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The Pelvic Floor – a draughty window or something more…???

Pelvic Floor Physiotherapist

Julie Wiebe

This post was inspired by Tweets from Julie Wiebe (www.juliewiebept.com).

To quote Julie from Twitter...the question was "What specific conditions do you think need specialist WH Physio care?"

I think the answer [to] that can't be a formula and I think if we can change how we address MSK & pelvic floor and treat them together from the get go then women wouldn't end up [with] the really awful stuff that internal [physios] have to sort thru. When I give courses I equate it to a drafty window that eventually turns into a huge reno project [because] the true issue wasn't addressed early. Let's normalize the pelvic floor, integrate it early in MSK and see if we can avoid the major reno projects internal therapists are seeing. Your thoughts?
My Thoughts:
I have been thinking about this for a little while.
Firstly, Julie is absolutely correct. Sometimes we see the problem (a draughty window) and we try to fix it. Doctors will say "oh, you can't hold your bladder? Go see a WH physio" and then it becomes a "pelvic floor" problem, the patient doesn't improve and doesn't go back to the physio, gets referred for and has surgery (the big renovation) and a little while later the same problem is back... This is not a good result!
Julie's suggestion to "normalize the pelvic floor" is correct as well. The problem has been that this can be hard to do. The pelvic floor could be the victim or it could be the primary problem. Let's go through some brief examples but first a quick revision of the philosophy I use...
You may remember from other posts that I like to look at problems in a holistic manner. That means looking at:
1. The person's story, what has meaning to them, their virtual body representation, their goals of treatment and their emotions.
2. Articular System - bones, ligaments, cartilage, etc
3. Myofascial System - muscles, fascia, tendons, associated soft tissues
4. Neural System - Brain, spinal cord, nerves, coordination
5. Visceral System - internal organs and their associated soft tissues
6. Strategies for Performance and Function - how the patient does what they do
The Pelvic Floor as the Primary Problem.
 If the pelvic floor is the Primary (main) problem, it means that it is responsible for initiating the cascade of reactions that are ending up causing the symptoms. Some examples of this are:
1. A physical tear of one of the pelvic floor muscles or their attachment to the bones
2. Local nerve damage causing dysfunctional pelvic floor contraction
3. A truly weak pelvic floor
I know this is a limited list but I am struggling to find other problems. e.g. coordination issue is actually a neural issue to do with the brain, a fractured pelvis is not a pelvic floor problem as the primary. In any case, if I find a Primary Problem Pelvic Floor, I refer to a Women's Health (WH) Physio. I am happy to take  suggestions here for other conditions that require WH Physio...
The Pelvic Floor as a Secondary Problem
Now this part of the post is much easier! This is where a primary problem somewhere in the body impacts the pelvic floor in some way. Until you fix the primary problem, it will continue to affect the pelvic floor. Often, misdiagnosis of the pelvic floor as the Primary Problem results in frustration for the patient, therapist and doctor. If this happens, refer to a suitably qualified Musculoskeletal (MSK) Physio!!!
For me and my practice, the most common Primary problems come from around the pelvic region generating intra-abdominal pressure and so put pressure on the pelvic floor. Some examples:
1. Thorax and Lumbar dysfunctions - non-optimal biomechanics causing excessive activity of diaphragm, obliques or rectus abdominis with erector spinae tone. This can cause all sorts of secondary problems, one of which is a pelvic floor that appears to be weak but is really just tired of putting up with all this pressure from above! Or you can have asymmetrical pulling on the pelvic floor causing dysfunction.
2. Pelvic and hip dysfunctions - similar to above but sometimes dysfunctions can cause biomechanical disadvantages for the pelvic floor, compensations from other muscles bearing down to try stabilise a dysfunctional segment, altered neural input, etc etc
How do I manage these 2 different presentations?
Firstly, you have to diagnose correctly whether your patient's pelvic floor symptoms are truly a pelvic floor problem (primary problem) or whether the pelvic floor is affected by other problems (secondary problem).
Next, you then have to decide if you have the skills to deal with the primary problem. I know my strengths and weaknesses. I will give a patient a small amount of time to develop her endurance and strength if I feel that is the primary. If I feel that she has a myofascial or neural problem or associated visceral problems (bladder or uterine prolapse), then off to the WH physio she goes.
If a patient has a primary problem elsewhere, I have 1-3 sessions to prove to the patient and to myself that I am on track. Otherwise I refer them on. If it truly is a Primary problem elsewhere, you should see evidence of change within the session and between sessions.
Management involves treatment of the relevant components of their problem (articular, myofascial, neural, visceral, strategy, person in centre of puzzle). This should then allow proper coordination of the pelvic floor to occur. Once that does normalize, I develop strength and endurance and ensure that this develops during their meaningful functional tasks.
I must repeat, this should happen relatively soon. If it doesn't, you haven't got the primary problem. Having said that, it can take time for muscles to develop etc but you should see steady, consistent improvements. If you have improvements that go back down to near your baseline measures, you don't have the primary problem.
Check your ego at the door!
I believe that this is a lesson that most physios can learn. I know I have had to. Not knowing how to do something well does not mean that you are an ineffective physiotherapist. How you deal with a patient who doesn't respond as expected is a measure of how good a physio you really are!
In Australia, we have 3-4 tiers of physios - Your regular physio with a bachelors (or now graduate entry masters), a Titled Physiotherapist who has a clinical masters or equivalent, specialists in training (me) who have the title of Associate of the College of Physiotherapists (but are still just titled physiotherapists) and Specialists.
Ideally, physiotherapists would refer difficult patients to Titled Physiotherapists for an opinion and a plan and Titled Physiotherapists would refer to Specialists (or specialists in training) for those that they can't work out. It is like a General Practitioner doctor referring to Specialists - in Australian Physiotherapy, we have the Titled Physiotherapists in between.
When I refer someone, I send a letter explaining what I have found, what I would like assessed and for them to do what they think is necessary, just let me know what is going on.
When I get someone, I do the same back...so long as I know that is what they want! Sometimes I get nothing from the referring physio! They seem to want me to just take over...so I do...but no one learns!
Your patient knows you are a good physio and will actually appreciate your efforts to find someone who can help them. They will not appreciate you if you write them off as difficult or hold onto them as your patient for too long.
Conclusions:
1. Accurate diagnosis is so important to finding out if the Pelvic Floor is the Primary Problem or a Secondary Problem.
2. Once you have identified the Primary Problem, you should address it holistically and see improvements within 1-3 sessions.
3. If you don't see consistent improvements, refer to someone else to check your work. This is actually being a good physio!!!
4. Check your ego at the door. You are there to help your client. Find other physios you can liase with to help you - no one is the complete package!
Please leave your thoughts below. A tough but interesting post to write!

15 Responses

  1. Really well done! Thanks for the nod, too! You beat me to my own Q and A blog post. You saved me the trouble!

    I like how you distinguished between the primary pelvic floor vs secondary pelvic floor manifestation of a global dysfunction. I am very clear with folks when I think it is a primary pelvic floor issue what their options are, and that we should see fast results if I have the right skill set for them. If the results are happening then we need to collaborate with an internal therapist.

    While I like the distinction you made, I also see the secondary pelvic floor issues as well, primary, due to the critical role of the pelvic floor in rebalancing how our movement system functions as a whole not just as it relates to a typical women’s health type diagnosis. And even some of the primary issues as more global issues. Even a PF tear or damage due to a delivery should ultimately have a global or systems solution b/c the pregnancy alone created dysfunction in the relationship of the PF to the rest of the musculoskeletal system and in the woman’s alignment.

    I don’t have a cool graphic like Diane Lee’s rubric ( I too, am a huge fan of hers!), but I have a few add’l things I look at and address with my patients before referring them on or even giving manual care. Specifically I integrate the pelvic floor back in with the rest of the neuromuscular system, and the IAP pressure system. Train it as a foundational component of an inside-out force production in function with optimized alignment. This addresses both the secondary and primary issues with a whole body solution. I start there for ALL diagnoses whether they are primary or secondary pelvic floor issues-jaws, knees, incontinence, prolapse, even shoulders (see a blog on that here
    http://bit.ly/bWQWdG). And as you said if the results aren’t happening fast I then apply my manual skills or I am missing something or it is time for a different set of skills and eyes.

    As your previous blog stated…we all need to move more toward the center…women’s health and musculoskeletal practitioners. Integration, integration, integration!!

    Sorry so long….140 characters always forces me to be briefer!
    All the best! Julie

    1. Between the two of you I have only to add:
      I agree – and love the “check your ego at the door” because none of us have all the answers, at least I don’t!
      Boys have pelviseses too (pelvi? pelvis’)

      I think we do our patients a disservice if we limit our approach or their evaluation to one body part and/or one type of tissue or organ. You have both said that exceptionally well.

      I got more wordy on the Linked-in discussion here: http://goo.gl/HcjWz

      Sandy

  2. Great post and reply and thanks for getting the talk happening. Antony is right about the tiered system available in Australia but it is not compulsory and there are many of us with extensive clinical experience who have chosen not to follow the path of specialisation for many reasons.I have the greatest respect for those who do/have but – working , running a business and caring for a family doesn’t afford me personally the time to do so at this point in my career ( which is 27 years thus far & includes post grad exercise and sports science , time running a large public hospital and now running two businesses as well as clinical work).

    It does become a question of the chicken or the egg but you can’t fix one without the other. Even with primary PF there will always be secondary problems – mainly due to adaptive changes in trying to compensate for lack of PF control. Add to this the probable visceral component and the greatest of all – the psychological factors which can often be the underlying cause of primary PF dysfunction….. Referring on is essential if you don’t have the skill set ( and as you say , none of us are the full package no matter how good we think we are – well said there Antony).
    Personally I am lucky enough to work with @equuspilates who I shall invite to this forum – she is fabulous at Tx/Lx/pelvic and hip dysfunction. Once I have dealt with the internal issues I refer straight to her and likewise when she suspects primary PF issues she refers to me .

    I am also going to stick my neck out here and say I don’t think you can fully effectively treat pelvic floor dysfunction without actually feeling or seeing if it is working (either via a VE or biofeedback but preferably VE )- you wouldn’t Rx a neck or a knee without looking at and feeling the relevant muscles and joints . You can feel any trigger points, you can give immediate facilitation of better contraction and pattern. The number of times I have had verbal feedback – yes I can feel myself contract , then you do an internal and it’s all wrong….even after doing RTUS which requires great skill to get it right and in my opinion a reasonable contraction before you see much – hard to see small amounts of activity and if there is something happening it needs to be encouraged Am sure there are many who will disagree but that is my view from clinical experience. So I agree and it is a salient point you make Antony and a timely reminder to us all to look further than what is in front of you and share our skills with each other for the best outcome. I see ladies who have “been to the pelvic floor physio before”…..perhaps the issues weren’t fully looked at the last time and integrated with the whole person, perhaps costs were an issue , perhaps personal issues… perhaps things improved and then another episode has occured , just like neck and LBP can recur despite the best training.

    I have banged on long enough – look forward to further discussions and sharing

    1. Fantastic reply Fiona. I think we are all on the same page…I was thinking this morning that most physios would agree about what we say but why is it that many don’t behave according to what they say? I think I will blog about a book I am reading called “Everything is obvious…if you know the answer” 🙂 It is a good book!

      I have learned and developed some nice manual palpation skills but as you correctly point out, there is no substitute for putting your hands/fingers on the muscles. I don’t think my wife is particularly upset that I do not do internals – my insurance company and lawyer are also probably happy I stay away from it – I don’t need the stress of being sued for doing something to help someone!

      Your last point about revisiting things…it reminds me of a recent quit smoking campaign that I thought had a particularly good message – “Don’t give up on giving up”. Sometimes my adult patients behave like my children who are all under 10yrs old!! “I’ve tried that before. I am no good at it. ;m not going to try that again”!!

      BTW, if you ever want to write a post on your blog or mine, please feel free to add my post with trackbacks to your blog and I will do the same for you 🙂

      Thanks again!

  3. lbnicks@yahoo.com

    I love this discussion. I don’t feel I have much to add as you all have said it all! I love hearing everyone’s standpoint and views.

    Antony, I love your comment on referrals. I have only entered into the Women’s Health area in the last few years and really have only been practising MSK for about 7 years and I never feel like I know enough. I think referring on is so important and I do it when I know I have hit my limit! Since WH is a new territory for me and am in a private practice as the only one interested in what’s going on “down there”, I will never learn more clinically by just referring on if feedback isn’t provided! Unfortunately in the past, many were referred to Urogyn Specialists (and possibly onto surgeries they may not have necessarily needed, yet) who don’t seem to communicate very well at best of times. Now I have found such a great group of MSK/WH physios around Brissie here I can send to when needed!!!!

    Keep the great info coming all!!

    1. Thanks for the encouragement. Referring on is something I have learned to do over the years. It is nice to know other physios are out there doing te same thing 🙂

      Hope you enjoy the other posts…I am passionate about many things!

  4. Come on Antony – another techno thing for me to master! My IT guy told me to turn off trackbacks ( I think?) I will check with him how to do that.
    My comment re internals really just backing up the theme of referrals and am quite sure in your position the best option is not to go there!
    I also get great results with some pelvic pain by doing deep buttock releases such as piriformis initially and home stretching then gives the pt a sense of taking back some control, I then move on to internal work as appropriate
    Was impressed with the quit smoking one too – and yes it applies to everything……..and sometimes no matter how passionate we are as therapists in motivatung our pts , if it’s not the right time for them in their life then it won’t happen.
    Welcome to the commenter above – private practice can be a bit isolating which is why forums such as this can be so valuable. Get onto twitter too and you will find a great group of local and far away physios with great input. See you on Linked In group 🙂

    BTW how did you manage to get a google alert on this so quickly – have you been blogging for a long time ….I am working so hard on my SEO/meta titles etc etc (frustratingly so as it interupts my natural flow of writing) . IT tells me to be pt and I will gain traction *sighs and shrugs shoulders!*

    1. Yeah, trackbacks and pings are an issue. Just having the URL is good enough.

      Don’t do anything in particular for seo. Trying to just write naturally. Which google alert search word did you have an alert set up on?

      Thanks for contribution 🙂 just think positive with respect to technology etc…it is for good 🙂 SEO is a dark art…

  5. Well I just wrote a long philosophical windy piece to add something significant to this debate and then in a moment of madness hit the twitter button instead of the post comment grrrrrrrrrrr
    Can I rewrite it? Well we shall see how good ‘The Good Wife’ is tonight ……….

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