your toddler, we require a heck of a lot from our core muscles to stabilize our spine and allow us to lift that kiddo up. The pelvic floor is part of the core and absolutely needs to be strong to accomplish this task, that said if the rest of our core is weak, because we’ve only been doing kegels we may find ourselves straining and holding our breath to lift our kids. When we strain to lift, aka a Valsalva maneuver, we can put a heck of a lot of downward pressure on the bladder resulting in leaks. In order to fix this issue, we must treat the pelvic floor, but in order to give the pelvic floor a real fighting chance to keep us dry, we have to also address the rest of the core as well.


Additionally, strengthening outside of the pelvic floor can allow us to return to the sports we love, that we may have thought were causing the pelvic floor to over-tighten. As we have discovered, the pelvic floor is part of the core and if the rest of the components are weak or not working at the appropriate time the pelvic floor can overwork and over-tighten. It truly benefits us to approach strengthening from a holistic standpoint when rehabilitating the pelvic floor.


How do I know if Ember Physical Therapy is Right for Me?


There is a shocking amount of diversity in approaches to pelvic floor rehabilitation. It can be overwhelming when researching pelvic floor practitioners and practices. Frankly, any physical therapist can call themselves a pelvic floor physical therapist without any formal credentialing or education if they want to. Meaning a physical therapist may have only seen a handful of pelvic patients or has taken a one-weekend class, yet they can still call themselves a pelvic floor specialist. The rehabilitation of complex pelvic floor dysfunction requires years of experience and education.

The PRPC in my credentials stands for Pelvic Rehabilitation Practitioner Certificate issued by the Herman and Wallace Institute following years of clinical practice and successful completion of the PRPC exam. The PRPC certification is inclusive of clinical knowledge and practice for folks with pelvic floor dysfunction of all genders throughout the lifecycle. It and the WCS ( a women’s health-only credential) allow physical therapists to demonstrate clinical expertise in pelvic floor rehabilitation and distinguish them from other pelvic floor practitioners.


My treatment philosophy is that everyone has the potential to heal when provided the correct conditions like an ember eventually growing into a blaze. The name Ember comes from that philosophy. I have spent nearly a decade honing my practice and successfully treating hundreds of pelvic floor patients. I believe that offering a space where one can freely tell their own story coupled with the science and art of pelvic floor physical therapy can lead to great results.


At Ember, the care is specific to you and your goals. You will never be pawned off on a tech to do your exercises after spending 15 minutes with your therapist. Ember offers 1:1 hour-long treatments with the same therapist, me, Fiona McMahon to allow you the best care possible.


Still have questions? Call or email today for your free 15-minute phone consultation!

551-244-1186





Sources

Barakat A, Vogelzangs N, Licht CM, Geenen R, MacFarlane GJ, de Geus EJ, Smit JH, Penninx BW, Dekker J. Dysregulation of the autonomic nervous system and its association with the presence and intensity of chronic widespread pain. Arthritis Care Res (Hoboken). 2012 Aug;64(8):1209-16. doi: 10.1002/acr.21669. PMID: 22422576.

FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct. 2003 Oct;14(4):261-8. doi: 10.1007/s00192-003-1049-0. Epub 2003 Aug 2. PMID: 14530839.

Knotkova H, Hamani C, Sivanesan E, Le Beuffe MFE, Moon JY, Cohen SP, Huntoon MA. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012 Sep-Oct;41(5):680-91. doi: 10.1111/j.1552-6909.2012.01404.x. Epub 2012 Aug 3. PMID: 22862153; PMCID: PMC3492521.

Polackwich AS, Li J, Shoskes DA. Patients with Pelvic Floor Muscle Spasm Have a Superior Response to Pelvic Floor Physical Therapy at Specialized Centers. J Urol. 2015 Oct;194(4):1002-6. doi: 10.1016/j.juro.2015.03.130. Epub 2015 Apr 23. PMID: 25912491.





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