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 ProblemNow 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!
